At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are

Subjective

Objective and measurable

Reported by the patient

Hidden

Answer and Explanation

The Correct Answer is B

A: Subjective information refers to what the patient experiences and reports, not what is sensed by the observer.
B: Objective signs are those that can be observed and measured by someone other than the patient, such as visual inspections, palpations, and auditory cues.
C: Reported by the patient would be subjective data, opposite of what is sensed and recorded by healthcare providers.
D: Hidden signs would imply they are not readily observable, which contradicts the use of senses to identify them.

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Correct Answer is D

Explanation

A. Decreased plasma volume might cause overall weak pulses but would unlikely cause an absent pulse specifically localized in one or more extremities. Decreased plasma volume generally affects circulation systemically, not selectively in certain limbs.
B. Problems with the heart's electrical conduction system primarily affect the rhythm and rate of the heart but do not directly cause absent pulses in extremities. These issues lead to irregular or abnormal heartbeats, not localized absence of pulses.
C. Shock can result in weak or thready pulses due to poor blood flow, but shock alone would not typically cause a pulse to be completely absent in one extremity while present in others. Shock affects the circulatory system as a whole.

D. A blockage of blood flow is the most likely cause of an absent pulse in one or more extremities. This could be due to atherosclerosis, embolism, or thrombosis, which can obstruct blood flow in specific areas, leading to no detectable pulse in those extremities.

A. Rales B. Stridor C. wheezes D. Rhonchi

Correct Answer is B

Explanation

A: Rales are described as fine crackling sounds, not high-pitched crowing.

B: Stridor is a high-pitched, wheezing sound heard primarily during inhalation and is often caused by an obstruction in the upper airway.
C: Wheezes are typically associated with asthma and are musical in nature, occurring mostly during exhalation.
D: Rhonchi are low-pitched sounds that resemble snoring and are caused by obstructions in the larger airways.

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At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse performing an assessment would correctly note that an absent pulse in one or more of the extremities indicates

Correct Answer is D

Explanation

When auscultating a patient's lungs, a nurse hears an audible, high-pitched crowing sound. The nurse identifies this sound as

Correct Answer is B

Explanation

When performing a thorough physical assessment on a patient, the licensed practical nurse (LPN) begins collecting primary data. An example of primary data is that

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The nurse enters the patient's room and the patient states, "I think my feet are swollen.". Which would be the nurse's next action?

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