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 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.

A. Check the blood pressure with the client in a supine position. B. Place the client in a sitting position. C. Determine the client's blood pressure 1 min after each position change. D. Assist the client into a standing position.

Correct Answer is A

Explanation

A: To accurately assess for orthostatic hypotension, the initial blood pressure should be measured while the client is supine. This establishes a baseline for comparing subsequent measurements.
B: Placing the client in a sitting position is a subsequent step in the sequence to monitor changes but is not the first action.
C: Determining the client's blood pressure changes after each position is essential but follows the initial supine measurement.
D: Assisting the client into a standing position is also part of the assessment process for orthostatic hypotension but should occur after recording the supine and sitting blood pressures.

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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

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Naxlex Comprehensive Predictor Exams

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

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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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