The nurse is collecting data during an initial assessment. The patient tells the nurse, "i have a tremendous headache and my stomach is upset." These findings are called:

symptoms

signs

assessments

Observations

Answer and Explanation

The Correct Answer is A

A. Symptoms – Symptoms are subjective findings reported by the patient, such as headache or nausea, which cannot be measured directly by the nurse.

B. Signs – Signs are objective findings that can be observed or measured, such as a fever or rash.

C. Assessments – An assessment is the process of gathering data but is not a specific term for patient-reported issues.

D. Observations – Observations refer to what the nurse sees or detects rather than what the patient reports.

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Correct Answer is A

Explanation

A. Bruit – A bruit is an abnormal swishing sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis or narrowing of the vessel.

B. Crackle – Crackles are abnormal lung sounds caused by fluid in the alveoli, not vascular turbulence.

C. Thrill – A thrill is a palpable vibration over a blood vessel or heart valve, indicating turbulent blood flow but is felt rather than heard.

D. Wheeze – A wheeze is a high-pitched respiratory sound caused by narrowed airways, not vascular abnormalities.

A. 30 seconds to 1 minute B. 10-15 seconds C. 20 seconds D. 2-5 minutes

Correct Answer is D

Explanation

A. 30 seconds to 1 minute. – This time frame is characteristic of 3+ pitting edema, not 4+.

B. 10-15 seconds. – This time frame is associated with 2+ pitting edema, which indicates a moderate level of fluid retention.

C. 20 seconds. – This time frame is associated with 3+ pitting edema.

D. 2-5 minutes. – 4+ pitting edema is the most severe form, where the indentation remains for 2-5 minutes, indicating significant fluid retention and possible cardiac or renal dysfunction.

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The nurse is collecting data during an initial assessment. The patient tells the nurse, "i have a tremendous headache and my stomach is upset." These findings are called:

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As the assessment continues the nurse notes an abnormal swishing sound with auscultation of the carotid artery. The term for this sound is:

Correct Answer is A

Explanation

The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

Correct Answer is D

Explanation

When a disease results in a structural change in an organ that interferes with its functioning, this is a/an:

The nurse is meeting a patient for the first time. The initial step in initiating a nurse-patient relationship is for the nurse to:

Discoloration of an area of the skin or mucous membranes caused by extravasation of blood into subcutaneous tissue is termed:

Auscultation of the heart sounds will result in a lubb-dupp sound when using the bell and the diaphragm of the stethoscope. The lub part of the sound is caused by the:

Febrile is an abnormal elevation of:

The study of all factors involved in the development of the disease or the cause of the disease is termed:

An abnormal rapid rate of breathing seen in many disease conditions is called:

An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is called: