Which of the following are examples of findings a nurse may notice during inspection? (Select all that apply)

Choice A reason: Non-verbal indications of pain are behaviors or physical manifestations that communicate distress without the use of words. Facial grimacing, guarding of a painful area, and moaning are key non-verbal cues that the nurse observes directly to assess the impact of pain on the patient's functional movement.

Choice B reason: This is a verbal report of pain. While it provides critical information about the quality and location of the pain, it is classified as subjective verbal data. Non-verbal indications are specifically those that can be observed even if the patient is unable or unwilling to speak.

Choice C reason: Nausea and decreased appetite are associated symptoms or physiological responses to pain, but they are not behavioral indicators. These findings are often reported by the patient (subjective) or inferred by clinical history, rather than being an immediate non-verbal cue observed during the physical examination itself.

Choice D reason: Hypertension is a physiological (autonomic) response to pain. While it provides objective evidence of the body's stress response, it is a clinical measurement rather than a behavioral "non-verbal indication." Non-verbal indications typically refer to observable actions, gestures, or expressions that signify the patient's discomfort

Choice A reason: Inspection is the visual examination of the patient. Bruising (ecchymosis) and swelling (edema) are visible alterations in skin integrity and contour. A nurse can observe these findings without physical contact, making them primary examples of data gathered during the initial visual stage of a physical assessment.

Choice B reason: Skin color changes, such as cyanosis, jaundice, pallor, or erythema, are identified through careful visual inspection. These changes provide vital clues about oxygenation, hepatic function, and local inflammation. Because these findings are perceived through sight, they are classified strictly under the assessment technique of inspection.

Choice C reason: Assessing the symmetry of body parts involves comparing the left and right sides of the body visually. This helps identify unilateral abnormalities, such as muscle atrophy, hemi-paralysis, or localized enlargement. Symmetry is a fundamental observation made during the general survey and localized inspection of any body system.

Choice D reason: Respiratory rate and the effort required for breathing (such as the use of accessory muscles or nasal flaring) are assessed primarily through visual observation. By watching the rise and fall of the chest, the nurse gathers objective data on the patient's pulmonary status during the inspection phase.

Choice E reason: Tenderness on touch is an assessment finding identified through palpation, not inspection. This requires the nurse to apply pressure to a body part and observe for a response or wait for patient feedback. Since it involves physical contact to elicit a sensation, it is categorized as a palpation finding.