Which of the following are objective findings?
Chest pain
Palpitations
Shortness of breath
Tenderness on palpation of anterior chest
The Correct Answer is D
A. Chest pain is incorrect because it is a subjective finding. Subjective findings are symptoms that the client experiences and reports, but the nurse cannot directly measure or observe them. Chest pain is based on the client’s description of discomfort, pressure, or tightness in the chest, making it reliant on self-report rather than objective assessment.
B. Palpitations is incorrect because it is also subjective. Clients may describe sensations of their heart racing, skipping beats, or fluttering, but these sensations cannot be observed directly without using diagnostic tools such as an electrocardiogram (ECG) or heart rate monitoring.
C. Shortness of breath is incorrect because it is subjective. Although the nurse can measure respiratory rate, oxygen saturation, and work of breathing, the client’s feeling of being “unable to breathe adequately” is a symptom reported by the client and is therefore subjective, not an observable sign.
D. Tenderness on palpation of anterior chest is correct because it is an objective finding. Objective findings are observable or measurable by the nurse through physical assessment, laboratory tests, or imaging. When a nurse palpates the chest and notes tenderness, this can be directly verified and documented, making it a concrete, measurable sign rather than a self-reported symptom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Loss of balance when feet are together and eyes are closed is correct because a positive Romberg test indicates deficiency in proprioception or vestibular function. During the test, the patient stands with feet together and eyes open, then closes their eyes. Normally, the patient can maintain posture due to sensory input from vision, proprioception, and vestibular systems. If the patient loses balance when vision is removed, it suggests dysfunction in the dorsal columns of the spinal cord or vestibular system, confirming a positive Romberg sign.
B. Ability to maintain an upright posture with eyes closed is incorrect because this indicates a normal Romberg test, meaning the patient has intact proprioception and vestibular function.
C. Falling while feet are together and eyes are open is incorrect because losing balance with eyes open suggests a more generalized balance or cerebellar problem, not specifically a positive Romberg test. Romberg evaluates sensory input when visual cues are removed, not balance in general.
D. Patient report of feeling dizzy when eyes are closed is incorrect because subjective dizziness alone does not constitute a positive Romberg. The test relies on observed loss of balance, not just patient-reported sensations.
Correct Answer is B
Explanation
A. Macula is incorrect because the macula is part of the retina in the eye, responsible for central vision, and is not visualized during an otoscopic examination. It is examined during an ophthalmologic evaluation, not with an otoscope.
B. Cone of light is correct. The cone of light is a triangular reflection of light seen on the tympanic membrane when using an otoscope. It is a normal finding and indicates that the tympanic membrane is intact and healthy. The cone of light is usually seen at the 5 o’clock position in the right ear and 7 o’clock position in the left ear, radiating from the umbo of the malleus. Its presence helps the clinician confirm that the eardrum is not bulging, retracted, or perforated, which are signs of possible infection or other pathology.
C. Optic disc is incorrect because the optic disc is a structure of the eye visible during fundoscopic examination with an ophthalmoscope. It represents the point where the optic nerve enters the retina. It is not assessed with an otoscope and is irrelevant to ear examination.
D. Red reflex is incorrect because the red reflex refers to the reflection of light from the retina seen during an eye examination using an ophthalmoscope. It is used to detect ocular abnormalities such as cataracts or retinal disorders and is not relevant to the ear.
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