What is the most common sign during an initial assessment that alerts the nurse that the patient has chronic obstructive pulmonary disease?

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RATIONALE: 
The patient with chronic obstructive pulmonary disease (COPD) develops a barrel chest over time because trapped air enlarges the lungs and thoracic cavity, thereby reducing chest flexibility. Sunken chest, also known as funnel chest or pectus excavatum, is not related to COPD. Hyperventilation is not characteristically seen with COPD. Instead, the patient usually displays persistent dyspnea on exertion, with or without a chronic cough. Circumoral cyanosis is a bluish discoloration of the skin surrounding the mouth. It is usually an indication of a severely diminished level of oxygen and respiratory distress. Circumoral cyanosis can result from a variety of respiratory diseases and may be a late sign of the COPD disease process.
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