A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings?

Correct Answer: B

Rationale: The correct answer is B: The change in blood pressure readings is called orthostatic hypotension. This is because the blood pressure drop of 50/30 mm Hg between lying and standing positions meets the criteria for orthostatic hypotension (a drop of 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing). Choice A is incorrect as these readings indicate orthostatic hypotension, not just a normal response to position changes. Choice C is incorrect because the lying position reading is elevated for a 70-year-old. Choice D is incorrect as the significant drop in blood pressure is not considered within normal limits for the patient's age.

Correct Answer: A

Rationale: The correct answer is A: Lesions that run together. Confluent lesions refer to individual lesions that merge or run together to form a larger, continuous area of involvement. This term is commonly used to describe skin lesions that have coalesced. The other choices are incorrect because B refers to lesions forming a ring shape, C describes lesions following a nerve pathway, and D implies lesions grouped closely together but not necessarily merging. Thus, A is the best choice based on the description of confluent lesions.

Correct Answer: D

Rationale: The correct answer is D because the eustachian tube helps equalize air pressure on both sides of the tympanic membrane. This is important for maintaining proper function of the middle ear. The other choices are incorrect because: A) Cerumen is produced by the ceruminous glands, not the eustachian tube. B) The eustachian tube normally remains closed and only opens during swallowing, yawning, or sneezing to equalize pressure. C) The eustachian tube connects the middle ear to the nasopharynx, not the outer ear.

Correct Answer: D

Rationale: The correct answer is D because the presentation of a tender, reddish-blue auricle with vesicles suggests frostbite, which is caused by prolonged exposure to extreme cold. Understanding the patient's exposure to cold is crucial for proper treatment. A: Change in ability to hear is not directly related to the physical findings described. B: Recent drainage from the ear is not typically associated with the described symptoms. C: While trauma may cause similar symptoms, the presentation of vesicles is more indicative of frostbite rather than trauma.

Correct Answer: A

Rationale: The correct answer is A. Asking the patient if they are aware of having any allergies is the most appropriate question as the presentation of pale, gray, and swollen nasal mucosa could be indicative of an allergic reaction. By inquiring about allergies, the nurse can gather crucial information to potentially identify the cause of the nasal mucosa changes. Choice B ("Do you have an elevated temperature?") is incorrect as the symptoms described are more specific to nasal mucosa changes rather than a systemic infection. Choice C ("Have you had any symptoms of a cold?") is incorrect as the symptoms do not necessarily align with a typical cold presentation. Choice D ("Have you been having frequent nosebleeds?") is incorrect as it does not directly address the current observation of pale, gray, and swollen nasal mucosa.