A patient's weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category?

Correct Answer: B

Rationale: The correct answer is B) Prehypertension. Prehypertension is defined as a blood pressure reading that is higher than normal but not high enough to be considered hypertension. In this case, the patient's average blood pressure reading of 126/86 mm Hg falls within the prehypertension range. Option A) Normal blood pressure is incorrect because the patient's average blood pressure reading is higher than what is considered normal (which is typically around 120/80 mm Hg). Option C) Stage 1 hypertension and Option D) Stage 2 hypertension are also incorrect because the patient's blood pressure readings do not fall within the ranges defined for these categories. Stage 1 hypertension is typically defined as readings between 130-139/80-89 mm Hg, and Stage 2 hypertension is readings above 140/90 mm Hg. Educationally, understanding blood pressure categories is crucial for healthcare professionals to accurately assess and manage patients' cardiovascular health. Monitoring blood pressure trends over time helps in identifying potential health risks and guiding appropriate interventions to prevent complications associated with hypertension. It is essential for nurses to interpret and classify blood pressure readings correctly to provide optimal patient care.

Correct Answer: A

Rationale: In this scenario, option A is the correct answer because the patient's dizziness could be indicative of orthostatic hypotension, a common side effect of antihypertensive medications in the elderly. By evaluating the patient's blood pressure and pulse in the supine, sitting, and standing positions, the nurse can assess for postural changes that may be causing the dizziness. This is crucial for the early detection and management of orthostatic hypotension to prevent falls and other complications in older adults. Option B is incorrect because asking the patient to walk around the room before assessing blood pressure could potentially exacerbate the dizziness and is not a standard practice for evaluating orthostatic hypotension. Option C is incorrect because assessing blood pressure only at the beginning and end of the examination may miss important changes that occur with position changes, which are key in diagnosing orthostatic hypotension. Option D is incorrect because waiting 5 minutes between blood pressure measurements on different arms does not address the specific issue of orthostatic hypotension related to changes in position. Educationally, understanding the importance of assessing vital signs in different positions is essential for nurses to provide comprehensive care, especially for older adults who may be more prone to orthostatic hypotension. This rationale highlights the significance of thorough assessment techniques in addressing potential medication side effects and ensuring patient safety and well-being.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Color variation. The nurse is concerned with this finding because a mole that has started to burn and bleed, in addition to displaying color variation, could be indicative of malignant melanoma, a type of skin cancer. Color variation in pigmented lesions, such as moles, can be a warning sign of possible skin cancer as it may indicate uneven distribution of melanin or the presence of multiple colors within the lesion. The other options are incorrect in this context because: - B) Border regularity: While irregular borders can also be a sign of skin cancer, in this case, the presentation of burning and bleeding in addition to color variation raises more concern. - C) Symmetry of lesions: Symmetry of lesions is one of the ABCDEs of melanoma assessment, but in this case, the symptoms presented by the patient are more concerning than just symmetry. - D) Diameter of less than 6 mm: While the size of a lesion is important in assessing potential malignancy, the symptoms of burning and bleeding in this case take precedence over the size of the lesion. Educationally, this question highlights the importance of recognizing danger signs of pigmented lesions and the significance of color variation as a key indicator of potential skin cancer. Nurses and healthcare providers must be vigilant in assessing changes in moles and lesions and understand the significance of various characteristics in determining the need for further evaluation and management.

Correct Answer: D

Rationale: In the context of vital signs assessment, the correct answer is D) Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy. Clubbing of the fingernails is associated with certain medical conditions like respiratory or cardiovascular diseases. This abnormality presents with an angle of the nail base that is 180 degrees or greater and a nail base that feels spongy to palpation due to underlying tissue changes. Option A) Nail bases that are firm and slightly tender is incorrect because firmness and tenderness are not characteristic features of clubbing. Option B) Curved nails with a convex profile and ridges across the nails describe a different nail condition, not clubbing. Option C) Nail bases that feel spongy with an angle of the nail base of 150 degrees is incorrect as it does not meet the criteria for clubbing, which requires an angle of 180 degrees or greater. Educationally, understanding the significance of assessing for clubbing of the fingernails is crucial for nurses in detecting potential underlying health issues early. By recognizing the physical signs associated with clubbing, nurses can provide timely interventions and collaborate with healthcare providers to ensure comprehensive patient care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Is a normal finding, and no further follow-up is necessary. The presence of dry, flaky cerumen (earwax) in the ear canal is a common and normal finding in many individuals. Cerumen plays a crucial role in protecting the ear canal by trapping dust and debris, preventing infections, and maintaining the ear's pH balance. It also helps in cleaning and lubricating the ear canal. Option A) Is a sign of an ear infection is incorrect because dry, flaky cerumen alone does not necessarily indicate an ear infection. Signs of an ear infection typically include pain, redness, swelling, and possible discharge. Option B) Represents poor hygiene is incorrect as the production and consistency of cerumen are influenced by various factors such as genetics, age, and environment, rather than just hygiene practices. Option D) Could be indicative of a change in cilia; the nurse should assess for hearing loss is incorrect because while changes in cerumen consistency can sometimes be associated with changes in cilia function, it is not the primary concern when dry, flaky cerumen is observed in a patient's ear. Educationally, understanding normal variations in physical assessments like cerumen consistency is crucial for healthcare providers to avoid unnecessary interventions or treatments. It is essential to recognize what is within the range of normal findings to provide appropriate care and avoid unnecessary alarm or interventions based on benign variations.