The nurse understands that a patient with BP readings 164/102 and 176/100 on two separate occasions would be classified in which hypertension category?

Correct Answer: B

Rationale: The correct answer is B: Stage 2 hypertension. The patient's BP readings consistently fall within the range of 160-179 systolic or 100-109 diastolic, which aligns with the criteria for Stage 2 hypertension based on the current guidelines. This classification indicates a higher level of hypertension that requires prompt medical attention and intervention to reduce the risk of complications. Choices A, C, and D are incorrect because they do not correspond to the BP readings provided, falling outside the range for prehypertension, Stage 1 hypertension, and posthypertension.

Correct Answer: A

Rationale: The correct answer is A: Raccoon eyes. Basilar skull fracture can result in periorbital bruising, known as raccoon eyes, due to blood pooling in the soft tissues around the eyes. This occurs because the fracture involves the base of the skull near the orbits. Choice B: Amnesia is not a typical symptom of basilar skull fracture. Amnesia may occur in head injuries but is not specific to basilar skull fractures. Choice C: Halo sign is a term used to describe a ring of clear fluid surrounding a blood spot, typically seen in cases of a cerebrospinal fluid leak from the ear or nose, not specific to basilar skull fractures. Choice D: Paresthesia, which refers to abnormal sensations like tingling or numbness, is not a common symptom of basilar skull fractures. It is more associated with nerve damage rather than fractures involving the base of the skull.

Correct Answer: C

Rationale: Rationale: Step 1: Coughing is the primary way TB bacteria are spread. Step 2: By coughing into a handkerchief or tissue, the TB bacteria are contained. Step 3: Washing the handkerchief in hot water or discarding it prevents the bacteria from spreading. Step 4: This method reduces the risk of infecting family members. Summary of Incorrect Choices: A: Wearing gloves does not prevent airborne transmission of TB. B: Keeping windows closed can increase the concentration of bacteria in the air. D: Boiling water is not necessary to prevent TB transmission.

Correct Answer: A

Rationale: The modified Trendelenburg position involves placing the client with their legs elevated higher than their head. This position promotes venous return to the heart, increasing preload and cardiac output, thereby leading to an increase in blood pressure. Elevating the legs helps to reduce peripheral edema and improve circulation. Therefore, the correct answer is A. Choice B is incorrect because the Trendelenburg position does not directly affect the respiratory rate. Choice C is incorrect as the position is not intended to increase heart rate but rather improve venous return. Choice D is also incorrect as the primary goal of the Trendelenburg position is not to decrease blood loss, although it may help in some cases by improving circulation.

Correct Answer: B

Rationale: The correct answer is B because Toni's behavior of minimizing her visual problems, focusing on future goals, seeking information about job opportunities, and expressing desire for more children reflects coping mechanisms used to deal with the exacerbation of her illness. This behavior suggests that she is trying to maintain a sense of normalcy and control in the face of her health challenges. A: Inappropriate euphoria is excessive happiness or excitement, which is not evident in Toni's behavior. C: Remission phase typically involves a decrease in symptoms, which is not reflected in Toni's situation. D: Realistic for her current level of physical functioning does not explain her behavior as coping mechanisms.