A nurse is precepting a new nurse providing education on blood pressure assessment. Which statements by the new nurse demonstrates an understanding of what the systolic pressure indicates for a blood pressure reading of 140/90 mmHg? Select all that apply

A. Receding gum line and bleeding of the gums are common oral effects of chewing tobacco. These signs indicate periodontal disease or gingival irritation caused by the abrasive and chemical effects of tobacco on oral tissues. While these findings require assessment, oral hygiene interventions, and patient education, they are generally chronic and not immediately life-threatening.

B. Thick raised white patch on the edge of the tongue is highly concerning because it may represent leukoplakia, a precancerous lesion often associated with chronic tobacco use. Leukoplakia appears as a white, firm, raised area that cannot be scraped off and can potentially progress to oral squamous cell carcinoma if left untreated. In a client with a history of chewing tobacco, this finding requires immediate follow-up, including referral to a dentist, oral surgeon, or primary care provider for biopsy and evaluation. Early detection and intervention are critical to prevent malignant transformation and improve prognosis.

C. Persistent sore throat and red tonsils may indicate infection or inflammation, such as pharyngitis or tonsillitis. While these symptoms need assessment and possible treatment with antibiotics or supportive care, they are generally less urgent than a lesion suspicious for malignancy, especially in a high-risk client with chronic tobacco use.

D. Mild tongue discoloration and discolored teeth are typically cosmetic or minor mucosal changes caused by prolonged chewing tobacco. While these changes reflect the oral health risks associated with tobacco use, they do not indicate acute pathology or precancerous changes and are not a priority for immediate follow-up.

A. This is an intervention, not a goal. Applying barrier cream is a specific nursing action used to prevent skin breakdown, but goals should focus on desired client outcomes rather than tasks performed by the nurse.

B. Assessing the skin is an important part of care and a nursing intervention, but it does not describe the expected end result or outcome for the client. Goals should reflect what the client is expected to achieve or maintain.

C. This is the most appropriate goal for a client at risk for skin breakdown. It is client-centered, measurable, and outcome-oriented, indicating the desired result of nursing interventions. Maintaining intact skin directly reflects prevention of pressure injuries, abrasions, or other skin compromise.

D. While minimizing pain is important, it is not the primary goal related to the risk of skin breakdown unless the client is already experiencing painful lesions. The priority for a client at risk is preventing skin compromise.