According to current guidelines, which of the following reflects a normal adult blood pressure reading?

Choice A reason: Facial droop is an unexpected neurological finding, often indicating cranial nerve VII (facial nerve) dysfunction, as seen in stroke or Bell’s palsy. It disrupts symmetrical muscle movement, signaling potential brain or nerve pathology. This abnormality requires urgent evaluation to determine underlying causes like ischemia or inflammation.

Choice B reason: Swallowing without coughing is a normal finding, reflecting intact cranial nerves IX and X. Dysphagia or coughing during swallowing would suggest neurological impairment, but this choice indicates expected function, making it a typical result in a neurological assessment of swallowing capability.

Choice C reason: Spontaneous eye opening is a normal finding, indicating intact brainstem and cranial nerve function, particularly cranial nerve III. It is expected in conscious patients and does not suggest neurological dysfunction, unlike failure to open eyes, which could indicate coma or severe impairment.

Choice D reason: Understandable speech is a normal finding, reflecting coordinated function of cranial nerves and brain regions like Broca’s area. Slurred or incoherent speech would be abnormal, but this choice indicates expected neurological performance, not an unexpected outcome in a standard assessment.

Choice A reason: Full thickness skin loss with visible bone indicates a stage 4 pressure injury, not stage 1, which involves intact skin with erythema. Misidentifying this overstates severity, risking inappropriate interventions like surgical debridement instead of preventive measures like repositioning, critical for managing early-stage pressure injuries to prevent progression.

Choice B reason: Stage 1 pressure injury presents as intact skin with non-blanchable localized erythema, often over bony prominences, due to early tissue compression. This finding guides preventive care, like pressure relief and skin protection, to halt progression. Accurate identification ensures timely interventions, reducing risk of deeper tissue damage in at-risk patients.

Choice C reason: Full thickness skin loss with visible adipose tissue describes a stage 3 pressure injury, not stage 1, which has intact skin. Assuming this misdiagnoses severity, leading to unnecessary aggressive treatments like wound dressings, while neglecting early interventions like offloading pressure, critical for preventing worsening of stage 1 injuries.

Choice D reason: Partial-thickness skin loss with red tissue indicates a stage 2 pressure injury, not stage 1, which shows intact skin with erythema. Misidentifying this risks inappropriate wound care, delaying preventive strategies like skin moisturizing or repositioning, essential for managing stage 1 injuries and preventing progression to deeper ulcers.