The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

Reassess the blood pressure measurement.

Notify the provider.

Recheck the blood pressure measurement in 30 minutes.

Have the patient care tech take the blood pressure measurement again.

Answer and Explanation

The Correct Answer is A

A. Reassessing the blood pressure measurement is correct because the nurse should always verify abnormal findings before taking further action. The initial reading could be due to equipment error, improper cuff size, or patient positioning.
B. Notifying the provider is incorrect at this time because the nurse should first confirm the accuracy of the reading before escalating concerns.
C. Rechecking the BP in 30 minutes is incorrect because if the reading is accurate, waiting 30 minutes could delay necessary interventions.
D. Having the patient care tech take the BP again is incorrect because the nurse should personally validate the abnormal finding rather than delegating it.

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Correct Answer is D

Explanation

A. Thinning of the vertebral discs leads to a decrease in height, not weight.
B. Lean body mass actually decreases with aging, contributing to weight loss rather than gain.
C. Spinal kyphosis affects posture but does not significantly contribute to changes in body weight.
D. Loss of muscle tissue (sarcopenia) is correct because aging leads to a decline in muscle mass, which contributes to weight loss. Additionally, a slower metabolism and reduced physical activity further affect body composition.

A. Solid, dark brown color B. Asymmetric, irregular borders C. Flat with silvery scales D. Diameter of 3 mm

Correct Answer is B

Explanation

A. A solid, dark brown color alone is not necessarily indicative of melanoma. Melanomas often have multiple colors, including black, brown, blue, or red.
B. Asymmetric, irregular borders is correct. Melanoma lesions are often asymmetrical, with irregular, poorly defined borders. They also tend to have varied pigmentation and may change over time. The ABCDE rule (Asymmetry, Border irregularity, Color variation, Diameter >6mm, Evolution) is used to assess suspicious moles.
C. Flat with silvery scales describes psoriasis, not melanoma.
D. A diameter of 3 mm is smaller than the typical >6 mm size seen in melanoma.

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The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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