The nurse is caring for a client who presents with dermatitis. When performing a complete skin assessment, which action should the nurse Implement?

A. The difference between the systolic and diastolic pressures is referred to as the pulse pressure, calculated by subtracting diastolic from systolic pressure (e.g., 140 – 90 = 50 mmHg). While pulse pressure provides useful information about arterial compliance and stroke volume, it does not define systolic pressure itself. Therefore, this statement does not reflect correct understanding of the systolic reading.

B. The pressure in the veins when the ventricles are contracting is incorrect. Venous pressure is generally low and does not fluctuate significantly with ventricular contraction, unlike arterial pressure. Systolic pressure is measured in the arteries, not veins, so this option demonstrates a misunderstanding.

C. The pressure in the veins when the ventricles are pushing blood forward is also incorrect for the same reason. Venous pressure is largely influenced by venous return and right atrial pressure, not the force of ventricular contraction. Systolic pressure refers exclusively to arterial pressure during ventricular contraction, not venous pressure.

D. The pressure in the arteries when the ventricles are pushing blood forward is correct. During ventricular systole, the left ventricle contracts, propelling blood into the aorta and systemic arteries, which creates the highest pressure in the arterial system. This peak arterial pressure is recorded as the systolic value in a blood pressure reading.

E. The pressure in the arteries when the ventricles are contracting is also correct. “Contracting” is another way of describing ventricular systole. Systolic pressure represents the maximum arterial pressure generated during this phase of the cardiac cycle, making this statement accurate.

• Squinting during the visual acuity exam – Abnormal
  Squinting may indicate visual impairment such as refractive errors (myopia, hyperopia, or astigmatism) or difficulty focusing. A normal response is being able to read the chart without compensatory behaviors.
• Yellowing of the sclera – Abnormal
  Yellow sclera indicates jaundice, which can result from liver dysfunction, hemolysis, or bile duct obstruction. Sclera should normally be white.
• Reflection of light in the same spot on each eye – Normal
  This demonstrates proper alignment of the eyes and normal corneal light reflex, indicating no strabismus or ocular misalignment.
• Gaze fixed and steady – Normal
  A fixed and steady gaze shows normal extraocular muscle function and cranial nerve integrity. Abnormal findings would include nystagmus or uncontrolled eye movements.
• Clear conjunctiva – Normal
  Normal conjunctiva should be pink and moist without redness, swelling, or discharge. Abnormal findings include pallor (anemia), redness (infection or irritation), or jaundice.