An adolescent female arrives at the wellness clinic reporting fears that she will hurt herself. The nurse observes scars on both wrists of the client. Which priority action should the nurse implement?

Choice A reason: Taking two more readings confirms elevated BP, as a single reading may reflect technique errors or transient factors like pain, which increase sympathetic activity and vasoconstriction. Multiple readings ensure accuracy, critical for diagnosing hypertension and guiding intervention to prevent cardiovascular complications like stroke.

Choice B reason: Assigning a UAP to recheck BP in an hour delays assessment of potentially dangerous hypertension, which risks acute complications like myocardial ischemia. Immediate confirmation is needed, as elevated BP from norepinephrine release increases vascular resistance, making delayed rechecking inappropriate for urgent evaluation.

Choice C reason: Retaking BP in the opposite arm verifies accuracy, as differences may indicate arterial occlusion. Elevated BP increases catecholamine-driven vascular resistance. Measuring both arms rules out localized issues, ensuring reliable data to guide management of hypertension, critical to prevent end-organ damage like renal failure.

Choice D reason: Assessing apical-radial pulse deficit is relevant for atrial fibrillation, not directly for elevated BP. Hypertension results from increased vascular resistance, not pulse discrepancies. Confirming BP and assessing context are more immediate to determine urgency, making this less relevant than verifying readings or identifying triggers.

Choice E reason: Determining activity and feelings identifies transient BP elevation causes, like stress or exercise, which raise norepinephrine, increasing heart rate and vascular tone. This contextualizes the reading, differentiating situational from chronic hypertension, ensuring appropriate intervention to manage cardiovascular risk and guide further assessment.

Choice A reason: Thick, dry, dark areas on heels suggest chronic skin changes, not early pressure ulcers. Persistent redness over bone is the earliest sign (Stage 1). This indicates later damage, per pressure injury staging and prevention protocols in nursing care for immobile clients.

Choice B reason: Broken skin indicates a Stage 2 pressure ulcer, beyond the earliest stage. Persistent redness (Stage 1) signals initial tissue compromise. Broken skin requires intervention but is not the earliest sign, per pressure ulcer assessment and prevention standards in nursing practice.

Choice C reason: Persistent redness over bone is the earliest sign of a Stage 1 pressure ulcer, indicating tissue compromise due to pressure. Early intervention prevents progression in bedrest clients with heart failure, per pressure injury prevention and skin assessment protocols in nursing care.

Choice D reason: A superficial sacral ulcer (Stage 2) is more advanced than persistent redness (Stage 1), the earliest sign. Redness allows earlier intervention to prevent ulceration. Ulcers indicate progression, per pressure ulcer staging and prevention guidelines for immobile clients in nursing.