A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes that:

Correct Answer: D

Rationale: The correct answer is D because it is important to gather more information before making assumptions or conclusions about the woman's appearance. Without a comprehensive assessment of her mental health, personal preferences, cultural background, and any potential underlying issues, it would be inappropriate to jump to conclusions about her attire. Choice A is incorrect because judging solely based on appearance is not a valid way to assess someone's well-being. Choice B is incorrect as dismissing her appearance as a mere attempt to shock overlooks the potential reasons behind her choices. Choice C is incorrect because associating her appearance with a manic syndrome without proper evaluation is premature and stigmatizing.

Correct Answer: A

Rationale: The correct answer is A: Palpation. Palpation is the technique of using the sense of touch to assess various aspects such as texture, temperature, moisture, and swelling. It involves feeling the body with the hands to gather information about the underlying structures. Inspection (B) is the visual examination, not tactile. Percussion (C) is tapping on the body to listen for sounds, not assessing through touch. Auscultation (D) is listening to sounds within the body using a stethoscope, not related to touch assessment.

Correct Answer: B

Rationale: The correct answer is B: Dorsal surface of the hand. This is because the dorsal surface of the hand is less sensitive to temperature variations compared to the palmar surface, allowing for a more accurate assessment of skin temperature. Using the fingertips may lead to inaccurate results due to their high sensitivity to temperature changes. The ulnar portion of the hand is not commonly used for assessing skin temperature. Overall, the dorsal surface of the hand provides a more reliable and consistent assessment of skin temperature due to its lower sensitivity to temperature changes.

Correct Answer: A

Rationale: The correct answer is A because older adults tend to have a lower baseline body temperature compared to younger adults. This is due to age-related changes in metabolism and decreased efficiency of thermoregulation. As people age, their metabolic rate decreases, leading to less heat production. Additionally, older adults may have impaired ability to adapt to temperature changes. Choice B is incorrect because young children typically have higher body temperatures than older adults. Choice C is incorrect as body temperature may vary slightly with different types of thermometers but the overall trend of lower temperature in older adults remains. Choice D is incorrect as while older adults may have decreased heat control mechanisms, their body temperature still tends to be lower rather than widely varying.

Correct Answer: C

Rationale: Rationale: 1. Recording blood pressure in lying, sitting, and standing positions helps assess for orthostatic hypotension. 2. Orthostatic hypotension can cause fainting episodes when changing positions. 3. Lying, sitting, and standing readings provide a comprehensive evaluation of blood pressure changes. 4. It helps in identifying if there is a significant drop in blood pressure from lying to standing. 5. This approach aligns with best practices in diagnosing syncope and fainting episodes. Summary of Other Choices: A. Taking blood pressure in arms and thighs is not relevant to assessing orthostatic changes. B. Only taking blood pressure in a lying position does not provide a complete evaluation of potential orthostatic issues. D. Averaging lying and sitting positions may miss important changes when transitioning to a standing position.