Correct Answer: B

Rationale: The correct answer is B because having the patient rate her fatigue on a scale allows for a subjective assessment directly from the patient, providing valuable insight into the severity and impact of fatigue on her daily life. This approach considers the patient's perspective, which is crucial in understanding her experience and tailoring interventions. Choice A (observing activity level) may not accurately capture the subjective experience of fatigue. Choice C (monitoring vital signs) does not directly assess fatigue but rather general health status. Choice D (monitoring hemoglobin and hematocrit values) can indicate anemia but may not fully capture the patient's fatigue experience.

Correct Answer: D

Rationale: The correct answer is D: Active listening. Active listening involves fully concentrating, understanding, responding, and remembering what is being said. In end-of-life care, it is crucial to provide emotional support and create a safe space for clients and their families to express their thoughts and feelings. Active listening helps the nurse to establish trust, show empathy, and validate the emotions of the clients and their families. Reflection (A), Clarification (B), and Interpretation (C) may be beneficial in certain situations, but in end-of-life care, active listening plays a pivotal role in fostering meaningful and supportive communication.

Correct Answer: D

Rationale: The correct answer is D because interviewing a client suspected of being a victim of abuse involves critical thinking in assessment by gathering relevant information, analyzing the situation, and making informed decisions. This activity helps identify potential risks and ensures the client's safety. On the other hand, options A and C involve implementing orders and diagnosing conditions, respectively, which are more related to clinical decision-making rather than assessment. Option B focuses on education, which is not directly linked to assessment activities.

Correct Answer: B

Rationale: The correct answer is B: Disturbed body image. The client's concern about the external fixation device making his leg look ugly indicates a disturbance in his perception of his own body image. This diagnosis focuses on the client's feelings and emotions related to his appearance, which can impact his self-esteem and psychological well-being. Rationale: 1. Impaired physical mobility (A) is not the most appropriate diagnosis in this scenario as the client's concern is related to the appearance of his leg, not his ability to move. 2. Risk for infection (C) is not the best choice because the client's concern is not directly related to the risk of infection but rather to the aesthetic aspect of his leg. 3. Risk for social isolation (D) is not the most suitable diagnosis as the client's concern is more about his own perception of his appearance rather than the potential impact on his social interactions.

Correct Answer: C

Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own. Incorrect Answers: A: Purplish stools - This is not a common side effect of lymphangiography. B: Redness of the upper part of the feet - Redness is not typically associated with this procedure. D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.