Correct Answer: C

Rationale: The correct answer is C because asking the client if they are experiencing pain is a direct action of assessment. This step involves gathering information directly from the client to understand their condition and needs. By asking the client about pain, the nurse is actively assessing the client's well-being. A: The nurse bathing the client is not an action of assessment but rather a task related to providing care. B: The nurse documenting the incident is important for recording the event but does not directly involve assessing the client's condition. D: The nurse removing the wash basin is a task related to the physical care process and does not involve direct assessment of the client's well-being.

Correct Answer: C

Rationale: The correct answer is C: A 6-hour glucose tolerance test. This test involves measuring blood glucose levels at specific intervals after consuming a glucose solution, providing a comprehensive assessment of glucose utilization over time. This test is particularly useful in evaluating how the body processes glucose after a meal and can help diagnose conditions such as diabetes. A: A fasting blood glucose test would not provide a comprehensive picture of glucose utilization over time since it only measures glucose levels in a fasted state. B: A test of serum glycosylated hemoglobin (HbA1c) reflects average blood glucose levels over the past 2-3 months but does not directly assess glucose utilization after a meal. D: A test for urine ketones is used to detect ketones in the urine, which can indicate diabetic ketoacidosis but does not directly measure glucose utilization.

Correct Answer: C

Rationale: The correct nursing diagnosis is C: Deficient fluid volume. The patient's symptoms indicate dehydration, as evidenced by tachycardia, increased thirst, decreased urine output, and increased body temperature. This points to a lack of fluid in the body. Option A, adult failure to thrive, does not address the immediate issue of fluid volume. Option B, hypothermia, is incorrect as the patient has an increased body temperature. Option D, nausea, is not a primary issue compared to the symptoms indicating dehydration. Therefore, the correct nursing diagnosis is C: Deficient fluid volume.

Correct Answer: A

Rationale: The correct answer is A: Positive family history. Pernicious anemia is an autoimmune condition where the body attacks its own intrinsic factor, leading to vitamin B12 deficiency. Genetic predisposition plays a significant role in the development of pernicious anemia. Family history is a key risk factor as individuals with a family history of pernicious anemia are more likely to develop the condition. Summary of why the other choices are incorrect: B: Infectious agents or toxins do not directly cause pernicious anemia, although they can lead to other types of anemia. C: Acute or chronic blood loss can result in iron-deficiency anemia, not pernicious anemia. D: Inadequate dietary intake of vitamin B12 can lead to vitamin B12 deficiency anemia, but pernicious anemia specifically involves the body's inability to absorb B12 due to intrinsic factor deficiency, not dietary intake alone.

Correct Answer: A

Rationale: The correct answer is A: Yearly after age 40. This recommendation aligns with the American Cancer Society guidelines that suggest women should start getting annual mammograms at age 40. This age is important as it is when the risk of breast cancer increases. Yearly screenings help in early detection and better treatment outcomes. The other choices (B, C, D) are incorrect because they do not follow the ACS guidelines. Option B is incorrect as it does not specify an age for starting mammograms. Option C is incorrect as it suggests starting after the first menstrual period, which might be too early. Option D is incorrect as it recommends screenings every 3 years between ages 20 and 40, which is not in line with the ACS recommendation for yearly screenings after age 40.