Correct Answer: A

Rationale:
Choice A is correct because the family may interpret the client's hallucinations through their cultural lens, potentially viewing them as normal or spiritually significant. Understanding and acknowledging the cultural context is essential for providing culturally sensitive care.

Choices B, C, and D are incorrect because while talking circles and seeking guidance from a medicine man may be culturally relevant interventions in some contexts, the priority in this situation is to recognize and respect the family's perspective on the client's hallucinations.

Correct Answer: A

Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway.
Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe.

Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.

Correct Answer: C

Rationale: When a patient on anticoagulant therapy experiences sudden, severe back pain, the priority nursing action is to assess for signs of internal bleeding. Severe back pain in this context could be indicative of internal bleeding, such as a retroperitoneal bleed, which is a critical condition requiring immediate attention. Administering pain medication or applying a cold compress may mask or delay the identification of a potentially life-threatening situation. Repositioning the patient for comfort is not the priority when internal bleeding needs to be ruled out.

Correct Answer: B

Rationale: Blood pressure is the most critical information to report to the RN in this scenario. The presence of edema, along with high blood pressure, can be indicative of preeclampsia, a severe condition in pregnancy. Monitoring blood pressure is essential for assessing the patient's condition and taking appropriate actions if necessary.

Choices A, C, and D are not as urgent in this situation. The due date, gravida, and parity are important for overall assessment but do not address the immediate concern of potential preeclampsia. Fundal height is used to assess fetal growth and position but is not the priority when edema and high blood pressure are present.

Correct Answer: D

Rationale: Measuring vital signs is crucial in this situation as it helps to determine if the client is experiencing a physical health issue or if the symptoms are related to a mental health crisis, such as anxiety or agitation. The presence of diaphoresis and pacing may indicate physiological changes requiring immediate attention. Providing a drink high in electrolytes or persuading the client to lie down may not address the underlying cause of the symptoms. Simply observing the client during the shift without taking necessary actions to assess his physiological status may delay appropriate intervention.