A 28-year-old Aboriginal woman attending a prenatal visit describes her nutritional intake over the past 24 hours to the nurse. It includes two slices of pizza, two cans of soda, and three cookies. The nurse must:

Correct Answer: D

Rationale: The correct answer is D: discuss how the patient's food choices may affect her health and that of her baby. This is the most appropriate response because it addresses the potential impact of the patient's current diet on her health and the health of her baby during pregnancy. By discussing the implications of her food choices, the nurse can educate the patient on the importance of a balanced and nutritious diet for a healthy pregnancy. This approach promotes awareness and empowers the patient to make informed decisions for her and her baby's well-being. Incorrect choices: A: This option does not provide guidance or education on improving the patient's diet, which is crucial for a healthy pregnancy. B: Focusing on weight gain rather than nutritional content may not address the underlying issue of poor dietary choices. C: Assuming the patient's ability to cook or go grocery shopping may not address the immediate need for dietary education and guidance.

Correct Answer: A

Rationale: The correct answer is A because a smooth, glossy dorsal surface of the tongue is abnormal in adults and may indicate glossitis or nutritional deficiencies. B is incorrect as a thin white coating is normal. Raised papillae (choice C) may indicate transient lingual papillitis but are not typically abnormal. Visible venous patterns (choice D) are normal on the ventral surface.

Correct Answer: A

Rationale: The correct answer is A: A trained interpreter. Choosing a trained interpreter ensures accurate communication and confidentiality. Professional interpreters have the necessary language skills and cultural competence to facilitate effective communication between the healthcare provider and the patient. Using a family member (choices B and C) may compromise confidentiality and accuracy due to potential bias or lack of professional training. Similarly, selecting a volunteer university student (choice D) may result in misinterpretation or breach of privacy as they may not have the same level of expertise as a trained interpreter. Ultimately, the most appropriate choice is a trained interpreter to ensure clear and accurate communication while respecting the patient's privacy and dignity.

Correct Answer: C

Rationale: The correct answer is C: explaining progression of the disease to the client and family. This measure helps the client and family understand the disease, leading to better coping and acceptance, thus promoting a positive body image. Administering immune globulin (A) is not directly related to body image. Assessing extremities (B) and heart sounds (D) are important for monitoring the disease but do not directly impact body image.

Correct Answer: D

Rationale: The correct response is D because it encourages the mother to provide specific information about the toddler's behavior indicating pain. This helps the nurse assess the severity and nature of the earache accurately. Options A and C are dismissive and may overlook a potential health issue. Option B suggests immediate action without gathering information first, which may not be necessary.

Correct Answer: D

Rationale: The correct answer is D: It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube connects the middle ear to the nasopharynx, allowing for pressure equalization. During activities like swallowing or yawning, the tube opens to allow air to flow in or out, maintaining equal pressure. This function is crucial for proper hearing and preventing discomfort or damage to the tympanic membrane. Choice A is incorrect as cerumen is produced by ceruminous glands in the ear canal, not the eustachian tube. Choice B is incorrect as the eustachian tube normally remains closed and opens only intermittently during specific actions. Choice C is incorrect as the eustachian tube does not connect the middle and outer ear; it connects the middle ear to the nasopharynx.

Correct Answer: A

Rationale: The correct answer is A: Epinephrine. It is the first-line treatment for anaphylaxis as it rapidly reverses severe allergic reactions by constricting blood vessels, relaxing airway muscles, and increasing heart rate. Diphenhydramine (B) and steroids (C) are used as adjunct therapies but do not provide immediate relief like epinephrine. Albuterol (D) is used for bronchospasm in asthma, not for anaphylaxis. In summary, epinephrine is the most effective and life-saving medication for treating anaphylaxis.

Correct Answer: C

Rationale: The correct answer is C because asking open-ended questions helps the patient express their feelings without feeling pressured. This approach allows the patient to share at their own pace and comfort level. Choice A may make the patient feel uncomfortable or pressured. Choice B may not address the underlying issue of the patient's avoidance of eye contact. Choice D is more direct and may not be effective if the patient is not ready to discuss their emotions. Ultimately, using open-ended questions promotes a safe and supportive environment for the patient to open up willingly.

Correct Answer: A

Rationale: The correct first action when a client develops a fever after surgery is to administer antipyretics (A). Fever post-surgery can indicate infection, and antipyretics help lower the body temperature. Administering pain medications (B) may mask the fever's underlying cause. Providing fluids (C) is essential but not the priority. Providing wound care (D) is important but comes after addressing the fever. Administering antipyretics promptly helps manage the fever and allows for further assessment and intervention if needed.