A jaundiced client has just been diagnosed with stage IV pancreatic cancer. The nurse anticipates the client will display which clinical manifestation?
Clay-colored stools
Hematuria
Pale dilute urine
Weight gain
The Correct Answer is A
A. Stage IV pancreatic cancer often leads to bile duct obstruction, causing decreased bile flow into the intestines. This results in clay-colored stools due to the absence of bile pigments.
B. Hematuria, or blood in the urine, is not a common symptom of pancreatic cancer, even in advanced stages. It is more associated with conditions affecting the urinary system.
C. Jaundice causes dark, concentrated urine rather than pale, dilute urine due to the accumulation of bilirubin in the bloodstream, which is excreted through the kidneys.
D. Weight loss, rather than weight gain, is a common manifestation in clients with advanced pancreatic cancer due to malabsorption and cachexia.
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Correct Answer is C
Explanation
A. While no episodes of diarrhea may be beneficial, it is not a direct indicator of the effectiveness of ondansetron, which is used primarily to prevent nausea and vomiting.
B. Maintaining a normal hemoglobin level is not an expected outcome related to ondansetron, as it does not influence blood counts.
C. The ability to tolerate oral fluid intake indicates that the client is managing nausea effectively, demonstrating that ondansetron is working as intended.
D. Hair loss is a common side effect of many chemotherapeutic agents, and ondansetron does not affect this outcome. Therefore, it is not an appropriate indicator of the medication's effectiveness.
Correct Answer is B
Explanation
A. Inserting an oral airway and suctioning may be indicated for airway management, but the primary concern is the impaired function of the glossopharyngeal and vagus nerves, which affects swallowing and the risk of aspiration.
B. Withholding oral fluids or foods is crucial because impaired function of these cranial nerves increases the risk of aspiration and can lead to choking or pneumonia, making this the priority action.
C. Speaking clearly while facing the client is a good communication practice but does not address the immediate concern of impaired swallowing and risk of aspiration.
D. Applying artificial tears is important for protecting the cornea, but it is not directly related to the functions of CN IX and CN X or the immediate management of swallowing difficulties.