The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?
Anxiety and grieving related to progression of disease.
Chronic pain related to tissue destruction by tumor.
Risk for aspiration related to difficulty swallowing.
Imbalanced nutrition less than body requirements.
The Correct Answer is C
Choice A rationale
Anxiety and grieving are important issues but are not the priority when the client is at risk for aspiration.
Choice B rationale
Chronic pain is significant, but the immediate risk of aspiration due to dysphagia takes precedence.
Choice C rationale
Risk for aspiration related to difficulty swallowing is the priority nursing problem. Aspiration can lead to serious complications such as pneumonia.
Choice D rationale
Imbalanced nutrition is important but is secondary to the immediate risk of aspiration.
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Correct Answer is B
Explanation
Choice A rationale
Obtaining vital signs every 2 hours is important for monitoring the patient’s overall condition, but it is not the immediate priority following the surgical removal of glass from the eye.
Choice B rationale
Providing an eye shield to be worn while sleeping is crucial to protect the eye from injury and promote healing after the surgical removal of glass. This intervention helps prevent accidental rubbing or pressure on the eye.
Choice C rationale
Teaching a family member to administer eye drops is important for ongoing care, but it is not the immediate priority following the procedure. The immediate focus should be on protecting the eye and ensuring proper healing.
Choice D rationale
Encouraging deep breathing and coughing exercises is important for preventing respiratory complications, but it is not directly related to the immediate care of the eye following the surgical removal of glass.
Correct Answer is B
Explanation
Choice A rationale
Providing step-by-step verbal directions may not be effective for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness, impaired judgment, and difficulty concentrating.
Choice B rationale
Escorting the client to the cafeteria is the best approach as it ensures the client reaches the destination safely. Clients with Huntington’s disease often have unsteady gait and involuntary movements, making it difficult for them to navigate independently.
Choice C rationale
Orienting the client to the color-coding system may not be effective due to the cognitive impairments associated with Huntington’s disease, such as difficulty concentrating and impaired judgment.
Choice D rationale
Using the hospital map to show the client where the cafeteria is located is not practical for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness and difficulty concentrating.