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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?

A.

Anxiety and grieving related to progression of disease.

B.

Chronic pain related to tissue destruction by tumor.

C.

Risk for aspiration related to difficulty swallowing.

D.

Imbalanced nutrition less than body requirements.

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Laying down on each side with knees bent and breathing from the abdomen is not an effective technique for improving gas exchange in emphysema patients.

Choice B rationale

Increasing the breathing rate for a full 30 seconds can lead to hyperventilation and is not recommended for improving gas exchange.

Choice C rationale

Raising hands above the head to expand the diaphragm is not a recognized technique for improving gas exchange in emphysema patients.

Choice D rationale

Drawing air in through the nose and exhaling slowly through pursed lips is an effective technique for improving gas exchange in emphysema patients. This method helps to keep the airways open longer and improves the removal of trapped air.

Correct Answer is C

Explanation

Choice A rationale

Potatoes are naturally gluten-free and safe for individuals with celiac disease.

Choice B rationale

Corn chips are also naturally gluten-free and safe for individuals with celiac disease.

Choice C rationale

Oatmeal can be contaminated with gluten during processing, making it unsafe for individuals with celiac disease unless it is certified gluten-free.

Choice D rationale

Fried rice is typically gluten-free, but it is essential to ensure that no gluten-containing ingredients or cross-contamination occurs during preparation.

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