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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

Trouble sleeping is not directly relevant to the administration of pyridostigmine, which is used to improve muscle strength in myasthenia gravis.

Choice B rationale

Unexplained weight loss is not a primary concern when administering pyridostigmine. The focus should be on the patient’s ability to swallow and recent oral intake.

Choice C rationale

Difficulty with urination is not a primary concern for pyridostigmine administration. The medication’s effects on muscle strength and swallowing are more critical.

Choice D rationale

Recent oral intake is crucial to assess because pyridostigmine can cause gastrointestinal side effects, and food intake can affect its absorption and effectiveness.

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.

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