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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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Correct Answer is A

Explanation

Choice A rationale

Asking the client to describe the pain is the best approach to assess the quality of pain. This allows the nurse to gather detailed information about the pain’s characteristics.

Choice B rationale

Identifying effective pain relief measures is important but does not directly assess the quality of pain.

Choice C rationale

Observing body language and movement can provide clues about pain but is not as effective as directly asking the client to describe the pain.

Choice D rationale

Providing a numeric pain scale helps quantify the pain but does not provide detailed information about the pain’s quality.

Correct Answer is A

Explanation

Choice A rationale

Suctioning to clear secretions from the airway is the first intervention to implement. The client’s weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise.

Choice B rationale

Offering a prescribed PRN analgesic is important for overall comfort but is not the most immediate intervention needed to address the client’s respiratory distress.

Choice C rationale

Obtaining arterial blood gases may provide valuable information but is not the most immediate intervention needed to address the client’s respiratory distress.

Choice D rationale

Administering a prescribed antipyretic is not the most immediate intervention needed to address the client’s respiratory distress.

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