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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 B

Explanation

Choice A rationale

Serum blood glucose level is not directly related to the presence of purulent drainage at a wound site. While blood glucose levels can affect wound healing, they do not provide specific information about the presence of infection.

Choice B rationale

Culture for sensitive organisms is the most appropriate laboratory value to note when purulent drainage is observed. This test helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment.

Choice C rationale

C-reactive protein (CRP) level is a marker of inflammation and can indicate the presence of an infection, but it does not provide specific information about the bacteria causing the infection.

Choice D rationale

Blood pH level is not directly related to the presence of purulent drainage at a wound site. While blood pH can be affected by severe infections, it is not a specific indicator of wound infection.

Correct Answer is C

Explanation

Choice A rationale

Topical antifungals are used to treat fungal infections and are not effective for psoriasis, which is an autoimmune condition.

Choice B rationale

Colloidal oatmeal-based lotion can help soothe the skin but does not address the underlying inflammation and scaling associated with psoriasis.

Choice C rationale

Topical corticosteroids are the mainstay of treatment for psoriasis. They help reduce inflammation, itching, and redness associated with psoriatic plaques.

Choice D rationale

Topical analgesics can help relieve pain but do not address the underlying inflammation and scaling associated with psoriasis.

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