A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis.
The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements.
Which factor is the most likely cause for this problem?
Nausea.
Fatigue.
Pain when eating.
Altered taste sensation.
The Correct Answer is C
Choice A rationale:
Nausea can be a significant factor contributing to decreased food intake, but it is not the most likely cause in this scenario. Xerostomia (dry mouth) and mucositis are mentioned as symptoms in the question stem. Nausea alone does not explain why the client is consuming less than their body requirements.
Choice B rationale:
Fatigue can also contribute to decreased food intake, but it is not the most likely cause in this case. While fatigue can be a side effect of cancer treatment and may lead to reduced appetite, the question specifically mentions xerostomia and mucositis as issues contributing to imbalanced nutritional intake.
Choice C rationale:
Pain when eating is the most likely cause of imbalanced nutritional intake in this scenario. The client's laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the client from eating, leading to decreased nutritional intake.
Choice D rationale:
Altered taste sensation can affect food preferences, but it is not the most likely cause in this case. Pain when eating is a more direct and immediate barrier to food intake, especially in the context of mucositis and laryngeal cancer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.
Choice B rationale:
Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.
Choice C rationale:
Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.
Choice D rationale:
Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.
Correct Answer is D
Explanation
Choice A rationale:
Aspirin is not typically contraindicated in a client who has taken sildenafil unless there are specific contraindications or allergies. Aspirin is often used in the management of acute chest pain to help prevent blood clot formation.
Choice B rationale:
Heparin is not contraindicated solely because the client has taken sildenafil. Heparin is an anticoagulant commonly used in various clinical settings, including the management of certain cardiac conditions.
Choice C rationale:
Morphine is not necessarily contraindicated based solely on the client's use of sildenafil. Morphine can be used to relieve chest pain in some cases of acute coronary syndrome. However, its use should be carefully evaluated based on the client's overall clinical presentation.
Choice D rationale:
Nitroglycerin should be withheld in this scenario. Sildenafil is a medication used to treat erectile dysfunction and pulmonary arterial hypertension. It can potentiate the vasodilatory effects of nitroglycerin, leading to a severe drop in blood pressure. Concomitant use of nitroglycerin and sildenafil is contraindicated due to the risk of significant hypotension, which can be life-threatening.
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