A nurse is providing care for a client who has esophageal cancer and has received radiation therapy.
Which of the following findings should the nurse identify as the priority?
Dysphagia.
Xerostomia.
Excoriation of the skin on the neck and chest.
Client reports a pain level of 6 on a scale from 0 to 10.
The Correct Answer is A
Choice A rationale:
Dysphagia (difficulty swallowing) is a common complication of esophageal cancer and can lead to malnutrition and aspiration pneumonia. It is the priority finding because addressing the client's ability to swallow is essential for maintaining adequate nutrition and preventing complications.
Choice B rationale:
Xerostomia (dry mouth) is another common side effect of radiation therapy, but while uncomfortable, it does not pose an immediate risk to the client's health compared to dysphagia.
Choice C rationale:
Excoriation of the skin on the neck and chest is likely due to the radiation therapy and can be managed with appropriate skin care measures. Although important, it is not the priority compared to dysphagia.
Choice D rationale:
The client's self-reported pain level of 6 on a scale from 0 to 10 is concerning and requires attention, but addressing dysphagia takes precedence due to its potential impact on the client's nutritional status and overall well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation: Sweet potato is a food that is high in potassium, which is an electrolyte that regulates fluid balance, nerve impulses, and muscle contractions in the body. A medium- sized sweet potato contains about 541 mg of potassium, which is more than 10% of the recommended daily intake for adults. Baked chicken breast, wheat bread, and canned green beans are foods that are low or moderate in potassium, containing less than 300 mg per serving.
Correct Answer is B
Explanation
Choice A rationale:
Moderate variability in the FHR is a reassuring sign of fetal well-being, indicating a responsive fetal autonomic nervous system to normal physiologic stimuli. It is considered a normal finding in active labor, suggesting that the fetus is well-oxygenated and able to cope with contractions.
Choice B rationale:
Prolonged decelerations are concerning patterns on the fetal heart rate (FHR) monitor, indicating potential fetal distress. Prolonged decelerations are defined as lasting more than 2 minutes but less than 10 minutes. These decelerations can be caused by umbilical cord compression, placental insufficiency, or maternal hypotension. Prompt intervention is required, making this choice the correct answer.
Choice C rationale:
Three uterine contractions within 10 minutes, also known as a contraction stress test (CST), is a normal finding. It assesses the fetal response to stress and is used to evaluate the placental function and fetal well-being.
Choice D rationale:
A baseline FHR of 115/min is within the normal range (110-160 beats per minute) for a term fetus. It indicates a stable fetal heart rate, and there is no immediate need for intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today