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?

Chronic pain related to tissue destruction by tumor.

Anxiety and grieving related to progression of disease.

Risk for aspiration related to difficulty swallowing.

Imbalanced nutrition: less than body requirements.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Chronic pain is a significant concern for this client, but it is not the immediate priority. Pain can be managed with medications and comfort measures, while aspiration can be life-threatening.

Tissue destruction by the tumor is likely contributing to the pain, but addressing the risk of aspiration takes precedence.

Uncontrolled pain can exacerbate anxiety and make it difficult to focus on other interventions, but ensuring airway safety is paramount.

Choice B rationale:

Anxiety and grieving are expected reactions to a diagnosis of esophageal cancer, and they should be addressed as part of the client's care plan. However, they are not the immediate priority in this case.

The progression of the disease is a significant stressor, but attending to the risk of aspiration is essential for the client's safety. Psychological distress can negatively impact coping and quality of life, but addressing physical needs takes precedence.

Choice D rationale:

Imbalanced nutrition is a concern for this client due to dysphagia and anorexia. However, it is not the immediate priority. Nutritional interventions can be implemented once the risk of aspiration is addressed.

Difficulty swallowing can lead to inadequate intake and malnutrition, but ensuring airway safety is the primary concern.

Anorexia can further contribute to nutritional deficits, but preventing aspiration is the most pressing issue.

Choice C is the priority nursing problem because:

The client's dysphagia puts them at immediate risk for aspiration, which can lead to pneumonia, respiratory failure, and even death.

Addressing the risk of aspiration is essential to ensure the client's safety and prevent life-threatening complications. It's crucial to implement interventions to minimize the risk of aspiration, such as:

Elevating the head of the bed during meals and for 30-60 minutes after eating Thickening liquids and pureeing foods

Encouraging small, frequent meals

Monitoring for signs of aspiration, such as coughing, choking, or difficulty breathing

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Correct Answer is ["B","C"]

Explanation

Choice B rationale:

Gravity Facilitates Drainage:

Positioning the patient strategically utilizes gravity to encourage the flow of fluids and secretions away from the surgical site. This aids in preventing fluid accumulation and potential infection.

Reduces Pressure on Surgical Site:

Certain positions can minimize pressure on the incision and internal organs, promoting healing and reducing discomfort.

This is particularly important for patients with comorbidities like hypertension and heart failure, as they may have impaired wound healing and be more susceptible to respiratory complications.

Enhances Respiratory Function:

Specific positions can improve lung expansion and ventilation, which is essential for patients with a history of heart failure or respiratory issues.

This helps prevent atelectasis (collapsed lung areas) and pneumonia, which are common postoperative risks.

Common Post-Cholecystectomy Positions:

Semi-Fowler's Position:

The head of the bed is elevated 30-45 degrees, with knees slightly bent.

This position eases breathing, reduces pressure on the incision, and promotes drainage of fluids. Right Side-Lying Position:

The patient lies on their right side with a pillow between their knees.

This position encourages drainage from the liver and gallbladder, aiding in bile flow. Left Side-Lying Position:

The patient lies on their left side with a pillow between their knees.

This position promotes drainage from the stomach and pancreas, assisting in digestion. Supine Position:

The patient lies flat on their back with a pillow under their knees.

This position may be used for short periods, but prolonged supine positioning can increase pressure on the incision and lungs. High Fowler's Position:

The head of the bed is elevated 60-90 degrees, with knees slightly bent.

This position is often used for patients with respiratory issues or difficulty breathing, as it improves lung expansion.

Choice C rationale:

Performing drainage immediately after meals aids in efficient removal of bile and gastric secretions, preventing complications such as:

Bile Reflux:

Delayed drainage can cause bile to back up into the stomach, leading to nausea, vomiting, and discomfort. Infection:

Accumulation of fluids in the surgical site can increase the risk of bacterial growth and infection. Pancreatitis:

In rare cases, delayed drainage can cause inflammation of the pancreas due to obstruction of the pancreatic duct.

I'll address the rationales for choices A and D in the following sections.

A. Colloidal oatmeal-based lotion. B. Topical corticosteroids. C. Topical analgesics. D. Topical antifungal.

Correct Answer is B

Explanation

Choice A rationale:

Colloidal oatmeal-based lotions can be soothing and moisturizing for dry, itchy skin, but they are not effective in treating the inflammation and scaling associated with psoriasis.

They do not address the underlying hyperproliferation of skin cells that is characteristic of psoriasis.

While they may provide temporary relief of symptoms, they are not a long-term solution for managing the condition.

Choice B rationale:

Topical corticosteroids are the mainstay of treatment for psoriasis.

They work by reducing inflammation, slowing the growth of skin cells, and easing itching and scaling. They come in a variety of strengths and formulations, including creams, ointments, gels, and foams.

The type of corticosteroid and the strength of the medication will depend on the severity of the psoriasis and the location of the lesions.

It's important to follow the healthcare provider's instructions for use carefully, as overuse of topical corticosteroids can lead to side effects such as thinning of the skin and rebound flares.

Choice C rationale:

Topical analgesics, such as lidocaine or benzocaine, can be used to temporarily relieve pain and itching associated with psoriasis.

However, they do not address the underlying inflammation and scaling, and they should not be used as a primary treatment for the condition.

They may be used as adjunctive therapy in conjunction with topical corticosteroids or other psoriasis medications.

Choice D rationale:

Topical antifungal medications are used to treat fungal infections of the skin, such as athlete's foot or ringworm. They are not effective in treating psoriasis, which is an autoimmune condition rather than a fungal infection.

Using a topical antifungal medication for psoriasis could potentially worsen the condition or lead to other skin problems.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C"]

Explanation

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Correct Answer is B

Explanation

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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?