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 ["C","D"]

Explanation

Choice A rationale:

PaCO2 55 mm Hg on a blood gas indicates ineffective treatment. Normal PaCO2 levels range from 35-45 mm Hg.

Elevated PaCO2 (hypercapnia) suggests that the lungs are not effectively removing carbon dioxide from the body. This can be due to various factors, including:

Incomplete resolution of pneumonia Airway obstruction

Impaired respiratory muscle function

Choice B rationale:

Rhonchi in the right lung indicates ineffective treatment.

Rhonchi are coarse, rattling sounds heard in the lungs during auscultation.

They are often associated with mucus accumulation in the airways, which can occur in pneumonia.

The presence of rhonchi suggests that inflammation and mucus production persist, despite antibiotic and respiratory therapy.

Choice C rationale:

Oxygen saturation greater than 94% indicates effective treatment. Normal oxygen saturation levels are typically 95% or higher.

A saturation of 94% or above suggests that the lungs are able to effectively oxygenate the blood. This is a positive sign that the pneumonia is responding to treatment.

Choice D rationale:

Client ambulates without shortness of breath indicates effective treatment. Shortness of breath (dyspnea) is a common symptom of pneumonia.

It occurs when the lungs are unable to provide enough oxygen to the body, leading to a feeling of breathlessness.

The ability to ambulate without shortness of breath suggests that the pneumonia has improved and that the lungs are functioning more effectively.

A. Auscultate the patient's bowel sounds and measure the abdominal girth. B. Confirm that the patient is taking the medication one hour after meals. C. Notify the healthcare provider that the patient may need a change in dosage. D. Advise the patient that healing typically takes several weeks to occur.

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Auscultating bowel sounds and measuring abdominal girth are not directly related to the management of erosive esophagitis and GERD symptoms. These actions are more pertinent to assessing gastrointestinal motility and distension, not the effectiveness of lansoprazole.

Choice B rationale: Lansoprazole is a proton pump inhibitor that should be taken before meals to reduce stomach acid production effectively. Confirming that the patient is taking the medication before meals could help optimize its efficacy but is not the most immediate step.

Choice C rationale: Notifying the healthcare provider about a potential need for a dosage change may be considered if symptoms persist. However, since healing with proton pump inhibitors can take several weeks, this action may be premature after only one week of use.

Choice D rationale: It is appropriate to inform the patient that healing of erosive esophagitis and symptom relief from GERD can take several weeks with lansoprazole. This education helps set realistic expectations and encourages adherence to the prescribed treatment.

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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

A 51-year-old male client with pneumonia has undergone several days of antibiotic and respiratory treatment. Given the following assessment findings, mark whether they indicate that the treatment was effective or ineffective:

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

Explanation

A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

Correct Answer is D

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?