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 C
Explanation
C) Eat a light snack before bedtime.
The nurse should include the instruction to eat a light snack before bedtime to promote nighttime sleep in an older adult. A light snack can help prevent hunger pangs during the night, making it easier to fall asleep and stay asleep.
The other options are not recommended for promoting nighttime sleep:
A) Performing exercises prior to bedtime can increase alertness and make it more difficult to fall asleep.
B) Taking a 1-hour nap during the day can disrupt the sleep-wake cycle and make it more challenging to sleep at night.
D) Staying in bed for at least 1 hour if unable to fall asleep is not recommended. If the client cannot fall asleep, it's better to get out of bed, engage in a quiet and relaxing activity, and return to bed when feeling sleepy to avoid frustration and anxiety associated with not being able to sleep.
Correct Answer is A
Explanation
Choice A rationale:
Potato pancakes made from potatoes do not contain gluten, making them suitable for someone with celiac disease. Gluten is a protein found in wheat, barley, and rye, so individuals with celiac disease must avoid foods containing these grains.
Choice B rationale:
Wheat crackers contain gluten and are not appropriate for someone with celiac disease. Avoiding gluten is crucial for individuals with this condition to prevent damage to the small intestine.
Choice C rationale:
White flour tortillas are typically made from wheat flour and contain gluten. Individuals with celiac disease should avoid products made from wheat flour to prevent adverse reactions.
Choice D rationale:
Canned barley soup contains barley, which is a gluten-containing grain. Individuals with celiac disease should avoid barley-based products as they contain gluten.
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