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 D
Explanation
The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.
Correct Answer is B
Explanation
B) Speak in a neutral tone when addressing the client.
When creating a plan of care for a client with paranoid personality disorder who refuses to take their medication, it's essential to approach the client in a way that fosters trust and reduces anxiety. Speaking in a neutral, non-confrontational, and non-threatening tone can help build rapport and facilitate communication with the client.
The other options are not appropriate interventions:
A) Mixing medication with the client's food without their consent can be seen as a breach of trust and may worsen the client's paranoia.
C) Limiting the client's opportunities to socialize with others can lead to increased isolation and potentially exacerbate the client's paranoid tendencies.
D) Rotating staff members caring for the client may also contribute to feelings of mistrust and may not be conducive to establishing a therapeutic nurse-client relationship. Consistency in care can be more helpful for individuals with paranoid personality disorder.
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