The nurse is caring for a client receiving radiation therapy for treatment of oral cancer. Which new finding is the greatest concern?

Stomatitis

Stridor

Nausea

Xerostomia

Answer and Explanation

The Correct Answer is B

A. Stomatitis is a common side effect of radiation therapy for oral cancer, and while it requires management, it is not immediately life-threatening.
B. Stridor indicates potential airway obstruction, which is a critical and urgent condition that requires immediate intervention, making it the greatest concern among the options presented.
C. Nausea is a typical side effect of cancer treatment but is usually manageable and not considered an immediate threat.
D. Xerostomia, or dry mouth, is another common side effect of radiation to the head and neck, but it is not as urgent as the risk of airway compromise indicated by stridor.

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Correct Answer is C

Explanation

A. The absence of bowel sounds shortly after surgery is a common finding and does not necessarily indicate a complication at this time; it is expected during the initial postoperative period.
B. An SPO2 of 90% while the client is asleep is concerning, but it does not take precedence over signs of possible surgical complications that could require immediate intervention.
C. Increasing abdominal distention is a critical sign that could indicate serious complications such as an anastomotic leak, bowel obstruction, or intra-abdominal bleeding, and it requires immediate notification of the surgeon for further evaluation and potential intervention.
D. A small amount of green-tinged fluid from the nasogastric tube is typical postoperatively and does not necessitate immediate notification to the surgeon unless the volume is excessive or other concerning signs are present.

A. Request the physician order an antidepressant medication for the client B. Encourage the client to verbalize feelings about the diagnosis C. Explain the improved prognosis for colon cancer with new treatment D. Allow the client time to reflect on the diagnosis

Correct Answer is B

Explanation

A. Requesting antidepressant medication may be appropriate later, but it does not address the immediate need for emotional support and communication.
B. Encouraging the client to verbalize feelings about their diagnosis provides an opportunity for the client to express their concerns and emotions, fostering a therapeutic relationship and aiding in emotional processing.
C. While explaining improved prognosis can provide hope, it may minimize the client’s feelings of fear and uncertainty and could be perceived as dismissive.
D. Allowing time for reflection is important, but it should be balanced with the need for communication and support to prevent isolation.

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The nurse is caring for a client receiving radiation therapy for treatment of oral cancer. Which new finding is the greatest concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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