Hesi RN Adult Health
Hesi RN Adult Health ( 57 Questions)
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 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.
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.
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
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 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