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An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom?
- A. Hiatal hernia
- B. Gastroesophageal reflux disease
- C. Gastritis
- D. Esophageal tumor
Correct Answer: D
Rationale: The finding of an esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but are less likely to be as significant as esophageal tumor/cancer.
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The nurse is caring for a client with oral cancer who reports severe mouth sensitivity. The client asks the nurse what might be done about the condition. What should the nurse include in the response?
- A. I can arrange a nutritional consultation.
- B. Cold liquids may help soothe the sensitivity.
- C. An anesthetic mouthwash may be used, but I will need to consult with the primary provider.
- D. A special diet may be necessary based on your ability to chew and swallow.
- E. Your doctor may prescribe a systemic analgesic for pain relief if necessary.
Correct Answer: A,C,D,E
Rationale: When responding to a client reporting severe mouth sensitivity due to oral cancer, the nurse should inform the client of possible options for managing the sensitivity. These include nutritional consultations, the use of anesthetic mouthwash if approved by the primary provider, the formulation of a special diet around the client's ability to chew and swallow, and a systemic analgesic for pain relief if the provider deems it necessary. It is inaccurate for the nurse to respond that cold liquids may soothe the sensitivity, because cold and hot liquids may increase the discomfort of sensitive oral tissues.
The nurse has placed a feeding tube for a client with a gastroesophageal disorder. What recommendation(s) should the nurse follow to confirm proper placement of the tube? Select all that apply.
- A. Observe for respiratory distress.
- B. Measure pH of feeding tube aspirates.
- C. Auscultate.
- D. Monitor aspirate for sudden change in amount.
- E. Mark the tube at the exit site.
- F. Obtain radiographic confirmation.
Correct Answer: A,B,D,E,F
Rationale: The nurse should observe for respiratory distress, measure the pH of feeding tube aspirates, monitor the aspirate for a sudden change in the amount, and mark the tube at the exit site after radiographic confirmation and then use the marker to ensure that the correct location is maintained during use. Auscultation should not be used to determine location, because this is not a valid way to confirm tube placement.
The nurse is teaching a client with a family history of oral cancer about the early stage of the disease. Which statement(s) should the nurse include in the teaching? Select all that apply.
- A. The early stage of oral cancer is characteristically asymptomatic.
- B. A lesion, lump, or other abnormality may be present on the lips or mouth.
- C. Difficulty eating or tasting food may occur.
- D. Pain and numbness are typically present.
- E. Persistent hoarseness is a hallmark sign.
Correct Answer: A,B
Rationale: The nurse should inform the client that oral cancer is characteristically asymptomatic in its early stage, though lesions, lumps, or other abnormalities may be present on the lips and mouth. While it is true that oral cancer may cause difficulty eating or tasting food, pain and numbness, and persistent hoarseness, these events occur later in the disease's progression and are not relevant in discussion of the early stage.
The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.
- A. 6 hours
Correct Answer: A
Rationale: Step 1: 2 * 8 oz = 16 oz Step 2: 1 oz : 30 mL :: 16 oz : X mL X = 480 mL Step 3: 480 mL / 80 mL = 6 hours
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply.
- A. Encourage the client to eat frequent, small, well-balanced meals.
- B. Inform the client to remain upright for at least 2 hours after meals.
- C. Encourage the client to eat later in the day before bedtime rather than early in the morning.
- D. Instruct the client to avoid alcohol or tobacco products.
- E. Instruct the client to eat slowly and chew the food thoroughly.
Correct Answer: A,B,D,E
Rationale: The nurse should encourage the client to eat frequent, small, well-balanced meals, inform the client to remain upright for at least 2 hours after meals, instruct the client to avoid alcohol or tobacco products, and instruct the client to eat slowly and chew the food thoroughly when teaching the client how to reduce reflux. The nurse should discourage the client from eating before bedtime.