A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:

Correct Answer: B

Rationale: In a client with esophageal cancer who is experiencing difficulty swallowing, maintaining a patent airway is the highest priority. The client is at risk for aspiration due to the compromised ability to swallow, which could lead to respiratory distress, choking, or aspiration pneumonia. Adequate oxygenation is essential for the client's survival and must be addressed as the priority issue. While coping with body image, preventing injury, and ensuring nutrition are important aspects of care, they are secondary to ensuring the client's airway remains open and clear to prevent respiratory complications.

Correct Answer: C

Rationale: When evaluating a client with rheumatoid arthritis, the nurse should check for joint abnormalities first because it is the most obvious manifestation of the disease. Rheumatoid arthritis primarily affects the joints, causing inflammation, pain, stiffness, and potentially deformity over time. Assessing for joint abnormalities can provide crucial information about the severity and progression of the disease, guiding further assessment and intervention plans. Muscle weakness, painful subcutaneous nodules, and gait disturbances can also be present in rheumatoid arthritis, but joint abnormalities are the hallmark feature that should be assessed initially.

Correct Answer: A

Rationale: Primary hyperaldosteronism is a condition characterized by excessive production of aldosterone by the adrenal cortex. Aldosterone is a hormone produced by the adrenal glands that plays a key role in regulating blood pressure and electrolyte balance in the body. When there is an overproduction of aldosterone, it can lead to increased sodium retention and potassium excretion, resulting in hypertension. Therefore, in this case, the client's hypertension is caused by excessive hormone secretion from the adrenal cortex, making option A the correct answer.

Correct Answer: A

Rationale: Maintaining strict records of intake and output is the best way to assess the client's fluid balance in this situation. Severe burns can lead to fluid loss, which can result in dehydration and other complications. By carefully monitoring the amount of fluid the client is taking in (intake) and the amount of fluid being eliminated from the body (output), healthcare providers can assess the client's fluid balance and make necessary adjustments to prevent dehydration or fluid overload. This approach provides accurate and specific information to guide fluid management and ensure optimal recovery for the client with burns. Monitoring skin turgor, daily weight, and checking for edema are also important measures, but maintaining strict records of intake and output is the most direct and effective method for assessing fluid balance in a client with burns.

Correct Answer: C

Rationale: An early clinical manifestation of bilirubin encephalopathy in a newborn is lethargy or irritability. Bilirubin encephalopathy, also known as kernicterus, is a serious condition that occurs when high levels of unconjugated bilirubin build up in the brain tissues. Initially, the baby may become lethargic or irritable due to the toxic effects of bilirubin on the central nervous system. As the condition progresses, symptoms may include poor feeding, high-pitched crying, muscle tone abnormalities, and eventually may lead to more severe consequences such as seizures and irreversible neurological damage. Prompt recognition and treatment of bilirubin encephalopathy are crucial to prevent long-term complications.