Question

The nurse is caring for a client with cancer who is exhibiting the following symp- tomology: back pain, lower extremity weakness, decreased motor abilities, numb- ness of the legs, and bladder incontinence. What is the most appropriate initial nursing action? ? A. Notify the physician ? B. Administer acetaminophen (Tylenol) for pain ? C. Call supply to obtain incontinent pads ? D. Insert a Foley catheter

Short answer

Answer: The most appropriate initial nursing action is to notify the physician, as they can assess the severity of the symptoms and provide appropriate treatment for the client's condition.

Step-by-step solution

List the symptoms

The client with cancer is exhibiting the following symptoms: - Back pain - Lower extremity weakness - Decreased motor abilities - Numbness of the legs - Bladder incontinence

Analyze each option

Let's analyze each of the given options: A. Notify the physician: It's important to inform the physician as they can assess the severity of the symptoms and provide appropriate treatment. B. Administer acetaminophen (Tylenol) for pain: Acetaminophen can provide temporary relief of back pain but may not address the other symptoms. C. Call supply to obtain incontinent pads: While this addresses the bladder incontinence symptom, it does not provide a comprehensive solution to the client's condition. D. Insert a Foley catheter: A Foley catheter can help manage bladder incontinence but does not address the other symptoms nor provide a complete solution.

Determine the most appropriate initial nursing action

Based on the analysis of each option, the most appropriate initial nursing action is to notify the physician (Option A). This is because the physician can assess the severity of the symptoms and provide appropriate treatment, addressing all the symptoms the client is experiencing.

Key concepts

Patient Assessment

Patient assessment is a crucial step in nursing care, especially for individuals showing complex symptoms like those related to cancer. When assessing a patient, nurses gather information on their health status to help understand the underlying issues. It involves observing physical signs and symptoms, like back pain and weakness in extremities. Thorough assessment enables nurses to identify any deterioration that can affect recovery. Such information guides the next steps to take for effective treatment. In the case presented, identifying all symptoms, including decreased motor abilities and incontinence, ensures that comprehensive care needs are addressed. By understanding the entire spectrum of the patient’s issues, nurses can provide a more accurate and suitable intervention plan.

Symptom Management

Managing symptoms in patients with severe illnesses like cancer is essential for improving their quality of life. Nurses play a pivotal role in this aspect by applying their knowledge and skills to alleviate discomfort. This includes providing medications like acetaminophen for pain relief, which can help manage one aspect of the patient's condition. However, symptom management extends beyond just medical interventions. It involves monitoring the patient's responses to treatment and adjusting care accordingly. Effective symptom management demands a holistic approach, considering every symptom's potential impact, such as numbness and limb weakness, which may require further investigation or additional supportive therapies. This strategic management is vital in maintaining the patient’s overall well-being and ensuring they receive comprehensive care.

Cancer Care

Cancer care is a specialized area of nursing that requires a deep understanding of both the disease and its impacts on the patient's life. Nurses in this field must be adept at managing complex health issues and providing support for both the patient and their families. Cancer patients often experience a wide array of symptoms that need immediate attention and management. Providing tailored care plans that address each unique aspect of the patient’s condition is crucial. This can include everything from pain management strategies to supportive therapies for motor function difficulties. With cancer's progressive nature, nurses must stay vigilant, anticipating complications before they arise, and ensuring proper coordination with the healthcare team to provide timely interventions.

Nursing Decision-Making

Nursing decision-making involves critical thinking and prioritizing patient needs effectively. It requires evaluating all available data to undertake the best possible action. In assessing the scenario, notifying the physician is identified as the appropriate initial step, as it leverages the physician's ability to evaluate and address severe symptoms. Effective decision-making is not just about solving immediate issues but also forecasting potential complications. This includes recognizing the urgency of symptoms like new or worsening numbness, which might indicate serious underlying issues. Nurses must always weigh the severity of symptoms versus the most beneficial action available, striving to ensure patient safety and optimal outcomes. Through systematic and informed decision-making, nurses substantially contribute to patient recovery and safety.