A nurse is assessing a 58-year-old male client who has been diagnosed with laryngeal cancer. Which assessment finding would be most concerning and require immediate intervention?
1Hoarseness that has persisted for 3 months
2Difficulty swallowing solid foods
3Enlarged cervical lymph nodes
4Sudden onset of stridor with respiratory distress✓ 정답
해설
Stridor with respiratory distress indicates airway obstruction, a life-threatening emergency requiring immediate intervention like tracheostomy or intubation. Other findings (hoarseness, dysphagia, lymphadenopathy) are important but not immediately life-threatening.
The assessment finding that requires the most immediate intervention is the sudden onset of stridor with respiratory distress. In a client with a known laryngeal mass, this finding signals acute airway compromise, which is a life-threatening emergency.
Pathophysiology and Clinical Reasoning
The larynx is a critical structure that serves as the gateway to the lower airway. A tumor in this region, whether malignant or, as noted in the provided research, a lesion mimicking carcinoma, can cause progressive airway narrowing [1]. The transition from a stable, partially obstructive lesion to an acutely life-threatening situation represents a fundamental change in the client's condition.
Analysis of Assessment Findings
* Sudden onset of stridor with respiratory distress (Option 4): This is the priority finding. Stridor is a high-pitched, harsh sound produced by turbulent airflow through a significantly narrowed upper airway. Its sudden onset indicates a rapid change, such as tumor edema, hemorrhage into the lesion, or a shift in the mass's position, leading to critical obstruction [1]. The accompanying respiratory distress confirms that the client's oxygenation and ventilation are failing. This situation demands immediate intervention to secure the airway before complete obstruction and respiratory arrest occur. The provided study highlights how a laryngeal mass can cause "supraglottic airway narrowing" leading to dyspnea, a process that, when accelerated, manifests as this emergency [1].
* Hoarseness that has persisted for 3 months (Option 1): Persistent hoarseness is a classic, often early, symptom of laryngeal pathology, including carcinoma. It results from the tumor interfering with the vibration of the vocal cords. While it is a concerning finding that necessitates thorough diagnostic evaluation, it is a chronic symptom. It does not indicate an immediate threat to the airway's patency and is therefore not the priority for immediate intervention.
* Difficulty swallowing solid foods (Option 2): Dysphagia, particularly to solids, suggests that the tumor has grown to a size that mechanically obstructs the esophageal inlet or impairs the coordinated movement of the pharyngeal muscles. This is a significant finding indicating local disease progression and can lead to malnutrition and aspiration risk. However, it does not represent an immediate airway emergency like stridor. The client's airway is still patent, making this a lower priority than a finding of acute respiratory distress.
* Enlarged cervical lymph nodes (Option 3): Palpable cervical lymphadenopathy is a key finding that strongly suggests regional metastasis of the laryngeal cancer. It is critical for staging the disease and planning treatment. Nevertheless, it is a finding related to the chronic progression of the malignancy. It does not pose an immediate threat to the client's airway, breathing, or circulation, and therefore is not the priority for immediate nursing intervention.
NCLEX-RN Priority-Setting Framework
This question tests the application of the ABC (Airway, Breathing, Circulation) priority-setting framework. A sudden onset of stridor with respiratory distress is a direct "A" (Airway) and "B" (Breathing) problem. The nurse's immediate action must be to recognize this as a sign of impending airway loss, call for the rapid response team, and prepare for emergency airway management, such as intubation or a surgical airway. The other options represent "C" (Circulation/metastasis) or other less acute physiological needs, which are addressed after the airway is secured.
References (research sources)
[1]
Clinically Suspected Fungal Laryngitis Masquerading as Laryngeal Carcinoma in a High-Risk Patient.Research articleModi K, Gibbs S, Diks J. (2026) · DOI: 10.7759/cureus.110604
Clinical Scenario
A 58-year-old male with known laryngeal cancer presents with a sudden onset of high-pitched stridor and signs of respiratory distress, including tachypnea, use of accessory muscles, and nasal flaring. His oxygen saturation is dropping on pulse oximetry.
Immediate Nursing Actions
Activate Emergency Response: Call a code blue or the rapid response team immediately. Do not leave the patient unattended.
Maintain Airway Patency: Position the patient upright (high-Fowler's) to maximize chest expansion and reduce airway pressure unless contraindicated. Avoid supine positioning.
Administer High-Flow Oxygen: Apply a non-rebreather mask at 15 L/min if the patient is breathing spontaneously, while preparing for further intervention.
Prepare for Advanced Airway Management: Anticipate the need for an emergency surgical airway (cricothyroidotomy or tracheostomy) if the obstruction is complete or cannot be managed with bag-valve-mask ventilation or endotracheal intubation. Have emergency airway equipment (crash cart, suction) at the bedside.
Administer Emergency Medications: As ordered, prepare to administer nebulized racemic epinephrine to reduce mucosal edema and intravenous corticosteroids (e.g., dexamethasone) to decrease inflammation around the tumor.
Continuous Monitoring: Closely monitor respiratory rate, depth, breath sounds, oxygen saturation, and level of consciousness for signs of impending respiratory arrest.
Pathophysiology and Rationale
A laryngeal tumor can cause progressive airway narrowing. A sudden worsening, indicated by acute stridor, often results from hemorrhage into the tumor, rapid edema, or a positional shift of the mass, leading to a critical reduction in the airway lumen. This is a pre-terminal event requiring immediate intervention to prevent complete obstruction and cardiac arrest.
Key Safety Considerations
Never perform a blind finger sweep in an attempt to dislodge a visible tumor, as this can cause trauma, bleeding, and worsen the obstruction.
Do not sedate the patient unless an experienced provider is present to secure the airway, as loss of respiratory drive can lead to rapid decompensation.
Reassure the patient and maintain a calm environment to reduce anxiety, which can increase oxygen consumption and the sensation of breathlessness.
Stridor — A high-pitched, harsh sound heard during inspiration or expiration caused by turbulent airflow through a narrowed upper airway, indicating significant obstruction.
Laryngeal Cancer — A malignancy arising from the tissues of the larynx, often presenting with hoarseness, dysphagia, or a neck mass, and capable of causing airway compromise.
Airway Obstruction — A blockage of the respiratory passages that prevents normal breathing; in the context of a laryngeal mass, it is a life-threatening emergency.
Respiratory Distress — A clinical state characterized by increased work of breathing, often with signs such as tachypnea, use of accessory muscles, and nasal flaring, indicating failing gas exchange.