The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

Assist the client to lie down and turn to the side.

Recommend the use of supplemental liquid feedings.

Demonstrate use of a tucked-chin position while eating.

Encourage the use of assistive feeding devices.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assisting the client to lie down may increase the risk of aspiration.

Choice B reason: Supplemental liquid feedings may be considered but do not address the immediate issue.

Choice C reason: Demonstrating the tucked-chin position can help reduce the risk of aspiration by ensuring the airway is protected during swallowing.

Choice D reason: Assistive feeding devices may help but do not address the immediate issue of frequent coughing during meals.

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Correct Answer is A

Explanation

Choice A reason: Holding the infant with head and shoulders slightly elevated helps prevent aspiration during feeding.

Choice B reason: Using the syringe plunger to push formula can increase the risk of aspiration and is not recommended.

Choice C reason: Microwaving formula can create hot spots and is not a safe method to warm formula.

Choice D reason: Measuring and discarding residual gastric contents is not typically recommended for routine feeding and can lead to improper assessment.

A. Leg numbness. B. Cold sensitivity. C. Slow weight loss. D. Muscle weakness.

Correct Answer is B

Explanation

Choice A reason: Leg numbness is not a typical symptom of thyroid dysfunction and may be related to other conditions such as peripheral neuropathy.

Choice B reason: Cold sensitivity is a common symptom of hypothyroidism and warrants evaluation of thyroid function.

Choice C reason: Slow weight loss is not a typical symptom of thyroid dysfunction; unexplained weight gain is more indicative of hypothyroidism.

Choice D reason: Muscle weakness can be associated with various conditions, but cold sensitivity is more specific to thyroid issues.

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The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

Nursing Test Bank

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