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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is C
Explanation
Choice A reason: Divalproex is not used for treating acute dystonic reactions.
Choice B reason: Lorazepam can be used for certain types of acute reactions but is not the first line of treatment for dystonic reactions with laryngeal spasm.
Choice C reason: IV administration of benztropine is appropriate for treating acute dystonic reactions, including laryngeal spasm, as it helps to relieve the muscle contractions.
Choice D reason: IV administration of isotonic crystalloid fluid is not a treatment for dystonic reactions but may be used to maintain hydration and electrolyte balance.
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