A home health nurse is caring for an older adult client who reports. "I keep coughing when I try to swallow my food, but not at other times." Which of the following actions should the nurse take?
Instruct the client that this is due to increased salivary flow that occurs with aging
Encourage the client to increase fluid intake when the cough is present.
Recommend an antitussive 30 min prior to each meal
initiate a consultation with a speech-language pathologist
The Correct Answer is D
Rationale:
A. Instruct the client that this is due to increased salivary flow that occurs with aging: While aging can affect swallowing, persistent coughing specifically during meals suggests dysphagia or aspiration risk, not just increased saliva. Dismissing it as normal aging could delay necessary evaluation and intervention.
B. Encourage the client to increase fluid intake when the cough is present: Increasing fluids without assessing swallowing ability could worsen aspiration risk. Proper evaluation of swallowing mechanics is necessary before recommending fluid intake adjustments.
C. Recommend an antitussive 30 min prior to each meal: Suppressing the cough reflex can be dangerous in clients with swallowing difficulties, as the cough helps prevent aspiration. Using antitussives in this situation may increase the risk of choking or pneumonia.
D. Initiate a consultation with a speech-language pathologist: A speech-language pathologist can perform a swallowing assessment, identify aspiration risk, and recommend safe feeding strategies. Referral ensures proper evaluation and helps prevent complications such as aspiration pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Biofeedback requires concentration to control physiological responses.": Biofeedback is a technique that helps clients gain voluntary control over involuntary bodily functions, such as muscle tension, heart rate, or skin temperature. Through focused concentration and real-time feedback from monitoring devices, clients learn to reduce stress and prevent migraine triggers.
B. “Biofeedback improves energy flow through soft tissue manipulation to increase circulation.": This description aligns more with massage or energy-based therapies, not biofeedback. Biofeedback does not involve physical manipulation of tissues but relies on monitoring and controlling physiological responses through mental focus.
C. "Biofeedback uses herbs to reduce inflammation": Herbal therapy is a complementary approach unrelated to biofeedback. Biofeedback does not incorporate herbal remedies and instead emphasizes self-regulation techniques using bio-monitoring equipment.
D. “Biofeedback stimulates certain pressure points to relax muscles": Stimulating pressure points is characteristic of acupressure or acupuncture, not biofeedback. While muscle relaxation is a goal of biofeedback, it is achieved through self-regulation and feedback, not external stimulation.
Correct Answer is B
Explanation
Rationale:
A. Report the pump has a frayed cord and proceed with the infusion: Using a pump with a frayed cord is unsafe and poses a risk of electrical shock or malfunction. The pump should not be used until it is repaired or replaced, so proceeding with the infusion is inappropriate.
B. Check the expiration date on the safety inspection sticker of the pump: Verifying that the infusion pump has a current safety inspection ensures that the device has been tested and is functioning properly. This action is essential to prevent mechanical failure and maintain patient safety during IV therapy.
C. Obtain a surge protector that can accommodate the pump and several other appliances: Infusion pumps should be plugged directly into a properly grounded outlet to ensure consistent power and prevent electrical hazards. Connecting multiple devices through a surge protector can overload the circuit and compromise pump function.
D. Verify that the extension cord for the pump is ungrounded: Using an ungrounded extension cord increases the risk of electrical shock and device malfunction. Only properly grounded outlets and cords should be used with infusion pumps to maintain safety.
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