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: Starting with less sensitive questions helps build rapport and makes the client feel more comfortable before addressing more sensitive topics such as domestic violence.

Choice B reason: Getting the most difficult questions over with first can make the client feel uncomfortable and defensive, potentially hindering the interview process.

Choice C reason: Sharing personal values is not appropriate and can bias the interview, making the client less likely to open up.

Choice D reason: Asking vague, nonspecific questions does not help gather the necessary information effectively and may confuse the client.

A. Twin siblings admitted with scarlet fever that is complicated with pneumonia. B. A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB). C. An older client with scabies who is admitted from an extended care facility. D. A female adolescent admitted with multiple genital Herpes simplex II lesions.

Correct Answer is B

Explanation

Choice A reason: Scarlet fever and pneumonia require droplet precautions, not airborne.

Choice B reason: A positive Mantoux test and positive sputum cultures for AFB indicate tuberculosis, which requires airborne precautions and a negative airflow room.

Choice C reason: Scabies requires contact precautions, not airborne.

Choice D reason: Genital Herpes simplex II requires standard precautions, not airborne.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Explanation

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