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 ["A","B","C","D","E"]
Explanation
Choice A reason: Orthostatic hypotension is a common issue in PD and requires interventions to prevent falls.
Choice B reason: Stooped posture is characteristic of PD and affects mobility and balance.
Choice C reason: Bradykinesia (slowness of movement) is a hallmark of PD and impacts daily activities and mobility.
Choice D reason: Muscular rigidity is a key symptom of PD and affects the client's ability to move freely.
Choice E reason: A shuffling, propulsive gait is typical in PD and requires interventions to ensure safety and improve mobility.
Correct Answer is C
Explanation
Choice A reason: Mononucleosis typically presents with fever, sore throat, and lymphadenopathy but does not commonly cause a rash on the hands and feet.
Choice B reason: Herpes simplex virus usually causes painful vesicular lesions rather than a diffuse rash on the hands and feet.
Choice C reason: Syphilis can present with a fever, sore throat, and a characteristic rash on the hands, palms, and soles of the feet, particularly in the secondary stage of the infection.
Choice D reason: Toxic shock syndrome is associated with high fever, rash, and shock, but the rash is not typically confined to the hands and feet.
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