When planning care, for which client would the nurse include ...

[colton]

When planning care, for which client would the nurse include close observation for a decreased or absent cough reflex?
 
  1. The client with a nasal fracture
  2. The client with impairment of vagus nerve conduction
  3. The client with a sinus infection
  4. The client with reduction in respiratory membrane conduction

Question 2

The nurse is caring for a client with a tracheostomy. For what protective mechanism will the nurse monitor in the client?
 
  1. The ability to cough
  2. Filtration and humidification of inspired air
  3. The sneeze reflex initiated by irritants in the nasal passages
  4. Decrease in oxygen-carrying capacity of the trachea

[Sarahjh]

Answer to Question 1

Correct Answer: 2
Rationale 1: Nasal fracture does not depress the cough reflex.
Rationale 2: The cough reflex depends upon nerve impulse transmission via the vagus nerve to the medulla. The nurse must monitor clients with vagus nerve impairment (through spinal cord injury, trauma, CNS depression, or other means) for a decreased or absent cough reflex. This decreased or absent reflex places the client at high risk for aspiration or development of pneumonia or other respiratory infections.
Rationale 3: A sinus infection will not depress the cough reflex.
Rationale 4: The respiratory membrane is the alveolar/capillary membrane and is not implicated in decreased or absent cough reflex.

Answer to Question 2

Correct Answer: 2
Rationale 1: The client is able to cough.
Rationale 2: When the nasal passages are bypassed as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages is also bypassed.
Rationale 3: The client can sneeze.
Rationale 4: There is no decrease in the oxygen-carrying capacity of the trachea.

[colton]

Excellent

[kusterl]

Thanks for the timely response, appreciate it