When planning care, for which client should the nurse include close ob

When planning care, for which client should 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

ANSWER

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.