During an assessment, a patient begins to cough. How would the nurse evaluate this finding?
1. The patient has a cold.
2. The patient is nervous.
3. Something other than air was entering the larynx.
4. The patient is not fully conscious.
3
Rationale 1: A cough does not indicate the presence of a cold. Additional assessment would be necessary.
Rationale 2: A cough is not sufficient assessment data to determine that a patient is nervous.
Rationale 3: If anything other than air enters the larynx, a cough reflex expels the foreign substance before it can enter the lungs.
Rationale 4: The protective reflex of coughing may not be present if the person is unconscious. A cough is not enough data to determine level of consciousness.
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