A client is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited.
What dysfunction does the nurse determine the client has?
Dysfunction of the spinal accessory nerve.
Dysfunction of the acoustic nerve.
Dysfunction of the facial nerve.
Dysfunction of the vagus nerve.
Dysfunction of the vagus nerve.
The Correct Answer is D
Choice A rationale
The spinal accessory nerve (cranial nerve XI) controls the sternocleidomastoid and trapezius muscles, which are responsible for movements of the head and shoulders. Dysfunction in this nerve would not affect the gag reflex.
Choice B rationale
The acoustic nerve (cranial nerve VIII) is responsible for hearing and balance. Dysfunction in this nerve would lead to hearing loss and balance issues, not an absent gag reflex.
Choice C rationale
The facial nerve (cranial nerve VII) controls muscles of facial expression and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. Dysfunction here results in facial paralysis or weakness but not in the absence of a gag reflex.
Choice D rationale
The vagus nerve (cranial nerve X) innervates muscles of the pharynx and larynx, which are involved in swallowing and the gag reflex. Dysfunction in the vagus nerve would result in an absent gag reflex, which is why the nurse determines this as the issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Deficient fluid volume is not the primary concern related to weight loss or ill-fitting dentures. While fluid intake should be monitored, it is less immediate than gastrointestinal issues from fiber deficiency.
Choice B rationale
Excessive intake of convenience foods might relate to weight loss but does not directly indicate a health risk. The primary risk is more focused on gastrointestinal function.
Choice C rationale
Constipation is a major risk due to limited fiber intake. Fiber is essential for bowel movement regularity, and its deficiency, coupled with ill-fitting dentures, increases the risk.
Choice D rationale
Infection is not directly related to the dietary concerns noted. While poor nutrition can weaken the immune system, it is not the most immediate health risk connected to the given symptoms. .
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Bradycardia (slow heart rate) is one of the key components of Cushing's triad, which indicates increased intracranial pressure and impending herniation.
Choice B rationale
Bradypnea (slow respiratory rate) is another manifestation of Cushing's triad and reflects brainstem compression.
Choice C rationale
Hypertension (high blood pressure) is the third component of Cushing's triad, resulting from the body's attempt to maintain cerebral perfusion.
Choice D rationale
Tachycardia (rapid heart rate) is not a sign of Cushing's triad and is not associated with increased intracranial pressure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.