A nurse is assessing a client’s cranial nerves. What cranial nerve would be assessed when checking a client’s gag reflex?
CN IX
CN V
CN X
CN XII
The Correct Answer is A
Choice A reason: The glossopharyngeal nerve (CN IX) is primarily responsible for the gag reflex. It provides sensory input from the pharynx and posterior third of the tongue, which triggers the gag reflex when stimulated. This nerve plays a crucial role in swallowing and the reflexive action to prevent choking.
Choice B reason: The trigeminal nerve (CN V) is responsible for facial sensation and motor functions such as biting and chewing. It does not play a direct role in the gag reflex. While it is important for other sensory and motor functions, it is not involved in the reflex being assessed here.
Choice C reason: The vagus nerve (CN X) also contributes to the gag reflex by providing motor innervation to the muscles of the pharynx and larynx. However, the primary sensory input for the gag reflex comes from the glossopharyngeal nerve (CN IX). The vagus nerve works in conjunction with CN IX to complete the reflex action.
Choice D reason: The hypoglossal nerve (CN XII) controls the movements of the tongue. It is essential for speech and swallowing but does not have a role in the gag reflex. The hypoglossal nerve’s primary function is motor control of the tongue muscles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
“Do not take the medication before bedtime” is incorrect because the timing of medication administration depends on the specific medication and its intended effects. Some medications are specifically prescribed to be taken at bedtime to help with sleep or to reduce side effects that might occur during the day.
Choice B Reason:
“Take the medication with a full glass of water” is correct because many medications require adequate hydration to ensure proper absorption and to prevent irritation of the esophagus and stomach. Taking medication with a full glass of water helps to ensure that the medication reaches the stomach quickly and reduces the risk of esophageal irritation or damage.
Choice C Reason:
“This medication must be taken on an empty stomach” is incorrect unless the specific medication requires it. Some medications are better absorbed on an empty stomach, but this is not a universal rule and depends on the medication’s formulation and intended use.
Choice D Reason:
“Expect abdominal pain with this medication” is incorrect because not all medications cause abdominal pain. If a medication is known to cause abdominal pain, the nurse should provide additional instructions on how to manage this side effect or discuss alternative medications with the healthcare provider.
Correct Answer is A
Explanation
Choice A reason: Starting chest compressions is the priority intervention for a client who is unresponsive, not breathing, and without a pulse. This situation indicates cardiac arrest, and immediate chest compressions are crucial to maintain circulation and oxygen delivery to vital organs. Early initiation of chest compressions improves the chances of survival and neurological outcomes.
Choice B reason: Obtaining a central line is not an immediate priority in the context of cardiac arrest. While central lines are important for administering medications and fluids, the first step in resuscitation is to establish effective chest compressions. Central line placement can be considered after initial resuscitation efforts are underway.
Choice C reason: Completing a comprehensive assessment is important, but it is not the immediate priority in a cardiac arrest situation. The primary focus should be on initiating chest compressions and basic life support measures. A detailed assessment can be performed once the client is stabilized.
Choice D reason: Providing rescue breathing is part of cardiopulmonary resuscitation (CPR), but it should follow the initiation of chest compressions. Current guidelines emphasize the importance of starting chest compressions immediately and then integrating rescue breaths. Effective chest compressions are the foundation of CPR.
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