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: Placing a surgical mask on the client during transport is not the primary precaution for C. difficile infections. C. difficile is primarily transmitted through contact with contaminated surfaces and not through respiratory droplets. Therefore, while masks may be used for other infections, they are not the main precaution for C. difficile.
Choice B reason: Using gown and gloves when entering the room is essential for preventing the spread of C. difficile. This infection is highly contagious and can be transmitted through contact with contaminated surfaces or feces. Gown and gloves provide a barrier that helps prevent the transmission of the bacteria to healthcare workers and other patients.
Choice C reason: Using an alcohol-based agent to perform hand hygiene is not effective against C. difficile spores. Hand washing with soap and water is recommended because it is more effective at removing the spores from the hands. Alcohol-based hand sanitizers do not kill C. difficile spores and should not be relied upon for hand hygiene in this context.
Choice D reason: Obtaining a blood specimen to test for C. difficile is not the standard diagnostic method. C. difficile infections are typically diagnosed through stool tests that detect the presence of the bacteria or its toxins. Blood tests are not used for diagnosing C. difficile infections.
Correct Answer is C
Explanation
Choice A Reason:
Alginate dressings are typically used for wounds with moderate to heavy exudate because they are highly absorbent. Stage I pressure ulcers do not usually produce exudate, making alginate dressings unnecessary and inappropriate for this type of wound.
Choice B Reason:
Hydrogel dressings are designed to provide moisture to dry wounds and are more suitable for wounds with minimal to no exudate. While they can be used for stage I pressure ulcers, they are not the most common choice as these ulcers do not typically require additional moisture.
Choice C Reason:
Transparent dressings are ideal for stage I pressure ulcers because they protect the skin from friction and shear while allowing for continuous observation of the wound. These dressings maintain a moist environment, which is beneficial for healing, and are easy to apply and remove without causing additional trauma to the skin.
Choice D Reason:
Wet-to-dry gauze dressings are generally used for debridement of necrotic tissue in more advanced wounds. They are not suitable for stage I pressure ulcers, which do not have necrotic tissue and do not require debridement.
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