A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?
Risk for aspiration
Risk for falls
Risk for impaired skin integrity
Decreased intracranial adaptive capacity
The Correct Answer is A
A. Risk for aspiration: The gag reflex is crucial for preventing aspiration. An absent gag reflex significantly increases the risk of food or fluids entering the airway, leading to aspiration pneumonia or choking.
B. Risk for falls: While risk for falls is a concern in stroke patients, the immediate risk related to the absence of the gag reflex is more directly associated with aspiration.
C. Risk for impaired skin integrity: Impaired skin integrity is important but is a secondary concern compared to the risk of aspiration due to the absence of the gag reflex.
D. Decreased intracranial adaptive capacity: This diagnosis relates to the brain's ability to adapt to changes. While important, it is less immediately relevant compared to the risk of aspiration from the loss of the gag reflex.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Disorganized speech: Disorganized speech involves incoherent or illogical speech patterns, which is not the primary observation here.
B. A hallucination: The client is interacting with an unseen entity, which suggests a hallucination, a false sensory perception, particularly common in schizophrenia.
C. An illusion: An illusion involves a misinterpretation of a real external stimulus, which is not applicable in this situation as there is no stimulus present.
D. Anhedonia: Anhedonia refers to a loss of interest or pleasure in activities, which does not describe the behavior observed.
Correct Answer is D
Explanation
A. Baked chicken: Baked chicken, if cooked thoroughly, is generally safe for a client with neutropenia (low WBC count) as it does not pose a high risk for infection.
B. Bagels: Bagels, if they are from a safe, uncontaminated source, are generally considered safe for neutropenic clients.
C. A factory-sealed box of chocolates: Factory-sealed chocolates are usually safe as they are unlikely to be contaminated.
D. Fresh fruit basket: Fresh fruits can carry bacteria, especially on the skin or peel, and pose a risk of infection for a client with neutropenia. Therefore, this is the item that should be prohibited.
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