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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Related Questions
Correct Answer is B
Explanation
A. Monro-Kellie hypothesis: The Monro-Kellie hypothesis explains the relationship between the volumes of brain tissue, blood, and cerebrospinal fluid in the cranium, but it is not a diagnostic tool for assessing LOC.
B. Glasgow Coma Scale: The Glasgow Coma Scale (GCS) is a standardized tool used to assess a client's level of consciousness, particularly in cases of head injury. It evaluates eye opening, verbal response, and motor response.
C. Cranial nerve function: Cranial nerve assessment is important in evaluating neurological function, but it is not a comprehensive tool for gauging LOC.
D. Mental status examination: A mental status examination assesses cognitive functions, but the Glasgow Coma Scale is more appropriate for evaluating LOC in the context of head trauma.
Correct Answer is B
Explanation
A. Pharmacotherapy: While medication is crucial in managing bipolar disorder, the immediate priority during a manic episode is ensuring the client's safety, as they may engage in risky behavior.
B. Client safety: Client safety is the highest priority during a manic episode, as clients may act impulsively, which can lead to harm to themselves or others.
C. Cognitive-behavioral therapy: CBT is an important therapeutic intervention for long-term management, but it is not the immediate priority during a manic episode.
D. Distraction therapy: Distraction techniques can be helpful, but they are not a priority compared to ensuring the client’s safety.
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