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 D
Explanation
A. Psychopharmacology: Psychopharmacology involves the use of medications to treat mental health disorders. It does not focus on altering irrational thinking, which is more relevant to therapy techniques.
B. Desensitization: Desensitization, or systematic desensitization, is a technique used to reduce anxiety by gradually exposing the client to the anxiety-provoking stimulus. It is not specifically aimed at altering irrational thinking.
C. Changing Therapy: The term "Changing Therapy" is not a standard therapy technique. It is not a recognized method for altering irrational thinking.
D. Cognitive Behavioral Therapy (CBT): CBT is specifically designed to help clients identify and alter irrational or distorted thinking patterns. It focuses on changing maladaptive thought processes and behaviors.
Correct Answer is D
Explanation
A. Disturbed body image related to depression: While body image disturbances can occur with depression, it is not the primary concern following a suicide attempt.
B. Imbalanced nutrition: Less than body requirements related to depression: While nutritional imbalances may be present in clients with depression, the most pressing concern after a suicide attempt is safety.
C. Hygiene self-care deficit related to depression: A self-care deficit is often present in depression but is not the most urgent diagnosis after a suicide attempt.
D. Risk for self-directed violence related to depression: This is the most appropriate nursing diagnosis following a suicide attempt, as it directly addresses the client’s risk of harm to themselves.
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