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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Demonstrate empathy for the client by trying to mimic the client's state of anxiety. This is not appropriate as it could exacerbate the client’s anxiety rather than alleviate it. The nurse should remain calm and provide reassurance.

B. Tell the client that you must leave to go report his symptoms to the psychiatrist on duty. Leaving the client alone during a panic attack could increase their feelings of fear and isolation, worsening the situation.

C. Tell the client this is an acute exacerbation with a positive prognosis and low morbidity. While this information is correct, it does not directly address the client's immediate need for reassurance and safety during the panic attack.

D. Stay with the client, emphasizing that he is safe and that you will remain with him. This is the most appropriate intervention as it provides the client with a sense of safety and security, which is crucial during a panic attack.

A. Generalized anxiety disorder B. Posttraumatic stress disorder C. Obsessive-compulsive disorder D. Social phobia

Correct Answer is B

Explanation

A. Generalized anxiety disorder: Generalized anxiety disorder involves persistent and excessive worry, but it does not typically present with the specific symptoms of nightmares and flashbacks related to trauma.

B. Posttraumatic stress disorder: PTSD is characterized by symptoms such as nightmares, flashbacks, and difficulty sleeping, especially following exposure to traumatic events. This fits the soldier’s presentation.

C. Obsessive-compulsive disorder: OCD involves recurrent, intrusive thoughts (obsessions) and/or repetitive behaviors (compulsions). The symptoms described do not align with OCD but rather with trauma-related symptoms.

D. Social phobia: Social phobia involves intense fear of social situations, not the trauma-related symptoms described. It is less relevant to the soldier’s experience of nightmares and flashbacks.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is being treated in the emergency department for a panic attack. Which of the following nursing interventions would be most appropriate?

Correct Answer is D

Explanation

A soldier has been back from Iraq for two weeks. He is being seen in the outpatient mental health clinic due to complaints of inability to sleep, nightmares, and flashbacks. The nurse would expect the client to be diagnosed with which of the following?

Correct Answer is B

Explanation

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