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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A desire to initiate conversation with roommates. Clients with depression typically withdraw socially and may not seek to initiate conversations or engage with others.
B. Expansive and dramatic movements. Expansive and dramatic movements are more characteristic of mania, not depression.
C. Decelerated movements and flat affect. Depression often leads to psychomotor retardation, where the client’s movements are slow and their affect is flat, showing a lack of emotional expression.
D. Overly excited interest in the admission. An overly excited interest would be inconsistent with the symptoms of depression, which often include a lack of interest or enthusiasm.
Correct Answer is A
Explanation
A. Body temperature control: The hypothalamus regulates body temperature. Damage to this area can lead to difficulties with maintaining normal body temperature.
B. Balance and equilibrium: Balance and equilibrium are primarily managed by the cerebellum and vestibular system, not the hypothalamus.
C. Visual acuity: Visual acuity is regulated by the occipital lobe of the brain, not the hypothalamus.
D. Thinking and
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.