The neurologic assessment of a patient indicated impaired function of the glossopharyngeal nerve (CN 10) and the vagus nerve (C.N X). Based on these findings, the nurse plans to;

insert an oral airway and suction as needed.

withhold oral fluids and food.

apply artificial pears to protect the cornea.

speak clearly while facing the patient.

Answer and Explanation

The Correct Answer is B

A) Insert an oral airway and suction as needed:
This is generally not the first intervention for impaired glossopharyngeal (CN IX) and vagus nerve (CN X) function. The glossopharyngeal and vagus nerves play a critical role in swallowing, gag reflex, and the ability to protect the airway. While an airway might be necessary in cases of severe dysfunction, withholding food and fluids is a more immediate and specific concern when these cranial nerves are impaired, as it prevents aspiration risk.

B) Withhold oral fluids and food:
The glossopharyngeal nerve (CN IX) is involved in taste and swallowing, and the vagus nerve (CN X) is crucial for the motor control of the pharynx and larynx, which are involved in swallowing and protecting the airway. Dysfunction of these nerves can lead to difficulty swallowing (dysphagia), increased risk for aspiration, and the inability to protect the airway effectively. Withholding oral fluids and food helps prevent aspiration, a major risk when these nerves are impaired, until further assessment and management can be done.

C) Apply artificial tears to protect the cornea:
While it is important to protect the cornea in patients with cranial nerve dysfunction (specifically the facial nerve, CN VII), this does not directly relate to the glossopharyngeal (CN IX) and vagus (CN X) nerves. The glossopharyngeal and vagus nerves affect swallowing and airway protection, not eye lubrication. Applying artificial tears would not address the risk associated with impaired swallowing or airway protection.

D) Speak clearly while facing the patient:
Although speaking clearly and facing the patient might be helpful for communication, especially if the patient has difficulty with speech due to nerve impairment, it does not address the immediate and more critical concern of impaired swallowing and airway protection associated with dysfunction of the glossopharyngeal and vagus nerves. The primary concern is ensuring the patient is not at risk for aspiration while eating or drinking.

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Correct Answer is D

Explanation

A) Ice packs may be applied to the site for 30 minutes every hour for comfort:
This is not an appropriate recommendation for skin care related to radiation therapy. Applying ice packs to the skin can cause vasoconstriction and might worsen skin irritation or damage from radiation. Instead, the patient should be advised to avoid extreme temperatures, including hot or cold compresses, which could exacerbate skin issues in the radiation field.

B) Incorporate rest periods throughout the day:
While rest is important for overall well-being during radiation therapy, this instruction does not directly address the skin care needs associated with radiation. The primary concern with radiation therapy is protecting the skin from further irritation and damage, so specific skin care measures are more crucial in this context than general rest periods.

C) Do not share bathrooms/toilets with others for 48 hours after treatment:
This instruction is not necessary for most patients undergoing radiation therapy, especially for lung cancer. The concern about not sharing bathrooms or toilets generally applies to patients receiving brachytherapy or radioactive implants, where radiation is placed inside the body. For external radiation, there is no risk of contamination through shared bathroom use.

D) Wear loose, soft clothing over the treated area:
This is the most appropriate instruction for skin care during radiation therapy. Radiation therapy can cause the skin to become tender, red, and irritated, so wearing loose, soft clothing will help minimize friction and pressure on the skin. Tight or rough clothing can irritate the radiation site, increasing the risk of skin breakdown. Loose, breathable fabrics like cotton can help keep the skin comfortable and allow it to heal while protecting it from further damage.

A. includes the head-to-toe anterior and posterior assessment B. focuses on the ABCDE's to identify life threating problems C. includes the use of a standard pain scale and past medical/surgical history D. consists of analyzing the results of the diagnostic testing

Correct Answer is B

Explanation

A) Includes the head-to-toe anterior and posterior assessment:
While a head-to-toe physical assessment is important in trauma care, it is not the first priority. The primary assessment focuses on immediate life-threatening conditions, and the head-to-toe assessment would come after the initial stabilization of the patient's airway, breathing, circulation, and disability. A comprehensive physical examination is crucial but secondary to addressing urgent life threats.

B) Focuses on the ABCDE's to identify life-threatening problems:
The ABCDE's (Airway, Breathing, Circulation, Disability, Exposure) are the primary framework for assessing and stabilizing a trauma patient. This approach is used to identify and prioritize life-threatening problems. It ensures that the most critical issues, such as airway obstruction, respiratory failure, shock, and neurological deficits, are addressed first. This protocol is the gold standard in trauma care and is the most appropriate initial assessment in major trauma.

C) Includes the use of a standard pain scale and past medical/surgical history:
While it is important to assess pain and gather a medical history in the trauma patient, these are secondary considerations after addressing immediate threats to life. Pain management and obtaining a full history are crucial, but they are not as urgent as addressing airway, breathing, and circulation issues. These should be part of a more detailed secondary assessment once the patient is stable.

D) Consists of analyzing the results of the diagnostic testing:
Diagnostic testing, such as imaging studies and lab work, are important but are not the first priority. The primary assessment should focus on the ABCDE's. Diagnostic results are typically analyzed after the patient is stabilized, as they provide additional information but do not address immediate survival needs.

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The neurologic assessment of a patient indicated impaired function of the glossopharyngeal nerve (CN 10) and the vagus nerve (C.N X). Based on these findings, the nurse plans to;

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Naxlex Comprehensive Predictor Exams

Which instruction is most important for the nurse to provide a client who is receiving radiation therapy for lung cancer when teaching about skin care?

Correct Answer is D

Explanation

The nurse understands the primary assessment for a patient following a major trauma:

Correct Answer is B

Explanation

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