The neurologic assessment of a patient indicates impaired function of the glossopharyngeal (CN IX) and the vagus nerve (CN X). Based on these findings the nurse plans to:

Insert an oral airway and suction as necessary.

Withhold oral fluids or foods.

Speak clearly while facing the client.

Apply artificial tears to protect the cornea.

Answer and Explanation

The Correct Answer is B

A. Inserting an oral airway and suctioning may be indicated for airway management, but the primary concern is the impaired function of the glossopharyngeal and vagus nerves, which affects swallowing and the risk of aspiration.
B. Withholding oral fluids or foods is crucial because impaired function of these cranial nerves increases the risk of aspiration and can lead to choking or pneumonia, making this the priority action.
C. Speaking clearly while facing the client is a good communication practice but does not address the immediate concern of impaired swallowing and risk of aspiration.
D. Applying artificial tears is important for protecting the cornea, but it is not directly related to the functions of CN IX and CN X or the immediate management of swallowing difficulties.

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Correct Answer is B

Explanation

A. Requesting antidepressant medication may be appropriate later, but it does not address the immediate need for emotional support and communication.
B. Encouraging the client to verbalize feelings about their diagnosis provides an opportunity for the client to express their concerns and emotions, fostering a therapeutic relationship and aiding in emotional processing.
C. While explaining improved prognosis can provide hope, it may minimize the client’s feelings of fear and uncertainty and could be perceived as dismissive.
D. Allowing time for reflection is important, but it should be balanced with the need for communication and support to prevent isolation.

A. Slow the rate of infusion B. Apply a warm compress to the site C. Discontinue the infusion D. Check for blood return

Correct Answer is C

Explanation

A. Slowing the rate of infusion may provide some temporary relief, but it does not address the underlying issue and may worsen the situation.
B. Applying a warm compress may soothe discomfort but is not the priority action when a burning sensation is reported, which could indicate potential extravasation.
C. Discontinuing the infusion is the best first action to prevent further damage to the tissue and to assess for complications such as infiltration or extravasation.
D. Checking for blood return can help assess the patency of the IV line, but the priority is to stop the infusion immediately to prevent complications.

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The neurologic assessment of a patient indicates impaired function of the glossopharyngeal (CN IX) and the vagus nerve (CN X). Based on these findings the nurse plans to:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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