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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.
B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.
C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.
D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.
Correct Answer is D
Explanation
A. The prone position is not suitable post-craniotomy as it can increase intracranial pressure and may compromise respiratory function.
B. The dorsal recumbent position is not ideal for patients post-craniotomy, as it can hinder optimal intracranial pressure management.
C. The lateral recumbent position is generally avoided immediately after craniotomy to prevent pressure on the surgical site and ensure proper cerebral perfusion.
D. The Semi-Fowler's position helps reduce intracranial pressure, promotes venous drainage, and is generally recommended for post-operative care following a craniotomy.
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