A client is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited.

What dysfunction does the nurse determine the client has?

Dysfunction of the spinal accessory nerve.

Dysfunction of the acoustic nerve.

Dysfunction of the facial nerve.

Dysfunction of the vagus nerve.

Answer and Explanation

The Correct Answer is D

Choice A rationale

The spinal accessory nerve (cranial nerve XI) controls the sternocleidomastoid and trapezius muscles, which are responsible for movements of the head and shoulders. Dysfunction in this nerve would not affect the gag reflex.

Choice B rationale

The acoustic nerve (cranial nerve VIII) is responsible for hearing and balance. Dysfunction in this nerve would lead to hearing loss and balance issues, not an absent gag reflex.

Choice C rationale

The facial nerve (cranial nerve VII) controls muscles of facial expression and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue. Dysfunction here results in facial paralysis or weakness but not in the absence of a gag reflex.

Choice D rationale

The vagus nerve (cranial nerve X) innervates muscles of the pharynx and larynx, which are involved in swallowing and the gag reflex. Dysfunction in the vagus nerve would result in an absent gag reflex, which is why the nurse determines this as the issue.

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Correct Answer is B

Explanation

Choice A rationale

Temporal lobe damage affects auditory processing and memory rather than visual stimuli interpretation, impacting functions like language comprehension and memory formation.

Choice B rationale

Occipital lobe is the primary visual processing center of the brain, responsible for interpreting visual stimuli. Damage to this lobe impairs visual perception and recognition, aligning with the symptoms described.

Choice C rationale

Frontal lobe injury affects executive functions, behavior, and motor skills, not visual stimuli interpretation. Symptoms include problems with planning, movement, and personality changes rather than visual processing issues.

Choice D rationale

Parietal lobe processes sensory information such as touch, temperature, and pain, and helps in spatial orientation. It does not primarily interpret visual stimuli, making it less relevant to the described visual interpretation difficulty.

A. MRI. B. Lumbar puncture. C. Cerebral angiography. D. EEG.

Correct Answer is B

Explanation

Choice A rationale

MRI is a non-invasive imaging technique that uses magnetic fields and radio waves to create detailed images of the body's structures. The preparation for an MRI typically involves removing metal objects and sometimes fasting, but it is not similar to a myelogram.

Choice B rationale

A lumbar puncture, like a myelogram, involves inserting a needle into the spinal canal to collect cerebrospinal fluid or inject contrast dye. The preparation for both procedures includes obtaining consent, positioning the patient, and ensuring proper hydration. This similarity is why the nurse should explain that the preparation is akin to a lumbar puncture.

Choice C rationale

Cerebral angiography is an invasive procedure used to visualize blood vessels in the brain, requiring catheter insertion and contrast dye. The preparation is more complex, involving fasting and possible sedation, differing from the simpler preparation for a myelogram.

Choice D rationale

An EEG (electroencephalogram) measures electrical activity in the brain using electrodes placed on the scalp. The preparation is generally non-invasive and less intensive than that for a myelogram, typically involving clean hair and avoiding caffeine.

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A client is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the client has?

Nursing Test Bank

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Correct Answer is B

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Correct Answer is B

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A client is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited.

What dysfunction does the nurse determine the client has?