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 D

Explanation

Choice A rationale

Keeping the dressing very wet at all times is not advisable with autolytic debriding agents. Excess moisture can cause maceration of the surrounding skin and increase the risk of infection. The dressing should maintain an optimal level of moisture to promote autolysis without causing harm.

Choice B rationale

Not using a dressing for 6 hours/day is incorrect advice. Continuous application of the dressing is essential for the autolytic process. Removing the dressing for extended periods disrupts the environment needed for autolysis, delaying wound healing.

Choice C rationale

Cleansing the wound with Dakin's solution is not recommended with autolytic debridement. Dakin's solution is a chemical debriding agent, and its use can interfere with the natural autolytic process. It is better to use saline or appropriate cleansers as directed.

Choice D rationale

The wound may have a foul odor due to the autolytic debridement process. As dead tissue is broken down, it can produce a distinct odor. Educating the client about this expected outcome helps them understand that it is a normal part of the healing process and not necessarily a sign of infection.

A. Ataxic. B. Dystrophic. C. Steppage. D. Helicopod. E. Helicopod.

Correct Answer is D

Explanation

Choice A rationale

Ataxic gait is characterized by uncoordinated movement, wide-based steps, and irregular distances between steps, often seen in cerebellar dysfunctions.

Choice B rationale

Dystrophic gait is associated with muscle weakness, often seen in muscular dystrophies, where there is difficulty in walking, a waddle-like walk, and frequent falls.

Choice C rationale

Steppage gait is associated with foot drop, where the individual lifts their knees higher than usual to avoid dragging their toes, often seen in peripheral neuropathies.

Choice D rationale

Helicopod gait involves the feet making a half-circle with each step and is often seen in individuals with certain neurologic disorders, such as hemiplegia or certain types of ataxia.

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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

Naxlex Comprehensive Predictor Exams

A client's orders include a wound dressing using an autolytic debriding agent. The nurse providing discharge instructions to the client should include which statement?

Correct Answer is D

Explanation

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Correct Answer is D

Explanation

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Pressure ulcers are caused by:

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?