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.
Dysfunction of the vagus nerve.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Cushing syndrome is not associated with high urine output post-craniotomy. It is related to excessive cortisol production leading to weight gain, hypertension, and other symptoms.
Choice B rationale
Adrenal crisis involves insufficient production of cortisol and aldosterone, leading to symptoms like hypotension, fatigue, and abdominal pain, not high urine output.
Choice C rationale
Arginine vasopressin deficiency (AVP-D), also known as diabetes insipidus, causes the kidneys to excrete large amounts of dilute urine due to lack of ADH, leading to high urine output.
Choice D rationale
Syndrome of inappropriate antidiuretic hormone (SIADH) causes water retention and low urine output due to excess ADH, not the increased urine output seen in the scenario.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale
Coping strategies are relevant to overall health and well-being, but they are not directly related to nutritional assessment. Nutritional assessments focus on physical and dietary data rather than psychological coping mechanisms.
Choice B rationale
Wrist circumference can be used as an anthropometric measure of body frame size, but it is not a standard parameter in a comprehensive nutritional assessment. More common measurements include height, weight, and BMI.
Choice C rationale
Clinical examination findings are critical in nutritional assessments to identify physical signs of malnutrition, such as muscle wasting, edema, or skin changes. These observations help assess the client’s nutritional status and needs.
Choice D rationale
BMI (Body Mass Index) is a widely used indicator of body fat based on height and weight. It helps classify individuals into categories like underweight, normal weight, overweight, or obese, providing insight into nutritional health.
Choice E rationale
Dietary data, including food intake, preferences, and restrictions, are essential components of a nutritional assessment. Understanding a client's dietary habits allows the nurse to identify nutritional deficiencies or excesses and plan appropriate interventions
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