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 B
Explanation
Choice A rationale
Cushing triad is a late sign of increased ICP, characterized by bradycardia, hypertension, and irregular respirations, appearing after other symptoms like decreased LOC.
Choice B rationale
Decreased LOC is one of the earliest signs of increased ICP as it reflects the brain's response to pressure changes, alerting the need for immediate intervention.
Choice C rationale
Headache can be an early sign but is not as sensitive or specific as changes in LOC when assessing for increased ICP.
Choice D rationale
Coma is a late sign of significantly increased ICP, indicating severe brain dysfunction, often following initial symptoms like decreased LOC.
Correct Answer is C
Explanation
Choice A rationale
Furuncles, also known as boils, are deep folliculitis caused by bacterial infection, not sebum blockage.
Choice B rationale
Carbuncles are clusters of furuncles connected under the skin and are also caused by bacterial infection, not sebum blockage.
Choice C rationale
Comedones are primary lesions of acne caused by the blockage of hair follicles by sebum and keratin. They can be open (blackheads) or closed (whiteheads).
Choice D rationale
Striae, also known as stretch marks, are caused by the tearing of the dermis due to rapid stretching of the skin and are not related to sebum blockage in hair follicles. .
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