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

Administering a bolus of normal saline may not directly address the cause of increased respiratory effort, which could be related to increased intracranial pressure (ICP). Normal saline administration is not the priority intervention in this case.

Choice B rationale

Bronchodilators are used to manage bronchoconstriction, not increased respiratory effort due to potential increased ICP. Monitoring the client's level of consciousness (LOC) is important, but bronchodilators are not indicated here.

Choice C rationale

Increasing the client's bed height can help with respiratory effort, but it does not directly address the potential underlying issue of increased ICP. Reassessing in 30 minutes might delay necessary interventions.

Choice D rationale

Increased respiratory effort in a client with a head injury may indicate rising ICP. Informing the care team and assessing for further signs of increased ICP is crucial for timely intervention to prevent further complications.

A. Water or saline. B. Sodium bicarbonate. C. Colloids. D. Medicated tars.

Correct Answer is D

Explanation

Choice A rationale

Water or saline baths can help soothe skin but are not typically prescribed for psoriasis as a therapeutic measure.

Choice B rationale

Sodium bicarbonate baths are often used for itching and skin irritation but are not specifically recommended for psoriasis.

Choice C rationale

Colloids like oatmeal can be soothing for skin conditions, but they do not have the therapeutic properties needed for treating psoriasis flares.

Choice D rationale

Medicated tars are commonly used in the treatment of psoriasis because they can help reduce scaling, itching, and inflammation. They work by slowing the rapid growth of skin cells and are often prescribed for severe cases.

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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?

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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?