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 A
Explanation
Choice A rationale
Positioning the client flat as directed is the priority intervention after a lumbar puncture to prevent cerebrospinal fluid (CSF) leakage, which can lead to a post-lumbar puncture headache. This position helps maintain normal CSF pressure and promotes sealing of the puncture site.
Choice B rationale
Leaving the client to rest without performing any assessments is not appropriate, as continuous monitoring is necessary to detect any complications such as bleeding or changes in neurological status. Regular assessments help ensure timely intervention if issues arise.
Choice C rationale
Providing caffeine-rich drinks is sometimes recommended to alleviate headaches caused by CSF leakage post-lumbar puncture. However, it is not the priority intervention immediately after the procedure, which focuses on positioning and monitoring.
Choice D rationale
Avoiding analgesic agents is incorrect. Pain management is an important aspect of care post-lumbar puncture, and appropriate analgesics should be administered as needed. The focus should be on positioning and monitoring, not withholding pain relief.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Dryness of the eyes, or xerophthalmia, is a common symptom of keratoconjunctivitis. It indicates the involvement of the conjunctiva and cornea, often seen in conditions like Stevens-Johnson syndrome or toxic epidermal necrolysis.
Choice B rationale
Skin peeling on the eyelids suggests severe involvement of the ocular adnexa and can be a sign of advancing keratoconjunctivitis. This symptom reflects significant mucocutaneous damage.
Choice C rationale
Pruritus, or itching, is less specific for keratoconjunctivitis and more commonly associated with allergic reactions or less severe irritations. It is not a primary indicator of the disease's progression.
Choice D rationale
Burning of the eyes is a symptom of keratoconjunctivitis, indicating inflammation and irritation of the conjunctiva and cornea. This symptom helps in identifying the progression of the condition. .
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