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","B","C"]
Explanation
Choice A rationale
Scales represent the accumulation of dead skin cells that flake off, a common secondary lesion in eczema resulting from the chronic inflammation and rapid skin cell turnover.
Choice B rationale
Erosion occurs when the superficial layer of skin is lost, typically due to scratching or friction in eczema, exposing the underlying epidermis and sometimes leading to infection.
Choice C rationale
Crusts form when serum, blood, or purulent exudate dries on the skin surface, often seen in eczema as a result of weeping lesions and subsequent drying.
Choice D rationale
Ulcers are deeper lesions extending into the dermis or subcutaneous tissue and are not typically associated with eczema. Eczema usually affects the epidermis, causing secondary lesions like scales, erosion, and crusts rather than deep tissue ulcers.
Correct Answer is C
Explanation
Choice A rationale
Swallowing involves the glossopharyngeal and vagus nerves, not the trigeminal nerve. Thus, trigeminal neuralgia does not typically affect swallowing.
Choice B rationale
Smelling involves the olfactory nerve (cranial nerve I), not the trigeminal nerve (cranial nerve V). Therefore, trigeminal neuralgia does not affect the sense of smell.
Choice C rationale
Trigeminal neuralgia involves the trigeminal nerve, which is responsible for sensation in the face and motor functions such as biting and chewing. Therefore, chewing can be significantly affected.
Choice D rationale
Tasting involves the facial nerve (cranial nerve VII) and glossopharyngeal nerve (cranial nerve IX), not the trigeminal nerve. Thus, trigeminal neuralgia does not typically affect taste.
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