A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

Risk for aspiration

Risk for falls

Risk for impaired skin integrity

Decreased intracranial adaptive capacity

Answer and Explanation

The Correct Answer is A

A. Risk for aspiration: The gag reflex is crucial for preventing aspiration. An absent gag reflex significantly increases the risk of food or fluids entering the airway, leading to aspiration pneumonia or choking.

B. Risk for falls: While risk for falls is a concern in stroke patients, the immediate risk related to the absence of the gag reflex is more directly associated with aspiration.

C. Risk for impaired skin integrity: Impaired skin integrity is important but is a secondary concern compared to the risk of aspiration due to the absence of the gag reflex.

D. Decreased intracranial adaptive capacity: This diagnosis relates to the brain's ability to adapt to changes. While important, it is less immediately relevant compared to the risk of aspiration from the loss of the gag reflex.

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Correct Answer is D

Explanation

A. Disturbed body image related to depression: While body image disturbances can occur with depression, it is not the primary concern following a suicide attempt.

B. Imbalanced nutrition: Less than body requirements related to depression: While nutritional imbalances may be present in clients with depression, the most pressing concern after a suicide attempt is safety.

C. Hygiene self-care deficit related to depression: A self-care deficit is often present in depression but is not the most urgent diagnosis after a suicide attempt.

D. Risk for self-directed violence related to depression: This is the most appropriate nursing diagnosis following a suicide attempt, as it directly addresses the client’s risk of harm to themselves.

A. "I wouldn't tell, if I were you." B. “In my experience, clients who know are more likely to be involved with their plan of care." C. "The shock of learning the diagnosis may be too much stress for an elderly person.” D. "This is a private concern that should include the physician, not me."

Correct Answer is B

Explanation

A. "I wouldn't tell if I were you." This response is inappropriate because it imposes the nurse's personal opinion rather than supporting the family in making an informed decision.

B. "In my experience, clients who know are more likely to be involved with their plan of care." This is the best response because it encourages transparency and patient autonomy, allowing the client to participate in their care decisions.

C. "The shock of learning the diagnosis may be too much stress for an elderly person.” This response is not based on evidence and may discourage the family from being honest with the client, which could prevent the client from making informed decisions.

D. "This is a private concern that should include the physician, not me." While the physician should be involved in the discussion, the nurse also plays a crucial role in providing support and guidance to the family. This response dismisses the nurse's role in the situation.

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A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with depression is admitted to the hospital following a suicide attempt. Which nursing diagnosis would be most appropriate at this time?

Correct Answer is D

Explanation

An elderly client has been diagnosed with metastatic cancer and has a poor prognosis of survival. The family asks the nurse for advice on whether to tell the client of the diagnosis or to keep it quiet. Which is the best response from the nurse?

Correct Answer is B

Explanation

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