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
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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Related Questions
Correct Answer is C
Explanation
A. Comprehend spoken words: This is part of global aphasia, but it does not fully encompass the deficits associated with this condition. Global aphasia involves more extensive language impairment.
B. Form words that are understandable: This is part of global aphasia, but it alone does not fully capture the severity of the language deficit, as it also includes comprehension issues.
C. Form words that are understandable or comprehend spoken words: Global aphasia is the most severe form of aphasia, characterized by profound impairment in both the ability to produce understandable speech and comprehend spoken language. This choice accurately reflects the full scope of the language deficits in global aphasia.
D. Speak at all: Clients with global aphasia may still attempt to speak, but their speech is typically not understandable and is often meaningless. Therefore, saying they cannot "speak at all" is not entirely accurate.
Correct Answer is A
Explanation
A. Hematologic spread: Hematologic spread (through the bloodstream) is a common mechanism for metastasis to distant organs like bones and liver. This is the most likely mechanism for the spread described.
B. Lymphatic circulation: Lymphatic spread often leads to regional lymph nodes rather than distant organs like bones and liver.
C. Invasion: Invasion involves local spread into adjacent tissues but does not typically account for distant metastasis.
D. Angiogenesis: Angiogenesis refers to the formation of new blood vessels to supply the tumor, not the mechanism by which cancer cells spread to distant sites.
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