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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pharmacotherapy: While medication is crucial in managing bipolar disorder, the immediate priority during a manic episode is ensuring the client's safety, as they may engage in risky behavior.
B. Client safety: Client safety is the highest priority during a manic episode, as clients may act impulsively, which can lead to harm to themselves or others.
C. Cognitive-behavioral therapy: CBT is an important therapeutic intervention for long-term management, but it is not the immediate priority during a manic episode.
D. Distraction therapy: Distraction techniques can be helpful, but they are not a priority compared to ensuring the client’s safety.
Correct Answer is A
Explanation
A. Place the client in a private room. This is the correct action because clients with radioactive implants need to be isolated to minimize radiation exposure to others.
B. Place a chair next to the bed to allow the spouse to sit. While emotional support is important, prolonged close contact with someone who has a radioactive implant is not recommended due to the risk of radiation exposure.
C. Have visitors wear dosimeters for safety. While this is a good safety measure, the primary concern is limiting visitors and ensuring the client is in a private room to minimize exposure.
D. Allow visitors to telephone only. While telephone communication can be safe and supportive, the best initial action is to place the client in a private room to control radiation exposure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.