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 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.

A. A desire to initiate conversation with roommates. B. Expansive and dramatic movements. C. Decelerated movements and flat affect. D. Overly excited interest in the admission.

Correct Answer is C

Explanation

A. A desire to initiate conversation with roommates. Clients with depression typically withdraw socially and may not seek to initiate conversations or engage with others.

B. Expansive and dramatic movements. Expansive and dramatic movements are more characteristic of mania, not depression.

C. Decelerated movements and flat affect. Depression often leads to psychomotor retardation, where the client’s movements are slow and their affect is flat, showing a lack of emotional expression.

D. Overly excited interest in the admission. An overly excited interest would be inconsistent with the symptoms of depression, which often include a lack of interest or enthusiasm.

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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

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Correct Answer is C

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