The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?

Trigeminal nerve.

Facial nerve.

Glossopharyngeal nerve.

Vagus nerve.

Answer and Explanation

Correct Answer : C,D

Choice A rationale

The trigeminal nerve is responsible for facial sensation and motor functions like chewing, not related to gag reflex impairment.

Choice B rationale

The facial nerve controls facial expressions, taste sensations, and other functions but does not influence the gag reflex.

Choice C rationale

The glossopharyngeal nerve (cranial nerve IX) plays a crucial role in the gag reflex as it innervates part of the pharynx and is responsible for sensory functions in the throat.

Choice D rationale

The vagus nerve (cranial nerve X) also contributes to the gag reflex, providing motor innervation to the pharyngeal muscles and aiding in swallowing and speech functions.

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Correct Answer is C

Explanation

Choice A rationale

Increased intracranial pressure can result from various conditions, including brain injuries, tumors, or infections. However, decerebrate posturing is specifically associated with brain stem dysfunction rather than increased intracranial pressure alone.

Choice B rationale

Dysfunction in the cerebrum can lead to different posturing responses, such as decorticate posturing, which involves abnormal flexion of the arms. Decerebrate posturing, on the other hand, indicates more severe damage lower in the brain stem.

Choice C rationale

Dysfunction in the brain stem is indicated by decerebrate posturing, which involves extension and outward rotation of the arms and legs in response to painful stimuli. This type of posturing signifies serious damage to the brain stem and carries a poor prognosis.

Choice D rationale

Dysfunction in the spinal column may result in various neurological deficits but does not specifically cause decerebrate posturing. This type of posturing is indicative of brain stem damage rather than spinal column issues.

A. Gently pressing the bones on the neck. B. Moving the head toward both sides. C. Lightly tapping the lower portion of the neck to detect sensation. D. Moving the head and chin toward the chest.

Correct Answer is D

Explanation

Choice A rationale

Gently pressing the bones on the neck does not effectively test for neck rigidity, which is a common indicator of meningeal irritation or inflammation. This method may detect tenderness or bony abnormalities but not rigidity.

Choice B rationale

Moving the head toward both sides primarily assesses range of motion and flexibility. While reduced range of motion can be noted, this method doesn't specifically test for the resistance characteristic of neck rigidity.

Choice C rationale

Lightly tapping the lower portion of the neck to detect sensation tests for sensory nerve function but is not relevant to assessing muscle tone or rigidity, which is related to motor nerve and muscular response.

Choice D rationale

Moving the head and chin toward the chest is a proper technique to test for neck rigidity. This maneuver can elicit pain or resistance in cases of meningeal irritation, providing a reliable assessment for rigidity.

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The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Correct Answer is C

Explanation

The nurse is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly?

Correct Answer is D

Explanation

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