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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
MRI is a non-invasive imaging technique that uses magnetic fields and radio waves to create detailed images of the body's structures. The preparation for an MRI typically involves removing metal objects and sometimes fasting, but it is not similar to a myelogram.
Choice B rationale
A lumbar puncture, like a myelogram, involves inserting a needle into the spinal canal to collect cerebrospinal fluid or inject contrast dye. The preparation for both procedures includes obtaining consent, positioning the patient, and ensuring proper hydration. This similarity is why the nurse should explain that the preparation is akin to a lumbar puncture.
Choice C rationale
Cerebral angiography is an invasive procedure used to visualize blood vessels in the brain, requiring catheter insertion and contrast dye. The preparation is more complex, involving fasting and possible sedation, differing from the simpler preparation for a myelogram.
Choice D rationale
An EEG (electroencephalogram) measures electrical activity in the brain using electrodes placed on the scalp. The preparation is generally non-invasive and less intensive than that for a myelogram, typically involving clean hair and avoiding caffeine.
Correct Answer is D
Explanation
Choice A rationale
Interactive dressings are designed to interact with the wound environment to promote healing. These can include dressings that release medication or create an optimal moisture balance. They are not typically used for acutely inflamed and oozing skin lesions.
Choice B rationale
Passive dressings are protective covers that keep the wound clean and protected from external contaminants. They do not have additional properties to manage wound exudate or inflammation.
Choice C rationale
Protective dressings are generally used to shield wounds from further injury or contamination. They do not specifically address the needs of an oozing and inflamed lesion.
Choice D rationale
Occlusive dressings are designed to maintain a moist wound environment, which can aid in the healing of oozing wounds. They can also provide a barrier to external contaminants and help manage exudate effectively, making them suitable for acutely inflamed and oozing lesions.
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