Practice Question
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?
Answer Choices:
Correct Answer:
Risk for aspiration
Rationale:
🔴 Absent gag reflex means the client cannot protect their airway during swallowing.
🔴 This greatly increases risk of aspiration pneumonia.
🔴 The vagus nerve (CN X) is essential for the swallow reflex and airway protection.
🔴 Aspiration can cause hypoxia, infection, and airway obstruction.
🔴 Swallowing safety interventions must be implemented immediately.
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This question is from Med surg exam( river valley college) which contains 68 questions.
More Questions from This Exam
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?
Answer Choices:
A. Maintaining accurate records of intake and output
B. Maintaining a patent airway
C. Inserting a nasogastric (NG) tube as prescribed
D. Providing appropriate pain control
A soldier has been back from Iraq for two weeks. He is being seen in the outpatient mental health clinic due to complaints of inability to sleep, nightmares, and flashbacks. The nurse would expect the client to be diagnosed with which of the following?
Answer Choices:
A. Generalized anxiety disorder
B. Posttraumatic stress disorder
C. Obsessive-compulsive disorder
D. Social phobia
A client has a blood alcohol level that is double the legal limit for driving yet does not exhibit behaviors of intoxication. The nurse knows that this is due to which effect?
Answer Choices:
A. Tolerance
B. Addiction
C. Alcoholism
D. Relapse
Which of the following assessment findings is observed in a client with opiate use?
Answer Choices:
A. Diarrhea
B. Pinpoint-sized pupils
C. Weight gain
D. Bulimia
A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive symptoms. Obsessive- compulsive disorder (OCD) is associated with:
Answer Choices:
A. Repetitive thoughts and recurring impulses
B. Physical signs and symptoms with no physiologic cause
C. Apprehension
D. Inability to concentrate
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: General Exams
- Domain: Medical-surgical📚
- Answer Choices: 4