Question: A nurse notes that the physician has updated the orders for a client who had a stroke by changing the medication route from parenteral to oral. Before administering the oral medications, it would be most important for the nurse to assess which cranial nerves?
1. Facial and vagus
2. Trigeminal and vagus
3. Trigeminal and hypoglossal
4. Glossopharyngeal and vagus
Rationale: Cranial nerves IX (glossopharyngeal) and X (vagus) control swallowing and the gag reflex. The nurse must assess the gag reflex before administering oral medications or feedings, to prevent the risk of aspiration. Cranial nerve VII (facial) (1) controls the motor function of the face and the taste sensation of the anterior 2/3s of the tongue. Cranial nerve V (trigeminal) (2, 3) controls sensation of the forehead, face, nasal cavity, teeth, and eyes as well as the motor function of the muscles used for mastication. Cranial nerve XII (hypoglossal) (3) controls the motor function of the intrinsic and extrinsic muscles of the tongue.
Cognitive Level: Analysis
Nursing Process: Implementation
NCLEX Test Plan Category: Physiological Integrity
This week’s NCLEX exam practice question came from:
Manno: Mosby's Review Cards for the NCLEX-RN Exam, 3rd Edition, Medical-surgical nursing, Card 619, Question 258
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