Editing Anatomy and Physiology – RN Practice Questions (section)

==Question 14==
A nurse is assessing a patient 24 hours after an ischemic stroke involving the left middle cerebral artery territory. Which findings would increase the nurse's concern for aspiration risk? '''Select all that apply.'''
# Absent gag reflex on stimulation of the posterior pharynx.
# A wet, gurgling voice quality after sipping water.
# Deviation of the tongue when the patient is asked to protrude it.
# Pooling of secretions in the mouth with drooling.
# Equal and reactive pupils bilaterally.

'''Answer:''' 1, 2, 3, and 4 (A, B, C, D).

''Rationale:'' Safe swallowing depends on cranial nerves IX (glossopharyngeal) and X (vagus) for the gag reflex and pharyngeal phase and on cranial nerve XII (hypoglossal) for tongue movement that propels the bolus. An absent gag, a wet or gurgling voice after fluid intake, tongue deviation, and pooled oral secretions all indicate impairment of these nerves and a high risk of aspiration. The patient should remain nil by mouth until a formal swallow screen is completed. Option 5 is incorrect because pupillary responses reflect cranial nerves II and III and provide no information about swallowing.