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NCLEX NCLEX-RN Exam Questions
National Council Licensure Examination - NCLEX-RN (Page 12 )

Updated On: 21-Feb-2026
Page 12 of 345
PDF with 862 Questions

A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:

  1. Dizziness and tachypnea
  2. Circumoral pallor and lightheadedness
  3. Headache and facial flushing
  4. Pallor and itching of the face and neck

Answer(s): C

Explanation:

(A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms.



A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report:

  1. Dizziness and tachypnea
  2. Circumoral pallor and lightheadedness
  3. Headache and facial flushing
  4. Pallor and itching of the face and neck

Answer(s): C

Explanation:

(A) Tachypnea is not a symptom. (B) Circumoral pallor is not a symptom. (C) Autonomic dysreflexia is an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation, which results in vasoconstriction and elevated blood pressure. (D) Pallor and itching are not symptoms.



Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)?

  1. Increased core body temperature
  2. Decreased serum osmolality
  3. Administration of hypo-osmolar fluids
  4. Decreased PaCO2

Answer(s): D

Explanation:

(A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known.



  1. Increased core body temperature
  2. Decreased serum osmolality
  3. Administration of hypo-osmolar fluids
  4. Decreased PaCO2

Answer(s): D

Explanation:

(A) An increase in core body temperature increases metabolism and results in an increase in ICP. (B) Decreased serum osmolality indicates a fluid overload and may result in an increase in ICP. (C) Hypo-osmolar fluids are generally voided in the neurologically compromised. Using IV fluids such as D5W results in the dextrose being metabolized, releasing free water that is absorbed by the brain cells, leading to cerebral edema. (D) Hypercapnia and hypoventilation, which cause retention of CO2 and lead to respiratory acidosis, both increase ICP. CO2 is the most potent vasodilator known.



Which of the following activities would be most appropriate during occupational therapy for a client with bipolar disorder?

  1. Playing cards with other clients
  2. Working crossword puzzles
  3. Playing tennis with a staff member
  4. Sewing beads on a leather belt

Answer(s): C

Explanation:

(A) This activity is too competitive, and the manic client might become abusive toward the other clients. (B) During mania, the client's attention span is too short to accomplish this task. (C) This activity uses gross motor skills, eases tension, and expands excess energy. A staff member is better equipped to interact therapeutically with clients. (D) This activity requires the use of fine motor skills and is very tedious.






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