2026-2027 REVISED NCLEX EXAM WITH VERIFIED
QUESTIONS AND ANSWERS
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse
should avoid which measure to minimize the risk of occurrence?
1.
Strict adherence to a bowel retraining program
2.
Keeping the linen wrinkle-free under the client
3.
Preventing unnecessary pressure on the lower limbs
4.
Limiting bladder catheterization to once every 12 hours
4
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too
infrequent), and Foley catheters should be checked frequently to prevent kinks in the tubing.
Constipation and fecal impaction are other causes, so maintaining bowel regularity is important.
Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse
administers care to minimize risk in these areas.
,The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord
injury. Which observation indicates that spinal shock persists?
1.
Hyperreflexia
2.
Positive reflexes
3.
Flaccid paralysis
4.
Reflex emptying of the bladder
3
Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to
noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of
the bladder.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which
action by the nurse is contraindicated?
,1.
Loosening restrictive clothing
2.
Restraining the client's limbs
3.
Removing the pillow and raising padded side rails
4.
Positioning the client to the side, if possible, with the head flexed forward
2
Nursing actions during a seizure include providing for privacy, loosening restrictive clothing,
removing the pillow and raising padded side rails in the bed, and placing the client on one side
with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate
drainage. The limbs are never restrained because the strong muscle contractions could cause
the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the
client to the floor, if possible, protects the head from injury, and moves furniture that may
injure the client.
The nurse is planning to institute seizure precautions for a client who is being admitted from the
emergency department. Which measures should the nurse include in planning for the client's
safety? Select all that apply.
1.
, Padding the side rails of the bed
2.
Placing an airway at the bedside
3.
Placing the bed in the high position
4.
Putting a padded tongue blade at the head of the bed
5.
Placing oxygen and suction equipment at the bedside
6.
Having intravenous equipment ready for insertion of an intravenous catheter
1, 2, 5, 6
Seizure precautions may vary from agency to agency, but they generally have some common
features. Usually, an airway, oxygen, and suctioning equipment are kept available at the
bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The
client has an intravenous access in place to have a readily accessible route if anticonvulsant
medications must be administered. The use of padded tongue blades is highly controversial, and
they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure
more likely will harm the client who bites down during seizure activity. Risks include blocking
the airway from improper placement, chipping the client's teeth, and subsequent risk of
aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse
enough time to place an oral airway before seizure activity begins.
QUESTIONS AND ANSWERS
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse
should avoid which measure to minimize the risk of occurrence?
1.
Strict adherence to a bowel retraining program
2.
Keeping the linen wrinkle-free under the client
3.
Preventing unnecessary pressure on the lower limbs
4.
Limiting bladder catheterization to once every 12 hours
4
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight
catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too
infrequent), and Foley catheters should be checked frequently to prevent kinks in the tubing.
Constipation and fecal impaction are other causes, so maintaining bowel regularity is important.
Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse
administers care to minimize risk in these areas.
,The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord
injury. Which observation indicates that spinal shock persists?
1.
Hyperreflexia
2.
Positive reflexes
3.
Flaccid paralysis
4.
Reflex emptying of the bladder
3
Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to
noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of
the bladder.
The nurse is caring for a client who begins to experience seizure activity while in bed. Which
action by the nurse is contraindicated?
,1.
Loosening restrictive clothing
2.
Restraining the client's limbs
3.
Removing the pillow and raising padded side rails
4.
Positioning the client to the side, if possible, with the head flexed forward
2
Nursing actions during a seizure include providing for privacy, loosening restrictive clothing,
removing the pillow and raising padded side rails in the bed, and placing the client on one side
with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate
drainage. The limbs are never restrained because the strong muscle contractions could cause
the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the
client to the floor, if possible, protects the head from injury, and moves furniture that may
injure the client.
The nurse is planning to institute seizure precautions for a client who is being admitted from the
emergency department. Which measures should the nurse include in planning for the client's
safety? Select all that apply.
1.
, Padding the side rails of the bed
2.
Placing an airway at the bedside
3.
Placing the bed in the high position
4.
Putting a padded tongue blade at the head of the bed
5.
Placing oxygen and suction equipment at the bedside
6.
Having intravenous equipment ready for insertion of an intravenous catheter
1, 2, 5, 6
Seizure precautions may vary from agency to agency, but they generally have some common
features. Usually, an airway, oxygen, and suctioning equipment are kept available at the
bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The
client has an intravenous access in place to have a readily accessible route if anticonvulsant
medications must be administered. The use of padded tongue blades is highly controversial, and
they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure
more likely will harm the client who bites down during seizure activity. Risks include blocking
the airway from improper placement, chipping the client's teeth, and subsequent risk of
aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse
enough time to place an oral airway before seizure activity begins.
