Neuro NCLEX Exam Questions and Answers for NSG403, Exams of Nursing

Download Neuro NCLEX Exam Questions and Answers for NSG403 and more Exams Nursing in PDF only on Docsity! NSG403 100 NEURO NCLEX EXAM QUESTIONS AND CORRECT ANSWERS GRADED A-PLUS NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ 100 Neuro NCLEX questions 1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?  Reposition the client to avoid neck flexion  Administer 1 g Mannitol IV as ordered  Increase the ventilator’s respiratory rate to 20 breaths/minute  Administer 100 mg of pentobarbital IV as ordered. 2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid Dilantin administration can cause cardiac arrhythmias.  Dilantin should be mixed in dextrose in water before administration. • Dilantin should be administered through an IV catheter in the client’s hand. NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+  Hemiparesis  Paraplegia 4. Tetraplegia 9. . A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected?  Autonomic dysreflexia  Hypervolemia  Neurogenic shock  Sepsis 10. The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?  Side-lying, with legs pulled up and head bent down onto the chest  Side-lying, with a pillow under the hip  Prone, in a slight Trendelenburg’s position  Prone, with a pillow under the abdomen. 11. A nurse is assisting with caloric testing of the oculovestibular reflex NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:  A cerebral lesion  A temporal lesion  An intact brainstem  Brain death 12. The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?  Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.  Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.  Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.  Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure. 13. The nurse is evaluating the status of a client who had a craniotomy NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:  A positive Brudzinski’s sign  A negative Kernig’s sign  Absence of nuchal rigidity  A Glascow Coma Scale score of 15 14. A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to: NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ 18. The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. 1. Head tilt 2. Vomiting 3. Polydipsia 4. Lethargy 5. Increased appetite 6. Increased pulse 1,2,4 19. A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis? 1. Cloudy CSF, decreased protein, and decreased glucose 2. Cloudy CSF, elevated protein, and decreased glucose 3. Clear CSF, elevated protein, and decreased glucose 4. Clear CSF, decreased pressure, and elevated protein 20. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ following would be included in the plan of care? 1. No precautions are required as long as antibiotics have been started 2. Maintain enteric precautions 3. Maintain respiratory isolation precautions for at least 24 hours after the NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ initiation of antibiotics 4. Maintain neutropenic precautions 21. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?  Elevate the client’s legs  Put the client flat in bed Put the client in the Trendelenburg’s position  Put the client in the high-Fowler’s position 22 A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?  Bladder distension  Neurological deficit  Pulse ox readings  The client’s feelings about the injury NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ conditions?  Extent of intracranial bleeding  Sites of brain injury  .Activity of the brain  Percent of functional brain tissue 29. A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?  Subdural hematoma  Subarachnoid hemorrhage  Epidural hematoma  Contusion 30. After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect?  Quadriplegia with gross arm movement and diaphragmatic breathing  Quadriplegia and loss of respiratory function NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+  Paraplegia with intercostal muscle loss  Loss of bowel and bladder control 31. A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected. How should the first- responder open the client’s airway for rescue breathing?  By inserting a nasopharyngeal airway  By inserting a oropharyngeal airway  By performing a jaw-thrust maneuver  By performing the head-tilt, chin-lift maneuver 32. The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1. Elevate the HOB to 90 degrees 2. Loosen constrictive clothing 3. Use a fan to reduce diaphoresis 4. Assess for bladder distention and bowel impaction 5. Administer antihypertensive medication NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ 6. Place the client in a supine position with legs elevated 1,2,4,5 33. The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer:  Desmopressin (DDAVP, Stimate)  Dexamethasone (Decadron)  Ethacrynic acid (Edecrin)  Mannitol (Osmitrol) 34. The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with:  Skull fracture  Concussion  Subdural hematoma  Epidural hematoma 35. The nurse is caring for a client who suffered a spinal cord injury 48 NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+  Raise the head of the bed  Contact the physician  Loosen tight clothing on the client  Administer an antihypertensive medication 2,4,1,3,5 41. A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?  Unequal pupil size  Decreasing systolic blood pressure  Tachycardia  Decreasing body temperature 42. Which of the following respiratory patterns indicate increasing ICP in the brain stem?  Slow, irregular respirations  Rapid, shallow respirations  Asymmetric chest expansion  Nasal flaring 43. Which of the following nursing interventions is appropriate for a NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ client with an ICP of 20 mm Hg?  Give the client a warming blanket  Administer low-dose barbiturate  Encourage the client to hyperventilate  Restrict fluids 44. A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition?  Widening pulse pressure  Decrease in the pulse rate  Dilated, fixed pupil  Decrease in LOC 45. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?  Place her in a jacket restraint  Wrap her hands in soft “mitten” restraints  Tuck her arms and hands under the draw sheet  Apply a wrist restraint to each arm 46. Which of the following describes decerebrate posturing? NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+  Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers  Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet  Supination of arms, dorsiflexion of feet  Back arched; rigid extension of all four extremities. 47. A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?  Count the rate to be sure the ventilations are deep enough to be sufficient  Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score.  Call the physician to adjust the ventilator settings.  Check deep tendon reflexes to determine the best motor response 48. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ 53. After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A. Give him a barbiturate. B. Place him on mechanical ventilation. C. Perform a lumbar puncture. D. Elevate the head of his bed. 54. When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: A. Light flashes and floaters in front of the eye. B. A recent driving accident while changing lanes. C. Headaches, nausea, and redness of the eyes. D. Frequent episodes of double vision. 55. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ D. Risk for injury 56. To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should: A. Stay with the client and encourage him to eat. B. Help the client fill out his menu. C. Give the client privacy during meals. D. Fill out the menu for the client. 57. The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function 58. Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed? A. In 30 to 45 seconds B. In 10 to 15 minutes NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ C. In 30 to 45 minutes D. In 1 to 2 hours 59. A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? A. Parasympathomimetic agent B. Sympatholytic agent C. Adrenergic blocker D. Cholinergic blocker 60. Emergency medical technicians transport a 27-year-old iron worker to the emergency department. They tell the nurse, “He fell from a two- story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has the highest priority? NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ 65. A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client’s feet make a half circle. To document the client’s gait, the nurse should use which term? A. Ataxic B. Dystrophic C. Helicopod D. Steppage 66. A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses’ station B. An isolation room three doors from the nurses’ station C. A semi private room with a 32-year-old client who has viral meningitis D. A two-bed room with a client who previously had bacterial meningitis 67. A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client’s history. Which preexisting condition would contraindicate the use of pyridostigmine? NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ A. Ulcerative colitis B. Blood dyscrasia C. Intestinal obstruction D. Spinal cord injury 68. A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière’s disease. When assessing this client, the nurse expects to note: A. Vertigo, tinnitus, and hearing loss. B. Vertigo, vomiting, and nystagmus C. Vertigo, pain, and hearing impairment. D. Vertigo, blurred vision, and fever. 69. A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A. “Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours.” B. “Try to ambulate independently after about 24 hours.” C. “Shampoo your hair every day for ten (10) days to help prevent ear infection.” D. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ or expose yourself to loud sounds for 30 days.” 70. Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? A. Excessive tearing B. Urine retention C. Muscle weakness D. Slurred speech 71. The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A. Tachycardia B. Increased salivation C. Hypotension D. Apnea 72. A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ B. Medulla C. Midbrain D. Cortex 78. The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? A. Vision changes B. Absent deep tendon reflexes C. Tremors at rest D. Flaccid muscles 79. The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the physician immediately. 80. During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This assessment NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ evaluates: A. Cranial nerves I and II. B. Cranial nerves III and V. C. Cranial nerves VI and VIII. D. Cranial nerves IX and X. 81. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? 1. Vomiting continues 2. Intracranial pressure (ICP) is increased 3. The client needs mechanical ventilation 4. Blood is anticipated in the cerebrospinal fluid (CSF) 82. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? 1. To reduce intraocular pressure 2. To prevent acute tubular necrosis 3. To promote osmotic diuresis to decrease ICP 4. To draw water into the vascular system to increase blood pressure NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ 83. A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? 1. Urine output increases 2. Pupils are 8 mm and nonreactive 3. Systolic blood pressure remains at 150 mm Hg 4. BUN and creatinine levels return to normal 84. Which of the following values is considered normal for ICP? 1. 0 to 15 mm Hg 2. 25 mm Hg 3. 35 to 45 mm Hg 4. 120/80 mm Hg 85. Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? 1. Ataxia and confusion 2. Sodium depletion 3. Tonic-clonic seizure 4. Urinary incontinence NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ 92. A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?  Place the client flat in bed  Assess patency of the indwelling urinary catheter  Give one SL nitroglycerin tablet  Raise the head of the bed immediately to 90 degrees 93. A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?  To hasten wound healing  To immobilize the cervical spine  To prevent autonomic dysreflexia  To hold bony fragments of the skull together 94. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? 1. Insert an indwelling urinary catheter to straight drainage 2. Schedule intermittent catheterization every 2 to 4 hours  Perform a straight catheterization every 8 hours while awake  Perform Crede’s maneuver to the lower abdomen before the client voids. NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ 95. A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?  Laceration of the middle meningeal artery  Rupture of the carotid artery  Thromboembolism from a carotid artery  Venous bleeding from the arachnoid space 96. A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?  Position the client flat in bed  Check the fluid for dextrose with a dipstick  Suction the nose to maintain airway patency  Insert nasal and ear packing with sterile gauze 97 . When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+ NSG403 100 NEURO NCLEX LATEST EXAM QUESTIONS & ANSWERS BEST GUARANTEED 2022\2023 RATED A+  An interval when the client’s speech is garbled  An interval when the client is alert but can’t recall recent events  An interval when the client is oriented but then becomes somnolent  An interval when the client has a “warning” symptom, such as an odor or visual disturbance. 98. Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?  A client with a brain injury  A client with a herniated nucleus pulposus 3. A client with a high cervical spine injury 4. A client with a stroke 99. Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia?  Absence of pain sensation in chest  Spasticity  Spontaneous respirations  Urinary continence 100. A nurse assesses a client who has episodes of autonomic dysreflexia.