LPN Medical-Surgical Nursing: Musculoskeletal and Neurological 3 — Questions and Answers
Question 1: A patient is admitted with suspected meningitis. Which assessment finding is the nurse most likely to identify?
- Positive Kernig's sign (Correct answer)
- Negative Babinski reflex
- Decreased deep tendon reflexes
- Bradycardia with hypotension
Correct answer: Positive Kernig's sign
A positive Kernig's sign (inability to extend the knee when the hip is flexed) is a classic clinical indicator of meningeal irritation seen in meningitis.
Question 2: A patient with a traumatic brain injury has a GCS score of 8. How should the nurse interpret this finding?
- Normal neurological function
- Mild traumatic brain injury
- Severe traumatic brain injury (Correct answer)
- Moderate traumatic brain injury
Correct answer: Severe traumatic brain injury
A GCS score of 8 or below indicates severe traumatic brain injury and is associated with significant risk of complications including herniation.
Question 3: The nurse is monitoring a patient for signs of increased intracranial pressure (ICP). Which set of findings represents Cushing's triad?
- Tachycardia, hypotension, and tachypnea
- Bradycardia, widened pulse pressure, and irregular respirations (Correct answer)
- Hypertension, tachycardia, and shallow breathing
- Bradycardia, hypotension, and apnea
Correct answer: Bradycardia, widened pulse pressure, and irregular respirations
Cushing's triad — bradycardia, widened pulse pressure (hypertension with low diastolic), and irregular respirations — is a late, ominous sign of severely elevated ICP.
Question 4: A patient with a spinal cord injury at the T4 level suddenly develops a pounding headache, flushing above the injury level, and a blood pressure of 190/100 mmHg. What should the nurse do first?
- Administer an antihypertensive medication
- Place the patient in Trendelenburg position
- Sit the patient upright and identify the triggering stimulus (Correct answer)
- Notify the physician and document the findings
Correct answer: Sit the patient upright and identify the triggering stimulus
This presentation is autonomic dysreflexia; sitting the patient upright to lower BP and immediately removing the triggering stimulus (e.g., full bladder, kinked catheter) is the first action.
Question 5: A patient is admitted after a tonic-clonic seizure. During the postictal period, which nursing intervention takes priority?
- Reorienting the patient to time and place
- Placing the patient in a lateral recovery position (Correct answer)
- Administering prescribed antiepileptic medication
- Applying supplemental oxygen via non-rebreather mask
Correct answer: Placing the patient in a lateral recovery position
Placing the patient on their side prevents aspiration of secretions or vomitus during the postictal period when protective reflexes may be diminished.
Question 6: A nurse is caring for a patient who had an ischemic stroke 2 hours ago. The physician is considering tPA administration. Which assessment finding would be a contraindication?
- Blood glucose of 110 mg/dL
- Blood pressure of 148/88 mmHg
- Patient on warfarin with an INR of 2.8 (Correct answer)
- Onset of symptoms within 3 hours
Correct answer: Patient on warfarin with an INR of 2.8
An INR greater than 1.7 due to anticoagulation therapy is a contraindication to tPA because of the significantly increased risk of hemorrhagic conversion.
Question 7: Which patient action best demonstrates understanding of safety measures following a diagnosis of epilepsy?
- 'I will take showers rather than baths to prevent drowning.' (Correct answer)
- 'I can drive as long as I have not had a seizure in 30 days.'
- 'I should stop my antiepileptic medication if I feel well.'
- 'Swimming is completely safe as long as I wear a life vest.'
Correct answer: 'I will take showers rather than baths to prevent drowning.'
Showers are safer than baths for patients with epilepsy because a seizure during a bath can result in drowning; this statement reflects appropriate safety understanding.
LPN Medical-Surgical Nursing: Musculoskeletal and Neurological 3
A patient is admitted with suspected meningitis.
Which assessment finding is the nurse most likely to identify?