LPN Medical-Surgical Nursing: Musculoskeletal and Neurological 3

Question 1

A patient is admitted with suspected meningitis. Which assessment finding is the nurse most likely to identify?

Accepted Answer

Positive Kernig's sign

Answer

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?

Accepted Answer

Severe traumatic brain injury

Answer

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?

Accepted Answer

Bradycardia, widened pulse pressure, and irregular respirations

Answer

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?

Accepted Answer

Sit the patient upright and identify the triggering stimulus

Answer

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?

Accepted Answer

Placing the patient in a lateral recovery position

Answer

Placing the patient on their side prevents aspiration of secretions or vomitus during the postictal period when protective reflexes may be diminished.

(LPN) Certified Practical Nurse Practice Test

(LPN) Certified Practical Nurse Practice Test

LPN Medical-Surgical Nursing: Musculoskeletal and Neurological 3