LPN Medical-Surgical Nursing: Musculoskeletal and Neurological 1 — Questions and Answers

Question 1: A client with a fractured femur is placed in skeletal traction. The LPN's priority assessment is:

Pain level and analgesic effectiveness
Neurovascular status of the affected extremity (Correct answer)
Weight hanging freely and ropes unobstructed
Pin sites for signs of infection

Correct answer: Neurovascular status of the affected extremity

Neurovascular assessment — checking the 6 Ps (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia) — is the priority because traction can impair circulation or nerve function.

Traction can compromise neurovascular integrity in the affected extremity. The LPN must assess the 6 Ps every 1–2 hours: Pain (severe or increasing), Pallor, Pulselessness (absent distal pulse), Paresthesia (numbness/tingling), Paralysis (inability to move), and Poikilothermia (coolness). These signs indicate compartment syndrome or vascular compromise requiring emergency intervention. While pin care, proper traction setup, and pain management are all important, neurovascular assessment is the safety priority.

Question 2: A client had a left-sided stroke with resulting right-sided hemiplegia. When assisting with meals, the LPN should:

Place food on the left side of the tray within the client's visual field (Correct answer)
Feed the client entirely to prevent aspiration
Position the client in a chair with head tilted to the right
Place food on the right side of the tray and encourage self-feeding

Correct answer: Place food on the left side of the tray within the client's visual field

Left hemisphere stroke often causes right-sided visual field deficits (right homonymous hemianopia). Placing food on the intact left visual field enables the client to see and reach food safely.

A left-sided stroke affecting the occipital lobe can cause right homonymous hemianopia (loss of right visual field in both eyes). The LPN should place food and items within the client's intact left visual field. Encourage the client to turn their head to scan the right side. Promote independence with adaptive utensils and assess for dysphagia before each meal. Tilting the head to the right is incorrect and may increase aspiration risk. Complete feeding prevents autonomy and cognitive rehabilitation opportunities.

Question 3: A client with a cervical spine injury at C5-C6 is being bathed. Which finding requires the LPN to stop and immediately notify the charge nurse?

Muscle spasms in the upper extremities
Sudden severe headache, sweating above the injury, and bradycardia (Correct answer)
Mild skin redness over the sacrum
Urinary incontinence

Correct answer: Sudden severe headache, sweating above the injury, and bradycardia

These are classic signs of autonomic dysreflexia, a life-threatening condition in clients with SCI at T6 or above, caused by an unrecognized stimulus below the injury level.

Autonomic dysreflexia (AD) is a medical emergency in clients with spinal cord injury at T6 or above. Stimuli below the injury (full bladder, fecal impaction, tight clothing, skin irritation) trigger an uncontrolled sympathetic response causing severe hypertension, bradycardia, pounding headache, profuse sweating and flushing above the injury, and pallor below. Treatment: sit the client upright immediately to lower BP, identify and remove the trigger (check catheter, bladder, bowel), notify the charge nurse and provider. Untreated, it can cause stroke or death.

Question 4: A client with osteoporosis is taught about fall prevention. Which statement indicates correct understanding?

I should avoid weight-bearing exercise to protect my bones
I will remove loose rugs and install grab bars in my bathroom (Correct answer)
Calcium supplements will reverse my bone loss completely
I should wear soft slippers when walking around my home

Correct answer: I will remove loose rugs and install grab bars in my bathroom

Removing fall hazards (loose rugs, poor lighting) and installing safety equipment (grab bars, non-slip mats) directly reduces fracture risk in osteoporosis.

Fall prevention for clients with osteoporosis includes: remove loose rugs, cords, and clutter; ensure adequate lighting especially at night; install grab bars in bathrooms and stairways; use non-slip mats in shower/tub; wear well-fitting, supportive footwear (not soft slippers); keep frequently used items at reachable heights; use assistive devices as prescribed. Weight-bearing exercise (walking, resistance training) actually strengthens bones. Calcium and vitamin D slow further bone loss but cannot completely reverse existing osteoporosis.

Question 5: A client with Parkinson's disease is at risk for which complication requiring the highest nursing vigilance?

Hypertension and stroke
Aspiration pneumonia from dysphagia and choking (Correct answer)
Deep vein thrombosis from immobility
Pressure ulcers from incontinence

Correct answer: Aspiration pneumonia from dysphagia and choking

Dysphagia and slowed swallowing in Parkinson's disease significantly increase the risk of aspiration, which is a leading cause of morbidity and mortality in this population.

Parkinson's disease causes bradykinesia, rigidity, and tremors affecting the muscles of mastication and swallowing, leading to dysphagia. Aspiration of food, liquid, or oral secretions into the airway causes aspiration pneumonia, a leading cause of death in Parkinson's clients. Nursing interventions: upright 90-degree positioning during and after meals, thickened liquids as ordered, chin-tuck technique, small bites, speech therapy evaluation, and monitoring for coughing/choking. While DVT and pressure ulcers are also concerns, aspiration carries the highest mortality risk.

Question 6: A client returns from hip replacement surgery. The LPN should position the client to prevent hip dislocation by:

Crossing the legs at the ankles when in bed
Keeping the operated leg adducted and internally rotated
Maintaining hip flexion greater than 90 degrees when sitting
Using an abduction pillow between the legs and avoiding crossing the legs (Correct answer)

Correct answer: Using an abduction pillow between the legs and avoiding crossing the legs

After total hip arthroplasty, dislocation is prevented by keeping the hip in abduction, avoiding adduction past midline, crossing legs, or flexing the hip beyond 90 degrees.

Total hip arthroplasty (THA) requires hip precautions for 6–12 weeks to allow the capsule to heal and prevent dislocation. Precautions include: use an abduction pillow between the legs, do NOT cross the legs or ankles, do NOT flex the hip beyond 90 degrees (no low chairs, no bending at the waist to put on shoes), do NOT internally rotate the operated leg. Signs of dislocation include sudden severe pain, shortened externally rotated leg, and inability to bear weight. The LPN should reinforce these precautions with every interaction.

Question 7: A client with multiple sclerosis (MS) is experiencing a relapse with worsening fatigue. The most important nursing intervention is:

Encouraging the client to push through fatigue with regular exercise
Scheduling rest periods throughout the day and avoiding heat exposure (Correct answer)
Keeping room temperature warm to improve muscle function
Administering high-dose aspirin for pain relief

Correct answer: Scheduling rest periods throughout the day and avoiding heat exposure

Fatigue management in MS includes scheduled rest, energy conservation techniques, and avoiding heat (Uhthoff's phenomenon), which worsens symptoms by slowing nerve conduction.

Fatigue is one of the most debilitating symptoms of MS. Uhthoff's phenomenon describes worsening of neurological symptoms with heat (fever, hot weather, hot baths). Nursing management includes: scheduled rest periods, energy conservation techniques (pacing activities), cool environment, adequate sleep, and referral to occupational therapy. Exercise is beneficial but should be low-intensity (aquatic therapy) to avoid overheating. Heat sources (hot tubs, saunas, heating pads) should be avoided. During a relapse, rest and symptom management are prioritized.

Question 8: A client with Alzheimer's disease becomes agitated and combative during bathing. The LPN's best approach is to:

Restrain the client to complete the bath safely
Stop the activity, allow the client to calm down, and attempt bathing later (Correct answer)
Increase the frequency of baths to build familiarity
Administer PRN sedative before each bath

Correct answer: Stop the activity, allow the client to calm down, and attempt bathing later

Agitation in dementia is often a response to overwhelming stimuli or discomfort. The best person-centered approach is to stop, allow the client to de-escalate, and retry the task with a modified approach.

Clients with Alzheimer's disease may experience catastrophic reactions to routine care tasks due to cognitive impairment, fear, or overstimulation. Best practices include: stop the triggering activity, speak calmly and quietly, use distraction, simplify the environment, and reattempt with a different approach or caregiver. Modified bathing approaches include bed baths, towel baths, or timing bathing when the client is least agitated. Physical restraints increase agitation and carry complications. PRN sedatives are a last resort and require a provider order.

Question 9: A client with a herniated lumbar disc (L4-L5) reports severe left leg pain radiating to the foot. The LPN recognizes this as:

Vascular claudication
Sciatica from nerve root compression (Correct answer)
Diabetic peripheral neuropathy
Restless legs syndrome

Correct answer: Sciatica from nerve root compression

Radiating leg pain from herniated disc at L4-L5 compresses the sciatic nerve, causing sciatica — sharp, shooting pain that travels from the lower back down the leg to the foot.

A herniated disc at L4-L5 can compress the L5 or S1 nerve roots, causing sciatica. Symptoms include sharp, burning, or shooting pain radiating from the lower back through the buttock, down the posterior thigh, and into the leg and foot — following the sciatic nerve distribution. Associated symptoms include numbness, tingling, and weakness. The positive straight leg raise (SLR) test reproduces the pain. Treatment includes rest, NSAIDs, physical therapy, and sometimes epidural steroid injections or surgery. The LPN should document the distribution and character of pain.

Question 10: A client after craniotomy for a brain tumor develops a blood pressure of 170/52 mmHg (widened pulse pressure), bradycardia of 48 bpm, and irregular respirations. The LPN recognizes this as:

Hypertensive crisis requiring emergency antihypertensives
Cushing's triad — a sign of increased intracranial pressure requiring immediate escalation (Correct answer)
Septic shock from surgical infection
Expected postoperative changes

Correct answer: Cushing's triad — a sign of increased intracranial pressure requiring immediate escalation

Cushing's triad (hypertension with widened pulse pressure, bradycardia, and irregular respirations) is a late sign of severely increased ICP and impending brain herniation.

Cushing's triad represents the brain's last attempt to maintain cerebral perfusion in the setting of markedly elevated intracranial pressure (ICP). It consists of: (1) hypertension with widened pulse pressure, (2) bradycardia, and (3) irregular respirations (Cheyne-Stokes or apneustic breathing). This is a late and ominous sign indicating impending transtentorial herniation. The LPN must immediately notify the charge nurse and neurosurgeon. Anticipated interventions include head elevation to 30 degrees, mannitol, hyperventilation, and emergency surgical decompression.

Question 11: A client with myasthenia gravis is admitted to the hospital. The LPN recognizes that a myasthenic crisis differs from a cholinergic crisis in that myasthenic crisis presents with:

Excessive secretions, bradycardia, and miosis
Muscle weakness that improves with edrophonium (Tensilon) test (Correct answer)
Hypertension and fever
Diarrhea and urinary incontinence

Correct answer: Muscle weakness that improves with edrophonium (Tensilon) test

In myasthenic crisis, the Tensilon test shows temporary improvement in muscle strength because insufficient acetylcholine is reaching the neuromuscular junction.

Myasthenia gravis (MG) involves autoantibodies against acetylcholine receptors, causing muscle weakness. Myasthenic crisis is caused by disease exacerbation or medication non-compliance; weakness temporarily improves with edrophonium (Tensilon) IV. Cholinergic crisis results from anticholinesterase medication overdose; Tensilon worsens weakness. Both can cause respiratory failure. Cholinergic crisis also produces SLUDGE symptoms (Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis) plus bradycardia and miosis. Both are respiratory emergencies requiring ICU monitoring.

Question 12: A client with Guillain-Barré syndrome is being monitored in the hospital. Which assessment finding is the most critical?

Paresthesia in both feet
Declining forced vital capacity and inability to cough effectively (Correct answer)
Mild weakness in both hands
Areflexia in the lower extremities

Correct answer: Declining forced vital capacity and inability to cough effectively

Guillain-Barré syndrome causes ascending paralysis that can involve the respiratory muscles. Declining FVC and inability to cough signals impending respiratory failure requiring immediate intervention.

Guillain-Barré syndrome is an autoimmune polyneuropathy causing ascending muscle weakness from distal to proximal. The greatest danger is involvement of the respiratory muscles (intercostals, diaphragm). The LPN should monitor respiratory status every 2–4 hours, including respiratory rate, depth, oxygen saturation, and forced vital capacity (FVC). FVC <20 mL/kg or an inability to count to 20 in one breath is an indication for elective intubation before respiratory arrest occurs. Other assessments include blood pressure (autonomic dysfunction) and pain management.

Question 13: A client with a newly applied leg cast reports increasing pain, tingling, and tightness in the foot. The capillary refill time is 4 seconds. The LPN should:

Elevate the extremity and apply ice over the cast
Administer the prescribed analgesic and reassess in 30 minutes
Immediately notify the charge nurse — these signs suggest compartment syndrome (Correct answer)
Reassure the client that cast discomfort is expected

Correct answer: Immediately notify the charge nurse — these signs suggest compartment syndrome

Increasing pain, paresthesia, pallor, and prolonged capillary refill (>3 seconds) with a cast are signs of compartment syndrome — a surgical emergency requiring fasciotomy if confirmed.

Compartment syndrome occurs when pressure within a muscle compartment exceeds perfusion pressure, causing ischemia. Signs include the 6 Ps: Pain (especially pain with passive stretch, most sensitive early sign), Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia. Capillary refill >3 seconds is abnormal. The LPN must notify the charge nurse and surgeon immediately. Remove or bivalve the cast, keep the extremity at heart level (not elevated, which worsens ischemia), and prepare for possible emergency fasciotomy. Time is critical — irreversible damage occurs within 6 hours.

Question 14: A client with a C4 spinal cord injury requires suctioning. The LPN should limit each suction pass to:

30–45 seconds
20–25 seconds
5–10 seconds (Correct answer)
15–20 seconds

Correct answer: 5–10 seconds

Each suctioning pass should last no more than 10 seconds to minimize hypoxia and prevent vagal stimulation, which can cause life-threatening bradycardia in high SCI clients.

Tracheal suctioning must be limited to 10–15 seconds per pass (some protocols cite 5–10 seconds) to prevent hypoxia, atelectasis, and vagal stimulation. In clients with cervical SCI at C4 or above, vagal stimulation during suctioning can cause severe bradycardia or even cardiac arrest. The LPN should pre-oxygenate with 100% oxygen before suctioning, suction only as needed, and monitor heart rate and oxygen saturation throughout. Atropine should be at the bedside for high-SCI clients requiring frequent suctioning.

Question 15: The LPN is caring for a client with a new diagnosis of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis takes the highest priority?

Ineffective coping related to terminal diagnosis
Impaired physical mobility related to muscle weakness
Risk for aspiration related to bulbar involvement (Correct answer)
Chronic pain related to muscle cramps

Correct answer: Risk for aspiration related to bulbar involvement

Bulbar involvement in ALS causes dysphagia and dysarthria, dramatically increasing aspiration risk, which can cause pneumonia — the most common immediate cause of death in ALS.

ALS (Lou Gehrig's disease) is a progressive motor neuron disease causing loss of voluntary muscle control. Bulbar ALS affects cranial nerve motor neurons controlling speech and swallowing, causing dysphagia and dysarthria. Aspiration is the most immediate life-threatening complication and the most common cause of death (along with respiratory failure). Priority nursing interventions include: swallow evaluation, modified diet (thickened liquids, soft foods), upright positioning during meals, and suctioning equipment at bedside. Emotional support and advance care planning are also essential but secondary to physiological safety.

Question 16: A client with low back pain is being treated with muscle relaxants and NSAIDs. Which patient education point is most important?

NSAIDs can be taken on an empty stomach for better absorption
Alcohol should be avoided while taking muscle relaxants due to CNS depression (Correct answer)
Muscle relaxants improve strength and can be used before heavy exercise
Double the NSAID dose if pain is not relieved within 1 hour

Correct answer: Alcohol should be avoided while taking muscle relaxants due to CNS depression

Muscle relaxants cause CNS depression; combining them with alcohol significantly enhances sedation and can cause respiratory depression, falls, and dangerous intoxication.

Skeletal muscle relaxants (cyclobenzaprine, methocarbamol, baclofen) work centrally to reduce muscle spasm and cause sedation. Alcohol combined with these medications produces additive CNS depression, increasing the risk of respiratory depression, profound sedation, and falls. NSAIDs should be taken with food or milk to protect the gastric mucosa. NSAIDs should never be doubled without provider guidance due to GI bleeding risk. Muscle relaxants do not increase strength and should not be used before exertion. Safety is the priority teaching point.

Question 17: A client with a spinal cord injury at T10 is being taught to perform intermittent self-catheterization. This client is ABLE to perform self-catheterization because:

T10 injury does not affect bowel or bladder function
Injury below T6 preserves upper extremity motor function needed for the procedure (Correct answer)
The client's bladder paralysis is temporary
A T10 injury causes only sensory loss, not motor loss

Correct answer: Injury below T6 preserves upper extremity motor function needed for the procedure

A T10 spinal cord injury spares the cervical and thoracic motor function, preserving arm and hand function needed to perform intermittent self-catheterization.

The level of SCI determines which functions are preserved. T10 injury causes paraplegia (lower extremity weakness/paralysis) with full preservation of cervical and upper thoracic function, including arm and hand dexterity. This allows the client to learn and perform intermittent self-catheterization. Clean intermittent catheterization (CIC) is preferred over indwelling catheters to reduce UTI risk and maintain bladder health. T10 injury causes neurogenic bladder (either flaccid or spastic), requiring either CIC or a voiding schedule. Bladder paralysis in SCI is typically permanent.

Question 18: During a post-fall neurological assessment, the nurse uses the Glasgow Coma Scale (GCS). A client opens eyes to voice, makes incomprehensible sounds, and withdraws from pain. The GCS score is:

9 (Correct answer)
10
8
7

Correct answer: 9

GCS: Eye opening to voice = 3, Verbal incomprehensible sounds = 2, Motor withdrawal = 4. Total = 9.

The Glasgow Coma Scale scores three responses: Eye (E): 4=spontaneous, 3=to voice, 2=to pain, 1=none; Verbal (V): 5=oriented, 4=confused, 3=inappropriate words, 2=incomprehensible sounds, 1=none; Motor (M): 6=obeys, 5=localizes, 4=withdraws, 3=flexion, 2=extension, 1=none. This client: E=3 (to voice) + V=2 (incomprehensible) + M=4 (withdraws) = GCS 9. A score ≤8 indicates severe brain injury requiring intubation consideration. The LPN must document and report any GCS change of 2 or more points immediately.

Question 19: A client with rheumatoid arthritis (RA) asks about managing morning joint stiffness. The LPN's best recommendation is:

Apply ice packs to stiff joints for 20 minutes each morning
Take a warm shower or apply warm compresses to stiff joints before activity (Correct answer)
Avoid all movement until stiffness resolves spontaneously
Increase dietary protein to rebuild inflamed joint tissue

Correct answer: Take a warm shower or apply warm compresses to stiff joints before activity

Warm therapy (shower, warm compress) increases circulation and reduces viscosity of synovial fluid, helping relieve the characteristic morning stiffness of RA.

Morning stiffness lasting >1 hour is a hallmark of rheumatoid arthritis caused by synovial inflammation. Warm therapy (warm shower, bath, heating pad, paraffin wax) increases blood flow, raises synovial fluid temperature, reduces viscosity, and promotes joint mobility. This is most effective first thing in the morning. Cold therapy is better for acute gout flares or acute inflammation. Clients should be encouraged to move gently during and after warming to maintain joint function. Dietary changes do not directly treat morning stiffness.

Question 20: A client post-laminectomy is reporting increased back pain with new onset weakness in both legs and bladder incontinence. The LPN should:

Administer the prescribed pain medication and reassess
Reposition the client and apply a warm compress to the back
Notify the charge nurse immediately — these signs suggest cauda equina syndrome (Correct answer)
Document the findings and report at the next shift change

Correct answer: Notify the charge nurse immediately — these signs suggest cauda equina syndrome

New bilateral leg weakness and bladder dysfunction after spinal surgery are hallmark signs of cauda equina syndrome — a neurosurgical emergency that can cause permanent paralysis and incontinence.

Cauda equina syndrome (CES) is caused by compression of the cauda equina nerve roots, resulting in: bilateral lower extremity weakness or paralysis, bowel and bladder dysfunction (incontinence or retention), saddle anesthesia (numbness in the perianal area, inner thighs), and severe back or leg pain. It is a neurosurgical emergency — permanent neurological deficits result if decompression does not occur within 24–48 hours. Post-laminectomy, CES may result from hematoma or recurrent disc herniation. The LPN must escalate immediately.

Question 21: A client with Parkinson's disease is prescribed levodopa-carbidopa. The LPN should teach the client to:

Take the medication with a high-protein meal for best absorption
Avoid vitamin B6 supplements which reduce levodopa effectiveness (Correct answer)
Expect rapid improvement in symptoms within 24 hours
Take the medication only when tremors become severe

Correct answer: Avoid vitamin B6 supplements which reduce levodopa effectiveness

Vitamin B6 (pyridoxine) enhances the peripheral decarboxylation of levodopa, reducing the amount reaching the brain. Carbidopa reduces this effect but high-dose B6 can overcome it.

Levodopa is converted to dopamine both peripherally and centrally. Carbidopa inhibits peripheral conversion, allowing more levodopa to cross the blood-brain barrier. However, high doses of vitamin B6 (pyridoxine) enhance peripheral aromatic amino acid decarboxylase activity, increasing peripheral metabolism of levodopa and reducing its central effectiveness. Clients should avoid vitamin B6 supplements and foods extremely high in B6. High-protein meals also compete with levodopa for transport across the blood-brain barrier — medication is best taken 30–60 minutes before or 1–2 hours after meals.

Question 22: A client with a complete C7 spinal cord injury. The LPN knows this client is MOST likely able to:

Walk with forearm crutches
Breathe independently without ventilator support
Perform all activities of daily living independently without adaptive equipment
Transfer independently using a sliding board (Correct answer)

Correct answer: Transfer independently using a sliding board

C7 injury preserves triceps function and allows wrist extension, enabling independent transfers using a sliding board and some ADL independence with adaptive equipment.

Functional levels of SCI: C7 injury preserves biceps, wrist extensors, and triceps, allowing the client to perform pressure relief maneuvers, use a manual wheelchair, and transfer independently with a sliding board. C7 is often the level at which meaningful upper extremity independence begins. Breathing is typically independent at C3-C5 (diaphragm = C3-4-5). Walking is not possible with complete C7 injury. Full ADL independence usually requires C8-T1 function. The LPN should support realistic goal-setting with the rehabilitation team.

Question 23: A client with epilepsy is having a generalized tonic-clonic seizure. The LPN's priority action is:

Restrain the client's limbs to prevent injury from flailing
Insert an oral airway to maintain the airway
Protect the client from injury and time the seizure duration (Correct answer)
Give a dose of benzodiazepine immediately

Correct answer: Protect the client from injury and time the seizure duration

The priority during a seizure is client safety: clear the environment, protect the head, turn the client to the side, and time the seizure. Nothing should be inserted into the mouth.

During a generalized tonic-clonic seizure, nursing priorities are: (1) Protect from injury — lower to the floor if possible, move hard objects away, cushion the head; (2) Position on the side (lateral) after the tonic phase to prevent aspiration; (3) Time the seizure duration — >5 minutes is status epilepticus requiring emergency medication; (4) Do NOT restrain (causes musculoskeletal injury); (5) Do NOT insert anything into the mouth (causes oral trauma, teeth may break off and aspirate); (6) Call for help. Document seizure type, duration, and post-ictal behavior.

Question 24: A client with osteoarthritis of the knee asks about weight management. The LPN should explain that excess body weight increases knee joint stress by:

2–3 times body weight with each step
4–6 times body weight with each step (Correct answer)
Equal to body weight
8–10 times body weight with running only

Correct answer: 4–6 times body weight with each step

Biomechanical studies show that each pound of excess body weight adds approximately 4–6 pounds of force on the knee joint with each step, dramatically accelerating cartilage wear.

Research demonstrates that the force across the knee joint is 4–6 times body weight during walking. This means losing 10 lbs reduces knee joint force by 40–60 lbs per step. Excess weight accelerates cartilage destruction, increases pain, and worsens osteoarthritis progression. Even modest weight loss (5–10% of body weight) significantly reduces pain and improves function. The LPN should emphasize that weight management combined with low-impact exercise (water aerobics, cycling) is one of the most effective non-pharmacological treatments for knee OA.

Question 25: A client with a T6 complete spinal cord injury has a distended bladder (last voided 6 hours ago) and is developing a pounding headache and facial flushing. The immediate action is:

Elevate the head of the bed to 90 degrees and check the urinary catheter for obstruction (Correct answer)
Lay the client flat and administer IV antihypertensives
Apply a heating pad to the abdomen to stimulate voiding
Document and continue monitoring every 15 minutes

Correct answer: Elevate the head of the bed to 90 degrees and check the urinary catheter for obstruction

These are signs of autonomic dysreflexia triggered by bladder distension. Sit the client upright to reduce BP and immediately check for and relieve the urinary trigger.

Autonomic dysreflexia (AD) is triggered by noxious stimuli below the SCI level (most commonly bladder distension or bowel impaction). Treatment protocol: (1) Immediately sit the client upright or elevate the head of bed to 90 degrees to lower BP through orthostatic effect; (2) Identify and remove the stimulus — check catheter for kinks/blockage and drain the bladder; check for bowel impaction; (3) Monitor blood pressure every 2–5 minutes; (4) Notify charge nurse; (5) Administer antihypertensives if ordered and BP remains critically high. Systolic BP >150 requires pharmacological intervention.

Question 26: A client with a plaster cast on the right arm reports a burning sensation under the cast. The LPN should:

Insert a padded tongue blade under the cast to scratch the area
Reassure the client that this is a normal sensation during drying
Notify the charge nurse and assess for signs of pressure injury (Correct answer)
Apply ice directly on top of the cast

Correct answer: Notify the charge nurse and assess for signs of pressure injury

A burning sensation under a cast may indicate a pressure ulcer or skin breakdown developing under the cast, requiring provider evaluation and possible cast windowing or replacement.

Burning pain under a cast is a red flag that should never be dismissed as normal. It may indicate: pressure injury from an improperly fitting cast, a foreign body, infection under the cast, or nerve compression. The LPN should notify the charge nurse and document the complaint. The provider may need to bivalve or window the cast to inspect the skin. Inserting objects under the cast can cause skin abrasion, worsen pressure injury, or introduce infection. A hot spot (area warm to touch) on the cast surface may also indicate infection or wound breakdown.

Question 27: A client with gout is having an acute attack in the right great toe. Which nursing intervention provides the most immediate relief?

Apply warm, moist compresses to increase blood flow
Elevate the extremity and apply ice packs wrapped in a cloth (Correct answer)
Encourage the client to walk to mobilize the joint
Massaging the joint firmly to break up uric acid crystals

Correct answer: Elevate the extremity and apply ice packs wrapped in a cloth

During acute gout, elevation reduces swelling and cold therapy numbs pain and decreases inflammation. The joint should not be massaged or walked on, as this intensifies pain.

Gout is caused by uric acid crystal deposition in joints, causing severe acute inflammatory arthritis. During an acute attack: elevate the affected extremity to reduce edema; apply ice or cold packs (wrapped to prevent frostbite) to reduce inflammation and pain; protect the joint from pressure (even bed sheets can be excruciating); bed rest during the attack. Cold therapy is preferred over heat (heat can increase blood flow and worsen inflammation in acute gout). Medications include colchicine, NSAIDs, and corticosteroids. Walking worsens pain and joint damage during an acute attack.

Question 28: A client is being assessed for signs of meningitis. Which finding is most significant?

Photophobia alone
Nuchal rigidity, positive Kernig's and Brudzinski's signs (Correct answer)
Elevated temperature of 38.2°C (100.8°F)
Mild headache relieved by ibuprofen

Correct answer: Nuchal rigidity, positive Kernig's and Brudzinski's signs

The classic triad of meningitis is fever, severe headache, and nuchal rigidity. Positive Kernig's and Brudzinski's signs confirm meningeal irritation and must be reported immediately.

Bacterial meningitis presents with the classic triad: fever, severe headache, and nuchal rigidity (stiff neck). Kernig's sign: resistance to leg extension at the knee when the hip is flexed (positive = meningeal irritation). Brudzinski's sign: flexion of the knees and hips when the neck is passively flexed. Additional signs include photophobia, phonophobia, altered mental status, and a petechial or purpuric rash (bacterial). Meningococcal meningitis is a medical emergency — the LPN must notify the charge nurse immediately and implement isolation precautions (droplet).

Question 29: A client recovering from a stroke develops left-sided neglect. The LPN documents this as the client's:

Inability to move the left arm voluntarily
Unawareness and inattention to stimuli on the left side of the body (Correct answer)
Vision loss in the left eye
Inability to understand spoken language

Correct answer: Unawareness and inattention to stimuli on the left side of the body

Unilateral neglect (hemi-inattention) is a cognitive-perceptual disorder where the client ignores stimuli on the affected side due to damage to the non-dominant parietal lobe.

Unilateral neglect (spatial neglect) most commonly results from right hemisphere stroke causing left-sided neglect. The client fails to perceive, respond to, or orient toward stimuli on the left side — not due to primary sensory or motor loss but due to attentional deficit. The client may eat food only from the right side of the plate, dress only the right side, or bump into objects on the left. Nursing interventions: approach from the unaffected side initially, then encourage scanning to the neglected side; position items on the affected side to promote awareness; place the call light on the affected side to encourage turning.

Question 30: A client post-total knee replacement is using a continuous passive motion (CPM) machine. The LPN should assess the client for which complication requiring the machine to be stopped?

Mild knee soreness during flexion
Significant wound drainage or suture separation (Correct answer)
Normal warmth around the incision
Swelling that reduces after elevation

Correct answer: Significant wound drainage or suture separation

Significant wound drainage, suture separation, or excessive edema indicates the CPM settings may be causing stress on the incision and the machine must be stopped and reported.

Continuous passive motion (CPM) machines flex and extend the knee to prevent contracture, reduce pain, and improve range of motion after total knee arthroplasty. The LPN must monitor: wound integrity (separation, excessive drainage), pain level (CPM should be within tolerable range), range of motion settings (per protocol), skin integrity under padding, and neurovascular status. If the wound shows suture separation, heavy drainage, or the client reports intolerable pain, stop the CPM and notify the charge nurse. The CPM is typically started within 24–48 hours of surgery and used for several hours daily.

Question 31: A client with a spinal cord injury at L2 is being assessed. The LPN understands this injury most likely results in:

Complete paralysis of all extremities (quadriplegia)
Paraplegia with preserved upper extremity function (Correct answer)
Loss of bowel control only with intact leg movement
Complete loss of all sensation but preserved motor function

Correct answer: Paraplegia with preserved upper extremity function

An L2 spinal cord injury causes paraplegia — weakness or paralysis of the lower extremities with full preservation of upper extremity and respiratory function.

The level of spinal cord injury determines which functions are affected below the lesion. L2 SCI affects the lower limbs (paraplegia) — weakness or paralysis of the hips, knees, and potentially the feet and ankles depending on the extent of injury. Upper extremity function, breathing, and swallowing are fully preserved. Lumbar injuries also affect bladder, bowel, and sexual function through disruption of sacral nerve roots. Cervical injuries cause quadriplegia (all four limbs) and potentially respiratory compromise. Thoracic injuries cause paraplegia with preserved arm function but affect intercostal muscles above the injury level.

Question 32: A client has bilateral knee osteoarthritis and asks about low-impact exercise options. The LPN's BEST recommendation is:

Running 5 miles per day to strengthen surrounding muscles
Swimming or water aerobics — buoyancy reduces joint load while maintaining fitness (Correct answer)
Complete rest until a knee replacement can be scheduled
Heavy resistance training with a focus on leg press machines

Correct answer: Swimming or water aerobics — buoyancy reduces joint load while maintaining fitness

Aquatic exercise (swimming, water aerobics) provides cardiovascular conditioning, muscle strengthening, and improved joint mobility with minimal weight-bearing stress on arthritic knees.

For clients with osteoarthritis, exercise is beneficial but must minimize joint stress. Aquatic therapy provides: buoyancy (reduces effective body weight by 80–90% in chest-deep water), resistance for muscle strengthening, improved range of motion, reduced pain, and cardiovascular conditioning. Other appropriate exercises include cycling (low impact), walking on flat surfaces, Tai Chi, and resistance exercises with light weights. Running and high-impact activities accelerate cartilage wear. Complete inactivity accelerates joint stiffness and muscle weakness. The OARSI guidelines recommend exercise as a core treatment for knee and hip OA alongside education and weight management.

Question 33: A client with a lumbar disc herniation is being prepared for a myelogram. Which information is most important for the LPN to communicate to the client before the procedure?

The test requires a 2-day hospital admission
The client must remain flat for 8 hours before the test to allow the contrast to settle
The client should increase fluid intake after the test and report severe headache (Correct answer)
The test involves injection of radioactive isotopes that glow on X-ray

Correct answer: The client should increase fluid intake after the test and report severe headache

After a myelogram (contrast injection into the spinal subarachnoid space), increased fluid intake helps eliminate contrast dye, and severe headache may indicate post-procedure spinal fluid leak requiring reporting.

A myelogram involves injection of contrast dye into the subarachnoid space (like a lumbar puncture) to visualize the spinal cord and nerve roots under fluoroscopy/CT. Post-procedure care: (1) Increase fluid intake (1.5–2 L over 24 hours) to help excrete the contrast dye and prevent dehydration from CSF loss; (2) Report severe headache (post-lumbar puncture headache from CSF leak — treated with bed rest, fluids, caffeine, or blood patch); (3) Head elevation (30–45 degrees) for 4–8 hours if a non-ionic water-soluble contrast was used; (4) Monitor for neurological changes, nausea, seizures (rare contrast reactions). Myelograms use contrast dye, not radioactive isotopes.

Question 34: A client in skeletal traction has pin sites with small amounts of dried serous exudate. The LPN should:

Immediately notify the charge nurse — this indicates pin site infection
Clean the pin sites with normal saline or chlorhexidine per facility protocol and document (Correct answer)
Leave the pin sites alone — all exudate indicates normal healing
Apply antibiotic ointment thickly over all pin sites

Correct answer: Clean the pin sites with normal saline or chlorhexidine per facility protocol and document

Small amounts of dried serous exudate around pin sites are normal. The LPN should clean the sites per protocol using normal saline or chlorhexidine, removing crusts that can harbor bacteria.

Skeletal traction pin site care aims to prevent pin tract infection (osteomyelitis risk). Normal findings: small amounts of serous or serosanguineous drainage forming crusts. Abnormal findings: purulent drainage, increasing redness or warmth, swelling, pain, odor, or pin loosening. Pin site care protocol typically involves: cleaning with normal saline and cotton-tipped applicators or chlorhexidine per facility policy; removing dried crusts; avoiding bulky dressings; monitoring for infection signs. Crusts that form at pin sites should be removed as they create a moist environment that promotes bacterial growth. Antibiotic ointment use varies by facility — follow specific protocol.

Question 35: A client with fibromyalgia asks about pain management strategies. The LPN should teach which non-pharmacological approach as the MOST evidence-based recommendation?

Complete bed rest to avoid muscle overuse and pain flares
Low-intensity aerobic exercise (walking, swimming) to improve pain and functioning (Correct answer)
Applying heat to all tender points for 6–8 hours daily
Avoiding all social and work activities to minimize stress

Correct answer: Low-intensity aerobic exercise (walking, swimming) to improve pain and functioning

Low-intensity aerobic exercise is the single most evidence-based non-pharmacological treatment for fibromyalgia, improving pain, fatigue, sleep, and mood over time.

Fibromyalgia is a chronic pain syndrome characterized by widespread musculoskeletal pain, fatigue, sleep disturbance, and cognitive issues. Evidence-based management combines pharmacological (duloxetine, milnacipran, pregabalin) and non-pharmacological approaches. Low-intensity aerobic exercise (30 minutes most days) has the strongest evidence base, improving: pain intensity, fatigue, function, mood, and sleep quality. Starting low and gradually increasing is key — sudden increases worsen symptoms. Other evidence-based approaches: cognitive-behavioral therapy (CBT), sleep hygiene, aquatic therapy, mindfulness. Complete rest, social isolation, and prolonged heat application are not recommended and may worsen outcomes.

Question 36: A client with a long arm cast reports fingers that are swollen, cool, and unable to make a fist. Capillary refill is 4 seconds. The LPN should:

Elevate the arm above heart level and apply an ice pack
Immediately notify the charge nurse — these are signs of compartment syndrome (Correct answer)
Administer the ordered pain medication and reassess in 1 hour
Apply a heating pad to improve circulation

Correct answer: Immediately notify the charge nurse — these are signs of compartment syndrome

Cool, swollen, immobile fingers with capillary refill >3 seconds in a casted extremity are signs of neurovascular compromise or compartment syndrome requiring immediate escalation.

Compartment syndrome in a casted upper extremity presents with the 6 Ps: Pain (especially with passive finger extension), Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (coolness). Capillary refill >3 seconds is abnormal. The LPN must notify the charge nurse and surgeon immediately. Interventions: bivalve the cast (split both sides to relieve pressure), keep the extremity at heart level (not elevated — this reduces arterial inflow), and prepare for possible emergency fasciotomy. Compartment syndrome can cause permanent nerve and muscle damage (Volkmann's contracture) if not decompressed within 6 hours. This is a time-sensitive surgical emergency.

LPN Medical-Surgical Nursing: Musculoskeletal and Neurological 1

A client with a fractured femur is placed in skeletal traction.
The LPN's priority assessment is:

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