Medical-Surgical Nursing: Musculoskeletal and Neurological Flashcards
7 cards from real LPN practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medical-Surgical Nursing: Musculoskeletal and Neurological flashcards as text
A patient is admitted with suspected meningitis. Which assessment finding is the nurse most likely to identify?
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.
A patient with a traumatic brain injury has a GCS score of 8. How should the nurse interpret this finding?
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.
The nurse is monitoring a patient for signs of increased intracranial pressure (ICP). Which set of findings represents Cushing's triad?
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.
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?
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.
A patient is admitted after a tonic-clonic seizure. During the postictal period, which nursing intervention takes priority?
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.
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?
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.
Which patient action best demonstrates understanding of safety measures following a diagnosis of epilepsy?
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.