The Pressure Is On!
A nurse must explain to a patient why they should not cough, sneeze, or blow their nose after a head injury. Why?
To prevent an increase in intracranial pressure (IICP)
Because most autoimmune treatments involve suppressing the immune system, this is the most critical education point for all these patients.
The increased susceptibility to/prevention of infection
To prevent hip contractures, the nurse knows a lower extremity stump should not be kept in this position for long periods after the first few days.
Elevated
This neurodegenerative disorder is characterized by a "pill-rolling" tremor, bradykinesia, and a shuffling gait.
Parkinson's Disease
This member of the interdisciplinary team is the only one legally responsible for acting as the "case manager" and creating the initial home care plan.
Registered Nurse (RN)
On the Glasgow Coma Scale, this is the lowest possible score a patient can receive (indicating a deep coma or death).
3
This scale is the "gold standard" for assessing a patient's level of consciousness, scoring eye-opening, motor, and verbal responses.
Glasgow Coma Scale (GCS)
This autosomal-dominant genetic disorder is characterized by abnormal movements (chorea) and a steady decline in intellectual capacity.
Huntington Disease
A nurse calculates a "widened pulse pressure" for a patient with a head injury. If the patient's BP is 160/70, this is the numerical pulse pressure.
90 (160 - 70 = 90)
This condition, often seen with Scleroderma, involves vasospasms of small vessels in the hands and is treated with BP medications.
Raynaud's Disease
While the LPN may perform treatments, this team member is legally responsible for the initial plan of care and case management in a home setting.
Registered Nurse (RN)
In Myasthenia Gravis, the nurse must prioritize assessing this function above all others, especially during a "crisis."
Respiratory status (or airway/breathing)
This is the primary goal of home care nursing for a patient with a chronic, disabling condition.
Keep the patient as independent as possible and enable them to stay at home
This lab value is the primary diagnostic focus for a patient experiencing an acute "Gouty attack."
Serum Uric Acid
A patient with a head injury exhibits a "Smile Test" that is asymmetrical and a weak grip on the right side. The nurse identifies this as a potential injury to this specific side of the brain.
Left Side (Damage typically presents on the contralateral/opposite side)
A patient with Myasthenia Gravis is scheduled for several diagnostic tests and physical therapy. The nurse should schedule these activities for this time of day to maximize muscle strength.
The morning (Muscle weakness in MG usually worsens as the day progresses).
This specific classification of medication is the only type that can cross the blood-brain barrier to reduce brain tissue swelling in IICP
Osmotic diuretics (e.g., Mannitol or Glycerol)
A patient with Sjogren Syndrome requires specific nursing interventions focused on these two types of glands.
The salivary and lacrimal (tear) glands
These two main factors are the primary causes of the urate crystal buildup seen in Gout.
A genetic increase in purine metabolism and a high-purine diet.
This rare facial pain syndrome, often triggered by touch or cold, is treated with anticonvulsants like carbamazepine (Tegretol).
Trigeminal Neuralgia (Tic Douloureux)
An LPN is caring for an immobile patient. To prevent the "stasis" complications of the respiratory system, the nurse implements these three actions.
Coughing, deep breathing, and frequent position changes (incentive spirometry)
While assessing an elderly patient with osteoporosis, the nurse knows that "dowager’s hump," a curve of the upper thoracic spine, is clinically known by this term.
Kyphosis
When managing a patient in "Cervical Traction" (like Crutchfield Tongs), this is the nurse's priority assessment regarding the weights.
Ensuring weights hang freely and do not touch the floor
A patient with Parkinson’s Disease is experiencing a "freezing gait." The nurse should teach the patient this specific technique to help initiate movement.
"Stepping over an imaginary line" or rocking side-to-side
A nurse identifies clear fluid leaking from a patient's nose following a basilar skull fracture. The nurse performs this test to confirm if it is Cerebrospinal Fluid (CSF).
Halo Sign (testing for rings on gauze)
A nurse is caring for a patient with Rheumatoid Arthritis on etanercept (Enbrel). The nurse should prioritize investigating this symptom above all others.
A fever or signs of infection
When assessing for a "bull's eye" rash, the nurse is screening for the early stages of this disease which can lead to chronic arthritis.
Lyme Disease
Unlike other disorders, this condition involves a rapid, ascending (bottom-up) paralysis that often follows a viral infection.
Guillain-Barré Syndrome
When transitioning a spinal cord injury patient to home, the LPN identifies these three categories of necessary adaptations.
Home, Transportation, and Personal Care/Feeding adaptations
A patient with a spinal cord injury suddenly has a BP of 190/110 and a slow heart rate. The nurse immediately checks for this common "trigger" under the sheets.
A kinked urinary catheter (or full bladder)
This triad of symptoms—bradycardia, hypertension with widened pulse pressure, and irregular respirations—indicates a late-stage emergency of IICP.
Cushing’s Triad
This neurodegenerative disorder involves the destruction of the myelin sheath, leading to symptoms like diplopia (double vision), weakness, and tingling.
Multiple Sclerosis (MS)
This nursing action is the top priority for a patient with a T4 spinal cord injury reporting a sudden, severe headache and flushing above the level of injury.
Sitting the patient upright and identifying/removing the stimulus (e.g., full bladder or bowel)
This systemic autoimmune disease can lead to pulmonary fibrosis (lung scarring) and protein in the urine, indicating kidney involvement.
Scleroderma
An LPN is caring for an elderly patient with osteoporosis; the nurse recognizes this non-weight-bearing complication as a major risk to the respiratory system.
Atelectasis or stasis pneumonia
A patient with Amyotrophic Lateral Sclerosis (ALS) is experiencing difficulty swallowing. This is the specific nursing priority to prevent aspiration.
Sitting the patient upright (90 degrees) and performing a swallow evaluation/thickening liquids
The LPN notes a family caregiver is becoming withdrawn and irritable. The nurse recognizes this as a need for this specific type of temporary care.
Respite Care
A nurse observes "decorticate posturing" (flexion) in a head-injury patient. This indicates damage to this specific part of the brain.
The cerebral cortex or upper brainstem
Following a spinal cord injury, a patient develops "Spinal Shock." The nurse knows this condition is characterized by this specific state of the muscles.
Flaccid paralysis (loss of reflex activity below the level of injury)
While caring for a patient with ALS, the LPN observes the patient is becoming increasingly frustrated with their inability to speak. The nurse should implement this specific communication tool.
A communication board (or eye-blink system/assistive technology)
While monitoring a patient with a closed head injury, the nurse notes the following change in vitals over 2 hours:
1400: BP 124/80, Pulse 78, Resp 16.
1600: BP 150/60, Pulse 52, Resp 10 (irregular)
Name this clinical phenomenon and state the immediate nursing priority regarding the head of the bed.
Cushing’s Triad and the priority is to elevate the Head of the Bed (HOB) to 30–45 degrees (neutral position) to facilitate venous drainage
A patient with Scleroderma (Systemic Sclerosis) is being discharged. The nurse is creating a teaching plan that must address the "CREST" syndrome. To prevent the most life-threatening complication of this systemic disease, the nurse must teach the patient to report these two specific "organ-related" symptoms immediately.
Shortness of breath (pulmonary fibrosis) and Decreased urine output/High BP (renal crisis)
A nurse is caring for a patient 48 hours post-above-the-knee amputation (AKA). The patient is crying and refuses to look at the limb, stating, "I can still feel my toes itching." Identify the therapeutic term for this sensation and state which task the LPN can safely delegate to a UAP: (A) Applying the initial compression shrinker, or (B) Assisting the patient to the prone position for 20 minutes.
Phantom Limb Sensation and the LPN can delegate (B) Assisting the patient to the prone position (once the patient is stable and the LPN has performed the assessment)
A patient with Myasthenia Gravis is admitted with severe muscle weakness and respiratory distress. The nurse knows that if the patient is experiencing a Cholinergic Crisis, the symptoms are caused by this medication error, and the administration of the Tensilon (edrophonium) test will result in this specific reaction.
Over-medication (too much anticholinesterase/cholinesterase inhibitor) and the patient’s muscle weakness will worsen (or show no improvement)
*Students often confuse Myasthenic Crisis (under-medicated) with Cholinergic Crisis (over-medicated). Understanding that Tensilon makes a Cholinergic Crisis worse is a high-level safety concept.
In the home health setting, an LPN is caring for a patient with a new spinal cord injury. While the LPN can perform treatments and collect data, the nurse recognizes that three specific actions remain the sole legal responsibility of the Registered Nurse (RN) and cannot be delegated. Name these three responsibilities.
Acting as the Case Manager, performing the initial assessment/developing the Plan of Care, and supervising to ensure care is delivered in an uninterrupted manner
While performing a neuro assessment on a patient with a suspected brainstem injury, the nurse observes the patient's arms are extended, adducted, and hyper-pronated, while the feet are in plantar flexion. Identify the clinical term for this posturing and state why it is considered a more "ominous" (serious) sign than decorticate posturing.
Decerebrate Posturing (Extension) and it is more serious because it indicates damage to the lower brainstem (midbrain or pons) rather than just the cerebral cortex
A patient with a T4 spinal cord injury suddenly reports a pounding headache and nasal stuffiness. Their BP is 190/100. While the nurse prepares to sit the patient up, they must identify the most common "hidden" triggers. Name the three primary systems/stimuli the nurse must check immediately to resolve this emergency.
Bladder (distention/kinked catheter), Bowel (impaction/constipation), and Skin (tight clothing, pressure sores, or a wrinkle in the sheet).
A patient with Myasthenia Gravis presents with increased muscle weakness and respiratory distress. To distinguish between a Myasthenic Crisis and a Cholinergic Crisis, the nurse anticipates the provider will use the Tensilon (edrophonium) test. If the patient’s strength improves after the medication, the nurse identifies the crisis as this, caused by this medication error.
Myasthenic Crisis caused by under-medication (too little anticholinesterase)
*Students constantly flip these two. Remembering that "Myasthenia = More meds needed" (improvement with Tensilon) versus "Cholinergic = Clogged/Too much" (worsening with Tensilon) requires deep understanding of the neuromuscular junction.
You have four patients on a Med-Surg unit. Rank them in order of who the LPN must assess FIRST to LAST based on immediate life-safety risk:
A patient with Parkinson's who has a "mask-like" face and is drooling.
A patient with a T6 Spinal Cord Injury who is suddenly flushed and has a BP of 210/110.
A patient with Scleroderma who is complaining of "heartburn" after eating.
A patient with Guillain-Barré whose pulse oximetry has dropped from 96% to 91% in the last hour.
2, 4, 1, 3.
Rationale: * #2 First: This is Autonomic Dysreflexia, an immediate hypertensive emergency/stroke risk.
#4 Second: Dropping O2 in GBS indicates ascending paralysis reaching the diaphragm (respiratory failure).
#1 Third: Drooling in Parkinson's is a chronic symptom (risk for aspiration, but not as acute as #2 or #4).
#3 Last: Heartburn (Esophageal dysmotility) is a common, non-emergent finding in Scleroderma.