Brain & Nervous System
A client with meningitis complains of a stiff neck when the nurse tries to bend their chin to their chest. The nurse documents this finding using what medical term?
What is nuchal rigidity?
Rationale: Nuchal rigidity means neck stiffness, a classic sign of meningeal irritation.
An older adult client says straight lines look wavy and they are losing the vision right in the middle of their eye, but their side vision is fine. What condition is this?
What is macular degeneration?
Rationale: Macular degeneration destroys central vision, while peripheral (side) vision stays intact.
After a total hip replacement (posterior approach), what special device is placed between the client's legs to stop them from crossing their legs or turning their hip inward?
an abduction pillow (or wedge)
Rationale: Abduction keeps the legs spread apart so the new hip joint doesn't pop out of place (dislocate)
An adult client has burns on their entire chest and abdomen (front trunk) plus the front of both arms. Using the Rule of Nines, what percentage of their body is burned?
27
Rationale: Front trunk = 18% Front of each arm = 4.5% (4.5 + 4.5 = 9%). 18 + 9 = 27%.
A provider orders Acetaminophen 650 mg PO. The bottle from pharmacy reads "160 mg per 5 mL." How many mL will the nurse give?
20.3mL
A client who had a left-sided brain stroke has weakness on the right side of their body. What emotional or behavioral trait should the LPN/VN expect this client to show?
being cautious, slow, or anxious?
Rationale: Left-brain stroke clients are usually aware of their deficits, making them cautious and anxious, while right-brain stroke clients are impulsive.
A client with Meniere disease has severe dizziness (vertigo) and ringing in the ears. What simple dietary change helps lower the fluid pressure in their inner ear?
What is a low-sodium (low-salt) diet?
Rationale: Less sodium keeps fluid from building up in the inner ear.
The nurse inflates a blood pressure cuff on a client's arm, and within 3 minutes, the client's wrist and fingers spasm and curl up. What low electrolyte level causes this sign?
low calcium (hypocalcemia)
Rationale: This is Trousseau sign, a key warning sign of severe hypocalcemia and muscle tetany.
Which kidney lab value is the most reliable indicator of kidney function, with a normal range of 0.6 to 1.2 mg/dL?
Serum Creatinine
Rationale: Creatinine shows how well the kidneys filter waste; if it goes up, kidney function is going down.
An IV bag of 1,000 mL Normal Saline needs to run over 8 hours on an IV pump. What rate in mL/hr should the nurse set on the pump?
125mL/hr
A client with Myasthenia Gravis notices their eyelids drooping and muscles getting tired by the end of the day. The nurse knows this muscle weakness improves with what simple daily measure?
What is rest (or taking rest periods)
Rationale: Muscle weakness in Myasthenia Gravis worsens with activity and improves with rest.
When assessing a client with suspected appendicitis, the nurse presses down on the left lower side of the abdomen, and the client feels pain on the right lower side. What is the name of this sign?
What is Rovsing sign?
Rationale: Pressing the left side pushes gas toward the inflamed appendix on the right, causing pain at McBurney's point.
A client has an adrenal tumor (Pheochromocytoma) that causes dangerous spikes in blood pressure. Why is it critical that the nurse never press or palpate the client's abdomen?
it can trigger a sudden severe spike in blood pressure (hypertensive crisis)
Rationale: Pressing on the tumor squeezes a massive dose of adrenaline straight into the bloodstream.
An arterial blood gas (ABG) result shows a low pH of 7.28 and a high PaCo2 of 52 mmHg. How would the nurse interpret this acid-base balance?
Respiratory Acidosis?
Rationale: Low pH (<7.35) means acidosis, and high PaCO2 (>45) means the lungs are holding onto acid (CO2).
When mixing Regular insulin and NPH insulin together in the same syringe, in what order does the nurse draw up the insulins?
Clear before Cloudy (or Regular before NPH)
Rationale: You inject air into NPH, air into Regular, then pull up Regular (clear) first so you don't contaminate the clear vial with NPH.
A client with a T6 spinal cord injury suddenly gets a severe pounding headache, high blood pressure, and flushed skin on their face. What is the very first thing the nurse should do?
What is sit the client upright ($90^\circ$)?
Rationale: Sitting the client up immediately lowers blood pressure through gravity before you search for the cause (like a full bladder or clogged catheter).
To prevent Dumping Syndrome after stomach surgery, the nurse tells the client to eat small, low-carb meals and do what right after eating?
lie down (supine) for 20 to 30 minutes?
Rationale: Lying down slows food from rushing too fast into the small intestine.
To stretch the hip flexor muscles and prevent hip contractures after an above-the-knee amputation, the nurse helps the client lie in what position several times a day?
lying on their stomach (prone position)
Rationale: Lying prone for 20-30 minutes keeps the hip joint straight and prevents permanent flexed muscle tightness.
A nurse listens to a client's heart with a stethoscope at the apex and gets 92 beats per minute, but another nurse feels the radial wrist pulse at the exact same time and gets 78. What is the pulse deficit?
14 beats per minute
Rationale: Pulse deficit = Apical pulse (92) minus Radial pulse (78) = 14.
An IV antibiotic of 100 mL needs to drip over 30 minutes using tubing with a drop factor of 15 gtt/mL. What is the drop rate in drops per minute?
50 gtt/min
A client brought to the emergency department immediately following a acute traumatic spinal cord injury has a complete loss of all reflexes, sensation, and movement below the level of the injury. The nurse recognizes this initial transient reaction as what condition?
Spinal Shock
Rationale: Spinal shock is the sudden, temporary loss of all reflex, motor, sensory, and autonomic activity below the level of a spinal cord injury.
A client with severe liver cirrhosis has enlarged, swollen veins in their esophagus that could burst and bleed. What cardiac medication is given to help prevent them from bleeding?
a beta-blocker (like Propranolol)?
Rationale: Beta-blockers lower blood pressure in the liver's portal vein, lowering the risk of these fragile esophageal veins bursting.
A client with Diabetic Ketoacidosis (DKA) is receiving IV Normal Saline and insulin. When their blood sugar drops down to $250\text{ mg/dL}$, what fluid does the nurse add to the IV?
Dextrose (D5W in 0.45% Saline)
Rationale: Adding sugar to the IV keeps blood glucose from dropping too fast, which protects the brain from swelling (cerebral edema).
A client starting a 24-hour urine collection accidentally flushes their afternoon urine specimen into the toilet. What must the nurse do next?
throw away the collection and start the test completely over
Rationale: Every single drop of urine over the 24 hours is needed for accurate lab math; missing one void ruins the whole test.
A client with kidney failure has a dangerously high potassium level 6.8 mEq/L. Which IV medication does the nurse expect the doctor to order to protect the heart muscle from lethal heart rhythms?
Calcium Gluconate
Rationale: Calcium gluconate acts like a shield for the heart muscle against dangerous high potassium levels.