Model Answer:

I would assure the parent that everything is totally normal! The doctor is assessing the baby’s superficial reflexes, one of which is the Babinski reflex.  In infants and young toddlers, a normal response to the Babinski test is for the big toe to dorsiflex and the other toes to fan upward (Slota, 2006). 

However, once a child is greater than 2 years old (through adulthood), the Babinski sign should be negative (plantarflexion of the great toe and toes curling inward). A positive Babinski sign, past infancy is indicative of damage to the cerebral cortex or spinal column (Acharya et al., 2023). The difference in assessments between infants and older children/adults is due to the maturation of the nervous system and full myelination of the spinal column (Acharya et al., 2023). 

The Intention of the Question: 

The intention of the question is to articulate that a neuro assessment that may indicate a severe health issue in an adult can be a normal finding in babies. It is a reminder that babies and children are not just small adults but have different needs from assessment through the care process.

References

Acharya, A. B., Jamil, R. T., & Dewey, J. J. (2023). Babinski reflex. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519009/ 

Slota, M.C. (2006). Core curriculum for pediatric critical care nursing. Saunders.

Question #2 by Muskan Priya

The client is a 19-month-old baby, born prematurely with active substance use histories. He is tracheostomy and ventilator dependent and requires a G/J tube for nutrition. His medical history includes tracheomalacia spells. Client had recently visited the Emergency Department for a skin rash, where multiple providers recommended a visit to rehabilitation services. At his rehab appointment, his provider is looking at his developmental milestone. 

Developmentally, the child can transfer objects from one hand to another, grasp and hold objects, and he is able to kick his legs. He prefers his left side more than his right. He can roll over in bed and push himself up with his hands. However, he is unable to sit or stand independently and requires support to maintain a seated position. He also demonstrates occasional delayed responses to his name. Provider notices client has low tone in his lower extremities.

• Given client’s development delays and complex medical history, could this be indicative of cerebral palsy? Why or why not? 

• What are the key signs and symptoms of cerebral palsy in infants and toddlers, and which of these does this client exhibit?

• What additional assessments (e.g., imaging, developmental evaluations) would help confirm or rule out a diagnosis of cerebral palsy?

Model Answer:

Given the child’s developmental delays and complex medical history, client can have characteristics of cerebral palsy. Cerebral palsy is a group of permanent disorders that affect movement, balance, and posture, which is caused by brain damage that occurs before, during or after birth. Some of the red flags that the client shows is premature birth, his mother being an active substance user during the pregnancy, trach/vent dependent, feeding difficulties and developmental delays. Also, since client cannot sit or stand independently, needs assistance with those tasks, and client has a delayed response with his name which is commonly seen in cerebral palsy. 

Signs and symptoms that the client is showing has lower tone in his lower extremities, feeding difficulties, poor motor control, not sitting, crawling, standing, walking independently, and his delayed response to his name. Also, his prematurity and respiratory difficulties are signs of cerebral palsy. 

Some additional assessments that need to be done for the client will be getting an MRI to check any brain abnormalities. Get an examination done by a neurologist to assess client’s muscle tone, reflexes, motor control and posture as he continues to grow. Also, work with OT/PT and speech therapy to start early interventions that could help support client throughout his diagnosis.

The Intention of the Question: 

This is one of the patients that I take care of at my facility. I had taken him to his rehab appointment awhile back. The provider was checking all his motor activities, and she suggested that he might have cerebral palsy which was referred to by his ED provider. The provider told us to continue to keep working with client’s movements and get an MRI done soon for him. We knew that client was a little delayed in his development but not as far behind as we thought. We had another baby in the facility who is two months younger than him, and we compare the interactions with each baby.

References

Cerebral Palsy Guide. (2025, March 27). Cerebral palsy symptoms. https://www.cerebralpalsyguide.com/cerebral-palsy/symptoms/ 

National Institute of Neurological Disorders and Stroke. (n.d.). Cerebral palsy. U.S. Department of Health and Human Services. https://www.ninds.nih.gov/health-information/disorders/cerebral-palsy 

Question #3 by Baylee Bortz

Jane, a 27-year-old female, has been receiving involuntary, inpatient psychiatric treatment for the past 6 weeks. Throughout her treatment, Jane’s provider has spoken with her multiple times about wanting to change her to a different antipsychotic medication due to her extrapyramidal symptoms (EPS). Each time the provider speaks to Jane about this Jane has become notably escalated. During the latest conversation with her provider about switching her antipsychotic, Jane threatened harm to the doctor and herself, stating, “I’ve been on Haldol for years, and I like it. It makes the voices say nice things to me. It’s not like it’ll cause me any real problems if you just keep giving me the other med with it. I swear, if you switch it on me, I’m going to either kill myself or break your neck.” 

While giving Jane her morning medications, her nurse notices that Jane is frequently smacking her lips together, grimacing, and protruding/twisting her tongue, in addition to repetitively twisting her hands while spreading her fingers and moving them as though she’s playing a piano. When asked, Jane denies being in pain and doesn’t seem to generally notice her repetitive movements, but does state, “It has been a bit harder to talk and eat lately.” Since the nurse hasn’t been at work in a couple of days and hasn’t seen Jane exhibit these movements before, they ask a coworker if these are new symptoms for Jane. The coworker responds, “No, she’s been doing that for a few days now. She keeps acting like she doesn’t know it’s going on, but you know how far some of these borderline patients will go to get attention.”

What is the most likely cause of Janes new symptoms? (Please give your rationale for why you chose the option you did)

• A.) Lithium toxicity

• B.) Tardive dyskinesia

• C.) Voluntary behavior

• D.) Drug-induced parkinsonism

What treatment/medication changes should the nurse expect and why? (you don’t have to go too in depth, 1-2 sentences is good)

When a coworker hears the nurse and provider discussing the planned treatment/medication changes, they say, “I’m worried that what you’re suggesting is going to cause Jane to hurt herself or someone else. Can’t we just wait and see if it gets worse?” What could the potential long-term effects of not addressing Jane’s new symptoms be?

Model Answer:

B.) Tardive dyskinesia

Tardive dyskinesia (TD) is a medication-induced movement disorder which causes involuntary, repetitive movements (Deik, 2024). The symptoms of this condition start after at least 4 weeks of taking an antipsychotic and most often include oro-bucco dysphasia (the grimacing, lip smacking, and tongue protruding/twisting seen in Jane), and the condition can also impact the arms (the hand twisting, finger spreading, and piano-playing finger movements seen in Jane). Additionally, Jane is at a higher risk of developing TD because she’s been on a higher dose of Haldol for a longer period and has a history of EPS and schizoaffective disorder, bipolar type. 

The nurse should expect the provider to discontinue Jane’s Haldol and switch her to an antipsychotic that’s a less potent dopaminergic D2 receptor blocker, such a clozapine or Seroquel (Liang, 2023). This is because the condition is caused by medications that block dopamine receptors. While stopping the use of antipsychotics all together is better for resolving TD, that fact that Jane has a pretty severe c

If Jenny’s suspected TD is not addressed, it could result in her continuing to have symptoms for life, even if she is later taken off Haldol (Liang, 2023). Additionally, if these symptoms continue, they can cause notable psychological distress which for a patient with borderline personality disorder can severely increase their risk of suicide.

The Intention of the Question: 

I generally find the concept of TD fascinating, especially since it’s possible to not have symptoms resolve once the medication that caused it is stopped. Also, while I haven’t seen it in this exact context, I have seen medical staff brush off symptoms in patients with borderline personality disorder due to the belief that they’re “just trying to get attention” when the patient had a serious medical problem causing their very real symptoms.

References

Deik, A. (2024). Tardive dyskinesia: Etiology, risk factors, clinical features, and diagnosis. UpToDate. Retrieved May 11, 2025, from https://www.uptodate.com/contents/tardive-dyskinesia-etiology-risk-factors-clinical-features-and-diagnosis?search=tardive%20dyskinesia&source=search_result&selectedTitle=2~67&usage_type=default&display_rank=2#H275833351 

Liang, T.-W. (2023). Tardive dyskinesia: Prevention, treatment, and prognosis. UpToDate. Retrieved May 11, 2025, from https://www.uptodate.com/contents/tardive-dyskinesia-prevention-treatment-and-prognosis?search=tardive%20dyskinesia&topicRef=4909&source=see_link#H708459590 

Question #4 by Teighler Gella

Toby, a 38-year-old male with no prior medical history, presents to the emergency department after falling at home due to progressive weakness and numbness in both legs. He reports that approximately 10 days ago, he noticed his "feet feeling heavy" following his usual daily run. He attributed this to deconditioning, as he had recently taken a two-week break from exercise due to a COVID-19 infection. However, over the next several days, the weakness ascended from his feet to his thighs. He now reports complete inability to move his legs and minimal sensation from the hips down. He denies recent trauma, back pain, or changes in bowel or bladder habits.

His focused neurological exam revealed the following:

• Motor: 0/5 strength in bilateral lower extremities; 5/5 strength in upper extremities

• Sensory: Decreased sensation from the mid-abdomen down

• Reflexes: Absent deep tendon reflexes in lower extremities

• Cranial nerves: Intact

1. What is the most likely diagnosis? How would you explain the diagnosis and prognosis to the patient?

2. What is the standard first line treatment? Why is early treatment important?

3. What is one complication of this disease? Include signs and symptoms or specific monitoring interventions.

Model Answer:

• 1. The patient most likely has Guillain-Barre Syndrome (GBS). I would explain to the patient that GBS is an autoimmune disorder that is triggered by a bacterial or viral infection. It causes your body to attack your peripheral nerves which leads to weakness and sensory changes. Most people with GBS fully recover or have minimal residual deficits however, recovery may take weeks to months. You may need physical therapy/rehabilitation to improve your mobility. (3 points)

• 2. The standard first-line treatment is IVIG or PLEX. It is important to start treatment early to reduce nerve damage. Delayed treatment could result in respiratory compromise or more severe paralysis. (3 points)

• 3. Major complications of GBS include: (3 points)

  • a. Respiratory failure – Serial pulmonary function tests (NIFs), watch for signs of respiratory compromise such as labored breathing, low oxygen saturations, shallow breathing

  • b. Autonomic dysfunction – Cardiac changes (bradycardia, tachycardia, arrhythmia), Diaphoresis, fluctuating blood pressure, orthostatic hypotension

  • c. DVT/PE – Calf assessment (pain, swelling, redness, heat), sudden SOB and chest pain, VTE prophylaxis

  • d. Aspiration Pneumonia – fever, crackles in lung songs, SOB, coughing or choking on food or liquids, SLP evaluations, bedside swallow

  • e. Pressure ulcers – pressure injury prevention (repositioning, skin checks, maintain nutrition, prophylactic dressing on bony prominences), non-blanchable redness, sores, skin breakdown

• 4. APA citation (1 point)

The Intention of the Question: 

As a med/surg neuro nurse, I have taken care of many patients with GBS. Most of them are younger, healthy individuals who happen to develop this unfortunate disease, usually after having a mild bacterial or viral infection. Although prognosis is usually good, most patients struggle with the sudden decrease/loss of mobility, long hospital stay, and long recovery process.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (Ninth edition). Elsevier.

Blanco, J., Bevers, M., Fedorowicz, Z., & Rae-Grant, A. (2024). Guillain-barre syndrome. DynaMedex. Retrieved from https://www-dynamedex-com/condition/guillain-barre-syndrome 

Chandrashekhar, S. & Dimachkie, M. (2025). Guillain-Barré syndrome in adults: Pathogenesis, clinical features, and diagnosis. UpToDate. Retrieved from https://www-uptodate-com/contents/guillain-barre-syndrome-in-adults-pathogenesis-clinical-features-and-diagnosis 

Model Answer:

Carpal Tunnel Syndrome is the most common nerve entrapment syndrome, affecting approximately 3.8% of the general population. The pathophysiology involves increased pressure on the median nerve as it traverses through the carpal tunnel leading to impaired blood flow, inflammation, and ischemic injury of the nerve. The median nerve has both motor and sensory functions, which can be affected in carpal tunnel syndrome. Early in the disease course, clinical features revolve around sensory deficits of the median nerve, with associated paresthesia, pain, and/or numbness in the palmar surface of the thumb, index, middle, and radial half of the ring finger. Rarely, patients may also report pain radiating proximally from the wrist towards the elbow. Sensory symptoms tend to occur with repetitive hand movements, sustained hand/ wrist postures, and often worsen at night. In later stages, patients may develop motor deficits of the median nerve with associated weakness of the thenar muscles leading to impaired pinch and grip of the hand (Stanford Medicine, 2025).

According to Asquith Health Collective. (n.d.)., there are several methods used to diagnose Carpal Tunnel Syndrome which includes the following:

• Medical history: They'll ask about your symptoms, when they started, and how they affect your daily life.

• Physical examination: Your Physiotherapist or Chiropractor will check your hand, wrist, arm, and neck for signs of carpal tunnel syndrome.

• Specific tests: There are several tests that can help diagnose carpal tunnel syndrome, such as:

• Tinel's sign: Tapping on the median nerve to see if it causes tingling in the fingers

• Phalen's maneuver: Holding the wrists in a flexed position to see if it causes symptoms

• Two-point discrimination test: Checking if you can feel two separate points of pressure close together

• Nerve conduction studies: These tests measure how well your median nerve is working.

• Imaging tests: In some cases, X-rays, ultrasound, or MRI scans may be recommended.

Although the exact etiology of increased carpal tunnel pressure remains uncertain, several conditions elevate the risk of CTS in patients. The risk of developing CTS is more likely when the carpal tunnel is modified, fluid equilibrium within the body is altered, or direct neuropathic factors are present. Examples of the risk factors associated with CTS include: dislocation or subluxation of the carpus, fractures or skewed consolidation of the distal radius, wrist arthrosis, inflammatory arthritis, and infectious arthritis, acromegaly, cysts or tumors within the tunnel, pregnancy, menopause, obesity, kidney failure, hypothyroidism, use of oral contraceptives, congestive heart failure, diabetes, alcoholism, vitamin deficiency or toxicity, exposure to toxins (Sevy et al., 2023). 

The Intention of the Question: 

I chose Carpal Tunnel Syndrome (CTS) for this quiz making because I do not know much about it. I personally got interested and intrigued after a conversation with my friends who works in the OR of their patients who undergo surgery for severe case of CTS. I also intentionally focused my question this time on physical assessment as I believe there are numerous clinical exams that we can do to evaluate and help diagnose CTS. I also foresee that students who will be answering my question will also actively learn and critically think about the underlying concepts of CTS.

References

Asquith Health Collective. (n.d.). Carpal Tunnel Syndrome.  https://www.asquith.health/conditions/carpal-tunnel-syndrome 

Sevy JO, Sina RE, Varacallo MA. Carpal Tunnel Syndrome. [Updated 2023 Oct 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448179/ 

Stanford Medicine (2025). Carpal Tunnel Exam. https://stanfordmedicine25.stanford.edu/the25/carpaltunnel.html 

Model Answer:

Immediate Concerns:

• Airway protection: Weak gag reflex and dysphagia place patient at high risk for aspiration and respiratory failure due to progressive muscle weakness affecting respiratory muscles.

• Neuromuscular progression: Descending weakness may soon impact diaphragm and intercostals.

• Autonomic dysfunction risk: Monitor for arrhythmias and blood pressure instability.

Priority Assessments:

• Respiratory status: Respiratory rate, oxygen saturation, breath sounds, vital capacity, and signs of impending failure (shallow breaths, fatigue).

• Swallowing/gag reflex: NPO until safe swallowing is confirmed.

• Neurological checks: Track cranial nerve function and progression of limb weakness.

• Cardiovascular monitoring: Monitor HR and BP for signs of dysautonomia.

Priority Interventions:

• Airway preparation: Notify provider, have suction and intubation equipment at bedside.

• Aspiration prevention: Elevate head of bed, maintain NPO

• Supportive care: ROM exercises, DVT prophylaxis, repositioning every 2 hrs.

• Communication tools: Whiteboard or speech aids for facial weakness.

• Patient/family education: Explain GBS progression and the possibility of ICU-level care.

• Treatments: Intravenous immunoglobulin therapy (IVIg) and Plasma exchange (PE), corticosteroids. 

The Intention of the Question: is to elicit critical thinking when working with a patient that is progressively declining in health and will be needing ICU care for weeks to follow. 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. (2023). Seidel’s guide to physical examination (Tenth edition.). Elsevier.

Haldeman, D., & Zulkosky, K. (2005). Treatment and Nursing Care for a Patient With Guillain-Barré Syndrome. Dimensions of Critical Care Nursing, 24(6), 267–272. https://doi.org/10.1097/00003465-200511000-00004

Rigo, D. de F. H., Ross, C., Hofstätter, M. L., & Ferreira, M. F. A. P. (2020). Guillain Barré syndrome: epidemiological clinical profile and nursing care. Enfermería Global, 19(1), 376–389. https://doi.org/10.6018/eglobal.19.1.366661

U.S. National Institute of Neurological Disorders and Stroke (NINDS). (2023). Guillain-Barré Syndrome Fact Sheet. Accessed May 2025.

Willison, H. J., Jacobs, B. C., & van Doorn, P. A. (2016). Guillain-Barré syndrome. The Lancet (British Edition), 388(10045), 717–727. https://doi.org/10.1016/S0140-6736(16)00339-1 

Question #7 by Ana Frota Penha

Part 1 (4 pts)

A 60-year-old patient comes to your clinic complaining of a sharp, shooting pain that starts in their lower back and radiates down their left leg to his ankle. He stated that the pain started a few days ago after lifting a heavy box. He also reports some tingling and numbness in their toes. Which of the following is the MOST likely cause of this patient's complaint?

• a) Hip osteoarthritis

• b) Peripheral neuropathy

• c) Lumbar disc herniation with sciatic nerve involvement

• d) Meralgia paresthetica (lateral femoral cutaneous nerve entrapment)

Part 2 (6pts)

What specific symptom, if present in this case, would raise immediate concern for a medical emergency requiring immediate evaluation and potential surgical intervention and why?

Question #8 by Daysi Rodriguez

James is a 62-year-old woman with progressive multiple sclerosis (MS) who has been living in a skilled nursing facility for the past two years. She is wheelchair-bound, has limited use of her arms, and experiences chronic neuropathic pain. Mrs. James is alert and cognitively intact but is often described by staff as “difficult to please” due to her frequent complaints, emotional outbursts, and refusal of care when she feels misunderstood or rushed. Mrs. James has a documented history of past trauma, including prior neglect in a long-term care setting, which contributes to her guarded behavior. She prefers consistent caregivers, values autonomy in her care decisions, and expresses frustration when her preferences are not followed.

How can the nurse incorporate trauma-informed care principles while managing the physical and emotional needs of a cognitively intact patient with progressive multiple sclerosis who exhibits resistance to care and values autonomy?

Model Answer:

• Nurse being calm and consistent, listening carefully, and always asking before helping her move or give medications. Explaining what’s going to happen before it happens can go a long way in making her feel comfortable and involved.

• Stay on top of her pain meds (like gabapentin), gently help with repositioning, and keep an eye out for things like pressure sores or fall risks. Since she spends a lot of time in her wheelchair, making sure she’s well-supported and her skin stays healthy is key.

• Important for nurses to remember that when a patient seems “difficult,” it might be because they’re trying to protect themselves—especially if they’ve been hurt or ignored in the past. So instead of taking it personally, it helps to see their behavior as a signal that they need more understanding, not less.

• Nurses using patience, empathy, and clear communication to lower the stress and build trust

The Intention of the Question: 

To take good care of a patient like Mrs. James, someone who has multiple sclerosis (MS), is mentally sharp, but often pushes back on care, it’s important for nurses to think about how they deliver care, not just what they do. Mrs. James has a tough medical condition that causes pain and limited movement, but she also carries emotional scars from past experiences where she didn’t feel safe or respected. That’s why using a trauma-informed approach matters so much.

This kind of care means creating an environment where the patient feels safe, respected, and in control.

References

Bruce, M. M., Kassam-Adams, N., Rogers, M., Anderson, K. M., Sluys, K. P., & Richmond, T. S. (2018). Trauma Providers' Knowledge, Views, and Practice of Trauma-Informed Care. Journal of trauma nursing : the official journal of the Society of Trauma Nurses, 25(2), 131–138. https://10.1097/JTN.0000000000000356 

Robles-Sanchez, M. A., Amil-Bujan, P., Bosch-Farré, C., Coll-Martínez, C., Arévalo, M. J., Anglada, E., Menéndez, R., Montalban, X., Sastre-Garriga, J., Ramió-Torrentà, L., & Bertran-Noguer, C. (2023). An expert patient program to improve the empowerment and quality of life of people with multiple sclerosis: protocol for a multicenter pre-post intervention study. Frontiers in neurology, 14, 1172640. https://10.3389/fneur.2023.1172640 

Model Answer:

1) I would expect the neurologist to make a diagnosis of Parkinson’s Disease. A diagnosis for Parkinson’s Disease (PD) is usually made through clinical examination, history and physical, and the response to medication treatments. There are no laboratory tests or imaging studies that can make a definitive diagnosis of PD. MRIs can be used to exclude differential diagnoses. DAT scans (dopamine transporter scans) are also an FDA approved imaging test that can help diagnose PD, but it is often used solely when other clinical exam findings are non-conclusive and is at this time not a first-line diagnostic tool for PD (Zafar & Yaddanapudi, 2023). 

2) A combination of carbidopa/levodopa is most effective for management of PD.  Dopamine agonists can also be indicated for younger patients and may not be as effective as carbidopa/levodopa but may have fewer side effects. Anticholinergics can also be used to treat tremor (Zafar & Yaddanapudi, 2023).  Deep brain stimulation can be another effective treatment that involves placing a device similar to a pacemaker under the skin on the chest that sends electrical pulses to the brain and can help reduce symptoms of PD. Physical therapy and speech therapy can also help manage symptoms related to PD. There is no cure for PD and it is a progressive disease, so treatment is focused on symptom management (Mayo Foundation for Medical Education and Research, 2024).

The Intention of the Question: 

The intention of this question was to challenge students to take a set of clinical findings and associated them with a condition like Parkinson’s Disease. Then, the student is challenged to think about the diagnosis of this condition and what medications or therapies can be helpful in managing symptoms. This question challenges students to take a clinical assessment and make an informed clinical diagnosis with help from trusted sources. 

References

Mayo Foundation for Medical Education and Research. (2024). Parkinson’s disease. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/parkinsons-disease/diagnosis-treatment/drc-20376062 

Zafar, S., & Yaddanapudi, S. (2023). Parkinson disease. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK470193/ 

Question #10 by Hillary Viswanathan

You are the nurse in an operating room circulating a revision total knee arthroplasty surgical case. Your patient is a 70-year-old woman and weighs 61.2 kg. Prior to the procedure start, your patient received a regional block in preop. During the surgery it becomes apparent the revision will take longer and be more complex than anticipated. The surgeon says to you, “I’m worried about pain control after this. Can you please get 20 mL of 0.50% marcaine and give it to the back table?” 

• 1) Before retrieving the requested dose, which other provider in the OR should you consult to determine the safety of administering more local anesthetic? (2 points)

• 2) What is the name of the toxicity you are concerned about? (1 point)

• 3) Consider your environment; identify 2 potential symptoms of this toxicity that you could observe in the OR. (2 points)

• 4) Identify two patient factors that could contribute to a higher risk for this toxicity. (2 points)

• 5) What is the rescue medication for this toxicity? (1 point)

Reference and citations (1 point)

BONUS: What role does epinephrine play when added to local anesthetics? You don’t need to explain the biochemical mechanism of action; simply state the physiological effect of epinephrine in the context of local anesthetics and therefore what it means in regard to dosing. (1 point)

Model Answer:

• 1) The nurse should consult with the anesthesia provider to determine the amount of local anesthetic already administered during the regional block (Warren & Pak, 2024. 

• 2) The nurse is concerned about Local Anesthetic Systemic Toxicity, or LAST (Warren & Pak, 2024).

• 3) The patient is sedated so signs and symptoms of LAST would be apparent on cardiac monitors. This would include tachycardia and hypertension or bradychardia and hypotension (Warren & Pak, 2024). Other signs may include muscle twitching, arrhythmias, or asystole. 

• 4) Patient risk factors include extremes of age (young and old), heart disease, renal insufficiency, severe liver disease, highly vascular block site, carnitine deficiency, and pregnancy (Warren & Pak, 2024).

• 5) The rescue medication for LAST is intravenous lipid emulsion (Warren & Pak, 2024). 

BONUS: Epinephrine slows the rate of absorption and reduces plasma levels (Jeng & Rosenblatt, 2025). As such, a higher dose of the local anesthetic could potentially be used when epinephrine is added (Warren & Pak, 2024). 

The Intention of the Question: 

Every member of the OR team is important and provides a specific type of care for the patient. It is the circulator’s job to have a balcony view, seeing every aspect and interplay of the patient’s care and how it all works together in concert. This question asks the nurse to consider the goals and actions of the surgeon as well as the anesthesia provider and apply that understanding to the overall safety of the patient. 

References

Jeng, C.L., & Rosenblatt, M.A. (2025, April 15). Overview of peripheral nerve blocks. UpToDate. Retrieved May 12, 2025 from https://www-uptodate-com/contents/overview-of-peripheral-nerve-blocks?search=epinephrine%20in%20local%20anesthetics&source=search_result&selectedTitle=8~150&usage_type=default&display_rank=8 

Warren, L., & Pak, A. (2024, July 23). Local anesthetic systemic toxicity. UpToDate. Retrieved May 12, 2025 from https://www.uptodate.com/contents/local-anesthetic-systemic-toxicity?search=local%20anesthetic%20systemic%20toxicity&source=search_result&selectedTitle=1~49&usage_type=default&display_rank=1 

Model Answer:

The medics are indicating that they are bringing in a stroke patient by using the commonly known FAST (Face-arm-speech-time) acronym and Los Angeles Motor Scale (LAMS) scoring tool. FAST positive means the patient is having a sudden alteration in their facial symmetry, arm or extremity strength, or speech fluency or production. 

The LAMS is a prehospital scoring tool used to identify patients with acute cerebral ischemia because of large vessel occlusion (LVO) for direct routing to comprehensive stroke centers capable of performing endovascular thrombectomy. It is validated with high sensitivity and specificity (Noorian et al., 2018). 

The patient is likely experiencing a right middle cerebral artery large vessel occlusion stroke, as evidenced by her contralateral facial droop, communication difficulties and profound left arm weakness (Ball et al., 2023, Chapter 23). 

The patient will hopefully be offered intravenous thrombolysis with alteplase or Tenecteplase if her history and exam do not exclude her from this treatment. She should also be considered for endovascular thrombectomy performed by a neurosurgeon or an interventional neuroradiologist (Powers et al., 2019). 

The Intention of the Question: 

It is valuable for the registered nurse to understand pre-hospital assessment tools, especially when receiving report from EMS. Understanding that a high LAMS indicates possible LVO and being able to localize the symptoms to an arterial region will prepare the stroke team for expedient diagnostic imaging and resource gathering. 

References

Ball, J., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier. 

Noorian, A. R., Sanossian, N., Shkirkova, K., Liebeskind, D. S., Eckstein, M., Stratton, S. J., Pratt, F. D., Conwit, R., Chatfield, F., Sharma, L. K., Restrepo, L., Valdes-Sueiras, M., Kim-Tenser, M., Starkman, S., Saver, J. L., & for the FAST-MAG Trial Investigators and Coordinators. (2018). Los Angeles Motor Scale to Identify Large Vessel Occlusion. Stroke, 49(3), 565–572. https://doi.org/10.1161/STROKEAHA.117.019228 

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., Brown, M., Demaerschalk, B. M., Hoh, B., Jauch, E. C., Kidwell, C. S., Leslie-Mazwi, T. M., Ovbiagele, B., Scott, P. A., Sheth, K. N., Southerland, A. M., Summers, D. V., & Tirschwell, D. L. (2019). Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, 50(12), e344–e418. https://doi.org/10.1161/STR.0000000000000211 

Model Answer:

Jason's physical examination revealed pelvic tilt, unequal scapulae and waist creases, and asymmetry during the forward bend test, all of which indicate adolescent idiopathic scoliosis (AIS). His remaining development potential increases his risk for curve progression, as he is 13 years old and has not yet reached puberty. The Cobb angle, which measures the degree of spine curvature, can be determined by ordering a standing posteroanterior (PA) and lateral spinal X-ray. This will assist in assessing the degree of scoliosis and deciding whether bracing, observation, or a referral for an orthopedic evaluation is necessary (DynaMedex, 2025).

The underlying pathophysiology involves a rotational deformity and lateral curvature of the spine that typically manifests during periods of rapid growth. Although AIS is frequently idiopathic, there may be a hereditary component. Regular monitoring might suffice if the patient is asymptomatic and the Cobb angle is less than 20 degrees. Bracing may be necessary to prevent progression if the curve exceeds 20 to 25 degrees and the patient is still developing. Surgical consultation is often required for curves larger than 45 to 50 degrees (Peng et al., 2024).

The Intention of the Question: 

Using a real-world patient scenario involving adolescent idiopathic scoliosis, this question aims to evaluate the learner's ability to apply clinical reasoning. To demonstrate their understanding of the typical presentation of scoliosis, the student is asked to assess the results of a physical examination and use those observations to formulate a clinical impression. Additionally, the question evaluates the learner's grasp of the condition's underlying pathophysiology and its impact on growth and development, particularly in adolescent patients. 

References

DynaMedex. (2025). Adolescent idiopathic scoliosis. Retrieved May 11, 2025, https://www-dynamedex-com./condition/adolescent-idiopathic-scoliosis 

Peng, C., Li, D., Guo, T., Li, S., Chen, Y., Zhao, L., & Mi, J. (2024). Efficacy of different exercises on mild to moderate adolescent idiopathic scoliosis. American Journal of Physical Medicine & Rehabilitation, 103 (6), 494-501. https://doi.org/10.1097/PHM.0000000000002389 

Question #13 by Jack Jorgensen

You are caring for a 14-year-old boy named Tony who recently had a cast applied to his right arm for a distal radial head fracture. Tony is complaining that their cast is too tight. What nursing assessments can you perform to rule out compartment syndrome? (8 points)

Tony’s assessment is positive for compartment syndrome – you notify the provider and their cast is removed, but symptoms persist. What is the definitive treatment for compartment syndrome and why? (2 points)

Model Answer:

Nursing assessments to rule out compartment syndrome include: 

• Evaluate for pain that is out of proportion to the injury, and/or unrelieved by analgesics and worsened by movement of Tony’s fingers

• Assess for numbness, tingling

• Assess for motor weakness. 

• Pulse assessment is important but likely impeded by Tony’s cast.

• Cap refill of the fingers

• Assess for swelling 

• Assess for changes in color/palor of the skin

• Temperature: assess for coolness of the skin (poikilothermia)

If Tony’s symptoms persist after removal or bi-valving the cast, the definitive treatment for compartment syndrome is emergent decompressive fasciotomy. In this procedure the fascia is surgically opened to relieve pressure in the affected limb/compartment, thus restoring perfusion and preventing irreversible damage. Untreated compartment syndrome can lead to muscle necrosis, permanent motor/sensory deficits, and loss of the affected limb. 

The Intention of the Question: 

Broken bones are common in the pediatric emergency setting and assessing the neuromuscular function of the affected limb is important to rule out compartment syndrome. I have never seen full-blown compartment syndrome, but I have caught the early signs/symptoms, and the case needed to be redone. 

References

Gottlieb, M., Adams, S., & Landas, T. (2019). Current approach to the evaluation and management of acute compartment syndrome in pediatric patients. Pediatric Emergency Care, 35(6), 432–437. https://doi.org/10.1097/PEC.0000000000001855 

Osborn, C. P. M., & Schmidt, A. H. (2020). Management of acute compartment syndrome. Journal of the American Academy of Orthopaedic Surgeons, 28(3), e108–e114. https://doi.org/10.5435/JAAOS-D-19-00270 

von Keudell, A. G., Weaver, M. J., Appleton, P. T., Bae, D. S., Dyer, G. S. M., Heng, M., Jupiter, J. B., & Vrahas, M. S. (2015). Diagnosis and treatment of acute extremity compartment syndrome. The Lancet, 386(10000), 1299–1310. https://doi.org/10.1016/S0140-6736(15)00277-9 

Question #14 by Mariah Wilson

Samantha is a 27-year-old female presented to the ED with a headache (9/10 on numeric pain scale), photophobia, and lethargy. Her girlfriend, Charlotte, reports that she has been sick since they got back from a music festival but has looked worse over the last few hours. 

Her vital signs are:

• HR = 124

• RR = 22

• BP = 91/42 (58)

• SpO2 = 95%

• T = 39.8 C

On assessment, Samantha has altered mental status (A/O X 1, GCS = 13), nuchal rigidity, and a positive Kernig and Brudzinski signs. You call Dr. Emergency and ask them to come examine the patient and say that you are going to call a sepsis huddle. Briefly describe how to assess Kernig and Brudzinski signs and what a positive result looks like.

After you hang up the phone Samantha begins to seize at 12:03. You note that she has whole-body contractions, and she has lost consciousness which you recognize as a tonic-clonic seizure. What are your three immediate priorities for Samantha? Provide a very brief rationale for your answers.

Dr. Emergency comes into the room and asks you what happened. Provide a short (1-2 sentences) SBAR in your own words.

It is now 12:09, and Samantha is still seizing despite multiple doses of IV Lorazepam. Dr. Emergency gives the following orders. In what order would you do these interventions? 

• 1. Administer 1500 mg of Levetiracetam

• 2. Insert 2 large-bore IVs, or an IO if unable to obtain venous access

• 3. Obtain a BMP, CBC, LFTs, and 2 sets of blood cultures

• 4. Prepare to assist with endotracheal intubation 

• 5. Administer 1L of Lactated Ringer’s

• 6. Start a propofol drip at 50 mcg/kg/min

• 7. Call the EEG tech for a STAT EEG

Samantha has now stabilized, and you call the ICU charge nurse to arrange transfer. You see Charlotte crying the corner and she asks you “What’s wrong with her? Is she going to be okay?”. In 2-4 sentences, how would you explain Samantha’s diagnosis to Charlotte?

Model Answer:

Briefly describe how to assess Kernig’s and Brudzinski’s signs and what a positive result looks like for each. 

• Kernig’s Sign: Flex one of the patient’s knees to a 90-degree angle and then assist the patient to straighten their leg. Repeat assessment on the other side (Ball, et al., 2019).

  • Positive result: The patient will express pain in the lower back or resist straightening their leg (Ball, et al., 2019).

• Brudzinski’s Sign: Gently assist the patient in tucking their chin towards their chest (Ball, et al., 2019).

  • Positive result: The patient will involuntarily flex their hips and knees (Ball, et al., 2019).

• 2 pts – 1 pt for each correct description

What are your three immediate priorities for Samantha? Provide a very brief rationale for your answers.

• 1. Turn the patient onto their side (left side preferred): this will prevent aspiration of any saliva or secretions (King, 2018).

• 2. Protect patient’s airway, provide oxygen with a non-rebreather, and ensure that suction is available if needed: Airway compromise during a seizure is a life-threatening complication, and having emergency equipment and providing oxygen therapy will protect the patient from further complications. Avoid placing suction in their mouth if possible (King, 2018).

• 3. Place seizure pads on the side rails: this is a protective measure to avoid injury from the hard surface of the bed (King, 2018).

3 pts – 1 pt for each correct intervention

Dr. Emergency comes into the room and asks you what happened. Provide a short (1-2 sentences) SBAR in your own words.

• Samantha lost consciousness and a tonic-clonic seizure started at 12:03. Prior to the seizure she had altered mental status, a fever of 39.8 C, nuchal rigidity, and positive Kernig and Brudzinski signs.

  • 2 pt – for full credit the student will include the time and description of the seizure and a brief assessment

    • References used to create the answer: Drislane, 2024a; Drislane, 2024b; Hasbun, 2024; King, 2018.

In what order would you do these interventions?

• Answer: 4, 2, 6, 5, 1, 3, 7

• Rationale: The nurse should always prioritize airway, breathing, and circulation (ABCs). 

  • 4 - Samantha needs to be intubated as quickly as possible to protect her airway and to regulate her breathing so oxygen can get to her brain. 

  • 2 - IV/IO access should occur next so that medications can be administered for her seizures and hypotension.

  • 5 - Samantha was hypotensive before the seizure started and is likely developing septic shock related to her bacterial meningitis. She will need aggressive fluid resuscitation.

  • 6 - Propofol has anti-epileptic properties and is also a sedative which will keep Samantha calm once she’s intubated. 

  • 1 – Levetiracetam is an anti-epileptic and will treat her seizures.

  • 3 – Samantha is likely in septic shock and will need labs and blood cultures ideally before administering antibiotics. It is also important to check for abnormal glucose and electrolyte levels which can cause seizures.

  • 7 – EEG should be started as soon as Samantha is stabilized to understand the quality of her seizures. Since she will also need to be heavily sedated this will also help indicate if her seizures have stopped.

• 1 pt for correct answer

  • References used to create answer: References used to formulate the answer: Drislane, 2024a; Hasbun, 2024; King, 2018.

Samantha has now stabilized, and you call the ICU charge nurse to arrange transfer. You see Charlotte crying the corner and she asks you “What’s wrong with her? Is she going to be okay?”. In 2-4 sentences, how would you explain Samantha’s diagnosis to Charlotte?

• The student should include the following in their explanation

  • Correct diagnoses: bacterial meningitis and status epilepticus

  • Current known treatment plan: protecting her airway with the ventilator, giving medications to stop her seizures, and treatment for her infection

  • Transferring to the ICU for further monitoring and higher level of care

  • Explanation should be worded with patient-friendly language that Charlotte will understand

• Example

  • Charlotte, we are doing everything we can to help Samantha right now. We believe she has an infection called meningitis that is making her sick and sometimes that can cause seizures. When seizures last for a long time we call that status epilepticus, and to keep her safe we needed to put her on a breathing machine and give her medications that will stop the seizure. We are going to transfer her to the ICU so she will have close monitoring and they will start treatment for her infection. 

• 2 pts – Full credit if most elements included and it is written in patient-friendly language.

  • References used to create answer: Drislane, 2024a; Drislane, 2024b; Hasbun, 2024.

The Intention of the Question: 

My intention for this question was to include elements of neurological illness, nursing assessment, and emergency response. I also included questions about communication because one of the most important aspects of successfully managing an emergency as a nurse is good, concise, communication. Seizing patients can be scary to manage as a nurse, and my hope is that by practicing how to respond nurses will feel more confident in these tough situations.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B.S., & Stewart, R. W. (2019). Neurologic system. Seidels’s guide to physical examination: An interprofessional approach (9th eds.). Elsevier.

Drislane, F. W. (2024a, July 3). Convulsive status epilepticus in adults: Management. UpToDate. Retrieved May 10, 2025, from https://www.uptodate.com/contents/convulsive-status-epilepticus-in-adults-management?search=status+epilepticus&topicRef=2217&source=see_link 

Drislane, F. W. (2024b, December 10). Convulsive status epilepticus in adults: Classification, clinical features, and diagnosis. UpToDate. Retrieved May 10, 2025, from https://www.uptodate.com/contents/convulsive-status-epilepticus-in-adults-classification-clinical-features-and-diagnosis?search=status%20epilepticus&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H1711530880 

Hasbun, R. (2024, June 25). Clinical features and diagnosis of acute bacterial meningitis in adults. UpToDate. Retrieved May 10, 2025 from https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-acute-bacterial-meningitis-in-adults?search=meningitis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 

King, M. (2018). Special neurologic patient populations. In V. Good, & P. Kirkwood (2nd Eds.). Advanced Critical Care Nursing [eBook edition]. Elsevier.

Model Answer:

What is the most likely diagnosis and what most likely contributed to this acute event, as mentioned in the patient’s history?

The most likely diagnosis of this patient is gout, more specifically a gout flare. A gout flare typically occurs in one joint and is intensely inflammatory, occurring in the lower extremities. A gout flare is usually provoked by a variety of factors including intake of alcohol and other triggering foods such as organ and red meat which are rich in purine (Gaffo, 2025). These provoking factors were reported by the patient when he mentioned the consumption of beer, pork, and liver at a party that he attended the night prior.

Identify at least one medication considered as first-line therapy for the patient’s condition and would likely be included in their treatment plan. 

Any of the following medications used in the initial management of gout flare with their corresponding rationale is considered correct: 

• Systemic/Intraarticular glucocorticoids – prednisone, triamcinolone, methylprednisolone

• Oral NSAIDs – naproxen, indomethacin, ibuprofen, diclofenac, meloxicam, celecoxib

• Oral colchicine (Gaffo, 2025)

Name at least one nonpharmacologic strategy to treat this condition that you can include when educating the patient.

• Treatment of comorbid conditions – Some comorbid conditions are associated with an increased risk of gout such as obesity, hypertension, and Diabetes mellitus. Treating them may reduce the risk of developing gout and subsequent gout flares. 

• Addressing medications that affect urate balance – Certain medications affect serum urate, including aspirin and certain types of diuretics, and can sometimes be modified to reduce the risk of gout flares. 

• Modifying diet – Many modifiable aspects of diet can affect serum urate, such as intake of purines, alcohol, high-fructose corn syrup, and sugar-sweetened beverages. 

  • Whole-diet approaches such as the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean diets should also be considered.

  • Obtaining adequate dietary protein from plant-based and/or low-fat dairy sources may also be helpful.

• Exercise – Participating in an exercise program that is appropriate for a patient's age and physical status can help improve overall health and achieve or maintain an optimal weight (Neogi, 2024).

The Intention of the Question: 

I have several relatives who often experience gout flares. I wanted to learn more about this condition to help them prevent future episodes.

References

Clinique Podiatrique St-Charles (n.d.). Understanding gout attack in the foot. https://st-charlespodiatrie.com/en-ca/2024/06/05/gout-attack-in-the-foot/ 

Gaffo, A. (2025). Gout: Clinical manifestations and diagnosis. UptoDate. Retrieved May 12, 2025, from https://www.uptodate.com/contents/gout-clinical-manifestations-and-diagnosis  

Gaffo, A. (2025). Gout: Treatment of flares. UptoDate, Retrieved May 12, 2025, from https://www.uptodate.com/contents/gout-treatment-of-flares 

Neogi, T. (2024). Gout: Nonpharmacologic strategies for prevention and treatment. UptoDate. Retrived May 12, 2025, from https://www.uptodate.com/contents/gout-nonpharmacologic-strategies-for-prevention-and-treatment 

Model Answer:

1. Based on the patient’s assessment and symptoms, he has gout due to pain, hot, swollen joints (especially the metatarsophalangeal joint), and a limited range of motion (Ball et al., 2023). 

2. Gout occurs due to the body's inability to metabolize/process uric acid due to a lack of the uricase enzyme (Banasik & Copstead, 2018). Uric acid is a waste product primarily filtered by the kidneys, but when the amount of uric acid present exceeds the amount removed by the body, it causes hyperuricemia and results in deposits of uric acid crystals within connective tissues of the joints (Banasik & Copstead, 2018). The presence of uric acid crystals within the joints attracts leukocytes into the area, leading to leukocyte extravasation and an increased inflammatory response leading to urate crystal-induced arthritis or gouty arthritis (Banasik & Copstead, 2018). 

3. Allopurinol is a uric acid-lowering medication used to treat grout, especially in patients experiencing recurrent flares or having tophi (Perez-Ruiz, 2025). In addition to taking this medication, alterations in diet are also recommended to prevent gout/gout flare-ups. Since uric acid is a waste product of purine metabolism, it is recommended that patients with gout decrease or eliminate the intake of foods rich in purines, such as organ meats, red meat, and seafood (Banasik & Copstead, 2018). Alcohol consumption also causes hyperuricemia, with beer causing the highest risk (Banasik & Copstead, 2018).

The Intention of the Question: 

Multiple people in my family have gout and have experienced gout flare-ups periodically over the past few years leading them to make lifestyle and diet changes. The goal of this question is to identify gout and its symptoms, understand the pathophysiology, medications, and lifestyle changes to help patients manage and prevent gout flare-ups at home. 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart. R. W. (2023). Seidel’s guide to physical examination. Elsevier Inc. https://www-clinicalkey-com./#!/content/book/3-s2.0-B9780323761833000231?scrollTo=%23top 

Banasik, J. L., & Copstead, L. E. (2018). Pathophysiology. Elsevier Inc. https://ebookcentral.proquest.com/lib/washington/detail.action?docID=5434807 

Perez-Ruiz, F. (2025). Gout: Pharmacologic urate-lowering therapy and treatment of tophi. UpToDate. Retrieved April 5, 2025, from https://www-uptodate-com./contents/gout-pharmacologic-urate-lowering-therapy-and-treatment-of-tophi?search=gout&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=4 

Model Answer:

Gary has sustained a femur fracture [signs and symptoms (Ball et al., 2023)]. The two recommended nonpharmacological pain interventions for a fracture are ice and elevation (Martinez et al., 2025). Typically, for a midshaft femur fracture, an intramedullary nailing (IMN) is the recommended fixation method (Martinez et al., 2025). This is the method of choice due to it being a stable fixation construct, minimally invasive, allowing immediate weight bearing post-op, and having lower complication rates (Martinez et al., 2025).

BONUS: Gary’s fracture is an oblique femur fracture. 

The Intention of the Question:

When I was a travel nurse, I did a contract at Harborview Medical Center’s Orthopedic/Trauma unit. I was fascinated but also not surprised at the number of electric scooter accidents I saw both in the emergency department and on the inpatient units. With orthopedic injuries, pain is one of the big concerns nurses tackle when aiding this patient population. It is important to know what we can do within our scope to help reduce pain if pharmacological intervention is not appropriate at the time. I saw more commonly elevation and ice were the go-to approaches for alleviating pain, but I also saw interventions such as distraction, music, prayer, ambulation/moving around to avoid being sedentary and stiffening up, comfort foods, and/or having family support present.

Rubric: 

Correct Diagnosis: 2 points

Nonpharmacological interventions: 3 points each (6 total)

What is IMN?: 2 points

BONUS: 2 points if deduction taken out in the above criteria 

References

Ball, J.W., Dains, J.E., Flynn, J.A., Solomon, B.S., Stewart, R.S. (2023). Musculoskeletal system. In Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. (10th Ed.). Seidel’s guide to physical examination. Elsevier.

Martinez, R.A., Lang, E., DeGeorge, K. (2025). Extreme lower extremity injury in the adult. Elsevier. Retrieved May 5, 2025, from https://www-clinicalkey-com.offcampus.lib.washington.edu/#!/content/clinical_overview/67-s2.0-T1623096546151#pain-management--heading-TOPIC_Q2J_C4M_VRB 

Sabiston, D. C. (2022). [Photograph fracture X-ray]. Elsevier. https://www-clinicalkey-com.offcampus.lib.washington.edu/#!/content/book/3-s2.0-B9780323640626000190?scrollTo=%23hl0001232 

Model Answer:

1) Patient is high risk of developing:

• Compartment syndrome

• Deep Vein Thrombosis (DVT) 

• Infection. 

2) Compartment Syndrome: This occurs when increased pressure within a muscle compartment reduces blood flow, leading to tissue ischemia and potential nerve damage. if not treated within 4-6 hours, it may result in permanent damage. Treatment involves an emergency fasciotomy, a surgical procedure to relieve the pressure 

DVT: Patient is high risk of developing DVT due to immobility and non-weight bearing on the left leg. Pt are given anticoagulants such as enoxaparin or apixaban are prescribed to prevent blood clots. 

Infection: Surgical patient is high risk of developing infection . MD will initiate Prophylactic antibiotics therapy to prevent further complications from infection and wounds are monitored closely for signs of redness, drainage or fever . 

3) Recovery from a Maisonneuve fracture with surgical intervention typically takes about one year before returning to high impact activities like baseball, depending on rehab progress and absence of complications. He can play after a year of the surgery. 

The Intention of the Question: 

Patients with Maisonneuve fracture commonly are not prone to have compartment syndrome but after the 6 hrs. of surgery, Pt started complaining of severe pain on his left lower leg which was 10 out 10. Surgeon suspected acute compartment syndrome.  He was taken to the OR back for an emergency fasciotomy to relieve pressure. after the fasciotomy , pt had immediate relief from pain, confirming the diagnosis of acute compartment syndrome.  

References

Imade, S., Takao, M., Miyamoto, W., Nishi, H., & Uchio, Y. (2009). Leg anterior compartment syndrome following ankle arthroscopy after Maisonneuve fracture. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 25(2), 215–218.  https://doi-org./10.1016/j.arthro.2007.08.027 

Question #19 by Hannah Pankratz

John is a 65 year old male presents to an urgent care for complaints of right foot pain in the setting of a poorly healing wound. He has history of Type 2 Diabetes and peripheral vascular disease, and is a pack a day smoker. You are the nurse taking him back to an exam room and gathering assessment data for the provider.

Vitals:

• Temp: 100.4 degrees F4

• BP: 145/80

• HR: 95

• RR: 18

• SpO2: 98% on room air

Upon assessment of John’s right foot, you note an open sore that is red around the edges on the side of his pinky toe. It is hard to tell but the wound is deep enough you are concerned you can see bone. He has pedal edema 2+ on the right foot, and no edema on the left foot. His right foot is erythematous and warm to the touch. The patient reports that his foot is painful with palpation.

• 1. Based on the assessments, what do you suspect John has with his right foot? (2 pts)

• 2. What is the pathophysiology of this condition? (4 pts)

• 3. What medications would you suspect would be administered for this patient? (2 pts)

• 4. List 2 pieces of patient education that you would discuss with John surrounding this condition and management (1 pt per education piece).

Model Answer:

• 1. Osteomyelitis of his right foot.

• 2. Osteomyelitis is an infection of the bone, which can result from an open wound such as what John is experiencing (Ball, 2023). The infectious material spreads into the bone and into the surrounding soft tissue, which can eventually cause bone necrosis and osteomyelitis (Ball, 2023). 

• 3. As osteomyelitis is an infection of the bone, antibiotics will need to be administered. Based on the culture results from a bone biopsy or probing the wound, pathogen-specific antibiotics should d be administered, usually for a duration of 4-6 weeks intravenously (Dynamedex, 2025). After IV antibiotics, it is common for a patient to then be on oral antibiotics for an additional 1-2 weeks (Lalani, 2024).

• 4. Any 2 of the following education topics:

  • a. If antibiotics do not help, John may need to have surgery to remove the infected bone, which could mean surgical debridement or even amputation (Dynamedex, 2025).

  • b. When taking antibiotics orally, it is important to finish the course of the antibiotics and take as directed, even when feeling better (Lalani, 2024).

  • c. Moving forward for John, it will be important that he checks his feet for any wounds or signs of infection given that he is diabetic (Lalani, 2024).

  • d. Counsel John on quitting smoking; him having diabetes, peripheral vascular disease and being a smoker all give him a higher chance of a slow healing wound that could lead to osteomyelitis (Lalani, 2024). 

  • e. Good blood sugar control will help with optimal wound healing (Lalani, 2024). 

  • f. Follow-up care with providers will be recommended for at least 6 months after the conclusion of antibiotic treatment to ensure that the osteomyelitis has resolved (Dynamedex, 2025).

The Intention of the Question: 

The intention of this question is for the student to recognize a patient that is suffering from osteomyelitis as this can commonly be seen in a hospital setting and especially with those who have diabetes. The student should be able to discuss the pathophysiology of osteomyelitis, discuss recommended medications for treatment of osteomyelitis, and education topics that they would discuss with the patient.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W., & Seidel, H. M. (2023). Seidel’s guide to physical examination (Tenth edition.). Elsevier.

DynaMedex. Osteomyelitis in Adults. EBSCO Information Services. Accessed May 12, 2025. https://www-dynamedex-com/condition/osteomyelitis-in-adults 

Lalani, T. (2024). Osteomyelitis in the absence of hardware: Approach to diagnosis in adults. UpToDate. Retrieved May 12, 2025 from https://www-uptodate-com.osteomyelitis-in-the-absence-of-hardware-approach-to-diagnosis-in-adults?search=osteomyelitis%20treatment&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5#H32824156 

Model Answer:

1. What assessments would you perform for this post-op patient who was just admitted to the floor? List at least three.

A thorough assessment following total hip arthroplasty (THA) begins with a neurovascular evaluation, which includes checking the color, temperature, capillary refill, sensation (such as numbness or tingling), movement, and distal pulses of the affected extremity to detect early signs of compromised circulation or nerve damage. Pain assessment is also essential, involving evaluation of the severity, location, and quality of pain or spasms. Pain is a common postoperative experience, and research indicates that approximately 50% of patients report moderate to severe pain on the first day after surgery (Moon et al., 2021). Lastly, assessment of the incision site is critical, including inspection of the dressing, presence and function of any drains (such as a Hemovac or wound vac), and signs of infection such as redness, warmth, swelling, or hematoma formation, all of which may indicate complications that require prompt intervention.

2. What are the appropriate nursing management interventions? List at least four.

Effective pain management is a cornerstone of postoperative care following total hip arthroplasty. Opioid analgesics, such as acetaminophen, Tramadol, Oxycodone, Dilaudid, or muscle relaxants like Robaxin, are routinely administered to control moderate to severe pain, with pain reassessment conducted 30-60 minutes after administration to evaluate effectiveness (Moon et al., 2021). The right leg should be elevated above heart level using pillows, without exceeding 90 degrees of hip flexion, to reduce edema and promote comfort; ice packs may also be applied to minimize swelling. Maintaining hip precautions is vital to prevent dislocation, and this includes avoiding adduction, internal rotation, and hip flexion beyond 90 degrees. If prescribed, an abduction pillow, such as a wedge pillow, should be used to support alignment. Fluid and dietary management includes continued IV fluid supplementation, such as Lactated Ringer’s at 75 mL/hr, with prn normal saline boluses if systolic blood pressure drops below 110 mmHg. Caution should also be taken to prevent orthostatic hypotension as the patient transitions to ambulation. Vital signs monitoring follows a structured protocol on the unit: upon arrival, every 15 minutes ×2, then every 30 minutes ×1, every hour ×1, followed by every 4 hours for the first 24 hours, and then every 8 hours thereafter.

3. What discharge education should be provided to the patient? List at least three topics.

At the time of discharge following total hip arthroplasty, patients should be educated on critical signs and symptoms to report, including fever, increased pain, drainage, redness or swelling at the incision site, and signs of deep vein thrombosis (DVT) such as calf pain or leg swelling, which may indicate a serious complication. The use of assistive devices, such as a front-wheeled walker, should be emphasized to support safe ambulation, with strict adherence to the prescribed weight-bearing status as directed by the surgical team. Patients should also receive clear instructions on narcotic pain medications, including how to follow PRN (as needed) dosing guidelines. While opioids are highly effective for short-term postoperative pain control, they carry risks such as nausea, vomiting, constipation, urinary retention, drowsiness, impaired cognition, and respiratory depression. Importantly, patients must be cautioned about the potential for misuse and addiction, even when used appropriately for acute pain. As such, these medications should only be used as directed and discontinued as soon as pain is tolerable with non-opioid options (Altizer, 2004).

The Intention of the Question: 

Total hip arthroplasty (THA) is one of the most successful orthopedic procedures performed today. For patients with hip pain due to a variety of conditions, THA can relieve pain, restore function, and improve quality of life (Erens & Crowley, 2024). My unit is Med/Surg, and hip surgery is the most common procedure. Most post-op patients stay one night and are discharged the next day. Sometimes, a couple of patients are discharged the same day, while others may stay longer, some even require transfer to a skilled nursing facility before going home. Our surgery days are usually scheduled from Monday to Wednesday, and these days tend to be busier due to the high patient turnover. Also, I remember that hip surgery is a popular topic on the NCLEX exam.

References

Altizer, L. (2004). Patient Education for Total Hip or Knee Replacement. Orthopaedic Nursing, 23(4), 283–288. https://doi.org/10.1097/00006416-200407000-00016 

Erens, G. A. & Crowley, M. (2024). Total hip arthroplasty. UpToDate. Retrieved May 1, 2025, from https://www.uptodate.com/contents/total-hip-arthroplasty?search=total%20hip%20arthroplasty&source=search_result&selectedTitle=1~145&usage_type=default&display_rank=1 

Moon, M., Oh, E. G., Baek, W., & Kim, Y. M. (2021). Effects of Nurse-Led Pain Management Interventions for Patients with Total Knee/Hip Replacement. Pain Management Nursing, 22(2), 111–120. https://doi.org/10.1016/j.pmn.2020.11.005