Keep sterile items sterile: if in doubt, it is not sterile; replace, never wipe.
Prevent harm in the environment: fall measures, restraints only as a last resort, RACE and PASS for fire.
Check the rights of medication administration, two identifiers and extra safeguards for high-alert drugs; report errors and near misses.
Prioritization & delegation
Method
Ask what will harm the patient soonest if nothing is done.
Apply ABC (C-A-B in cardiac arrest), then Maslow: physiological needs before safety, safety before psychological needs.
Compare the options: acute before chronic, unstable before stable, unexpected before expected, systemic before local, and check each finding against the patient’s baseline.
Assess before you act unless it is an emergency; then choose the step the others depend on.
For delegation, check the five rights: task, circumstance, person, directions and supervision. Assessment, teaching and evaluation stay with the RN.
Lab values & electrolytes
Method
Compare the value with the laboratory’s own reference range, then with the patient’s baseline and trend.
Check the sample: hemolysis, a delay, or blood drawn near an IV can give false results.
Link the value to its typical signs and to the drugs and conditions that cause it.
Look for interactions: low potassium or magnesium increases digoxin toxicity; dehydration raises lithium.
Act on the patient: assess, hold a drug if the level is unsafe, read back critical values and inform the prescriber.
Med-surg: cardiovascular & respiratory
Method
Name the problem: pump failure, blocked artery, rhythm, clot, airway narrowing, infection or a device problem.
Check the danger signs first: hypoxia, hypotension, chest pain, new confusion, a cold pulseless limb.
Match the oxygen to the patient: 94–98% for most, 88–92% for those at risk of CO₂ retention.
Link each drug to its test and its risk: warfarin and INR, heparin and aPTT and platelets, diuretics and potassium.
Choose the safe first action, then escalate and reassess.
Med-surg: neuro, endocrine & renal
Method
Check the glucose in every patient with new confusion, weakness or a seizure.
Use the level of consciousness as the earliest warning of brain trouble; pupils and Cushing’s triad come late.
For diabetes emergencies, separate DKA (ketones, acidosis) from HHS (very high osmolality, dehydration); give fluids first.
For sodium and water, decide whether ADH is in excess (SIADH) or missing (DI), and correct chronic changes slowly.
For kidney problems, sort the cause into pre-renal, intrinsic or post-renal, and watch potassium and fluid.
Med-surg: GI, perioperative & oncology
Method
Ask what could be hidden: internal bleeding, infection without fever, hypoventilation behind a normal SpO₂.
Use the timing after surgery to narrow the complications: bleeding in hours, chest problems in days, wound and leak problems later.
For pain, assess, treat with multimodal analgesia, reassess, and monitor sedation with every opioid.
For cancer patients, treat any illness during the nadir as neutropenic sepsis and know the oncological emergencies.
For burns, count only partial- and full-thickness areas, start the Parkland clock at the time of the burn and titrate to urine output.
Maternity & obstetric nursing
Method
Place the woman in time: weeks of pregnancy, stage of labour or day after birth, and decide what is normal at that point.
Look for the patient in danger: the mother, the fetus or the newborn, or more than one of them.
Link the finding to its cause: VEAL CHOP for decelerations, the four Ts for bleeding, BUBBLE-HE after birth.
Choose the action that improves blood flow and oxygen first (side-lying, stopping oxytocin, fundal massage), then escalate.
Pediatric nursing
Method
Note the child’s age first: it sets the normal vital signs, the milestones and the right pain scale.
Assess airway, breathing and circulation, remembering that children compensate and then deteriorate fast.
Match the action to the development stage and involve the family.
Check that the answer is safe for a child: weight-based, no aspirin in viral illness, no codeine under 12.
Mental health nursing
Method
Decide whether there is an immediate risk: suicide, violence, a drug emergency or a physical illness.
Act on safety first: observe, remove means, de-escalate, stop a harmful drug, get help.
Choose the therapeutic response: acknowledge feelings, present reality, avoid false reassurance and “why” questions.
Respect rights: the least restrictive option, consent and confidentiality with its limits.
Nursing math & unit conversions
Metric steps
1 kg = 1000 g, 1 g = 1000 mg, 1 mg = 1000 mcg, 1 L = 1000 mL
Weight and length
1 kg = 2.2 lb, 1 lb = 16 oz, 1 in = 2.54 cm, 1 ft = 12 in
Household measures
1 tsp = 5 mL, 1 tbsp = 15 mL, 1 fl oz = 30 mL, 1 cup = 8 fl oz = 240 mL
A patient on lisinopril for hypertension starts taking ibuprofen every day for knee pain. What is the main concern?
AFaster liver metabolism of lisinopril, so it stops working
BA large fall in blood pressure, with fainting and falls on standing up
CA higher risk of a dry cough than with lisinopril alone
DWeaker blood pressure control, kidney injury and high potassium
13.Med-surg: cardiovascular & respiratoryMedium
A patient with peripheral arterial disease has leg pain at night. Which position may ease it?
ARaising the legs on pillows above heart level
BApplying a hot water bottle directly to the feet
CHanging the legs down over the side of the bed
DWrapping the legs in compression bandages
14.Med-surg: cardiovascular & respiratoryHard
A patient taking apixaban for atrial fibrillation is booked for elective surgery. Which statement reflects correct practice?
AIt is always continued up to the morning of the operation
BIt is stopped and then reversed with oral vitamin K
CStop it two weeks before surgery and replace it with warfarin
DPause it for a set time, based on bleeding risk and kidney function
15.Med-surg: neuro, endocrine & renalMedium
A patient's fistula starts to bleed at home after the needles were removed. What should they do first?
ARaise the arm and let it bleed freely
BApply a tight tourniquet above the fistula
CWait for the next dialysis session
DPress firmly on the site with clean gauze
16.Med-surg: neuro, endocrine & renalHard
A haemodialysis patient missed their last two sessions. They are breathless, with crackles, and the potassium is 6.9 mmol/L. What is the priority?
AOral potassium supplements and rest
BUrgent dialysis, with cardiac monitoring meanwhile
CA routine dialysis session at the next planned slot
DLarge IV fluid boluses to improve the circulation
17.Med-surg: GI, perioperative & oncologyMedium
Which medicine commonly delays wound healing?
ASaline eye drops
BVitamin C supplements
CParacetamol
DLong-term corticosteroids
18.Med-surg: GI, perioperative & oncologyHard
An 80 kg adult has 30% TBSA partial- and full-thickness burns. Using the Parkland formula, how much crystalloid is planned for the first 8 hours from the time of the burn?
A9600 mL
B4800 mL
C3200 mL
D2400 mL
19.Maternity & obstetric nursingMedium
Where universal screening for group B streptococcus is used, when is the vaginal–rectal swab usually taken?
AAfter the membranes rupture in labour
BAt the first antenatal visit
CAt about 20 weeks
DAt about 36 to 37 weeks
20.Maternity & obstetric nursingHard
After the placenta is delivered, the nurse examines it. Why?
ATo check the mother's blood type and Rh factor
BTo check that it is complete and nothing is retained
CTo estimate the baby's gestational age from its weight
DTo decide whether the baby needs vitamin K
21.Pediatric nursingMedium
Which temperature is usually taken as fever in a child?
A39.5 °C (103.1 °F) or higher
B38.0 °C (100.4 °F) or higher
C37.0 °C (98.6 °F) or higher
D37.5 °C (99.5 °F) or higher
22.Pediatric nursingHard
The nurse has taught the parents of a newborn about safe sleep. Which statement shows a need for further teaching?
A"Nobody will smoke in the house or in the car."
B"We will put a soft bumper and a pillow in the cot so she is comfortable."
C"We will keep her cot in our bedroom for the first months."
D"We will put her on her back for every sleep, including naps."
23.Mental health nursingMedium
How does memantine work in Alzheimer's disease?
AIt inhibits the breakdown of acetylcholine
BIt blocks dopamine D2 receptors
CIt increases serotonin by blocking its reuptake
DIt blocks NMDA glutamate receptors
24.Mental health nursingHard
A patient has had delusions and hallucinations for a year. For most of this time he has also had episodes of major depression, but for at least two weeks at a time his psychotic symptoms continued without any mood symptoms. Which diagnosis best fits this pattern?
ADelusional disorder
BMajor depression with psychotic features
CBrief psychotic disorder
DSchizoaffective disorder
25.Nursing math & unit conversionsMedium
Practice exercise (made-up values, not clinical guidance). A patient’s temperature is 102.4 °F. Convert it to degrees Celsius T with °C = (°F − 32) × 5/9. Round to one decimal place.
102.4 °F
T = °C
26.Nursing math & unit conversionsHard
Practice exercise (made-up values, not clinical guidance). An infusion starts at 22:50 and finishes at 04:30 the next morning (24-hour clock). How many minutes t did it run?
22:5004:30
t = min
27.Dosage calculationsMedium
A child weighing 32 kg is prescribed 2.5 mg/kg of a drug. The stock solution contains 20 mg/mL. Draw up the dose: what volume V do you give?
32 kg2.5 mg/kg20 mg/mL
V = mL
28.Dosage calculationsHard
A patient weighs 118.8 lb. The prescription is 2 mg/kg as a single dose, and the stock contains 100 mg in 1 mL. Using 1 kg = 2.2 lb, what volume V do you give? Round to one decimal place.
118.8 lb2 mg/kg100 mg/1 mL1 kg = 2.2 lb
V = mL
29.IV infusion ratesMedium
An infusion is ordered at 150 mL/h, but no pump is available. It runs by gravity through a giving set of 60 gtt/mL. Find the drip rate R in drops per minute.
150 mL/h60 gtt/mL
R = gtt/min
30.IV infusion ratesHard
1500 mL was ordered over 6 hours. After 3 hours you find that 800 mL is still in the bag, and the order must still finish on time. By what percentage Δ must the original pump rate be increased?
1500 mL / 6 hafter 3 h: 800 mL
Δ = %
31.IV fluids & fluid balanceMedium
Practice exercise (made-up values, not clinical guidance). The record shows a patient's intake and output for one 12-hour shift. The IV infusion ran at the rate shown for the whole shift. Find the fluid balance B = intake − output in mL (a negative answer means a net loss).
Practice exercise (made-up values, not clinical guidance). A 1000 mL infusion starts at 07:00 at 80 mL/h. After 2 hours the rate is changed to 200 mL/h and is not changed again. How many hours t after the start will the bag be empty? Round to one decimal place.
1000 mL80 mL/h · 2 h200 mL/h
t = h
33.Clinical assessment scoresMedium
Practice exercise (made-up values, not clinical guidance). A practice chart records GCS 12, with E3 and V5. What motor score M was recorded, and which response does it describe? Give the number.
GCS 12E3V5
M =
34.Clinical assessment scoresHard
Practice exercise (made-up values, not clinical guidance). A practice patient is assessed with the Morse fall scale: history of falling in the last 3 months: no; secondary diagnosis: yes; ambulatory aid: none, bed rest or nurse assists; IV therapy or saline lock: no; gait: normal, bed rest or wheelchair; mental status: knows own limits. Using the cut-offs 0–24 low, 25–44 moderate and 45 or more high, click the fall-risk level.
1low risk
2moderate risk
3high risk
3Solutions
1.Nursing fundamentals
Answer: A · A rising respiratory rate
Why this is the answer
Tachypnoea is one of the earliest and most sensitive signs of deterioration and scores highly in early warning systems such as NEWS2.
Answer
A · A rising respiratory rate
2.Nursing fundamentals
Answer: B · Helping a stable patient walk to the bathroom
Why this is the answer
Routine help with care for a stable patient can be delegated. Assessment, teaching and evaluation need registered nurse judgement.
Answer
B · Helping a stable patient walk to the bathroom
3.Infection control & patient safety
Answer: A · Perform a user seal check
Why this is the answer
A fit test confirms that a model and size suit the person. A user seal check, breathing in and out to feel for leaks at the edges, is done every time the respirator is put on.
Answer
A · Perform a user seal check
4.Infection control & patient safety
Answer: D · Into a red outlet connected to the emergency generator
Why this is the answer
In US hospitals, red outlets are usually connected to the emergency generator. Life-support equipment is plugged into them, and battery backups are checked as part of emergency planning.
Answer
D · Into a red outlet connected to the emergency generator
5.Prioritization & delegation
Answer: D · Call for help and give back blows and abdominal thrusts
Why this is the answer
An adult who cannot speak, breathe or cough has a severe airway obstruction. Resuscitation guidelines such as those of the European Resuscitation Council recommend up to 5 back blows followed by up to 5 abdominal thrusts, repeated until the object clears; some guidelines start with abdominal thrusts. If the patient becomes unresponsive, CPR is started. A blind finger sweep can push the object further in.
Answer
D · Call for help and give back blows and abdominal thrusts
6.Prioritization & delegation
Answer: A · A 60-year-old with chest pressure, sweating and nausea for 20 minutes
Why this is the answer
Chest pressure with sweating and nausea may be a heart attack, so the patient needs an ECG within minutes. The other patients are stable and can safely wait.
Answer
A · A 60-year-old with chest pressure, sweating and nausea for 20 minutes
7.Clinical nursing
Answer: D · Do not stop them suddenly
Why this is the answer
Long-term steroids suppress the adrenal glands, so stopping suddenly can cause adrenal crisis. Patients should carry a steroid alert card or medical ID and follow sick-day guidance.
Answer
D · Do not stop them suddenly
8.Clinical nursing
Answer: C · "My output will be firm and formed like before."
Why this is the answer
Ileostomy output is liquid to porridge-like because it bypasses the colon. The other statements describe correct care: good hydration, emptying the bag before it is too heavy and recognising a healthy stoma.
Answer
C · "My output will be firm and formed like before."
9.Lab values & electrolytes
Answer: D · Gout is still possible, as urate can be normal in an attack
Why this is the answer
Serum urate can be normal or even low during an acute gout attack. The definitive test is joint aspiration showing needle-shaped urate crystals, which also helps rule out septic arthritis.Checked against:Gout · MedlinePlus (NIH) (2025); Synovial Fluid Analysis · MedlinePlus (NIH) (2024)
Answer
D · Gout is still possible, as urate can be normal in an attack
10.Lab values & electrolytes
Answer: B · Laryngospasm, an emergency needing urgent help and IV calcium
Why this is the answer
Severe hypocalcemia can cause spasm of the larynx, which blocks the airway. The nurse calls for urgent help, supports the airway and prepares IV calcium gluconate as prescribed, with cardiac monitoring.Checked against:Hypocalcemia (StatPearls) · StatPearls (NCBI Bookshelf) (2026)
Answer
B · Laryngospasm, an emergency needing urgent help and IV calcium
11.Pharmacology
Answer: C · It releases nitric oxide, mainly dilating veins and reducing cardiac workload
Why this is the answer
GTN is converted to nitric oxide, which relaxes vascular smooth muscle through cGMP. Venodilation lowers preload, so the heart works less and needs less oxygen.
Answer
C · It releases nitric oxide, mainly dilating veins and reducing cardiac workload
12.Pharmacology
Answer: D · Weaker blood pressure control, kidney injury and high potassium
Why this is the answer
NSAIDs block prostaglandins that dilate the afferent arteriole and promote sodium loss. With an ACE inhibitor this can reduce blood pressure control and cause kidney injury and hyperkalaemia, especially if a diuretic is also used.
Answer
D · Weaker blood pressure control, kidney injury and high potassium
13.Med-surg: cardiovascular & respiratory
Answer: C · Hanging the legs down over the side of the bed
Why this is the answer
Ischaemic rest pain is often relieved by lowering the legs, which improves arterial flow by gravity. Elevation worsens ischaemia. Compression is contraindicated in significant arterial disease, and direct heat can burn insensitive, ischaemic skin.
Answer
C · Hanging the legs down over the side of the bed
14.Med-surg: cardiovascular & respiratory
Answer: D · Pause it for a set time, based on bleeding risk and kidney function
Why this is the answer
Because DOACs wear off within days, they are usually paused for a defined period before surgery (often 1–3 days) depending on the procedure's bleeding risk and renal function; bridging with heparin is generally not needed. Vitamin K does not reverse DOACs.
Answer
D · Pause it for a set time, based on bleeding risk and kidney function
15.Med-surg: neuro, endocrine & renal
Answer: D · Press firmly on the site with clean gauze
Why this is the answer
Firm, direct pressure with clean gauze or a dressing is applied to the site. A tourniquet could clot the fistula. If bleeding does not stop, the patient calls emergency services, because fistula bleeding can be heavy.
Answer
D · Press firmly on the site with clean gauze
16.Med-surg: neuro, endocrine & renal
Answer: B · Urgent dialysis, with cardiac monitoring meanwhile
Why this is the answer
Missing dialysis causes fluid overload and hyperkalaemia, both of which can be fatal. The patient needs cardiac monitoring, emergency treatment of the potassium and urgent dialysis to remove fluid and potassium.
Answer
B · Urgent dialysis, with cardiac monitoring meanwhile
17.Med-surg: GI, perioperative & oncology
Answer: D · Long-term corticosteroids
Why this is the answer
Corticosteroids suppress the inflammatory phase, collagen formation and immunity, delaying healing and raising infection risk. Other factors include diabetes, smoking, malnutrition, poor perfusion and chemotherapy.
Answer
D · Long-term corticosteroids
18.Med-surg: GI, perioperative & oncology
Answer: B · 4800 mL
Why this is the answer
Parkland gives 4 × 80 × 30 = 9600 mL in 24 hours, with half (4800 mL) in the first 8 hours from the time of injury. The rate is then adjusted to urine output and clinical response. Many burn centres now start lower, for example at 2 mL/kg/%TBSA in adults, and titrate to urine output.
Answer
B · 4800 mL
19.Maternity & obstetric nursing
Answer: D · At about 36 to 37 weeks
Why this is the answer
Colonisation can come and go, so the swab is taken late in pregnancy, close to birth. A positive result leads to intrapartum antibiotics to protect the newborn. Some countries use a risk-based approach instead.
Answer
D · At about 36 to 37 weeks
20.Maternity & obstetric nursing
Answer: B · To check that it is complete and nothing is retained
Why this is the answer
The placenta and membranes are inspected for completeness. Retained fragments prevent the uterus contracting and cause postpartum haemorrhage and infection. The number of cord vessels is also checked.
Answer
B · To check that it is complete and nothing is retained
21.Pediatric nursing
Answer: B · 38.0 °C (100.4 °F) or higher
Why this is the answer
A temperature of 38.0 °C (100.4 °F) or higher is generally considered a fever in children. In young infants even a modest fever can signal serious infection and needs prompt assessment.
Answer
B · 38.0 °C (100.4 °F) or higher
22.Pediatric nursing
Answer: B · "We will put a soft bumper and a pillow in the cot so she is comfortable."
Why this is the answer
Soft bedding, pillows and bumpers increase the risk of suffocation and sudden infant death. Back sleeping, a separate cot in the parents' room and a smoke-free environment all reduce the risk.
Answer
B · "We will put a soft bumper and a pillow in the cot so she is comfortable."
23.Mental health nursing
Answer: D · It blocks NMDA glutamate receptors
Why this is the answer
Memantine is an NMDA receptor antagonist used in moderate to severe Alzheimer's disease. It may be combined with a cholinesterase inhibitor.
Answer
D · It blocks NMDA glutamate receptors
24.Mental health nursing
Answer: D · Schizoaffective disorder
Why this is the answer
In schizoaffective disorder, a major mood episode occurs alongside schizophrenia symptoms, mood episodes are present for most of the illness, and psychotic symptoms are also present for at least 2 weeks without a mood episode. In psychotic depression, the psychosis occurs only during the mood episode.
Answer
D · Schizoaffective disorder
25.Nursing math & unit conversions
Answer: T = 39.1 °C
Temperature: °C = (°F − 32) × 5/9 and °F = °C × 9/5 + 32. Subtract 32 before you multiply when going from °F, and add 32 after you multiply when going from °C. A quick check: 37 °C is 98.6 °F, and every 1 °C is 1.8 °F.
Subtract 32
102.4 − 32 = 70.4
Multiply by 5/9
T = 70.4·5/9 = 39.11 ≈ 39.1 °C
Answer
T = 39.1 °C
26.Nursing math & unit conversions
Answer: t = 340 min
24-hour clock: from 1 PM onwards add 12 to the hour (3:45 PM = 15:45). Midnight to 12:59 AM is 00:00–00:59, and 12:00–12:59 PM stays 12:00–12:59. Going back, subtract 12 from hours 13–23 and add PM; hours 00 become 12 AM. Count time across midnight in two parts: up to 24:00 (00:00), then from 00:00 on.
Before midnight
22:50 → 24:00 = 70 min
After midnight
00:00 → 04:30 = 270 min
Total
t = 70 + 270 = 340 min
Answer
t = 340 min
27.Dosage calculations
Answer: V = 4 mL
Drawing up a dose: volume = (prescribed dose/stock strength) × stock volume. Convert to the same units first, then check that the volume fits the syringe and lands on one of its graduations.
Dose from body weight
D = 2.5·32 = 80 mg
Volume
V = 80/20 = 4 mL
On the syringe
On this 10 mL syringe every small line is 0.2 mL.
Answer
V = 4 mL
28.Dosage calculations
Answer: V = 1.1 mL
Dose calculation: the amount to give equals what is prescribed divided by what you have, times the quantity it comes in: amount = (desired dose/stock strength) × stock volume. Always keep the units the same (convert g to mg, mg to mcg first) and check that the answer is sensible.
Weight in kg
118.8/2.2 = 54 kg
Dose
2·54 = 108 mg
Volume
V = (108/100)·1 = 1.08 ≈ 1.1 mL
Answer
V = 1.1 mL
29.IV infusion rates
Answer: R = 150 gtt/min
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Millilitres per minute
150/60 = 2.5 mL/min
Drip rate
R = 2.5·60 = 150 gtt/min
Answer
R = 150 gtt/min
With a microdrip set (60 gtt/mL), gtt/min equals mL/h.
30.IV infusion rates
Answer: Δ = 6.667 %
Infusion rates: a pump is set in mL/h = volume/time in hours. A gravity drip is counted in drops per minute: gtt/min = volume (mL) × drop factor (gtt/mL)/time (min). The drop factor is printed on the tubing package: macrodrip sets deliver 10, 15 or 20 gtt/mL (blood sets often 10 gtt/mL in the US, 15 in the UK) and microdrip sets 60 gtt/mL. Always use the drop factor the question or package gives.
Original rate
1500/6 = 250 mL/h
New rate
R = 800/3 = 266.7 mL/h
Percentage change
Δ = (266.7 − 250)/250·100% = 6.667%
Answer
Δ = 6.667%
Many hospitals allow such an adjustment up to 25% without a new order; check local policy.
31.IV fluids & fluid balance
Answer: B = −655 mL
Intake and output: intake counts everything that goes in (oral fluids, IV infusions, IV medications and flushes, tube feeds); ice chips count as half their volume. Output counts urine, drains, vomit and other losses. Balance = total intake − total output; a negative balance is a net loss. The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
Total intake
oral: 150 + 100 + 250 = 500 mL
IV infusion: 60·12 = 720 mL
IV antibiotic: 1·50 = 50 mL
total intake = 1270 mL
Total output
500 + 400 + 325 + 500 + 100 + 100 = 1925 mL
Balance
B = 1270 − 1925 = −655 mL
Answer
B = −655 mL
Negative: the patient lost more fluid than went in.
32.IV fluids & fluid balance
Answer: t = 6.2 h
Infusion time: time (h) = volume to infuse (mL)/rate (mL/h); use the volume still left in the bag, not the bag size. Volume infused = rate × time. Convert decimal hours to hours and minutes with the fraction × 60 (0.5 h = 30 min, not 50 min). The numbers are for practice only; at the bedside always follow local protocols and have high-risk doses double-checked.
First part
80·2 = 160 mL
1000 − 160 = 840 mL left
Second part
840/200 = 4.2 h
Total time
t = 2 + 4.2 = 6.2 h
Answer
t = 6.2 h
That is about 6 h 12 min, so the bag runs out at about 13:12.
33.Clinical assessment scores
Answer: M = 4
Glasgow Coma Scale: add the best response in three areas. Eye opening E: 4 spontaneous, 3 to sound or speech, 2 to pressure, 1 none. Verbal V: 5 oriented, 4 confused, 3 inappropriate words, 2 incomprehensible sounds, 1 none. Motor M: 6 obeys commands, 5 localises, 4 normal flexion (withdraws), 3 abnormal flexion, 2 extension, 1 none. The total runs from 3 to 15. After a head injury, 13–15 is usually called mild, 9–12 moderate and 3–8 severe.
Motor score
M = 12 − 3 − 5 = 4
M4: withdraws the limb from pressure (normal flexion)
Answer
M = 4
34.Clinical assessment scores
Answer: low risk
Morse fall scale: six items. History of falling: no 0, yes 25. Secondary diagnosis: no 0, yes 15. Ambulatory aid: none, bed rest or nurse assistance 0; crutches, cane or walker 15; holding on to furniture 30. IV therapy or saline lock: no 0, yes 20. Gait: normal, bed rest or wheelchair 0; weak 10; impaired 20. Mental status: knows own limits 0; overestimates or forgets limits 15. The total runs from 0 to 125. Risk cut-offs differ between hospitals; a common set is 0–24 low, 25–44 moderate and 45 or more high.
Score each item
history of falling in the last 3 months: no → 0
secondary diagnosis: yes → 15
ambulatory aid: none, bed rest or nurse assists → 0
IV therapy or saline lock: no → 0
gait: normal, bed rest or wheelchair → 0
mental status: knows own limits → 0
Add
Morse total = 0 + 15 + 0 + 0 + 0 + 0 = 15
Risk level
15 → low risk
Answer
low risk
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