BSN Medical-Surgical Nursing 2

Question 1

Which clinical manifestation is an early sign of increased intracranial pressure (ICP)?

Accepted Answer

Decreasing level of consciousness and restlessness

Answer

Cushing's triad (bradycardia, widening pulse pressure, irregular respirations)

Answer

Fixed and dilated pupils bilaterally

Answer

Decerebrate posturing

Question 2

A patient with chronic liver disease presents with asterixis (flapping tremor), confusion, and fetor hepaticus. Which dietary modification should the nurse anticipate in the care plan?

Accepted Answer

Protein restriction to reduce ammonia production

Answer

Increased sodium intake to maintain fluid balance

Answer

High-fat diet to provide caloric density

Answer

Fluid restriction to prevent ascites

Question 3

A patient post-thyroidectomy suddenly develops stridor, dysphagia, and tingling in the fingertips. What complication should the nurse suspect?

Accepted Answer

Hypocalcemia from inadvertent parathyroid removal

Answer

Recurrent laryngeal nerve damage

Answer

Hematoma compressing the airway

Answer

Thyroid storm

Question 4

A patient with a lower extremity amputation is complaining of pain in the amputated limb. The nurse correctly documents this as:

Accepted Answer

Phantom limb pain

Answer

Residual limb pain

Answer

Neuropathic referred pain

Answer

Psychosomatic pain

Question 5

A nurse is caring for a patient with a chest tube. The water-seal chamber shows continuous bubbling. What does this finding indicate?

Accepted Answer

An air leak in the system or the patient's pleural space

Answer

Normal function of the chest tube drainage system

Answer

The lung has fully re-expanded

Answer

The tube is clamped and needs to be released

Question 6

A patient with burns over 40% of their body surface area is in the emergent phase. Which IV fluid is the priority for initial resuscitation?

Accepted Answer

Lactated Ringer's solution

Answer

0.45% normal saline

Answer

5% dextrose in water (D5W)

Answer

Albumin 5% colloid