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

A decreasing level of consciousness is typically the earliest sign of rising ICP because the reticular activating system is sensitive to pressure changes.

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

Hepatic encephalopathy results from excess ammonia; reducing dietary protein decreases the substrate for ammonia production by gut bacteria.

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

Inadvertent removal or damage to the parathyroid glands causes acute hypocalcemia, manifesting as tetany, stridor, and perioral/fingertip tingling.

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

Phantom limb pain is real pain perceived in the absent limb due to persistent neural signals from the spinal cord and brain.

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

Continuous bubbling in the water-seal chamber indicates an ongoing air leak, which may originate from the patient's pleural space or a loose connection.

BSN - Degree Bachelor of Science in Nursing Practice Test

BSN - Degree Bachelor of Science in Nursing Practice Test

BSN Medical-Surgical Nursing 2