BSN Medical-Surgical Nursing 2 — Questions and Answers
Question 1: Which clinical manifestation is an early sign of increased intracranial pressure (ICP)?
- Decreasing level of consciousness and restlessness (Correct answer)
- Cushing's triad (bradycardia, widening pulse pressure, irregular respirations)
- Fixed and dilated pupils bilaterally
- Decerebrate posturing
Correct answer: Decreasing level of consciousness and restlessness
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?
- Protein restriction to reduce ammonia production (Correct answer)
- Increased sodium intake to maintain fluid balance
- High-fat diet to provide caloric density
- Fluid restriction to prevent ascites
Correct answer: Protein restriction to reduce ammonia production
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?
- Hypocalcemia from inadvertent parathyroid removal (Correct answer)
- Recurrent laryngeal nerve damage
- Hematoma compressing the airway
- Thyroid storm
Correct answer: Hypocalcemia from inadvertent parathyroid removal
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:
- Phantom limb pain (Correct answer)
- Residual limb pain
- Neuropathic referred pain
- Psychosomatic pain
Correct answer: Phantom limb pain
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?
- An air leak in the system or the patient's pleural space (Correct answer)
- Normal function of the chest tube drainage system
- The lung has fully re-expanded
- The tube is clamped and needs to be released
Correct answer: An air leak in the system or the patient's pleural space
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.
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?
- Lactated Ringer's solution (Correct answer)
- 0.45% normal saline
- 5% dextrose in water (D5W)
- Albumin 5% colloid
Correct answer: Lactated Ringer's solution
Lactated Ringer's is the isotonic crystalloid of choice for burn resuscitation per the Parkland formula because it replaces lost fluid and electrolytes.
BSN Medical-Surgical Nursing 2
Which clinical manifestation is an early sign of increased intracranial pressure (ICP)?