,NU189/NU 189 Exam 4 | Medical-Surgical Nursing II |
1. Which of the following laboratory findings is most consistent with the syndrome of inappropriate
antidiuretic hormone (SIADH)?
A) Serum sodium of 152 mEq/L and high serum osmolality
B) Serum sodium of 128 mEq/L and low serum osmolality
C) Serum potassium of 5.8 mEq/L and high BUN
D) Serum calcium of 12.5 mg/dL and high urine output
Correct Answer: Serum sodium of 128 mEq/L and low serum osmolality
Expert Rationale: SIADH causes water retention, leading to dilutional hyponatremia (low sodium) and
low serum osmolality. Patients may present with fluid overload, weight gain, and seizures. Treatment
includes fluid restriction and possibly tolvaptan.
2. A patient is admitted with suspected bacterial meningitis. Which diagnostic procedure should the
nurse prepare the patient for?
A) CT scan of the head
B) Lumbar puncture
C) MRI of the brain
D) EEG
Correct Answer: Lumbar puncture
Expert Rationale: A lumbar puncture is the definitive diagnostic procedure for meningitis, allowing for
cerebrospinal fluid (CSF) collection and analysis. CSF findings include elevated white blood cells, elevated
protein, and low glucose. The patient should be placed on respiratory isolation for suspected bacterial
meningitis.
3. A patient with cirrhosis is exhibiting flapping tremors of the hands and a musty breath odor. Which
complication should the nurse suspect?
A) Esophageal varices
,B) Hepatorenal syndrome
C) Hepatic encephalopathy
D) Spontaneous bacterial peritonitis
Correct Answer: Hepatic encephalopathy
Expert Rationale: Hepatic encephalopathy is a complication of cirrhosis caused by the accumulation of
neurotoxic substances, such as ammonia, in the blood. Asterixis (flapping tremors) and fetor hepaticus
(musty breath odor) are classic signs. Lactulose is prescribed to lower ammonia levels.
4. What is the priority nursing action for a patient experiencing a seizure?
A) Restrain the patient to prevent injury
B) Place a tongue blade in the patient's mouth
C) Observe the seizure and protect the patient from injury
D) Administer oral antiepileptic medication immediately
Correct Answer: Observe the seizure and protect the patient from injury
Expert Rationale: During a seizure, the priority is to observe the seizure activity and protect the patient
from injury by moving objects away and cushioning the head. Restraining the patient or placing objects
in the mouth can cause injury. IV (not oral) antiepileptic medications are administered for prolonged
seizures.
5. A patient with angina pectoris is prescribed sublingual nitroglycerin. How many doses may the patient
take before seeking emergency medical attention?
A) One dose
B) Two doses
C) Three doses
D) Four doses
Correct Answer: Three doses
, Expert Rationale: For angina, the patient should take one sublingual nitroglycerin tablet every 5 minutes,
up to a maximum of three doses. If chest pain persists after three doses, the patient should call 911 or
seek emergency medical care. Nitroglycerin works by vasodilation to improve coronary blood flow.
6. A nurse is assessing a patient with suspected increased intracranial pressure (ICP). Which finding is
the earliest and most sensitive indicator of rising ICP?
A) Hypertension with a widening pulse pressure
B) Bradycardia and irregular respirations
C) Lethargy and decreased level of consciousness
D) Pupillary dilation and fixation
Correct Answer: Lethargy and decreased level of consciousness
Expert Rationale: A change in level of consciousness, such as lethargy or delayed responses, is the
earliest and most sensitive indicator of rising ICP. Cushing's triad (hypertension, bradycardia, irregular
respirations) is a late, ominous sign of brainstem compression.
7. Cushing's triad, a late sign of increased intracranial pressure, includes which of the following findings?
A) Hypotension, tachycardia, and tachypnea
B) Systolic hypertension, bradycardia, and irregular respirations
C) Diastolic hypertension, tachycardia, and irregular respirations
D) Hypotension, bradycardia, and irregular respirations
Correct Answer: Systolic hypertension, bradycardia, and irregular respirations
Expert Rationale: Cushing's triad consists of systolic hypertension, bradycardia, and irregular
respirations. This triad indicates brainstem compression and is a medical emergency requiring
immediate intervention to prevent herniation.
8. A patient with a traumatic brain injury exhibits adduction of the arms and flexion of the elbows and
wrists in response to pain. The nurse should document this as:
1. Which of the following laboratory findings is most consistent with the syndrome of inappropriate
antidiuretic hormone (SIADH)?
A) Serum sodium of 152 mEq/L and high serum osmolality
B) Serum sodium of 128 mEq/L and low serum osmolality
C) Serum potassium of 5.8 mEq/L and high BUN
D) Serum calcium of 12.5 mg/dL and high urine output
Correct Answer: Serum sodium of 128 mEq/L and low serum osmolality
Expert Rationale: SIADH causes water retention, leading to dilutional hyponatremia (low sodium) and
low serum osmolality. Patients may present with fluid overload, weight gain, and seizures. Treatment
includes fluid restriction and possibly tolvaptan.
2. A patient is admitted with suspected bacterial meningitis. Which diagnostic procedure should the
nurse prepare the patient for?
A) CT scan of the head
B) Lumbar puncture
C) MRI of the brain
D) EEG
Correct Answer: Lumbar puncture
Expert Rationale: A lumbar puncture is the definitive diagnostic procedure for meningitis, allowing for
cerebrospinal fluid (CSF) collection and analysis. CSF findings include elevated white blood cells, elevated
protein, and low glucose. The patient should be placed on respiratory isolation for suspected bacterial
meningitis.
3. A patient with cirrhosis is exhibiting flapping tremors of the hands and a musty breath odor. Which
complication should the nurse suspect?
A) Esophageal varices
,B) Hepatorenal syndrome
C) Hepatic encephalopathy
D) Spontaneous bacterial peritonitis
Correct Answer: Hepatic encephalopathy
Expert Rationale: Hepatic encephalopathy is a complication of cirrhosis caused by the accumulation of
neurotoxic substances, such as ammonia, in the blood. Asterixis (flapping tremors) and fetor hepaticus
(musty breath odor) are classic signs. Lactulose is prescribed to lower ammonia levels.
4. What is the priority nursing action for a patient experiencing a seizure?
A) Restrain the patient to prevent injury
B) Place a tongue blade in the patient's mouth
C) Observe the seizure and protect the patient from injury
D) Administer oral antiepileptic medication immediately
Correct Answer: Observe the seizure and protect the patient from injury
Expert Rationale: During a seizure, the priority is to observe the seizure activity and protect the patient
from injury by moving objects away and cushioning the head. Restraining the patient or placing objects
in the mouth can cause injury. IV (not oral) antiepileptic medications are administered for prolonged
seizures.
5. A patient with angina pectoris is prescribed sublingual nitroglycerin. How many doses may the patient
take before seeking emergency medical attention?
A) One dose
B) Two doses
C) Three doses
D) Four doses
Correct Answer: Three doses
, Expert Rationale: For angina, the patient should take one sublingual nitroglycerin tablet every 5 minutes,
up to a maximum of three doses. If chest pain persists after three doses, the patient should call 911 or
seek emergency medical care. Nitroglycerin works by vasodilation to improve coronary blood flow.
6. A nurse is assessing a patient with suspected increased intracranial pressure (ICP). Which finding is
the earliest and most sensitive indicator of rising ICP?
A) Hypertension with a widening pulse pressure
B) Bradycardia and irregular respirations
C) Lethargy and decreased level of consciousness
D) Pupillary dilation and fixation
Correct Answer: Lethargy and decreased level of consciousness
Expert Rationale: A change in level of consciousness, such as lethargy or delayed responses, is the
earliest and most sensitive indicator of rising ICP. Cushing's triad (hypertension, bradycardia, irregular
respirations) is a late, ominous sign of brainstem compression.
7. Cushing's triad, a late sign of increased intracranial pressure, includes which of the following findings?
A) Hypotension, tachycardia, and tachypnea
B) Systolic hypertension, bradycardia, and irregular respirations
C) Diastolic hypertension, tachycardia, and irregular respirations
D) Hypotension, bradycardia, and irregular respirations
Correct Answer: Systolic hypertension, bradycardia, and irregular respirations
Expert Rationale: Cushing's triad consists of systolic hypertension, bradycardia, and irregular
respirations. This triad indicates brainstem compression and is a medical emergency requiring
immediate intervention to prevent herniation.
8. A patient with a traumatic brain injury exhibits adduction of the arms and flexion of the elbows and
wrists in response to pain. The nurse should document this as:
