WKU MED SURG FINAL EXAM
COMPLETE QUESTIONS WITH 100%
VERIFIED ANSWERS
\.A client in the emergency department (ED) has slurred speech, confusion, and
visual problems, and has been having intermittent episodes of worsening
symptoms. The symptoms have a gradual onset. The client also has a history of
hypertension and atherosclerosis. What does the nurse suspect that the client is
probably experiencing?
A. Embolic stroke
B. Hemorrhagic stroke
C. Thrombotic stroke
D. Transient ischemic attack - ANSWERS-C. Thrombotic stroke
\.Changes in musculoskeletal system related to aging - ANSWERS-o Changes:
diminished visual acuity and hearing, changes in gait, balance, and muscle
strength,
joint stiffness
o Hip fractures usually report groin pain or pain behind the knee on the affected
side, some cases
asymptomatic but unable to stand
\.Check pulse for - ANSWERS-o If no pulse within 10 seconds, start CPR, beginning
with chest compressions
,o If there is a pulse and absent breathing, start rescue breathing at 1 breath every
5-6 seconds.
o Check pulse about every 2 minutes (5 cycles of CPR)
\.Ensure Closed loop communication - ANSWERS-· Team leader gives a clear
message, order, or an assignment to the team member
· Both the team leader and team member should make eye contact and the team
member should confirm (verbalize) to the team leader the message was heard
and understood.
\.BLS Assessment - ANSWERS-· Make sure there is a safe environment!!! Take care
of you so you can take care of other people.
· Check responsiveness
· Shout for nearby help/activate the emergency response system and get the
AED/defibrillator
\.Primary Assessment: Airway - ANSWERS-· Maintain airway patency in
unconscious patients
o Head tilt- chin lift (if no suspicion of head/neck injury)
o Jaw thrust (if suspicion head/neck injury)
\.SAMPLE - ANSWERS-o Signs and symptoms: onset of illness or injury (what was
happening when this started)
o Allergies: food, medical, latex, associated reactions
o Medications: over the counter, prescribed, vitamins, inhalers, supplements, last
dose was given
,o Past medical history: surgeries, psych, immunizations (tetanus)
o Last meal consumed
o Events to present: if EMS was called, what happened there, time of onset, time
of last period, any use of alcohol or recreational drugs, head injury
\.H's and T's - ANSWERS-Hs: hypovolemia, hydrogen ion (acidosis),
hypo/hyperkalemia, hypothermia (those are causes that would cause the cardiac
arrest, so we need to fix it
Ts: tension pneumothorax, tamponade (cardiac), toxins, thrombosis (pulmonary),
thrombosis (cardiac)
· Identification of respiratory problems by severity
\.Clinical signs of respiratory distress - ANSWERS-o Tachypnea
o Increased respiratory effort
o Inadequate respiratory effort
o Abnormal airway sounds
o Tachycardia
o Pale, cool skin
o Changes in level of consciousness/agitation (if it doesn't get enough oxygen or
glucose)
o Use of abnormal muscles to assist in breathing
\.Respiratory Failure Clinical signs - ANSWERS-o Marked tachypnea
o Bradypnea (late sign)
, o Increased, decreased respiratory effort- get tired
o Poor to absent distal air movement
o Tachycardia (early)
o Bradycardia (late)
o Cyanosis
o Stupor, coma (late)
\.Physical Assessment - ANSWERS-• Assess all body systems for life-threatening
complications (prioritizing care- head, chest or abdomen (bleeding). Remove
clothing, use warm blankets, remove jewelry, full assessment!!!
• Check urine for blood (seatbelt injury)
• Assess for swelling, perfusion, skin integrity. Hip (posterior knee pain or groin).
Humeral shoulder or elbow pain. Support and comfort in effected area. Any bone
alignment issues, crepitus (bone on bone sounds), wounds or bruising at site,
assess bilaterally!
\.Acute compartment syndrome - ANSWERS-Serious and painful condition that
occurs when excessive pressure builds up inside an
enclosed muscle space in the body.
\.Acute compartment syndrome Clinical features - ANSWERS-● Pressure can
decrease blood flow, prevents nourishment, blood and oxygen from
reaching muscle cells
● *Can happen any enclosed space or compartment ; Commonly occurs in
forearms
and lower legs
COMPLETE QUESTIONS WITH 100%
VERIFIED ANSWERS
\.A client in the emergency department (ED) has slurred speech, confusion, and
visual problems, and has been having intermittent episodes of worsening
symptoms. The symptoms have a gradual onset. The client also has a history of
hypertension and atherosclerosis. What does the nurse suspect that the client is
probably experiencing?
A. Embolic stroke
B. Hemorrhagic stroke
C. Thrombotic stroke
D. Transient ischemic attack - ANSWERS-C. Thrombotic stroke
\.Changes in musculoskeletal system related to aging - ANSWERS-o Changes:
diminished visual acuity and hearing, changes in gait, balance, and muscle
strength,
joint stiffness
o Hip fractures usually report groin pain or pain behind the knee on the affected
side, some cases
asymptomatic but unable to stand
\.Check pulse for - ANSWERS-o If no pulse within 10 seconds, start CPR, beginning
with chest compressions
,o If there is a pulse and absent breathing, start rescue breathing at 1 breath every
5-6 seconds.
o Check pulse about every 2 minutes (5 cycles of CPR)
\.Ensure Closed loop communication - ANSWERS-· Team leader gives a clear
message, order, or an assignment to the team member
· Both the team leader and team member should make eye contact and the team
member should confirm (verbalize) to the team leader the message was heard
and understood.
\.BLS Assessment - ANSWERS-· Make sure there is a safe environment!!! Take care
of you so you can take care of other people.
· Check responsiveness
· Shout for nearby help/activate the emergency response system and get the
AED/defibrillator
\.Primary Assessment: Airway - ANSWERS-· Maintain airway patency in
unconscious patients
o Head tilt- chin lift (if no suspicion of head/neck injury)
o Jaw thrust (if suspicion head/neck injury)
\.SAMPLE - ANSWERS-o Signs and symptoms: onset of illness or injury (what was
happening when this started)
o Allergies: food, medical, latex, associated reactions
o Medications: over the counter, prescribed, vitamins, inhalers, supplements, last
dose was given
,o Past medical history: surgeries, psych, immunizations (tetanus)
o Last meal consumed
o Events to present: if EMS was called, what happened there, time of onset, time
of last period, any use of alcohol or recreational drugs, head injury
\.H's and T's - ANSWERS-Hs: hypovolemia, hydrogen ion (acidosis),
hypo/hyperkalemia, hypothermia (those are causes that would cause the cardiac
arrest, so we need to fix it
Ts: tension pneumothorax, tamponade (cardiac), toxins, thrombosis (pulmonary),
thrombosis (cardiac)
· Identification of respiratory problems by severity
\.Clinical signs of respiratory distress - ANSWERS-o Tachypnea
o Increased respiratory effort
o Inadequate respiratory effort
o Abnormal airway sounds
o Tachycardia
o Pale, cool skin
o Changes in level of consciousness/agitation (if it doesn't get enough oxygen or
glucose)
o Use of abnormal muscles to assist in breathing
\.Respiratory Failure Clinical signs - ANSWERS-o Marked tachypnea
o Bradypnea (late sign)
, o Increased, decreased respiratory effort- get tired
o Poor to absent distal air movement
o Tachycardia (early)
o Bradycardia (late)
o Cyanosis
o Stupor, coma (late)
\.Physical Assessment - ANSWERS-• Assess all body systems for life-threatening
complications (prioritizing care- head, chest or abdomen (bleeding). Remove
clothing, use warm blankets, remove jewelry, full assessment!!!
• Check urine for blood (seatbelt injury)
• Assess for swelling, perfusion, skin integrity. Hip (posterior knee pain or groin).
Humeral shoulder or elbow pain. Support and comfort in effected area. Any bone
alignment issues, crepitus (bone on bone sounds), wounds or bruising at site,
assess bilaterally!
\.Acute compartment syndrome - ANSWERS-Serious and painful condition that
occurs when excessive pressure builds up inside an
enclosed muscle space in the body.
\.Acute compartment syndrome Clinical features - ANSWERS-● Pressure can
decrease blood flow, prevents nourishment, blood and oxygen from
reaching muscle cells
● *Can happen any enclosed space or compartment ; Commonly occurs in
forearms
and lower legs
