Medical-Surgical Nursing III EXAM 3 LATEST 2024/2025
EXAM QUESTION ANSWER GRADED A+ WITH
RATIONALE
Spinal Cord Injury - ANSWER: Assess breathing pattern, cough lung sounds d/t
paralysis of the diaphragm, neuro exam, motor function, spinal shock [reflex, motor,
sensory, and autonomic activity below the level of the lesion that causes bladder
paralysis and distention], assess temp for hyperthermia.
Premature Ventricular Contractions (PVCs) - ANSWER: Extra heartbeats that begin in
one of the heart's two lower pumping chambers (ventricles). These extra beats
disrupt the regular heart rhythm, sometimes causing a sensation of a fluttering or a
skipped beat in the chest.
CD4 Count - ANSWER: The CD4+ count serves as the major laboratory indicator of
immune function and prophylaxis for opportunistic infections, and is the strongest
predictor of subsequent disease progression and survival. Normal CD4 count 1500-
500, Stage 2 HIV CD4 count 499-200, Stage 3 HIV CD4 count <200.
Poisoning in the House - ANSWER: Ingested poisons, food poisoning, carbon
monoxide poisoning, chemical burns can happen in the house environment. The
local poison control center should be called if an unknown toxic agent has been
taken or if it is necessary to identify an antidote for a known toxic agent.
AIDS Dementia - ANSWER: HIV encephalopathy was formerly referred to as AIDS
dementia complex. It is characterized by a progressive decline in cognitive,
behavioral, and motor functions as a direct result of HIV infection.
Heat Stroke - ANSWER: Inability to maintain cardiac output in the face of moderately
high body temperatures and is associated with dehydration. Exposure to prolonged
Environmental Temp 102.5 or greater although a heat index of greater than 35°C
(95°F) is associated with increased mortality.
Alcohol Intoxication Assessment - ANSWER: In the ED, the patient who is intoxicated
with alcohol or who presents with alcohol poisoning is assessed for head injury,
hypoglycemia (which mimics intoxication), and other health problems.
Hemorrhage Shock - ANSWER: #1. Stop the bleeding, pressure to site or surgical
interventions. #2 Large bore IV at least 2 lines. Monitor closely after infusion.
Benzodiazepines - ANSWER: Treatment of anxiety with benzodiazepines end in -pam,
-lam. Benzodiazepines are depressants that produce sedation and hypnosis, relieve
anxiety and muscle spasms, and reduce seizures.
Electrical Burns - ANSWER: Visual examination is not predictive of burn size and
severity. Mechanisms of injury include Flash and Conductive injuries.
, Near Drowning - ANSWER: Survival for at least 24 hours after submersion that
caused a respiratory arrest. The most common consequence is hypoxemia.
Ileal Conduit Postop Complications - ANSWER: Complications: Wound Infections,
Wound Dehiscence, Urinary leakage, ureteral obstruction, hyperchloremic acidosis,
small bowel obstructions, ileus, and gangrene of the stoma.
Auto Dysreflexia - ANSWER: Occurs in most patients with cord lesions above T6.
Severe, pounding headache with paroxysmal hypertension, profuse diaphoresis
above the spinal level of the lesion, nausea, nasal congestion, and bradycardia.
Septic Shock - ANSWER: Confusion w/ or w/o agitation and elevated RR are signs of
sepsis. Monitor Kidney/ Coagulation, Blood count labs, I&O, daily weights and
nutritional status.
AIDS Gas Exchange - ANSWER: Shortness of breath, dyspnea (labored breathing),
cough, chest pain, and fever are associated with various opportunistic infections.
DIC - ANSWER: Excessive clotting and bleeding. Massive amount of tiny clots forms in
the microcirculation.
Chest Trauma Complications - ANSWER: Sternal Rib Fx d/t MVA causing Resp
insufficiency or Resp failure, diminished ventilations or atelectasis.
Shock Fluid Management - ANSWER: Crystalloids: LR & 0.9% NS. Colloids: Albumin
5%, 25%. Blood Products: Plasma, Packed red blood cells and Platelets.
ICP Monitoring - ANSWER: Normal pressure being 0-15 mmHg as a result of
alterations in intrathoracic pressure. The earliest sign of increasing ICP is a change in
LOC.
Diaphragmatic breathing - ANSWER: Technique to expand alveoli, prevent
atelectasis.
Pursed-lip breathing - ANSWER: Technique to improve oxygenation and reduce
dyspnea.
Incentive spirometry - ANSWER: Device promoting lung inflation and cough
mechanism.
Chest tube transport - ANSWER: Keep drainage unit below chest level to facilitate
drainage.
Pneumothorax management - ANSWER: Apply sterile dressing, monitor respiratory
distress signs.
EXAM QUESTION ANSWER GRADED A+ WITH
RATIONALE
Spinal Cord Injury - ANSWER: Assess breathing pattern, cough lung sounds d/t
paralysis of the diaphragm, neuro exam, motor function, spinal shock [reflex, motor,
sensory, and autonomic activity below the level of the lesion that causes bladder
paralysis and distention], assess temp for hyperthermia.
Premature Ventricular Contractions (PVCs) - ANSWER: Extra heartbeats that begin in
one of the heart's two lower pumping chambers (ventricles). These extra beats
disrupt the regular heart rhythm, sometimes causing a sensation of a fluttering or a
skipped beat in the chest.
CD4 Count - ANSWER: The CD4+ count serves as the major laboratory indicator of
immune function and prophylaxis for opportunistic infections, and is the strongest
predictor of subsequent disease progression and survival. Normal CD4 count 1500-
500, Stage 2 HIV CD4 count 499-200, Stage 3 HIV CD4 count <200.
Poisoning in the House - ANSWER: Ingested poisons, food poisoning, carbon
monoxide poisoning, chemical burns can happen in the house environment. The
local poison control center should be called if an unknown toxic agent has been
taken or if it is necessary to identify an antidote for a known toxic agent.
AIDS Dementia - ANSWER: HIV encephalopathy was formerly referred to as AIDS
dementia complex. It is characterized by a progressive decline in cognitive,
behavioral, and motor functions as a direct result of HIV infection.
Heat Stroke - ANSWER: Inability to maintain cardiac output in the face of moderately
high body temperatures and is associated with dehydration. Exposure to prolonged
Environmental Temp 102.5 or greater although a heat index of greater than 35°C
(95°F) is associated with increased mortality.
Alcohol Intoxication Assessment - ANSWER: In the ED, the patient who is intoxicated
with alcohol or who presents with alcohol poisoning is assessed for head injury,
hypoglycemia (which mimics intoxication), and other health problems.
Hemorrhage Shock - ANSWER: #1. Stop the bleeding, pressure to site or surgical
interventions. #2 Large bore IV at least 2 lines. Monitor closely after infusion.
Benzodiazepines - ANSWER: Treatment of anxiety with benzodiazepines end in -pam,
-lam. Benzodiazepines are depressants that produce sedation and hypnosis, relieve
anxiety and muscle spasms, and reduce seizures.
Electrical Burns - ANSWER: Visual examination is not predictive of burn size and
severity. Mechanisms of injury include Flash and Conductive injuries.
, Near Drowning - ANSWER: Survival for at least 24 hours after submersion that
caused a respiratory arrest. The most common consequence is hypoxemia.
Ileal Conduit Postop Complications - ANSWER: Complications: Wound Infections,
Wound Dehiscence, Urinary leakage, ureteral obstruction, hyperchloremic acidosis,
small bowel obstructions, ileus, and gangrene of the stoma.
Auto Dysreflexia - ANSWER: Occurs in most patients with cord lesions above T6.
Severe, pounding headache with paroxysmal hypertension, profuse diaphoresis
above the spinal level of the lesion, nausea, nasal congestion, and bradycardia.
Septic Shock - ANSWER: Confusion w/ or w/o agitation and elevated RR are signs of
sepsis. Monitor Kidney/ Coagulation, Blood count labs, I&O, daily weights and
nutritional status.
AIDS Gas Exchange - ANSWER: Shortness of breath, dyspnea (labored breathing),
cough, chest pain, and fever are associated with various opportunistic infections.
DIC - ANSWER: Excessive clotting and bleeding. Massive amount of tiny clots forms in
the microcirculation.
Chest Trauma Complications - ANSWER: Sternal Rib Fx d/t MVA causing Resp
insufficiency or Resp failure, diminished ventilations or atelectasis.
Shock Fluid Management - ANSWER: Crystalloids: LR & 0.9% NS. Colloids: Albumin
5%, 25%. Blood Products: Plasma, Packed red blood cells and Platelets.
ICP Monitoring - ANSWER: Normal pressure being 0-15 mmHg as a result of
alterations in intrathoracic pressure. The earliest sign of increasing ICP is a change in
LOC.
Diaphragmatic breathing - ANSWER: Technique to expand alveoli, prevent
atelectasis.
Pursed-lip breathing - ANSWER: Technique to improve oxygenation and reduce
dyspnea.
Incentive spirometry - ANSWER: Device promoting lung inflation and cough
mechanism.
Chest tube transport - ANSWER: Keep drainage unit below chest level to facilitate
drainage.
Pneumothorax management - ANSWER: Apply sterile dressing, monitor respiratory
distress signs.
