WKU Med Surg final Exam WITH CORRECT ANSWERS

WKU Med Surg final Exam WITH |\ |\ |\ |\ |\ |\




CORRECT ANSWERS |\




A client in the emergency department (ED) has slurred speech,
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confusion, and visual problems, and has been having intermittent
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episodes of worsening symptoms. The symptoms have a gradual
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onset. The client also has a history of hypertension and
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atherosclerosis. What does the nurse suspect that the client is |\ |\ |\ |\ |\ |\ |\ |\ |\ |\


probably experiencing? |\




A. Embolic stroke
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B. Hemorrhagic stroke
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C. Thrombotic stroke
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D. Transient ischemic attack - CORRECT ANSWERS ✔✔C.
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Thrombotic stroke |\




Changes in musculoskeletal system related to aging - CORRECT
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ANSWERS ✔✔o Changes: diminished visual acuity and hearing,
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changes in gait, balance, and muscle strength,
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joint stiffness |\




o Hip fractures usually report groin pain or pain behind the knee
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on the affected side, some cases
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asymptomatic but unable to stand |\ |\ |\ |\




Check pulse for - CORRECT ANSWERS ✔✔o If no pulse within 10
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seconds, start CPR, beginning with chest compressions
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,o If there is a pulse and absent breathing, start rescue breathing
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at 1 breath every 5-6 seconds.
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o Check pulse about every 2 minutes (5 cycles of CPR)
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Ensure Closed loop communication - CORRECT ANSWERS ✔✔·
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Team leader gives a clear message, order, or an assignment to
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the team member|\ |\




· Both the team leader and team member should make eye
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contact and the team member should confirm (verbalize) to the
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team leader the message was heard and understood.
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BLS Assessment - CORRECT ANSWERS ✔✔· Make sure there is a
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safe environment!!! Take care of you so you can take care of
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other people. |\




· Check responsiveness
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· Shout for nearby help/activate the emergency response system
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and get the AED/defibrillator
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Primary Assessment: Airway - CORRECT ANSWERS ✔✔· Maintain
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airway patency in unconscious patients
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o Head tilt- chin lift (if no suspicion of head/neck injury)
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o Jaw thrust (if suspicion head/neck injury)
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SAMPLE - CORRECT ANSWERS ✔✔o Signs and symptoms: onset
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of illness or injury (what was happening when this started)
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o Allergies: food, medical, latex, associated reactions
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,o Medications: over the counter, prescribed, vitamins, inhalers,
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supplements, last dose was given |\ |\ |\ |\




o Past medical history: surgeries, psych, immunizations (tetanus)
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o Last meal consumed
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o Events to present: if EMS was called, what happened there,
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time of onset, time of last period, any use of alcohol or
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recreational drugs, head injury |\ |\ |\




H's and T's - CORRECT ANSWERS ✔✔Hs: hypovolemia, hydrogen
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ion (acidosis), hypo/hyperkalemia, hypothermia (those are causes
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that would cause the cardiac arrest, so we need to fix it
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Ts: tension pneumothorax, tamponade (cardiac), toxins,
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thrombosis (pulmonary), thrombosis (cardiac) |\ |\ |\




· Identification of respiratory problems by severity
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Clinical signs of respiratory distress - CORRECT ANSWERS ✔✔o
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Tachypnea
o Increased respiratory effort
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o Inadequate respiratory effort
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o Abnormal airway sounds
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o Tachycardia
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o Pale, cool skin
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o Changes in level of consciousness/agitation (if it doesn't get
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enough oxygen or glucose) |\ |\ |\




o Use of abnormal muscles to assist in breathing
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, Respiratory Failure Clinical signs - CORRECT ANSWERS ✔✔o |\ |\ |\ |\ |\ |\ |\ |\


Marked tachypnea |\




o Bradypnea (late sign)
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o Increased, decreased respiratory effort- get tired
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o Poor to absent distal air movement
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o Tachycardia (early)
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o Bradycardia (late)
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o Cyanosis
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o Stupor, coma (late)
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Physical Assessment - CORRECT ANSWERS ✔✔• Assess all body
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systems for life-threatening complications (prioritizing care- head,
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chest or abdomen (bleeding). Remove clothing, use warm
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blankets, remove jewelry, full assessment!!! |\ |\ |\ |\ |\




• Check urine for blood (seatbelt injury)
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• Assess for swelling, perfusion, skin integrity. Hip (posterior knee
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pain or groin). Humeral shoulder or elbow pain. Support and
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comfort in effected area. Any bone alignment issues, crepitus
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(bone on bone sounds), wounds or bruising at site, assess
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bilaterally!


Acute compartment syndrome - CORRECT ANSWERS ✔✔Serious
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and painful condition that occurs when excessive pressure builds
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up inside an
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enclosed muscle space in the body. |\ |\ |\ |\ |\