NSG233 Medical Surgical Nursing III HESI Final Exam Version A
Item Node Topic
3902 04.03.03 SCI [Spinal Cord Injury]- assess
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
3560 03.02.01 Cardiac arrythmia- PVCs
Premature ventricular contractions (PVCs)
are 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.
PVCs usually are not serious. PVCs that are
frequent and persistent may be treated with
amiodarone or sotalol, but long-term
pharmacotherapy for only PVCs is not usually
indicated.
normal beat, an extra beat (the PVC), a slight
pause, then a stronger-than-normal beat.
26179 11.02.02 and HIV CD4 count- pathology
11.02.03 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
CD4 count should increase with drug therapy
159525 01.04.01 Poisoning in the house
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.
Carbon monoxide poisoning, move pt to fresh air, open
doors/windows, loosen clothing etc..
,NSG233 Medical Surgical Nursing III HESI Final Exam Version A
3787 11.02.03 AIDS- dementia
HIV encephalopathy was formerly referred to as
AIDS dementia complex. It is a clinical syndrome
that is characterized by a progressive decline in
cognitive, behavioral, and motor functions as a
direct result of HIV infection.
Signs and symptoms may be subtle and difficult to
distinguish from fatigue, depression, or the adverse
effects of treatment for infections and
malignancies. Early manifestations include memory
deficits, headache, difficulty concentrating,
progressive confusion, psychomotor slowing,
apathy, and ataxia. Later stages include global
cognitive impairments, delay in verbal responses, a
vacant stare, spastic paraparesis, hyperreflexia,
psychosis, hallucinations, tremor, incontinence,
seizures, mutism, and death.
Confusion. Dementia, memory loss
24697 01.03.01 Heat stroke
Inability to maintain cardiac output in the face of
moderately high body temperatures and is
associated with dehydration. Vasoconstriction
raises blood pressure and sends more blood to
brain, also holds in heat and stops sweating.
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
Risk: Very old and very young people, or people on certain
meds [major tranquilizers, anticholinergics, diuretics,
beta-blockers]
Causes HYPERTHERMIA
S&S: CNS depression [unconscious], hot/dry skin
[no sweating], tachypnea, hypotension, tachycardia
Tx: IV access, Cooling Procedures: Cool sheets/towels, ice pack,
cooling blankets, cool fan, immersion in cold water bath
42256 01.03.01 Alcoholic- 1st assessment
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.
Look for S&S of withdrawal as delirium tremens can occur
, NSG233 Medical Surgical Nursing III HESI Final Exam Version A
48-96 hours after last drink
173906 03.02.01 Hemorrhage- shock
#1. Stop the bleeding, pressure to site or surgical interventions
#2 Large bore IV at least 2 lines
Blood products-Colloids [plasma, platelets & packed RBCs]
Baseline blood count, type & cross match
Monitor closely after infusion
Hypovolemic Shock s&s
Cold clammy skin [priority] notify MD ASAP!
Hypotension
Tachycardia
Low central venous pressure normal 2-6
Low urine output
Tx: #1 LOWER HEAD OF BED
1. IV NS [0.9]
2. IV NOREPINPHERE FIRST THEN DOPAMINE
SECOND!
173922 10.03.03 Burns- agitation
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.
1285953 07.01.02 ETT- assess
Assess how pt is coping [physiologic status]
ETT: Cuff pressure monitored q8h at pressure of 20-25mmHg,
assess for cuff leak, trach care q8h, oral hygiene, observe for
signs of hypoxia, HOB 30 degrees or higher.
1318966 06.01.03 IV-mL/hr lidocaine
56502 10.01.02 Burns- electrical
-visual examination is not predictive of burn size
and severity
-Mechanisms of injury include
Flash: Injury is caused by the heat generated to
exposed areas, or by flames from ignition of
clothing. Flash burns are thermal burns and have
fewer complications;
Conductive: Deep muscle injury may be present
without injury to superficial muscles, masking the
true extent of the injury.
Item Node Topic
3902 04.03.03 SCI [Spinal Cord Injury]- assess
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
3560 03.02.01 Cardiac arrythmia- PVCs
Premature ventricular contractions (PVCs)
are 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.
PVCs usually are not serious. PVCs that are
frequent and persistent may be treated with
amiodarone or sotalol, but long-term
pharmacotherapy for only PVCs is not usually
indicated.
normal beat, an extra beat (the PVC), a slight
pause, then a stronger-than-normal beat.
26179 11.02.02 and HIV CD4 count- pathology
11.02.03 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
CD4 count should increase with drug therapy
159525 01.04.01 Poisoning in the house
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.
Carbon monoxide poisoning, move pt to fresh air, open
doors/windows, loosen clothing etc..
,NSG233 Medical Surgical Nursing III HESI Final Exam Version A
3787 11.02.03 AIDS- dementia
HIV encephalopathy was formerly referred to as
AIDS dementia complex. It is a clinical syndrome
that is characterized by a progressive decline in
cognitive, behavioral, and motor functions as a
direct result of HIV infection.
Signs and symptoms may be subtle and difficult to
distinguish from fatigue, depression, or the adverse
effects of treatment for infections and
malignancies. Early manifestations include memory
deficits, headache, difficulty concentrating,
progressive confusion, psychomotor slowing,
apathy, and ataxia. Later stages include global
cognitive impairments, delay in verbal responses, a
vacant stare, spastic paraparesis, hyperreflexia,
psychosis, hallucinations, tremor, incontinence,
seizures, mutism, and death.
Confusion. Dementia, memory loss
24697 01.03.01 Heat stroke
Inability to maintain cardiac output in the face of
moderately high body temperatures and is
associated with dehydration. Vasoconstriction
raises blood pressure and sends more blood to
brain, also holds in heat and stops sweating.
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
Risk: Very old and very young people, or people on certain
meds [major tranquilizers, anticholinergics, diuretics,
beta-blockers]
Causes HYPERTHERMIA
S&S: CNS depression [unconscious], hot/dry skin
[no sweating], tachypnea, hypotension, tachycardia
Tx: IV access, Cooling Procedures: Cool sheets/towels, ice pack,
cooling blankets, cool fan, immersion in cold water bath
42256 01.03.01 Alcoholic- 1st assessment
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.
Look for S&S of withdrawal as delirium tremens can occur
, NSG233 Medical Surgical Nursing III HESI Final Exam Version A
48-96 hours after last drink
173906 03.02.01 Hemorrhage- shock
#1. Stop the bleeding, pressure to site or surgical interventions
#2 Large bore IV at least 2 lines
Blood products-Colloids [plasma, platelets & packed RBCs]
Baseline blood count, type & cross match
Monitor closely after infusion
Hypovolemic Shock s&s
Cold clammy skin [priority] notify MD ASAP!
Hypotension
Tachycardia
Low central venous pressure normal 2-6
Low urine output
Tx: #1 LOWER HEAD OF BED
1. IV NS [0.9]
2. IV NOREPINPHERE FIRST THEN DOPAMINE
SECOND!
173922 10.03.03 Burns- agitation
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.
1285953 07.01.02 ETT- assess
Assess how pt is coping [physiologic status]
ETT: Cuff pressure monitored q8h at pressure of 20-25mmHg,
assess for cuff leak, trach care q8h, oral hygiene, observe for
signs of hypoxia, HOB 30 degrees or higher.
1318966 06.01.03 IV-mL/hr lidocaine
56502 10.01.02 Burns- electrical
-visual examination is not predictive of burn size
and severity
-Mechanisms of injury include
Flash: Injury is caused by the heat generated to
exposed areas, or by flames from ignition of
clothing. Flash burns are thermal burns and have
fewer complications;
Conductive: Deep muscle injury may be present
without injury to superficial muscles, masking the
true extent of the injury.
