WKU Med Surg final Exam WITH
CORRECT ANSWERS| Updated
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
C. Thrombotic stroke
Changes in musculoskeletal system related to aging
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
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
· 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
· 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
· 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
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
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
, 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
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
CORRECT ANSWERS| Updated
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
C. Thrombotic stroke
Changes in musculoskeletal system related to aging
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
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
· 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
· 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
· 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
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
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
, 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
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
