Med Surge III HESI Final Exam
Study online at https://quizlet.com/_bvb20k
1. Spinal cord injury assessments: Loss of motor and sensory function below
level of injury
Spinal shock
Postural hypotension
Alteration in thermoregulation
Circulatory problems/edema
2. PVCs (Premature ventricular contractions): Rate: Depends
Rhythm: Irregular
P-wave: None
PR interval: None
QRS: Wide and bizarre
Cause: stimulants, sepsis, stress
S/S: skipped beat, pounding, quickening, pulse deficit, possible hypotension
Interventions: Treat cause, digoxin (discontinue/adjust), correct electrolytes, drugs
(procainamide, lidocaine, amiodarone)
3. HIV CD4 count pathology: HIV replicates inside the body by hijacking or taking
over & killing the CD4+ cells (T helper cells). These cells are vital in fighting off
infections & diseases. Since HIV cannot reproduce on its own, it attaches itself to
these T-helper cells & fuses together with it becoming one. HIV is a retrovirus which
carry their genetic material in the form of RNA rather than DNA.
Stage 1: HIV primary infection - Dramatic drops of CD4 counts
Stage 2: AIDS - CD4 count drops below 200
4. Carbon monoxide poisoning: Carbon monoxide poisoning: O2 is replaced by
CO which binds easily to Hgb, resulting in severe hypoxia leading to death
Cause: Inhaled car toxins, stoves/fuel burning like wood (poor ventilated areas)
S/S: vague, headache, dizziness, dyspnea, nausea, pulse ox not accurate (false
reading of high spO2)
Intervention: 100% O2 non-rebreather mask, flow rate 15 L/min
5. Lead poisoning: Patho: Toxic levels of lead build up in the blood stream; children
<6 y/o at most risk
Risk factors: lead-based paint in houses before 1970s, drinking from lead pipes
S/S: Neurocognitive impairment - mild (hyperactive, impulsive), moderate (learning
disabilities, vision/hearing), severe (seizures, death), anemia, weight loss, sluggish-
ness, fatigue
Education: follow-up blood tests for lead level, home inspection for lead source, wash
child's hands often (before meals)
Treatment: Chelated therapy (activated charcoal, EDTA injection)
, Med Surge III HESI Final Exam
Study online at https://quizlet.com/_bvb20k
6. AIDS dementia: AKA HIV encephalopathy
A clinical syndrome characterized by a progressive decline in cognitive, behavioral,
and motor functions (i.e. a change in writing)
7. Heat stroke: Prolonged exposure to the sun or a high environmental temperature
overwhelms the body's heat-loss mechanisms.
S/S: giddiness, excessive thirst, and nausea, increased heart rate (HR), tachypnea,
hypotension
Interventions: Lie flat with legs elevated, cooling blankets, cool bath, ice to
groin/neck/axillae
8. Alcoholic - CAGE: CAGE - Cut, Annoyed, Guilty, Eye-opener
C - If client has thought about cutting down on drinking (C in CAGE)
A - Have people annoyed you by criticizing your drinking?
G - Have you ever felt bad or guilty about your drinking?
E - Have you ever had a drink first thing in the morning to steady your nerves or get
rid of a hangover (eye-opener)?
9. Alcoholic first assessment: Psychosocial assessments: escape from problems,
cover up depression & anxiety, goal of counseling is to identify triggers
Withdrawal S/S: 24 hrs (anxiety, insomnia, palpitations), 48 hrs (seizures, unstable
VS), 48-72 hrs (delirium tremens, hand tremors, sweating, hallucinations, increased
VS, agitated, restless, seizures)
Teaching: accountability, coping, self-help/motivation
Interventions: monitor blood glucose, benzos, barbiturates, seizure precautions
10. Hemorrhage - shock: Excessive blood loss from trauma, gunshot wound,
surgery, or burns. The body initially attempts to compensate by maintaining periph-
eral vasoconstriction.
S/S: Low BP, high HR, cool clammy skin, low H/H (Hgb < 7 = Heaven),
Early signs are restlessness, thirst, cool skin, ortho hypo
Late sign is metabolic acidosis
Intervention: Treat cause, stop bleed by applying pressure or doing surgery, take
blood sample for labs
11. Burns - agitation: Signs of dehydration:
restlessness
disorientation
decreased urinary volume
increased urine specific gravity
Tx: Benzos + opioids
12. ETT assess: After removal: Respiratory distress, report stridor
During suctioning: Decreased HR, stop and reoxygenate
Study online at https://quizlet.com/_bvb20k
1. Spinal cord injury assessments: Loss of motor and sensory function below
level of injury
Spinal shock
Postural hypotension
Alteration in thermoregulation
Circulatory problems/edema
2. PVCs (Premature ventricular contractions): Rate: Depends
Rhythm: Irregular
P-wave: None
PR interval: None
QRS: Wide and bizarre
Cause: stimulants, sepsis, stress
S/S: skipped beat, pounding, quickening, pulse deficit, possible hypotension
Interventions: Treat cause, digoxin (discontinue/adjust), correct electrolytes, drugs
(procainamide, lidocaine, amiodarone)
3. HIV CD4 count pathology: HIV replicates inside the body by hijacking or taking
over & killing the CD4+ cells (T helper cells). These cells are vital in fighting off
infections & diseases. Since HIV cannot reproduce on its own, it attaches itself to
these T-helper cells & fuses together with it becoming one. HIV is a retrovirus which
carry their genetic material in the form of RNA rather than DNA.
Stage 1: HIV primary infection - Dramatic drops of CD4 counts
Stage 2: AIDS - CD4 count drops below 200
4. Carbon monoxide poisoning: Carbon monoxide poisoning: O2 is replaced by
CO which binds easily to Hgb, resulting in severe hypoxia leading to death
Cause: Inhaled car toxins, stoves/fuel burning like wood (poor ventilated areas)
S/S: vague, headache, dizziness, dyspnea, nausea, pulse ox not accurate (false
reading of high spO2)
Intervention: 100% O2 non-rebreather mask, flow rate 15 L/min
5. Lead poisoning: Patho: Toxic levels of lead build up in the blood stream; children
<6 y/o at most risk
Risk factors: lead-based paint in houses before 1970s, drinking from lead pipes
S/S: Neurocognitive impairment - mild (hyperactive, impulsive), moderate (learning
disabilities, vision/hearing), severe (seizures, death), anemia, weight loss, sluggish-
ness, fatigue
Education: follow-up blood tests for lead level, home inspection for lead source, wash
child's hands often (before meals)
Treatment: Chelated therapy (activated charcoal, EDTA injection)
, Med Surge III HESI Final Exam
Study online at https://quizlet.com/_bvb20k
6. AIDS dementia: AKA HIV encephalopathy
A clinical syndrome characterized by a progressive decline in cognitive, behavioral,
and motor functions (i.e. a change in writing)
7. Heat stroke: Prolonged exposure to the sun or a high environmental temperature
overwhelms the body's heat-loss mechanisms.
S/S: giddiness, excessive thirst, and nausea, increased heart rate (HR), tachypnea,
hypotension
Interventions: Lie flat with legs elevated, cooling blankets, cool bath, ice to
groin/neck/axillae
8. Alcoholic - CAGE: CAGE - Cut, Annoyed, Guilty, Eye-opener
C - If client has thought about cutting down on drinking (C in CAGE)
A - Have people annoyed you by criticizing your drinking?
G - Have you ever felt bad or guilty about your drinking?
E - Have you ever had a drink first thing in the morning to steady your nerves or get
rid of a hangover (eye-opener)?
9. Alcoholic first assessment: Psychosocial assessments: escape from problems,
cover up depression & anxiety, goal of counseling is to identify triggers
Withdrawal S/S: 24 hrs (anxiety, insomnia, palpitations), 48 hrs (seizures, unstable
VS), 48-72 hrs (delirium tremens, hand tremors, sweating, hallucinations, increased
VS, agitated, restless, seizures)
Teaching: accountability, coping, self-help/motivation
Interventions: monitor blood glucose, benzos, barbiturates, seizure precautions
10. Hemorrhage - shock: Excessive blood loss from trauma, gunshot wound,
surgery, or burns. The body initially attempts to compensate by maintaining periph-
eral vasoconstriction.
S/S: Low BP, high HR, cool clammy skin, low H/H (Hgb < 7 = Heaven),
Early signs are restlessness, thirst, cool skin, ortho hypo
Late sign is metabolic acidosis
Intervention: Treat cause, stop bleed by applying pressure or doing surgery, take
blood sample for labs
11. Burns - agitation: Signs of dehydration:
restlessness
disorientation
decreased urinary volume
increased urine specific gravity
Tx: Benzos + opioids
12. ETT assess: After removal: Respiratory distress, report stridor
During suctioning: Decreased HR, stop and reoxygenate
