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WKU MED SURG FINAL EXAM
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WKU MED SURG FINAL EXAM
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WKU MED SURG FINAL EXAMA 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 - answer- C. Thrombotic stroke
Changes in musculoskeletal system related to aging - answer- 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 - answer- 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 - answer- · 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 - answer- · 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 - answer- · 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 - answer- 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 - answer- 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 - answer- 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 - answer- 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 - answer- • Assess all body systems for life-threatening complications (prioritizing care- head, chest or abdomen (bleeding). Remove clothing, use warm blankets, remove jewelry, full assessment!!! • Check urine for blood (seatbelt injury)
• Assess for swelling, perfusion, skin integrity. Hip (posterior knee pain or groin). Humeral shoulder or elbow pain. Support and comfort in effected area. Any bone alignment issues, crepitus (bone on bone sounds), wounds or bruising at site, assess bilaterally!
Acute compartment syndrome - answer- Serious and painful condition that occurs when
excessive pressure builds up inside an
enclosed muscle space in the body.
Acute compartment syndrome Clinical features - answer- ● Pressure can decrease blood flow, prevents nourishment, blood and oxygen from reaching muscle cells
● *Can happen any enclosed space or compartment ; Commonly occurs in forearms
and lower legs
● Compartments are areas of blood vessels, muscles, and nerves are connected to
fascia
● Fascia- inelastic tissue that surrounds groups of muscles, blood vessels, and
nerves in the body
● Muscle damage occurs related to injury, bones are extremely vascular that can
cause significant bleeding
Ischemia-edema cycle - answer- ● Blood can accumulate within specific compartments,
causing increased pressure
that results in tissue ischemia
● The injury itself causes capillaries with the muscle to dilate, increasing pressure
within the compartment
● Ischemic tissue then releases histamine, causing plasma proteins to leak into the
interstitial space (or edema)
● Edema increases pressure within that compartment, causing worsening ischemia
● The cycle repeats itself until tissue death occurs
Cause of increased pressure (Compartment Syndrome) - answer- ● Internal source: blood or fluid accumulation; where bone marrow is located
o Severe burns, extensive insect or snake bites, IV infiltrate
● External source: tight dressings, casts- need to release pressure to get circulation
to area; has potential to create Acute compartment syndrome
Symptoms of Acute Compartment Syndrome - answer- Hallmark sign: Pain that occurs or intensifies with passive ROM
● Pain that is out of proportion to an injury or illness even after administration of
analgesics - notify provider
● Complain of paresthesia- Numbness and Tingling before motor or vascular
changes
● Due to compression of nerves
● Tissue death will occur if not treated in timely manner
Complications of Acute Compartment Syndrome
How to prevent them? - answer- ● Infection- need good perfusion for muscles to heal and gain oxygen (tissue may
die and cause infection)
● Persistent motor weakness in affected extremity
● Contracture- lack of tissue perfusion
● Myoglobinuric renal failure- myoglobin filters through kidneys causing failure
● Amputation due to tissue death (extreme case, no intervention done)
● Recognize S/S early to prevent complications; PT will report increased pain, decreased sensation, decreased mobility; perform neurovascular assessment
frequently- Cap. Refill, color, temp, pulses, movement, sensation, pain below
injury
Treatment of Acute Compartment Syndrome - answer- ● Monitor
o 6 p's = pain, pressure, paresthesia, paralysis, pallor, pulselessness
● Hand-held device that monitors pressure within compartment
● Fasciotomy - to treat loss of circulation to tissue or muscle
o Tissue is cut, limb saving procedure
o a surgical procedure where the fascia is cut to relieve tension or pressure;
can be a limb saving procedure; treats ACS
Neurovascular assessment - answer- "circ check" and "CMS" (circulation, movement & sensation)
and also known as the "Six P's"
o Pain
o Pressure
o Paralysis
o Paresthesia
o Pallor
o Pulse
Types of fractures - answer- Complete vs. Incomplete
Open (compound) vs. Closed (simple)
Pathologic
Fatigue: stress fracture
Compression
Colles fracture
Smith fracture
Stages of Bone healing - answer- • Stage 1- Hematoma formation: bone fractures and bleeding happen
• Stage 2- Hematoma to granulation formation: after a week or two, provides framework for bone healing
• Stage 3- Callus formation
• Stage 4- Osteoblastic proliferation
• Stage 5- Bone remodeling: becomes compact and returns to original state, weight bearing is then encouraged to promote the strength
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