NUR 1211 MEDICAL SURGICAL FINAL EXAM-QUESTIONS[ANSWERED]2022

NUR 1211 MEDICAL SURGICAL FINAL EXAM-QUESTIONS[ANSWERED]2022

MEDICAL SURGICAL FINAL EXAM

1. Know the assessment techniques

A. Inspection= The visual examination

-The critical observation of the client for any physical signs that indicate alteration from normal

-Can be done during hygiene care

-Used to assess body surface, shape, size, color, position, and symmetry

B. Palpation= Using the sense of touch (DEEP PALPATION IS NOT WITHIN THE SCOPE OF LPN)

-Texture of hair

-Temperature of skin

-Vibration of joints

-Size/ Position/ shape/ Consistency/ Texture/ Mobility of masses

-Collection of fluid/ Presence of distention

-Pulses

-Tenderness and Pain

C. Percussion= The deliberate striking or tapping of a body part to elicit sounds/vibrations

-Direct percussion: striking an area directly with 1 to 3 finger pads or with the pad of the middle

finger rapidly

-Indirect percussion: striking an object against the area (another finger)

-Assesses the size and shape of internal organs (boundaries)

-Assesses if the tissue is filled with fluid/ air/ solid

D. Auscultation= Listening for sounds produced by the body

-Direct: using the unaided ear

-Indirect: using a stethoscope

-Listen for intensity (loudness of softness of the sound)

-Listen for pitch (frequency of vibrations)

-Listen for duration (length of the sound; short to long)

-Listen for quality (the subjective description of the sound; whistling, gurgling etc.)

2. Difference between normal and adventitious breath sounds

Normal Breath Sounds:

A. Vesicular= soft, breezy, sighing sound; best heard over periphery/ bases

B. Bronchovesicular= blowing sound & large amt. of air through lung tube; best heard over first

and second intercostal spaces substernal

C. Bronchial= high pitched, harsh, loud sound caused by air moving through the trachea; best

heard over anterior trachea, not normally heard over lung tissue.

Adventitious Breath Sounds:

A. Crackles (rales)= cause by air passing through fluid/ mucous in air passages

i. heard on inspiration and is most commonly heard in the bases of the lungs

ii. usually do not clear with coughing

B. Gurgles (rhonchi)= air passing through narrow air passages as a result of secretions, swelling

or tumors.

i. clear with cough

NUR 1211 MEDICAL SURGICAL FINAL EXAM

ii. usually heard over trachea and bronchi

iii. best heard during expiration

iv. course gurgling, harsh sounds or like snoring

C. Wheezes= continuous, high-pitched, musical sound

i. caused by air passing through constricted bronchi because of secretions, swelling or tumors.

ii. best heard on expiration over all lung fields

iii. not usually cleared by coughing

D. Friction Rub= grating sound due to inflamed visceral and parietal pleurae rubbing

i. usually heard over the anterior lateral chest.

ii. can be heard on inspiration and expiration

iii. not relieved by coughing

3. Normal heart sounds

S1= Closure of the atrioventricular Valve (the “lub”)

a. mitral and tricuspid valves close when the ventricles have filled

S2= Closure of the Semilunar Valves (the “dub”)

a. higher pitched and shorter than S1

b. aortic and pulmonic valves close when the ventricles have emptied

Systole= when ventricles are contracted- begins with S1 and ends with the beginning of S2

Diastole= when ventricles relax- starts with S2 and ends with S1

4. Glasgow Coma Scale

-Originally used to predict head injury recovery- now used to assess Level of Consciousness

-Tests 3 areas:

a. Eye response

b. Motor response

c. Verbal response

(Total points= 15; less than 7= comatose)

Eye Opening -Spontaneous

-To verbal command

-To pain

-No Response

4

3

2

1

Motor Response -To verbal command

-To localized pain

-Flexes/ withdraws

-Flexes abnormal

-Extends abnormal

-No Response

6

5

4

3

2

1

Verbal Response -Oriented, converses

-Disoriented, converses

-Uses appropriate words

-Makes incomprehensible sounds

-No response

5

4

3

2

1

5. Signs of ETOH Withdrawal

-Occurs within 4 to 12 hours after last drink and may last several days after abstinence

-Signs:

a. coarse tremor of the hands, tongue, or eyelids

b. sweating

c. N/V

d. depressed mood or irritability

e. headache

f. insomnia

g. illusions/ hallucinations in some cases

6. Care of a patient with Obsessive Compulsive Disorder

-Obsessions= recurrent and persistent thoughts, urges, or images that are intrusive and

unwanted.

-Compulsions= repetitive behaviors (hand washing, checking something, etc.) or mental acts

(praying, counting, repeating words, etc.)

-The obsessions and/or compulsions are aimed at reducing or preventing anxiety or distress or

dreaded event or situation.

-Treatment= Cognitive therapy, desensitization therapy, SSRIs

7. Care of patient with suicidal ideations

-Suicide: often due to anger toward a person or event turned inward

-Most common reason: a solution

-Stimulus: intense psychological pain, helpless, and/or hopeless

-Goal: Relief from emotional pain

Interventions:

a. Provide a safe environment

b. constant supervision- 1:1 direct; no more than arm’s length away

c. NEVER leave the patient without relief from a competent staff member- always remember to

give report

d. be alert at all times, but warm and supportive

e. search belongings/ room for items that could be used to attempt suicide- new admits

especially

f. Remove: belts, shoes laces, sheets, shaving supplies, hangers, cosmetics, mirrors

g. conduct regular body searches and check oral cavity after medication administration

h. provide a safe environment

i. non-judgmental tone/ body language

j. create a support system list- family/friends/support groups/ community organizations

8. Care or a patient with Schizophrenia Spectrum Disorder

Nursing Care:

-Avoid touching patient

-Observe for signs of hallucinations

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