Exam (elaborations)
HESI MILESTONE #2 | QUESTIONS AND ANSWERS
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- HESI MILESTONE #2
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- HESI MILESTONE #2
HESI MILESTONE #2 | QUESTIONS AND ANSWERS
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HESI MILESTONE #2 | QUESTIONS AND ANSWERS-Chemo Side Effects ✔️Ans -o Nausea/vomiting (24-48 hr, can be
delayed up to 1 week)
Meningitis first step ✔️Ans -o Antibiotics - penicillin (ampicillin)
AND cephalosporin
o Corticosteroids
Multiple sclerosis and urinary retention ✔️Ans -o Sensation of void
heeded immediately (bed pan/urinal @ bedside)
o Voiding schedule (start 1/5-2hr then extend)
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
o Self-catherization
Acute renal failure priority ✔️Ans -o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings ✔️Ans -o Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid
and bronchial obstruction)
End of life plan of care ✔️Ans -o Signs and symptoms of impending
death are recognized and communicated in developmentally appropriate
language for children and patients with cognitive disabilities with respect to
family preference. Care appropriate to this phase of illness is proved to the
patient and the family
Cushing Syndrome ✔️Ans -o Can result from corticosteroids
***Attempt to reduce/taper medication while still treating underlying disease
,o Alternate day therapy decrease symptoms and allows adrenal glands to
recover
Valve replacement teaching ✔️Ans -o Anticoagulant therapy
(frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios
o Prevent infection
o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
Cancer intractable pain plan of care ✔️Ans -o Pain, other
symptoms and side effects are managed based on the best available evidence,
with attention to disease-specific pain and symptoms, which are skillfully and
systematically applied. ??????
Schizophrenia nursing diagnoses and interventions ✔️Ans -- Dx: 2
or more S&S for over 6 mo (Positive= delusions, hallucinations, disorganized
speech or Negative= 6 A's Anhedonia, Flat Affect, Apathy, Anergia, Algogia,
Avolition)
-Establish rapport and trust, ask about hallucinations, distract, lower
environmental stimuli, monitor suicidal ideation, 1st or 2nd generation
antipsych
Grief process therapeutic response ✔️Ans -Allow the 5 steps of
grieving (DABDA), active listening and offer a supportive presence
Dementia action refusing ADLs ✔️Ans -Encourage finger foods,
distraction, speak therapeutically
Alcohol withdrawal ✔️Ans -- Needs to be done under medical
supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce
temp.
- Tremors, nausea, vomiting
Methadone overdose ✔️Ans -S&S= constricted pupils, resp.
depression, circul. depression, LOC decreased
Give naloxone
, Domestic violence screening tool ✔️Ans -- Don't probe, write
evidence down verbatim, provide a safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Aggression response ✔️Ans -5-phase cycle= Triggering (event),
Escalation (movement toward a loss of control), Crisis (loss of control),
Recovery (regain control), Postcrisis (reconciliation)
***Hx = likely to occur again
Violence handling ✔️Ans -- Engage in dialogue to prevent
escalation, intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need for
meds, be consistent
Medication adverse reactions care (schizophrenia) ✔️Ans -
Constipation is a common side effect of antipsych meds, polydipsia occurs
after years of treatment
Nurse can help minimize effects of delusions with distraction techniques,
music, tv, writing and talking to friends, positive self-talk and positive thinking
Self care Maslow ✔️Ans -- Physiologic, safety, love and belonging,
self esteem, self-actualization
- Basic drive and needs that motivate people
Anxiety Suicide Risks: ✔️Ans -Restless, difficulty concentrating,
irritability
- "Have you had any suicidal thoughts since starting bupropion?"
Elder Abuse ✔️Ans -Someone stating "I no longer have time to do
anything for myself or anyone else" would be someone @ risk for abusing
elder.
Bruising around breasts and pelvic area = abuse
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