HESI Milestone #2 Exam with complete solutions

Chemo Side Effects - Answer- o Nausea/vomiting (24-48 hr, can be delayed up to 1 week) Meningitis first step - Answer- o Antibiotics - penicillin (ampicillin) AND cephalosporin o Corticosteroids Multiple sclerosis and urinary retention - Answer- 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 - Answer- o Maintain fluids o Avoid fluid excess o Renal replacement therapy o Reduce metabolic rate o Promote pulmonary function Acute Respiratory distress priority findings - Answer- 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 - Answer- 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 - Answer- 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 - Answer- 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 - Answer- 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 - Answer- - 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 - Answer- Allow the 5 steps of grieving (DABDA), active listening and offer a supportive presence Dementia action refusing ADLs - Answer- Encourage finger foods, distraction, speak therapeutically Alcohol withdrawal - Answer- - 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 - Answer- S&S= constricted pupils, resp. depression, circul. depression, LOC decreased Give naloxone Domestic violence screening tool - Answer- - 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 - Answer- 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 - Answer- - 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) - Answer- 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 - Answer- - Physiologic, safety, love and belonging, self esteem, self-actualization - Basic drive and needs that motivate people Anxiety Suicide Risks: - Answer- Restless, difficulty concentrating, irritability - "Have you had any suicidal thoughts since starting bupropion?" Elder Abuse - Answer- 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 Watch behavior toward family and document Make caregiver leave room during questioning *** include nonconsensual contact Grief Priority - Answer- Priority should be based on SHOCK! ADHD Exam/Assessment - Answer- - failure to listen/follow direction - difficulty playing quietly/sitting still - disruptive, impulsive behavior - distractibility to external stimuli - excessive talking - shifting from one unfinished task to another OCD - Answer- - Patient checks where car keys are 8 times - Patient has persistent thoughts about bacteria, germs and dirt - Help encourage participation in social activities Questions to ask someone with OCD - Answer- - are there other in your family who must do things a certain way - is it difficult to keep certain thoughts out of your awareness - do you do certain things over and over again Therapeutic communication abuse victim - Answer- 1. Physical manifestations of abuse 2. Client safety 3. Legal responsibilities of the nurse 4. For children, the nurse is legally responsible for reporting all suspected cases of abuse. In intimate-partner abuse, it is the adult's decision; the nurse should be supportive of the decision. Remember to document objective factual assessment data and the client's exact words in cases of sexual abuse and rape Therapeutic Relationship Stages- TERMINATION - Answer- Unresolved feelings related to loss most likely may be recognized during this stage. A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? - Answer- Making appropriate referrals Which features are prominent in anorexia nervosa? - Answer- -Amenorrhea for three cycles -Perfectionism -Powerlessness -Rigid food rituals Describe the clinical symptoms of anorexia nervosa: - Answer- Weight loss of at least 15% of ideal or original body weight; hair loss; dry skin; irregular heart rate; decreased pulse; decreased BP; amenorrhea; dehydration; electrolyte imbalance A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is discharged. What nursing intervention is appropriate in addressing this behavior? - Answer- Discuss activities that don't involve food that can take place after discharge. Discuss the cookbooks with the treatment team, and if the treatment plan so indicates, take the books from the client. Bizarre social behavior - Answer- - assess physical needs, suicide risk, ensure safety at all time - sit w/ client, silence, tell when leaving - limit stimuli / 1-1 interaction Complication Hypertension Risk - Answer- Elevated BUN = kidney dysfunction = associated with hypertension The nurse is reviewing blood pressure readings for a group of client's on a medical unit. Which client is at the highest risk for complications related to hypertension? - Answer- B. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL Hypothyroidism - Sleep/ Depression - Answer- - Depression can result from untreated hypo - falling/staying asleep difficult = avoid sedation - frequent rest but stay action Diverticulosis S/S - Answer- LLQ abdominal pain (descending/sigmoid colon) Bloating Fever Nausea/Vomiting Constipation alt. w/ diarrhea Anorexia Gout Medication- Allopurinol - Answer- - bone marrow depression, vomiting, abd. pain - avoid starting/increasing med during active flare up - AFTER MEALS! Gout Medication- Allopurinol teaching - Answer- - avoid alcohol - purine-rich foods (red meat/shellfish/fructose drinks) - increase fluids - reduce stress Diabetes Mellitus- Poor compliance - Answer- - The patient may use a urine dipstick (Ketostix or Chemstrip uK) to detect ketonuria. The reagent pad on the strip turns purple when ketones are present. → unmanaged diabetes or control over DM is deteriorating DKA: complication of type 1 diabetes, serum glucose 250, ketonuria in large amounts Left-Sided Heart Failure - Answer- (Left is LUNG) congestion, dyspnea, crackles, fatigue, pink/frothy sputum Right-Sided Heart Failure - Answer- (Systemic) congestion, peripheral edema, ascities, jugular vein distention, hepatomegaly Osteoarthritis Exercise - Answer- - Use correct posture/body mechanics, use of assistive devices, walking, physical therapy, strength training, yoga, tai chi. Small Bowel Obstruction Actions: - Answer- - Auscultate bowels - Measure correct length, advance decompression q1-2hr, reposition client q2hr, connect to suction, irrigate with NS, note amount, color, consistency, assess for dehydration, monitor electrolytes - IV fluids will be given to replace depleted water, sodium, chloride and potassium Pneumonia Vaccines: - Answer- - PCV13: 65, 19 with conditions that weaken immune system - PPSV23: 65, 19-64 year olds who smoke/have asthma Pneumonia Treatment: - Answer- - oxygen therapy, hydration, bed rest, positioning to facilitate breathing, deep breathing, humidified air, chest physiotherapy, suctioning prn, COPD oxygen therapy - Answer- -Max of 3L via NC - low concentration are better!! - do not want pH to fall Diverticulitis NPO (^ small pouches in intestines) - Answer- NPO or clear liquid diet during exacerbations to decrease inflammation, then progress to a low-fiber diet. Ongoing, eat a high fiber diet. Heart Failure = DIGOXIN! - Answer- - increase cardiac output and contractility. - Take apical pulse prior to giving do not give if less than 60. - Therapeutic level 0.5-2 ng/mL. Digoxin TOXICITY - Answer- loss of appetite lower stomach pain diarrhea weakness blurred or yellow vision headache rash ** Stop product and give potassium and DigiFab. IV fluids: hypertonic - Answer- Draws water from ICF to EFC causing cells to SHRINK (Saline / Lactated Ringers with 5% dextrose) Rheumatoid Arthritis Pain - Answer- - Early is treated with NSAIDS, Opioids, nonpharmacologic and DMARDs like rheumatrex, methotrexate, leflunomide, sulfasalazine that can take up to six weeks to work. - Advanced is treated with immunosuppressants such as high dose methotrexate, cyclophosphamide, and azathioprine Peptic Ulcer Disease (PUD) NG Tube - Answer- - During surgery stomach contents are drained by NG tube - Confirmation that obstruction is the cause of pt discomfort us done by assessing the amount of of fluid aspirated a residual of 400 mL indicated obstruction Prostatic Hyperplasia - Answer- - Benign growth - occur in men w/ elevated estrogen levels Prostatic Hyperplasia S/S - Answer- - urgency - nocturia - hesitancy - decreased/intermittent stream - incomplete emptying - less than 50-100mL's Type 1 DM tight control (nutrition) - Answer- - consistent with culture - promote 1-2 lbs weight loss per week = subtract 500-1000 calories from daily total and distribute among proteins, carbs and fats Type 1 DM tight control - Answer- - glucose checks at home - A1C should be 4-6% *** LESS THAN 7% COPD Treatment - Answer- - Smoking Cessation - Roflumilast (Daliresp) for severe COPD - bronchodilator or oxygen therapy, oral or IV corticosteroids. IBP - Peritonitis - Answer- - Fluid, colloid, and electrolyte replacement is the major focus - Antibiotic therapy Asthma Triggers: - Answer- Dust, mites, roaches, cloth, pets, horses, detergents, soaps, food, mold, pollens, seasonal ulcerative colitis- bloody diarrhea - Answer- - The nurse provides information about nutritional management; a bland, low-residue, high-protein, high-calorie, and high-vitamin diet relieves symptoms and decreases diarrhea arterial insufficiency symptoms - Answer- -weak pedal pulses -shiny and cool skin -intermittent claudication - aching/cramping - induced fatigue Arterial Insufficency - Answer- - mostly men - legs mostly affected GERD- Teaching - Answer- - Avoid fatty, fried, citrus, spicy foods, and caffeine. - Eat small meals. Remain upright. - Avoid tight-fitting clothes. - Wt loss. - Quit smoking. - Reduce alcohol intake. - Elevate HPB Preop labs - what's abnormal - Answer- WBC count higher than 5,000-10,000/mm3 = possible infection Seizure/unconscious patient - Answer- -Maintain patent airway, turn to side, loosen constructive clothing, ease to floor. May require suctioning or oxygen. after, assess level of understanding. -call 911 for seizures lasting more than 5 minutes - maintain bed in low position and keep side rails up. -safety is first. Urolithiasis, Lithotripsy - Answer- - kidney stones ***surgery- Lithotripsy which is the use of laser or shock-wave energy to break up the stones. Strain urine following procedure. Hematuria is expected. Post General Anesthesia Care - Answer- Asses airway, respiratory function, cardio, skin color, LOC, ability to respond to commands - relieve pain - vitals every 15 minutes - systolic under 90 = immediately reportable unless baseline!! Thrombocytopenia Labs - Answer- normal PT/PTT prolonged Bleeding time low platelet count Sickle cell- first sign of crisis - Answer- - pain - fatigue - swollen hands and feet - dehydration **give oxygen, fluids, pain med, infection prevention Duchenne Muscular Dystrophy - Answer- - X- linked recessive - delayed motor/speech, cognitive impairment, muscle weakness, waddle, calf enlargement, cardiomyopathy Febrile Seizures teaching - Answer- use seizure precautions, call 911 if lasts more than 5 minutes infant congenital heart defect assessment - Answer- - small/frequent meals - oxygen - high calorie formula *** cyanotic episodes bring knee's up to chest RSV distress- S/S - Answer- cough, sneezing, fever, wheezing, deep/rapid breathing, prolonged expiration RN care for RSV - Answer- nasal suctioning hydration calm O2 as needed Pyloric Stenosis S/S - Answer- (opening between stomach and small intestine is thickened) - vomiting - dehydration - colic - lethargic - lump in belly - failure to thirive - electrolyte imbalance Intussusception (part of intestine fold into the section next to it, cause obstruction) - Answer- - RUQ sausage shaped mass - vomiting - bloody mucus stool fever weight loss Placental abruption - Answer- when the placenta detaches from the uterus - can deprive baby of oxygen - heavy bleeding can occur - abd/back pain **c-section and bedrest Fetal Tachycardia - Answer- 160 bpm for 10 minutes or longer - antipyretic for maternal fever - IV fluids - oxygen Prolapsed Cord Care - Answer- 1.Call for assistance- a medical emergency 2. Sterile gloves, insert 2 fingers into the vagina (one on each side of the cord) & Elevate the fetal presenting part off the cord 3. Apply warm sterile saline soaked towel over cord 4. Administer O2 5. Prepare for birth Shoulder Dystocia Actions - Answer- - McRoberts Maneuver - Suprapubic Pressure (need step stool) Variable Decelerations of FHR - Answer- place pt knee-chest or reposition from side to side, d/c oxytocin, administer oxygen, notify HCP. amnioinfusion may be indicated. Boggy Uterus Actions - Answer- - massage and administer uterotonic to increase uterine contraction. - give oxytocin Seizures in child - Answer- monitor serum levels of antiepileptics Diarrhea- Diet - Answer- give Pedialyte (oral electrolytes) - no grape, orange, apple, or ginger ale juice! IUGR (intrauterine growth restriction) ultrasound - Answer- - diagnosed at this time Engorgement Teaching - Answer- encourage frequent breastfeeding every 2-3 hours should decrease the engorgement. For bottle feeding: encourage the woman to use ice packs, to wear a snug, supportive bra 24 hours a day, and to take mild analgesics such as acetaminophen. Encourage her to avoid any stimulation to the breasts that might foster milk production, such as warm showers or pumping or massaging the breasts. Cystic Fibrosis Teaching -