HESI MILESTONE 2 VERSION 2 EXAM WITH PERFECT QUESTIONS AND ANSWERS

HESI MILESTONE 2 VERSION 2 EXAM WITH PERFECT QUESTIONS AND ANSWERS Acute renal failure priority - Correct 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 - Correct 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 - Correct 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 - Correct 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 - Correct Answer-o Anticoagulant therapy (frequent followup/lab tests) § Pt on warfarin has specific normal ratios o Prevent infection o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!! Cancer intractable pain plan of care - Correct Answer-o Pain, other symptoms and side effects are managed based on the best available evidence, with attention to diseasespecific pain and symptoms, which are skillfully and systematically applied. ?????? Schizophrenia nursing diagnoses and interventions - Correct 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 -Chemo Side Effects - Correct Answer-o Nausea/vomiting (24-48 hr, can be delayed up to 1 week) Meningitis first step - Correct Answer-o Antibiotics - penicillin (ampicillin) AND cephalosporin o Corticosteroids Multiple sclerosis and urinary retention - Correct 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 Grief process therapeutic response - Correct Answer-Allow the 5 steps of grieving (DABDA), active listening and offer a supportive presence Dementia action refusing ADLs - Correct Answer-Encourage finger foods, distraction, speak therapeutically Alcohol withdrawal - Correct 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 - Correct Answer-S&S= constricted pupils, resp. depression, circul. depression, LOC decreased Give naloxone Domestic violence screening tool - Correct 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 - Correct 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 - Correct 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