HESI Milestone 2 Questions with Complete Rationale

Broca's Area - Speech The cortical area that is responsible for integrating the myriad pathways required for the comprehension and formulation of language is called Broca area. It is located in a convolution adjoining the middle cerebral artery. This area is responsible for control of the combinations of muscular movements needed to speak each word. Chemo Side Effects - Nausea Vomiting Myelosuppression SIADH, decrease renal perfusion, precipitate end products after cell lysis, and cause interstitial nephritis Cardiac Toxicity Testicular and ovarian function can be affected by chemotherapeutic agents, resulting in possible sterility. Chemotherapy-induced neurotoxicity, a potentially dose-limiting toxicity, can affect the central nervous system, peripheral nervous system, and/or the cranial nerves Chemo Brain: Many patients with cancer experience difficulty with remembering dates, multitasking, managing numbers and finances, organization, face or object recognition, inability to follow directions, feeling easily distracted, and motor and behavioral changes. Fatigue Expressive Aphasia - Inability to express oneself Meningitis First Step - Broad Spectrum Antibiotics Glaucoma Symptoms - The patient may not seek health care until he or she experiences blurred vision or "halos" around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache. Assessments for Guillain Barre - The patient is monitored for life-threatening complications (respiratory failure, cardiac dysrhythmias, VTE [including DVT or PE]) so that appropriate intervention can be initiated. Because of the threat to the patient in this sudden, potentially life-threatening disease, the nurse must assess the patient's and family's ability to cope and their use of coping strategies. Maintain respiratory function Enhancing physical mobility Promote adequate nutrition Improving communication Decreasing fear and anxiety Managing potential complications Multiple Sclerosis & Urinary Retention - A neurogenic bladder results in urinary retention or leakage. The patient may describe a sensation of bladder fullness or incomplete bladder emptying. The pharmacological treatment of urinary retention is administration of a cholinergic agonist From Google: Many multiple sclerosis (MS) patients are affected by urinary retention. Common causes include neurogenic underactive bladder and/or bladder outlet obstruction from detrusor sphincter dyssynergia Traction & Assessment (Blueprint- Fractured Femer Dim Pulses) - After skin traction is applied, the nurse assesses circulation of the foot within 15 to 30 minutes and then every 1 to 2 hours. Circulatory assessment consists of: Peripheral pulses, color, capillary refill, and temperature of the fingers or toes. Manifestations of deep vein thrombosis (DVT), which include unilateral calf tenderness, warmth, redness, and swelling. Compartment Syndrome - Diagnosis of compartment syndrome is based on clinical suspicion, assessment of the 6 P's (pain, poikilothermia, pallor, paresthesia, pulselessness, and paralysis) Normal Sinus Rhythm - Electrical conduction that begins in the SA node generates a sinus rhythm. Normal sinus rhythm occurs when the electrical impulse starts at a regular rate and rhythm in the SA node and travels through the normal conduction pathway. Normal sinus rhythm has the following characteristics: · Ventricular and atrial rate: 60 to 100 bpm in the adult · Ventricular and atrial rhythm: Regular · QRS shape and duration: Usually normal, but may be regularly abnormal · P wave: Normal and consistent shape; always in front of the QRS · PR interval: Consistent interval between 0.12 and 0.20 seconds · P:QRS ratio: 1:1 Valve Replacement Teaching - Patients who have undergone surgical valvuloplasty or valve replacements are admitted to the ICU. Care focuses on recovery from anesthesia and hemodynamic stability. Vital signs are assessed every 5 to 15 minutes and as needed. After the patient has recovered from anesthesia and sedation, is hemodynamically stable without IV medications, and has stable physical assessment parameters, he or she usually is transferred to a telemetry unit, typically within 24 to 72 hours of surgery. The nurse educates the patient about anticoagulant therapy, explaining the need for frequent follow-up appointments and blood laboratory studies. Engorgement Teaching - Suggesting a sandwich technique to insert the mother's breast into the newborn's mouth to elicit sucking might be helpful for the mother with large breasts. In the sandwich technique, the mother is taught to grasp her breast by making a "C" with her thumb and index finger. The thumb stabilizes the top of the breast while the remaining four fingers support her breast from below. Massage or pumping the breast may soften and extend the nipple for easier infant latch-on. Rhogam Refusal - Jehovah's Witnesses and others who belong to religions prohibiting the use of blood products should decide based on their conscience and possibly ecclesiastical leaders about the use of RhoGAM. Nurses need to respect whatever the mother's decision is. 24 Hour Jaundice - Physiologic jaundice is very common in newborns, with the majority demonstrating yellowish skin, mucous membranes, and sclera within the first 3 days of life. Advise mothers to nurse their infants at least eight to 12 times per day for the first several days Variable Decelerations - Variable decelerations present as visually apparent abrupt decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly demonstrating no consistent relationship to uterine contractions. Variable decelerations are associated with cord compression Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental perfusion or relieve cord compression. Normal Fetal Heart Rate - The normal baseline FHR ranges between 110 and 160 beats per minute (bpm) IUGR What is it? & What are NST Results? - intrauterine growth restriction Currently, an NST is recommended twice weekly (after 28 weeks' gestation) for clients with diabetes and other high-risk conditions, such as intrauterine growth restriction (IUGR), preeclampsia, post-term pregnancy, renal disease, and multifetal pregnancies A nonreactive test has been correlated with a higher incidence of fetal distress during labor, fetal mortality, and IUGR. Additional testing, such as a biophysical profile, should be considered Methadone - Methadone is an opioid Symptoms of opioid withdrawal cause significant distress, but do not require pharmacologic intervention to support life or bodily functions. Longer acting substances such as methadone may not produce significant withdrawal symptoms for 2 to 4 days, and the symptoms may take 2 weeks to subside. Also used to treat addiction & withdrawl Methadone can be used as a replacement for opioids, and the dosage is then decreased over 2 weeks. Substitution of methadone during detoxification reduces symptoms to no worse than a mild case of flu Client during Termination Phase - Abandons old needs Aspires to new goals Becomes independent of helping person Applies new problem-solving skills Maintains changes in style of communication and interaction Shows positive changes in view of self Integrates illness Exhibits ability to stand alone