HESI MILESTONE VERSION 2 ACTUAL EXAM
WITH VERIFIED ANSWERS. [GRADED A+].
2024/2025 UPDATE. NEW!! NEW!
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 at 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 - ANS✔✔-Priority should be based on SHOCK!
Shoulder Dystocia Actions - ANS✔✔-- McRoberts Maneuver
- Suprapubic Pressure (need step stool)
