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HESI EXIT!!!!! WITH CORRECT AND VERRIFIED ANSWERS 2024 NEW!!! Signs of systemic infection - -fever -increased pulse and respiratory rate if the fever is high -malaise and loss of energy -anorexia and, in some situations, nausea and vomiting -enlargement and tenderness of lymph nodes that drai...

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  • September 17, 2024
  • 39
  • 2024/2025
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HESI EXIT!!!!! WITH CORRECT AND
VERRIFIED ANSWERS 2024 NEW!!!

,lymphedema - swelling that occurs in the arm, breast, or torso, on the side of the
mastectomy due to buildup of lymph fluid in the area as a consequence of axillary node
dissection. S/S: swelling, achiness, tingling, or a full feeling in the extremity, tightness,
often with redness and hardening of the overlying skin

Crohn's Disease Interventions - 1. Yearly colonoscopy for colorectal cancer screening
starting 8-10 years after diagnosis.
2. Bone density tests for long term corticosteriod use
3. Routine liver and kidney function tests if client is taking methotrexate

Tumor Necrosis Factor Alpha (TNF-a) therapy - can be used for treatment of Crohn's
disease but annual screening for TB is recommended

NG tube placement - 1. sterile or non-sterile gloves
2. Client in high fowlers with neck flexed and chin on the chest
3. X-ray to confirm placement
4. Sips of water as long as client is NOT experiencing dysphagia

Signs of systemic infection - -fever
-increased pulse and respiratory rate if the fever is high
-malaise and loss of energy
-anorexia and, in some situations, nausea and vomiting
-enlargement and tenderness of lymph nodes that drain the area of infection
-White, clammy skin

Asymmetric Moro reflex - can be a sign of shoulder dystocia, brachial plexus injury, or a
clavicle fracture

erythema toxicum neonatorum - presence of erythematous macules, papules, and
postules on the trunk and extremities in the absence of fever. It develops in some term
infants. A Tzank smear should be performed to distinguish from herpes or varicella
zoster infection.

clubfoot observations - plantar flexion of the ankle, inversion and adduction of the
forefoot

jitteriness and tachypnea - signs of hypoglycemia in newborn?

,Pulmonary contusion - damage to the lung parenchyma with loss of normal lung
function and structure, edema and blood collection. Signs are tachypnea and
hypoxemia with a unilateral decrease in breath sounds with no revealed abnormalities
on the X-ray (up to 24 hours).

acute respiratory distress syndrome (ARDS) - respiratory insufficiency marked by
progressive hypoxia

pneumothorax - air in the pleural cavity caused by a puncture of the lung or chest wall; a
thin sharp line that separate normal lung tissue from the peripheral space on chest x-ray

Advance directive - legal documents composed by a competent client that describes the
preferences for medical if the client later becomes unable to make decisions
him/herself.

Fibrocystic change - a benign condition which develops freely moving masses in the
breast that typically exhibit mid-cycle tenderness and vary in shape due to menstrual
cycle.

Breast cancer findings - mass is most likely unmovable, irregularly shaped lump with
dimpling of the overlying skin

Intraductal papilloma - The most common cause of bloody nipple discharge. The client
also typically report breast pain and a lump behind the areola.

Hyperosmolar hyperglycemic non-ketotic syndrome (HHS) - 1. steep rise in glucose
level (>600 mg/dL)
2. No ketone formation
3. Hydration is KEY
4. typically provoked by an underlying infection, stress, or surgery

HHS interventions - 1. Assess Dehydration (start fluid replacement if needed)
2. Measure temperature and document
3. Send urine to lab for urinalysis and culture
4. Begin broad spectrum antibiotics while awaiting culture results

Dark brown drainage in NG Tube - can be a sign of gastric/upper GI bleeding and
requires urgent investigation

Cross-contamination prevention - -Implementing isolation
-Washing hands

Auto-contamination prevention - -Applying new sterile gloves for each wound
-Dressing each burned finger and toe individually
-Debriding necrotic tissue

, Gout - presence of hard nodules around the finger joints and in the ear. The nodules are
tophi, which are depositions of uric acid crystals in the skin, cartilage, and soft tissues.

Urolithiasis - kidney stones

Uhthoff's phenomenon - Multiple sclerosis phenomenon that results in decreased motor
function (fatigue, blurred vision, walking problems, and urinary urgency) with increase in
body temperature (example: a hot bath)

Digoxin dose - if a dose is missed, take the dose immediately has long as the next dose
is 12 hours away

Scleroderma - a connective tissue disorder that results in thickening of the skin and
fibrosis of the internal organs. Raynaud's phenomenon is common. The risk for
infections is higher due to the use of immunosuppressive drugs and decreased
pulmonary mucus clearing. The skin should be moisturized with emollients.

Raynaud's phenomenon - a peripheral arterial occlusive disease characterized by
severe pain and blue discoloration of the hands and feet caused by vasoconstriction of
the arterioles in these areas. Most episodes are triggered by stress or cold conditions.

Cushing's syndrome nursing diagnoses - 1. Risk for fluid volume overload because
cortisol promotes water retention by the kidneys
2. Overweight and at risk for insulin resistance, metabolic syndrome, and type 2
diabetes
3. Disturbed thought processes r/t excessive amount of cortisol which causes dramatic
changes which can led to anxiety, mood changes, insomnia, and emotional instability

Reposition the probe - first step in getting a lower than normal pulse oximeter reading

Codeine cough syrup - opioid with antitussive properties. It frequently causes
constipation. It can be used in the treatment of pertussis (whooping cough)

Cimetidine - H2 receptor antagonist that inhibits stomach acid production. Some side
effects are diarrhea, gynecomastia, and headaches.

Prednisone - Corticosteroid that can cause hypertension, blood glucose abnormalities,
weight gain, peptic ulcer formation.

Ganciclovir (Cytovene) - "Use: CMV, HSV, VZV infections
Class: Antiviral (inhibits viral DNA polymerases)
Intervention: monitor for abnormal lab values (anemia, thrombocytopenia, neutropenia)
and elevated liver function tests
AEs: Myelosuppression, fever, rash"

nail polish, henna, or tattoos - can interfere with pulse oximeter readings

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