HESI MILESTONE 2 VERSION A BLUEPRINT Graded A+
Schizophrenia care- - ANSWER-Establish trust and rapport, encourage the client to talk with you, be consistent in setting expectations, explain the procedures and be certain the client understands, give positive feedback for the client successes, show empathy, do not be judgemental, never convey to the client that you accept their delusions as reality.
Grief therapeutic response- - ANSWER-Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), active listening, and offering a supportive presence.
Nursing Plans and Interventions:
A. If needed, refer to grief counseling or a support group.
B. Encourage activities that allow the individual to use past coping strategies to promote
a feeling of self-worth and increased self-esteem.
C. Encourage the individual to share his or her feelings.
D. Encourage socialization with family peers and reminisce about significant life experiences.
Delirium care- - ANSWER-Know usual mental status and if changes noted are long-
term, it probably represents dementia; if they are sudden/acute in onset, it is more likely to be delirium. Recognize and report symptoms immediately. Treatment of underlying causes is important - if untreated, it can lead to permanent, irreversible brain damage and death. The primary goals of nursing care for clients with delirium are: PROTECTION FROM INJURY, MANAGEMENT OF CONFUSION, AND MEETING PHYSIOLOGICAL AND PSYCHOLOGICAL NEEDS. Ensure patient safety (fall risk) and manage behavioral problems.
Alert the prescriber of nonessential medications. Nutritional and fluid intake must be monitored.
A quiet and calm environment.
Encourage visitors to touch and talk to patients.
Assess/manage pain.
Alzheimer's hallucination- - ANSWER-Occurs in the late-middle to later stages of the disease process and is treated with antipsychotics such as Haldol
Alcohol withdrawal- - ANSWER-Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse, and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremors. Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however, and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms.
Nursing Plans and Interventions
A. Maintain safety, nutrition, hygiene, and rest.
B. Obtain a BAL on admission or when a client appears intoxicated after admission.
C. Implement suicide precautions if assessment indicates risk.
D. In general
1. Monitor vital signs, input and output (I&O), and electrolytes.
2. Observe for impending DTs.
3. Prevent aspiration; implement seizure precautions.
4. Reduce environmental stimuli.
5. Medicate with antianxiety medication, usually chlordiazepoxide (Librium) or lorazepam
(Ativan)
6. Provide high-protein diet and adequate fluid intake (limit caffeine).
7. Provide vitamin supplements, especially vitamins B1 and B complex.
8. Provide emotional support.
Methadone- - ANSWER-Detoxification and maintenance therapy for opioid use disorder.
Suppression of withdrawal symptoms during detox related to opioids such as heroin.
It can cause respiratory depression.
Do not give it to patients with acute or severe bronchial asthma. It is contraindicated for patients taking MAOIs.
Methadone Overdose:
A). Physical Assessment
-Constricted pupils
- Respiratory depression leading to respiratory arrest
-Circulatory depression leading to cardiac arrest
-Unconsciousness leading to coma
-Death
B). General Appearance
-General physical and mental deterioration
-Rapid tolerance-overdose likely if not monitored.
-Impaired judgment
Aggression response- - ANSWER-The nurse must protect others from these clients' manipulative or aggressive behaviors. At the beginning of treatment, he or she must set limits on unacceptable behavior. The limit setting involves the following three steps:
Inform clients of the rule or limits.
Explain the consequences if clients exceed the limit. State expected behavior.
Nursing Plans and Interventions: Conduct and Defiant Disorders A. Assess verbal and nonverbal cues for escalating behavior so as to decrease outbursts.
B. Use a nonauthoritarian approach.
C. Avoid asking "why" questions.
D. Initiate a "show of force" with a child who is out of control.
E. Use a "quiet room" when external control is needed.
F. Clarify expressions or jargon if meanings are unclear.
G. Teach to redirect angry feelings to safe alternative, such as a pillow or punching bag.
H. Implement behavior modification therapy if indicated. I. Role-play new coping strategies with client.
Duty to warn- - ANSWER-The obligation of a healthcare provider to warn third parties of
potential threats or harm aimed at them by another individual.
Schizophrenia- treatment evaluation- - ANSWER-1.) Clients should have decreased agitation, combativeness, and psychomotor activity. 2.) Decreased psychotic behaviors such as decreased hallucinations and delusions.
Anxiety drugs risk- - ANSWER-Most of these drugs are benzodiazepines, which are commonly prescribed for anxiety. Benzodiazepines have a high potential for abuse and dependence, so their use should be short-term, ideally no longer than 4 to 6 weeks. One chief problem encountered with benzodiazepines is their tendency to cause physical dependence. Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. This is especially a problem for clients with long-term benzodiazepine
use, such as those with panic or generalized anxiety disorder.
I am 100% convinced that this is the fact that three weeks after starting an anxiolytic, a patient is at a significantly higher risk of suicide due to increased energy and not wanting to go back to feeling anxious or depressed. It's mentioned both in Realize It and
in the HESI prep
ADHD exam- - 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.
- Underachievement in school performance
Obsessive compulsive disorder-Nursing Diagnosis - ANSWER-Nursing Diagnosis
Ineffective Coping
Inability to form a valid appraisal of the stressor
Inadequate choices of practiced responses and/or Inability to use available resources.
Nursing Assessment • Recurring, intrusive thoughts and repetitive behaviors that interfere with normal functioning
. Ambivalence regarding decisions or choices
• Disturbances in normal functioning due to obsessive thoughts or compulsive behaviors
(loss of job, loss of/or alienation of family members, etc.)
• Inability to tolerate deviations from standards
• Rumination
• Low self-esteem
• Feelings of worthlessness
. Lack of insight
Nursing interventions
A. Actively listen to the client's obsessive themes.
B. Acknowledge the effects that ritualistic acts have on the client.
C. Demonstrate empathy.
D. Avoid being judgmental.
E. Provide for client's physical needs.
F. Allow performance of the compulsive activity with attention given to safety (e.g., skin integrity of a hand washer).
G. Explore meaning and purpose of the behavior with client.
H. Avoid punishing and criticizing.
I. Establish routine to avoid anxiety-producing changes.
J. Assist client with learning alternative methods of dealing with stress.
K. Avoid reinforcing compulsive behavior.
L. Limit the amount of time for performance of ritual and encourage client to gradually decrease the time.
M. Administer antianxiety medications as prescribed
N. Administer SSRIs or tricyclic antidepressants as prescribed
Therapeutic communication abuse victim- - ANSWER--Listen. -Believe what the person says. -Empathize: validate the person's feelings. -Make it clear that the abuse was wrong and not the victim's fault.
Suicide Precautions
A. Obtain history.
-A previous suicide attempt is the most significant risk factor. Other risk groups include those with biologic and organic causes of depression, such as substance abuse, organic brain disorders, or other medical problems.
-Clients with a history of a family member's suicide are at heightened risk for suicide.
B. Be aware of the major warning signs of an impending suicide attempt.
-A client begins giving away the client's possessions.
- When a previously depressed client becomes happy, he or she may have decided to commit suicide and is no longer debating the possibility. The client may have regained the energy to act on suicidal feelings and has figured out how to accomplish the suicide.
Evaluation of Intent
A. Directly ask the client about intent to harm self. Example: "Have you thought about harming yourself?"
Schizophrenia care- - ANSWER-Establish trust and rapport, encourage the client to talk with you, be consistent in setting expectations, explain the procedures and be certain the client understands, give positive feedback for the client successes, show empathy, do not be judgemental, never convey to the client that you accept their delusions as reality.
Grief therapeutic response- - ANSWER-Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), active listening, and offering a supportive presence.
Nursing Plans and Interventions:
A. If needed, refer to grief counseling or a support group.
B. Encourage activities that allow the individual to use past coping strategies to promote
a feeling of self-worth and increased self-esteem.
C. Encourage the individual to share his or her feelings.
D. Encourage socialization with family peers and reminisce about significant life experiences.
Delirium care- - ANSWER-Know usual mental status and if changes noted are long-
term, it probably represents dementia; if they are sudden/acute in onset, it is more likely to be delirium. Recognize and report symptoms immediately. Treatment of underlying causes is important - if untreated, it can lead to permanent, irreversible brain damage and death. The primary goals of nursing care for clients with delirium are: PROTECTION FROM INJURY, MANAGEMENT OF CONFUSION, AND MEETING PHYSIOLOGICAL AND PSYCHOLOGICAL NEEDS. Ensure patient safety (fall risk) and manage behavioral problems.
Alert the prescriber of nonessential medications. Nutritional and fluid intake must be monitored.
A quiet and calm environment.
Encourage visitors to touch and talk to patients.
Assess/manage pain.
Alzheimer's hallucination- - ANSWER-Occurs in the late-middle to later stages of the disease process and is treated with antipsychotics such as Haldol
Alcohol withdrawal- - ANSWER-Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse, and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremors. Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however, and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms.
Nursing Plans and Interventions
A. Maintain safety, nutrition, hygiene, and rest.
B. Obtain a BAL on admission or when a client appears intoxicated after admission.
C. Implement suicide precautions if assessment indicates risk.
D. In general
1. Monitor vital signs, input and output (I&O), and electrolytes.
2. Observe for impending DTs.
3. Prevent aspiration; implement seizure precautions.
4. Reduce environmental stimuli.
5. Medicate with antianxiety medication, usually chlordiazepoxide (Librium) or lorazepam
(Ativan)
6. Provide high-protein diet and adequate fluid intake (limit caffeine).
7. Provide vitamin supplements, especially vitamins B1 and B complex.
8. Provide emotional support.
Methadone- - ANSWER-Detoxification and maintenance therapy for opioid use disorder.
Suppression of withdrawal symptoms during detox related to opioids such as heroin.
It can cause respiratory depression.
Do not give it to patients with acute or severe bronchial asthma. It is contraindicated for patients taking MAOIs.
Methadone Overdose:
A). Physical Assessment
-Constricted pupils
- Respiratory depression leading to respiratory arrest
-Circulatory depression leading to cardiac arrest
-Unconsciousness leading to coma
-Death
B). General Appearance
-General physical and mental deterioration
-Rapid tolerance-overdose likely if not monitored.
-Impaired judgment
Aggression response- - ANSWER-The nurse must protect others from these clients' manipulative or aggressive behaviors. At the beginning of treatment, he or she must set limits on unacceptable behavior. The limit setting involves the following three steps:
Inform clients of the rule or limits.
Explain the consequences if clients exceed the limit. State expected behavior.
Nursing Plans and Interventions: Conduct and Defiant Disorders A. Assess verbal and nonverbal cues for escalating behavior so as to decrease outbursts.
B. Use a nonauthoritarian approach.
C. Avoid asking "why" questions.
D. Initiate a "show of force" with a child who is out of control.
E. Use a "quiet room" when external control is needed.
F. Clarify expressions or jargon if meanings are unclear.
G. Teach to redirect angry feelings to safe alternative, such as a pillow or punching bag.
H. Implement behavior modification therapy if indicated. I. Role-play new coping strategies with client.
Duty to warn- - ANSWER-The obligation of a healthcare provider to warn third parties of
potential threats or harm aimed at them by another individual.
Schizophrenia- treatment evaluation- - ANSWER-1.) Clients should have decreased agitation, combativeness, and psychomotor activity. 2.) Decreased psychotic behaviors such as decreased hallucinations and delusions.
Anxiety drugs risk- - ANSWER-Most of these drugs are benzodiazepines, which are commonly prescribed for anxiety. Benzodiazepines have a high potential for abuse and dependence, so their use should be short-term, ideally no longer than 4 to 6 weeks. One chief problem encountered with benzodiazepines is their tendency to cause physical dependence. Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. This is especially a problem for clients with long-term benzodiazepine
use, such as those with panic or generalized anxiety disorder.
I am 100% convinced that this is the fact that three weeks after starting an anxiolytic, a patient is at a significantly higher risk of suicide due to increased energy and not wanting to go back to feeling anxious or depressed. It's mentioned both in Realize It and
in the HESI prep
ADHD exam- - 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.
- Underachievement in school performance
Obsessive compulsive disorder-Nursing Diagnosis - ANSWER-Nursing Diagnosis
Ineffective Coping
Inability to form a valid appraisal of the stressor
Inadequate choices of practiced responses and/or Inability to use available resources.
Nursing Assessment • Recurring, intrusive thoughts and repetitive behaviors that interfere with normal functioning
. Ambivalence regarding decisions or choices
• Disturbances in normal functioning due to obsessive thoughts or compulsive behaviors
(loss of job, loss of/or alienation of family members, etc.)
• Inability to tolerate deviations from standards
• Rumination
• Low self-esteem
• Feelings of worthlessness
. Lack of insight
Nursing interventions
A. Actively listen to the client's obsessive themes.
B. Acknowledge the effects that ritualistic acts have on the client.
C. Demonstrate empathy.
D. Avoid being judgmental.
E. Provide for client's physical needs.
F. Allow performance of the compulsive activity with attention given to safety (e.g., skin integrity of a hand washer).
G. Explore meaning and purpose of the behavior with client.
H. Avoid punishing and criticizing.
I. Establish routine to avoid anxiety-producing changes.
J. Assist client with learning alternative methods of dealing with stress.
K. Avoid reinforcing compulsive behavior.
L. Limit the amount of time for performance of ritual and encourage client to gradually decrease the time.
M. Administer antianxiety medications as prescribed
N. Administer SSRIs or tricyclic antidepressants as prescribed
Therapeutic communication abuse victim- - ANSWER--Listen. -Believe what the person says. -Empathize: validate the person's feelings. -Make it clear that the abuse was wrong and not the victim's fault.
Suicide Precautions
A. Obtain history.
-A previous suicide attempt is the most significant risk factor. Other risk groups include those with biologic and organic causes of depression, such as substance abuse, organic brain disorders, or other medical problems.
-Clients with a history of a family member's suicide are at heightened risk for suicide.
B. Be aware of the major warning signs of an impending suicide attempt.
-A client begins giving away the client's possessions.
- When a previously depressed client becomes happy, he or she may have decided to commit suicide and is no longer debating the possibility. The client may have regained the energy to act on suicidal feelings and has figured out how to accomplish the suicide.
Evaluation of Intent
A. Directly ask the client about intent to harm self. Example: "Have you thought about harming yourself?"
