HESI Milestone #2 2022/2023 Exam
Answered 100% Correct
-Chemo Side Effects - ANSWER-o Nausea/vomiting (24-48 hr, can be delayed up to 1
week)
Meningitis first step - ANSWER-o Antibiotics - penicillin (ampicillin) AND cephalosporin
o Corticosteroids.
Multiple sclerosis and urinary retention - 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
Acute renal failure priority - 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 - 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 - 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 - 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 - ANSWER-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 - ANSWER-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 - 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
Grief process therapeutic response - ANSWER-Allow the 5 steps of grieving (DABDA),
active listening and offer a supportive presence
Dementia action refusing ADLs - ANSWER-Encourage finger foods, distraction, speak
therapeutically
Alcohol withdrawal - 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 - ANSWER-S&S= constricted pupils, resp. depression, circul.
depression, LOC decreased
Give naloxone
Domestic violence screening tool - 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 - 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 - 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
Medication adverse reactions care (schizophrenia) - ANSWER-Constipation is a
common side effect of antipsych meds, polydipsia occurs after years of treatment
Answered 100% Correct
-Chemo Side Effects - ANSWER-o Nausea/vomiting (24-48 hr, can be delayed up to 1
week)
Meningitis first step - ANSWER-o Antibiotics - penicillin (ampicillin) AND cephalosporin
o Corticosteroids.
Multiple sclerosis and urinary retention - 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
Acute renal failure priority - 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 - 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 - 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 - 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 - ANSWER-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 - ANSWER-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 - 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
Grief process therapeutic response - ANSWER-Allow the 5 steps of grieving (DABDA),
active listening and offer a supportive presence
Dementia action refusing ADLs - ANSWER-Encourage finger foods, distraction, speak
therapeutically
Alcohol withdrawal - 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 - ANSWER-S&S= constricted pupils, resp. depression, circul.
depression, LOC decreased
Give naloxone
Domestic violence screening tool - 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 - 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 - 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
Medication adverse reactions care (schizophrenia) - ANSWER-Constipation is a
common side effect of antipsych meds, polydipsia occurs after years of treatment
