HESI Milestone #2 Practice Exam Questions and Answers

HESI Milestone #2 Practice Exam Questions and Answers -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 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 -Answer-- Physiologic, safety, love and belonging, self esteem, self- actualization - Basic drive and needs that motivate people Anxiety Suicide Risks: -Answer-Restless, difficulty concentrating, irritability - "Have you had any suicidal thoughts since starting bupropion?" Elder Abuse -Answer-Someone stating "I no longer have time to do anything for myself or anyone else" would be someone @ risk for abusing elder. Bruising around breasts and pelvic area = abuse Watch behavior toward family and document Make caregiver leave room during questioning