Milestone HESI Retake Exam 100% Correct Answers

Milestone HESI Retake Exam 100% Correct Answers Levels of Health Promotion - ANSWERS-primary, secondary, tertiary Application Examples of Levels of Promotion - ANSWERS-primary- weight loss, diet, smoking cessation Secondary- papsmears, mammograms, testicular exams Tertiary- medication therapy, surgical treatment, physical therapy, teaching foot care education to diabetic care Primary - ANSWERS-promotes health and preventing development of disease process or injury Secondary - ANSWERS-screening for early detection of disease Tertiary - ANSWERS-begins after illness is diagnosed and treatment. Aims to prevent long-term consequences of chronic illnesses or disabilities Nursing Assessments - ANSWERS-Comprehensive- (Head to Toe) = Can be done inpatient and through primary care (Physical assessment- annual exam) Focused- Health and physical hx of specific problem.- ex. Sick visit Emergency- crisis, life threatening. ex. airway, breathing, injury, disability, exposure, med reconciliation Phases of Interview process - ANSWERS-Pre-interaction, beginning, working (open and close ended questions), closing Data sources - ANSWERS-Primary- individual patient Secondary- chart info, family members Purposes of Documentation - ANSWERS-verbal communication, SBAR, written document Lifespan Nutritional Considerations - Nutrition: Pregnant Women - ANSWERS-need additional 300-500 cal/day (whole foods Lifespan Nutritional Considerations - Nutrition: infants/children - ANSWERS-infants/children: whole milk for ages 2-5 fat intake-brain development Lifespan Nutritional Considerations - Nutrition: Older - ANSWERS-BMR declines, Vitamin D supplements, Problems: decreased thirst, increase risk for osteoarthritis, osteoporosis, dementia, obesity, social isolation General Survey - ANSWERS-mental note of overall health (hygiene/appearance). Assessing pain: documentation, OLDCARTS/OPQRST. Aggravating and alleviating factors, pain goal and funtional goal Assessing Pain - Documentation - ANSWERS-Acute vs. Chronic-Location Priority - ANSWERS-Priority pain: stones (kidney, gallbladder, calcium and/or struvite), myocardial infarcation (HA), burns and sickle cell Heart Rate Elevated - ANSWERS-above 100 beats per minute Blood Pressure- Normal - ANSWERS-above systolic- 120-129, diastolic- less than 80, Blood Pressure- elevated - ANSWERS-Hypertension: Stage 1: 130-139 or 80-89, Stage Hypertension 2: more than 140, or greater than or equal to 90 When should BP be taken? - ANSWERS-after patient rests for 5 minutues or 30 minutes after caffeine, smoking Assessment of the Head and Neck - ANSWERS-Inspect, palpate, auscultate Infection - ANSWERS-If nodes are palpable, warm, tender = infection Assessment of the Ear - Techniques - ANSWERS-Adults: up and back Children: down and back Assessment of the Ear - Techniques Part 2 - ANSWERS-observe behavioral responses to speech, inspect ear formation (size, shape & any malformation to the auricle, condition) Perform whisper test & Rinne test. Pt plug one ear at a time Perform weber test (evaluate unilateral hearing loss Assessing the Chest - ANSWERS-inspect, palpate, percuss, auscultate Assessing Lung Sounds - Technique - ANSWERS-IPPA- inspect, palpate, percuss, auscultate Normal Lung Sounds - ANSWERS-Normal: bronchial (heard anteriorly) over larynx and trachea (INSPIRIATION slightly shorter than expiration), Bronchiovesicular (heard anteriorly and posteriorly)INSPIRATION AND EXPIRATION EQUAL , Vesicular (heard both) lower lungs, low pitch, INSPIRATION GREATER THAN EXPIRATION) Abnormal lung sounds: Rhonchi - ANSWERS-low- heard mainly in expiration when pt is breathing out (made up of one sound- whistle or whine and high pitch, musical instrument sound MULTIPLE sounds- mainly heard in expiration CONDITION: PNEUMONIA abnormal lung sounds: stridor - ANSWERS-airway obstruction, high pitch whispering or gas (CROUP, EMERGENCY, EPIGLOTTIS) Abnormal lung sounds: Crackles - ANSWERS-coarse(low pitch, wet sound) fine (high pitch, doesnt clear w/cough, crackling of fire sound) CONDITION:RESPIRATORY EDEMA/OBSTRUCTIVE DISEASE Abnormal lung sounds: Pleural Friction Rub - ANSWERS-Pleural friction rub (low pitch, harsh grating sound) Assessment of the Respiratory System - ANSWERS-tachypnea- rapid breathing bradypnea- slow breathing Normally, respirations are quiet and nonlabored, and occur at a rate of 12 to 20 times each minute in healthy adults. Note any flaring of the nostrils, muscular retractions, Heart Function System - ANSWERS-Abnormal size or location of the PMI or the presence of vibrations can indicate heart failure, myocardial infarction, disease of the heart valves, or other cardiac diseases. Abdominal Assessment - ANSWERS-Inspect, palpate, auscultate. Nurse assess lumps, masses or tenderness Musculoskeletal System - Pronation & Supination - ANSWERS-prone- plank (face downward), supine- on the back, Disorder: osteoporosis- break down of bone (weight bearing activity is encouraged) Secondary osteoporosis- steroids' aka bones porous and bone prone to fractures Compression fracture- changing position slowly, tenderness of palpitation of spine, in pain Neuro Assessment- Cranial Nerves - ANSWERS-Olfactory (smell),Cranial Nerve 2: optic, cranial nerve 3: oculomotor, cranial nerve 4: Trochlear, cranial nerve 5: Trigeminal nerve, Cranial nerve 6: abducens cranial nerve 7: facial nerve cranial nerve 8: acoustic, cranial nerve 9: Glossopharyngeal cranial nerve 10: vagus cranial nerve 11: accessory cranial nerve 12: hypoglossal Full Description - ANSWERS-(Cranial Nerve 1: Olfactory (smell),Cranial Nerve 2: confrontational field (cover up eye in fields in all fields) and visual acuity (Snellen Chart) reading at 20 feet from the chart . Cranial Nerve III: oculomotor- nystagmus- moving penlight in 6 cardinal fields of gaze, Cranial nerve IV: Trochlear: assess pupil constriction (normal: 3-5 mm), PERRLA and Cranial nerve VI: Abducens , Cranial nerve 5: Trigeminal nerve- mastification (feel temporal and masseter muscle)open and close mouth against resistance, cranial nerve 7: facial nerve (open and close eyes, frown, smile, Cranial nerve 8: occlude ears and whisper word and pt repeat, Cranial nerve 9: Glossopharyngeal-test gag reflex, vagus nerve- pt able to speak and swallow, cranial nerve 11- accessory- shrug shoulders w/ease, Hypoglossal: pt moves tongue from side to side Confusion Causes - ANSWERS-underlying infections, dehydration, electrolyte imbalances Preventive Screening and Symptom Assessment - Tools & Uses - ANSWERS-Braden pressure ulcer scale (Sensory perception, moisture, activity, mobility, nutrition, friction and shear), fall risk assessment Heart Sounds - Technique & Representation of Sounds - ANSWERS-S1- louder than S2 S1-"lub", S2- "dub"= Systole S3- "dub", S4- "lub" = diastole Murmur - ANSWERS-Murmur- blowing or swooshing sound due to cardio or circulatory disturbance. Ex. anemia, pregnancy Adults - ANSWERS-aortic stenosis, mitral insufficiency Abdominal Assessment - ANSWERS-Inspect, auscultate, percuss, palpate. Feel for lumps, masses or tenderness Pronation - ANSWERS-plank (face downward Supination - ANSWERS-on the back