HESI mid curricular Exam (Graded A+)
Complete Solutions
nursing process - Answer - ✔ assess
diagnose
outcome/planning
implement
evaluate
techniques of physical assessment - Answer - ✔ inspection
palpation
percussion
auscultation
start physical assessment with - Answer - ✔ general survey assess for
-appearance
-behavior
-height/weight/BMI
-nutritional status
-waist circumference which can indicate obesity
when assessing the integumentary system you are looking for - Answer - ✔ erythema -
indicating fever/inflammation
cyanosis - indicating O2 loss
jaundice - ^ billiruben
pallor - low on blood
ecchymosis
petechiae
lesions
integumentary assessment - Answer - ✔ palpate for temperature, moisture, turgor,
edema
and inspect
adventitious breath sounds - Answer - ✔ wheeze - high pitch indicating airway
obstruction
crackles - bubbling on in/ex
stridor - harsh high pitch sound on inhale
ronchi - sonourus , coarse low pitch
friction rub
extra heart sounds - Answer - ✔ s3-normal in children
s4- normal in older adults
,order to listen to heart sounds - Answer - ✔ APETM
aortic, pulmonic, erbs point, tricuspid, mitral
assessing the abdomen what order - Answer - ✔ inspect
auscultate
percussion
palpate
bowel sounds should occur - Answer - ✔ every 5-35 seconds
gurgling
if no sounds for 5 minutes = silent ileus
bruits - Answer - ✔ abnormal bowel sound auscultated during abdominal assessment
sounds like a swishing noise and indicates obstruction
neurovascular assessment - Answer - ✔ 6 P's
1. pain
2. pallor
3. peripheral pulses
4. paresthesia
5. paralysis
6. pressure
cranial nerve 5 - Answer - ✔ trigeminal
-motor/sensation
CHEWING
cranial nerve 7 - Answer - ✔ facial
SMILE
cranial nerve 9 - Answer - ✔ glossopharyngeal
SWALLOWING
cranial nerve 12 - Answer - ✔ tongue
STICK YOUR TONGUE OUT AT ME
when to assess VS - Answer - ✔ on admission
based on policy
with CHANGE in condition
loss of consciousness
before/after invasive procedure
before/after med admin
heat production measures the body takes - Answer - ✔ shivering
, piloerection
vasoconstriction
increased metabolism
heat losing measures the body takes - Answer - ✔ sweating
vasodilation
increased respirations
jellinek curve - Answer - ✔ phase 1 - pre alcoholic - using to relieve every day stress
phase 2 - early alcoholic - blackouts/needs it, secretive about it gulps 1st drink
phase 3 - crucial phase - lost control and gets defensive
phase 4 - chronic phase -
greatest risk for seizures in alcohol withdrawal is - Answer - ✔ within 7-48 hours of last
drink
CIWA-AR - Answer - ✔ monitors pt response to tx; determines need for medication,
prevents seizures. use ciwa-ar every 2 hours then 4 hours
alcoholism medications that promote sobriety - Answer - ✔ - Disulfiram (antabuse) -
causes severe neg. reaction to alcohol can lead to death even if only around paint
fumes.
-Naltrexone (ReVia) - reduces cravings by blocking the effects of alcohol PRN or
monthly inj.
-acamprosate (campral) - reduces want/craving can't be used for pt with renal failure (2
tab 3x/day)
3 groups of laxatives and their functions - Answer - ✔ 1. chemical laxatives
(stimulate/irritate lining of GI
2. bulk laxatives (causes feces to ^ in bulk by ^ water content)
3. lubricant (move more smoothly)
medications that cause diarrhea - Answer - ✔ antibiotics
magnesium
medications that cause constipation - Answer - ✔ opioids
antacids
iron sulfate
anticholinergics
GI bleed stool will be - Answer - ✔ black if bleed is high in GI tract
red/pink if bleed is closer to rectum
chemical stimulant laxatives - Answer - ✔ caster oil
cascara
Complete Solutions
nursing process - Answer - ✔ assess
diagnose
outcome/planning
implement
evaluate
techniques of physical assessment - Answer - ✔ inspection
palpation
percussion
auscultation
start physical assessment with - Answer - ✔ general survey assess for
-appearance
-behavior
-height/weight/BMI
-nutritional status
-waist circumference which can indicate obesity
when assessing the integumentary system you are looking for - Answer - ✔ erythema -
indicating fever/inflammation
cyanosis - indicating O2 loss
jaundice - ^ billiruben
pallor - low on blood
ecchymosis
petechiae
lesions
integumentary assessment - Answer - ✔ palpate for temperature, moisture, turgor,
edema
and inspect
adventitious breath sounds - Answer - ✔ wheeze - high pitch indicating airway
obstruction
crackles - bubbling on in/ex
stridor - harsh high pitch sound on inhale
ronchi - sonourus , coarse low pitch
friction rub
extra heart sounds - Answer - ✔ s3-normal in children
s4- normal in older adults
,order to listen to heart sounds - Answer - ✔ APETM
aortic, pulmonic, erbs point, tricuspid, mitral
assessing the abdomen what order - Answer - ✔ inspect
auscultate
percussion
palpate
bowel sounds should occur - Answer - ✔ every 5-35 seconds
gurgling
if no sounds for 5 minutes = silent ileus
bruits - Answer - ✔ abnormal bowel sound auscultated during abdominal assessment
sounds like a swishing noise and indicates obstruction
neurovascular assessment - Answer - ✔ 6 P's
1. pain
2. pallor
3. peripheral pulses
4. paresthesia
5. paralysis
6. pressure
cranial nerve 5 - Answer - ✔ trigeminal
-motor/sensation
CHEWING
cranial nerve 7 - Answer - ✔ facial
SMILE
cranial nerve 9 - Answer - ✔ glossopharyngeal
SWALLOWING
cranial nerve 12 - Answer - ✔ tongue
STICK YOUR TONGUE OUT AT ME
when to assess VS - Answer - ✔ on admission
based on policy
with CHANGE in condition
loss of consciousness
before/after invasive procedure
before/after med admin
heat production measures the body takes - Answer - ✔ shivering
, piloerection
vasoconstriction
increased metabolism
heat losing measures the body takes - Answer - ✔ sweating
vasodilation
increased respirations
jellinek curve - Answer - ✔ phase 1 - pre alcoholic - using to relieve every day stress
phase 2 - early alcoholic - blackouts/needs it, secretive about it gulps 1st drink
phase 3 - crucial phase - lost control and gets defensive
phase 4 - chronic phase -
greatest risk for seizures in alcohol withdrawal is - Answer - ✔ within 7-48 hours of last
drink
CIWA-AR - Answer - ✔ monitors pt response to tx; determines need for medication,
prevents seizures. use ciwa-ar every 2 hours then 4 hours
alcoholism medications that promote sobriety - Answer - ✔ - Disulfiram (antabuse) -
causes severe neg. reaction to alcohol can lead to death even if only around paint
fumes.
-Naltrexone (ReVia) - reduces cravings by blocking the effects of alcohol PRN or
monthly inj.
-acamprosate (campral) - reduces want/craving can't be used for pt with renal failure (2
tab 3x/day)
3 groups of laxatives and their functions - Answer - ✔ 1. chemical laxatives
(stimulate/irritate lining of GI
2. bulk laxatives (causes feces to ^ in bulk by ^ water content)
3. lubricant (move more smoothly)
medications that cause diarrhea - Answer - ✔ antibiotics
magnesium
medications that cause constipation - Answer - ✔ opioids
antacids
iron sulfate
anticholinergics
GI bleed stool will be - Answer - ✔ black if bleed is high in GI tract
red/pink if bleed is closer to rectum
chemical stimulant laxatives - Answer - ✔ caster oil
cascara
