HESI MILESTONE EXAM 1 QUESTIONS & ANSWERS 2023
1. Chemo Side Effects CORRECT ANSWER o Nausea/vomiting (24-48 hr., can be delayed up to 1 week)
2. Meningitis first step CORRECT ANSWER o Antibiotics - penicillin (ampicillin) AND cephalosporin
oCorticosteroids
3. Multiple sclerosis and urinary retention CORRECT ANSWER o Sensation of void heeded immediately (bed pan/urinal @ bedside)
oVoiding schedule (start 1/5-2hr then extend)
oDrink specific amt every 2 hour; urinate 30 min after w/ timer
oSelf-catherization
4. Acute renal failure priority CORRECT ANSWER o Maintain fluids o Avoid fluid excess
oRenal replacement therapy
oReduce metabolic rate
oPromote pulmonary function
5. Acute Respiratory distress priority findings CORRECT ANSWER o Hypoxia o Intercostal retractions
oCrackles
oBNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction)
6. End of life plan of care CORRECT 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
7. Cushing Syndrome CORRECT ANSWER o Can result from corticosteroids ***Attempt to reduce/taper medication while still treating underlying disease
oAlternate day therapy decrease symptoms and allows adrenal glands to recover 8. Valve replacement teaching CORRECT ANSWER o Anticoagulant therapy (frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios o Prevent infection
oANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES !!! 9. Cancer intractable pain plan of care CORRECT 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. ??????
10. Schizophrenia nursing diagnoses and interventions CORRECT 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
11. Grief process therapeutic response CORRECT ANSWER Allow the 5
steps of grieving (DABDA), active listening and offer a supportive presence
12. Dementia action refusing ADLs CORRECT ANSWER Encourage finger foods, distraction, speak therapeutically
13. Alcohol withdrawal CORRECT 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
14. Methadone overdose CORRECT ANSWER S&S= constricted pupils, resp. depression, circul. depression, LOC decreased
Give naloxone
15. Domestic violence screening tool CORRECT ANSWER - Don't probe, write evidence down verbatim, provide a safe environment
-Increase in violence during pregnancy
-Cycle of violence= tension building, violent, honeymoon
16. Aggression response CORRECT 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
1. Chemo Side Effects CORRECT ANSWER o Nausea/vomiting (24-48 hr., can be delayed up to 1 week)
2. Meningitis first step CORRECT ANSWER o Antibiotics - penicillin (ampicillin) AND cephalosporin
oCorticosteroids
3. Multiple sclerosis and urinary retention CORRECT ANSWER o Sensation of void heeded immediately (bed pan/urinal @ bedside)
oVoiding schedule (start 1/5-2hr then extend)
oDrink specific amt every 2 hour; urinate 30 min after w/ timer
oSelf-catherization
4. Acute renal failure priority CORRECT ANSWER o Maintain fluids o Avoid fluid excess
oRenal replacement therapy
oReduce metabolic rate
oPromote pulmonary function
5. Acute Respiratory distress priority findings CORRECT ANSWER o Hypoxia o Intercostal retractions
oCrackles
oBNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction)
6. End of life plan of care CORRECT 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
7. Cushing Syndrome CORRECT ANSWER o Can result from corticosteroids ***Attempt to reduce/taper medication while still treating underlying disease
oAlternate day therapy decrease symptoms and allows adrenal glands to recover 8. Valve replacement teaching CORRECT ANSWER o Anticoagulant therapy (frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios o Prevent infection
oANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES !!! 9. Cancer intractable pain plan of care CORRECT 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. ??????
10. Schizophrenia nursing diagnoses and interventions CORRECT 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
11. Grief process therapeutic response CORRECT ANSWER Allow the 5
steps of grieving (DABDA), active listening and offer a supportive presence
12. Dementia action refusing ADLs CORRECT ANSWER Encourage finger foods, distraction, speak therapeutically
13. Alcohol withdrawal CORRECT 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
14. Methadone overdose CORRECT ANSWER S&S= constricted pupils, resp. depression, circul. depression, LOC decreased
Give naloxone
15. Domestic violence screening tool CORRECT ANSWER - Don't probe, write evidence down verbatim, provide a safe environment
-Increase in violence during pregnancy
-Cycle of violence= tension building, violent, honeymoon
16. Aggression response CORRECT 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
