Hesi milestone 2 actual exam 3 lastest version V1,v2,v3, Version

. -Chemo Side Effects - ANSo Nausea/vomiting (24-48 hr, can be delayed up to 1 week) 24 hour- Jaundice - ANSPhysiologic jaundice occurs from a normal reduction in red blood cells. Pathologic jaundice occurs within first 24 hours of life OR persists beyond 7 days A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is discharged. What nursing intervention is appropriate in addressing this behavior? - ANSDiscuss activities that don't involve food that can take place after discharge. Discuss the cookbooks with the treatment team, and if the treatment plan so indicates, take the books from the client. A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? - ANSMaking appropriate referrals ABG findings - ANSpH: 7.35 - 7.45 PCO2: 35 - 45 mmHg HCO3: 22 - 26 mmHg Acute Pancreatitis assessment - ANSHistory, ETOH abuse, severe LUQ pain, tachy, restless, decrease bowel, jaundice, grey turner or Cullen signs, increase serum amylase/lipase or WBC, hyperlipidemia Acute renal failure priority - ANSo Maintain fluids o Avoid fluid excess o Renal replacement therapy o Reduce metabolic rate o Promote pulmonary function Acute Respiratory distress priority findings - ANSo Hypoxia o Intercostal retractions o Crackles o BNP levels (alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction) Addison's Crisis Hypoglycemia S/S - ANS- weakness Hesi milestone 2 actual exam 3 lastest version V1,v2,v3, Version - fatigue - severe hypotension - nausea/vomiting - dehydration - dysrhythmias - shock ADHD Exam/Assessment - ANS- failure to listen/follow direction - difficulty playing quietly/sitting still - disruptive, impulsive behavior - distractibility to external stimuli - excessive talking - shifting from one unfinished task to another Aggression response - ANS5-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 Alcohol withdrawal - ANS- 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 Alcoholic hepatis teaching - ANS- low sodium diet - small frequent meals - no alcohol Anxiety Suicide Risks: - ANSRestless, difficulty concentrating, irritability - "Have you had any suicidal thoughts since starting bupropion?" Arterial Insufficency - ANS- mostly men - legs mostly affected arterial insufficiency symptoms - ANS-weak pedal pulses -shiny and cool skin -intermittent claudication - aching/cramping - induced fatigue Asthma Triggers: - ANSDust, mites, roaches, cloth, pets, horses, detergents, soaps, food, mold, pollens, seasonal Bizarre social behavior - ANS- assess physical needs, suicide risk, ensure safety at all time - sit w/ client, silence, tell when leaving - limit stimuli / 1-1 interaction Boggy Uterus Actions - ANS- massage and administer uterotonic to increase uterine contraction. - give oxytocin Cancer intractable pain plan of care - ANSo 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. ?????? Cardiomyopathy care plan - ANS○ Medications- digoxin, diuretics, antidysrhythmic, antihypertensive medications ○ Surgery- septal myectomy, septal ablation, implanted devices (CRT, ICD, LVAD, pacemaker), heart transplantation Chronic Kidney Disease = metabolic acidosis - ANSkidneys fail, no longer reabsorb HCO3 (bicarb), serum bicarbonate decrease = acidosis occurs ** sodium bicarb administration Cirrhosis ascites dyspnea- S/S - ANSencephalopathy portal hypertension esophageal varices hemorrhage Compartment Syndrome S/S - ANSPain Paresthesia Paralysis Pallor Pulse-lessness Hard/swollen Muscle *** avoid cold, DO NOT ELEVATE LIMB Complication Hypertension Risk - ANSElevated BUN = kidney dysfunction = associated with hypertension COPD oxygen therapy - ANS-Max of 3L via NC - low concentration are better!! - do not want pH to fall COPD Treatment - ANS- Smoking Cessation - Roflumilast (Daliresp) for severe COPD - bronchodilator or oxygen therapy, oral or IV corticosteroids. Cushing Syndrome - ANSo 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