HESI Milestone Version 3 Retake Exam with Complete Solutions

HESI Milestone Version 3 Retake Exam with Complete Solutions Levels of Health Promotion - Correct Answer-primary, secondary, tertiary Application Examples of Levels of Promotion - Correct Answer-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 - Correct Answer-promotes health and preventing development of disease process or injury Secondary - Correct Answer-screening for early detection of disease Tertiary - Correct Answer-begins after illness is diagnosed and treatment. Aims to prevent long-term consequences of chronic illnesses or disabilities Nursing Assessments - Correct Answer-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 - Correct Answer-Pre-interaction, beginning, working (open and close ended questions), closing Data sources - Correct Answer-Primary- individual patient Secondary- chart info, family members Purposes of Documentation - Correct Answer-verbal communication, SBAR, written document Lifespan Nutritional Considerations - Nutrition: Pregnant Women - Correct Answer-need additional 300-500 cal/day (whole foods Lifespan Nutritional Considerations - Nutrition: infants/children - Correct Answerinfants/children: whole milk for ages 2-5 fat intake-brain development Lifespan Nutritional Considerations - Nutrition: Older - Correct Answer-BMR declines, Vitamin D supplements, Problems: decreased thirst, increase risk for osteoarthritis, osteoporosis, dementia, obesity, social isolation General Survey - Correct Answer-mental note of overall health (hygiene/appearance). Assessing pain: documentation, OLDCARTS/OPQRST. Aggravating and alleviating factors, pain goal and funtional goal Assessing Pain - Documentation - Correct Answer-Acute vs. Chronic-Location Priority - Correct Answer-Priority pain: stones (kidney, gallbladder, calcium and/or struvite), myocardial infarcation (HA), burns and sickle cell Heart Rate Elevated - Correct Answer-above 100 beats per minute Blood Pressure- Normal - Correct Answer-above systolic- 120-129, diastolic- less than 80, Blood Pressure- elevated - Correct Answer-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? - Correct Answer-after patient rests for 5 minutues or 30 minutes after caffeine, smoking Assessment of the Head and Neck - Correct Answer-Inspect, palpate, auscultate Infection - Correct Answer-If nodes are palpable, warm, tender = infection Assessment of the Ear - Techniques - Correct Answer-Adults: up and back Children: down and back Assessment of the Ear - Techniques Part 2 - Correct Answer-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 - Correct Answer-inspect, palpate, percuss, auscultate Assessing Lung Sounds - Technique - Correct Answer-IPPA- inspect, palpate, percuss, auscultate Normal Lung Sounds - Correct Answer-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)