HESI Milestone 2 Questions And
Correct Answers
\.Broca's Area - Answer- Speech
The cortical area that is responsible for integrating the myriad pathways required for the
comprehension and formulation of language is called Broca area. It is located in a convolution
adjoining the middle cerebral artery. This area is responsible for control of the combinations of
muscular movements needed to speak each word.
\.Chemo Side Effects - Answer- Nausea
Vomiting
Myelosuppression
SIADH, decrease renal perfusion, precipitate end products after cell lysis, and cause interstitial
nephritis
Cardiac Toxicity
Testicular and ovarian function can be affected by chemotherapeutic agents, resulting in
possible sterility.
Chemotherapy-induced neurotoxicity, a potentially dose-limiting toxicity, can affect the central
nervous system, peripheral nervous system, and/or the cranial nerves
Chemo Brain:
Many patients with cancer experience difficulty with remembering dates, multitasking,
managing numbers and finances, organization, face or object recognition, inability to follow
directions, feeling easily distracted, and motor and behavioral changes.
Fatigue
\.Expressive Aphasia - Answer- Inability to express oneself
,\.Meningitis First Step - Answer- Broad Spectrum Antibiotics
\.Glaucoma Symptoms - Answer- The patient may not seek health care until he or she
experiences blurred vision or "halos" around lights, difficulty focusing, difficulty adjusting eyes
in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.
\.Assessments for Guillain Barre - Answer- The patient is monitored for life-threatening
complications (respiratory failure, cardiac dysrhythmias, VTE [including DVT or PE]) so that
appropriate intervention can be initiated. Because of the threat to the patient in this sudden,
potentially life-threatening disease, the nurse must assess the patient's and family's ability to
cope and their use of coping strategies.
Maintain respiratory function
Enhancing physical mobility
Promote adequate nutrition
Improving communication
Decreasing fear and anxiety
Managing potential complications
\.Multiple Sclerosis & Urinary Retention - Answer- A neurogenic bladder results in urinary
retention or leakage. The patient may describe a sensation of bladder fullness or incomplete
bladder emptying. The pharmacological treatment of urinary retention is administration of a
cholinergic agonist
From Google:
Many multiple sclerosis (MS) patients are affected by urinary retention. Common causes include
neurogenic underactive bladder and/or bladder outlet obstruction from detrusor sphincter
dyssynergia
\.Traction & Assessment
,(Blueprint- Fractured Femer Dim Pulses) - Answer- After skin traction is applied, the nurse
assesses circulation of the foot within 15 to 30 minutes and then every 1 to 2 hours. Circulatory
assessment consists of:
Peripheral pulses, color, capillary refill, and temperature of the fingers or toes.
Manifestations of deep vein thrombosis (DVT), which include unilateral calf tenderness,
warmth, redness, and swelling.
\.Compartment Syndrome - Answer- Diagnosis of compartment syndrome is based on clinical
suspicion, assessment of the 6 P's (pain, poikilothermia, pallor, paresthesia, pulselessness, and
paralysis)
\.Normal Sinus Rhythm - Answer- Electrical conduction that begins in the SA node generates
a sinus rhythm. Normal sinus rhythm occurs when the electrical impulse starts at a regular rate
and rhythm in the SA node and travels through the normal conduction pathway. Normal sinus
rhythm has the following characteristics:
· Ventricular and atrial rate: 60 to 100 bpm in the adult
· Ventricular and atrial rhythm: Regular
· QRS shape and duration: Usually normal, but may be regularly abnormal
· P wave: Normal and consistent shape; always in front of the QRS
· PR interval: Consistent interval between 0.12 and 0.20 seconds
· P:QRS ratio: 1:1
\.Valve Replacement Teaching - Answer- Patients who have undergone surgical valvuloplasty
or valve replacements are admitted to the ICU. Care focuses on recovery from anesthesia and
hemodynamic stability. Vital signs are assessed every 5 to 15 minutes and as needed. After the
patient has recovered from anesthesia and sedation, is hemodynamically stable without IV
medications, and has stable physical assessment parameters, he or she usually is transferred to
a telemetry unit, typically within 24 to 72 hours of surgery. The nurse educates the patient
about anticoagulant therapy, explaining the need for frequent follow-up appointments and
blood laboratory studies.
, \.Engorgement Teaching - Answer- Suggesting a sandwich technique to insert the mother's
breast into the newborn's mouth to elicit sucking might be helpful for the mother with large
breasts. In the sandwich technique, the mother is taught to grasp her breast by making a "C"
with her thumb and index finger. The thumb stabilizes the top of the breast while the remaining
four fingers support her breast from below. Massage or pumping the breast may soften and
extend the nipple for easier infant latch-on.
\.Rhogam Refusal - Answer- Jehovah's Witnesses and others who belong to religions
prohibiting the use of blood products should decide based on their conscience and possibly
ecclesiastical leaders about the use of RhoGAM. Nurses need to respect whatever the mother's
decision is.
\.24 Hour Jaundice - Answer- Physiologic jaundice is very common in newborns, with the
majority demonstrating yellowish skin, mucous membranes, and sclera within the first 3 days of
life.
Advise mothers to nurse their infants at least eight to 12 times per day for the first several days
\.Variable Decelerations - Answer- Variable decelerations present as visually apparent abrupt
decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly
demonstrating no consistent relationship to uterine contractions. Variable decelerations are
associated with cord compression
Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental
perfusion or relieve cord compression.
\.Normal Fetal Heart Rate - Answer- The normal baseline FHR ranges between 110 and 160
beats per minute (bpm)
\.IUGR What is it? & What are NST Results? - Answer- intrauterine growth restriction
Correct Answers
\.Broca's Area - Answer- Speech
The cortical area that is responsible for integrating the myriad pathways required for the
comprehension and formulation of language is called Broca area. It is located in a convolution
adjoining the middle cerebral artery. This area is responsible for control of the combinations of
muscular movements needed to speak each word.
\.Chemo Side Effects - Answer- Nausea
Vomiting
Myelosuppression
SIADH, decrease renal perfusion, precipitate end products after cell lysis, and cause interstitial
nephritis
Cardiac Toxicity
Testicular and ovarian function can be affected by chemotherapeutic agents, resulting in
possible sterility.
Chemotherapy-induced neurotoxicity, a potentially dose-limiting toxicity, can affect the central
nervous system, peripheral nervous system, and/or the cranial nerves
Chemo Brain:
Many patients with cancer experience difficulty with remembering dates, multitasking,
managing numbers and finances, organization, face or object recognition, inability to follow
directions, feeling easily distracted, and motor and behavioral changes.
Fatigue
\.Expressive Aphasia - Answer- Inability to express oneself
,\.Meningitis First Step - Answer- Broad Spectrum Antibiotics
\.Glaucoma Symptoms - Answer- The patient may not seek health care until he or she
experiences blurred vision or "halos" around lights, difficulty focusing, difficulty adjusting eyes
in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.
\.Assessments for Guillain Barre - Answer- The patient is monitored for life-threatening
complications (respiratory failure, cardiac dysrhythmias, VTE [including DVT or PE]) so that
appropriate intervention can be initiated. Because of the threat to the patient in this sudden,
potentially life-threatening disease, the nurse must assess the patient's and family's ability to
cope and their use of coping strategies.
Maintain respiratory function
Enhancing physical mobility
Promote adequate nutrition
Improving communication
Decreasing fear and anxiety
Managing potential complications
\.Multiple Sclerosis & Urinary Retention - Answer- A neurogenic bladder results in urinary
retention or leakage. The patient may describe a sensation of bladder fullness or incomplete
bladder emptying. The pharmacological treatment of urinary retention is administration of a
cholinergic agonist
From Google:
Many multiple sclerosis (MS) patients are affected by urinary retention. Common causes include
neurogenic underactive bladder and/or bladder outlet obstruction from detrusor sphincter
dyssynergia
\.Traction & Assessment
,(Blueprint- Fractured Femer Dim Pulses) - Answer- After skin traction is applied, the nurse
assesses circulation of the foot within 15 to 30 minutes and then every 1 to 2 hours. Circulatory
assessment consists of:
Peripheral pulses, color, capillary refill, and temperature of the fingers or toes.
Manifestations of deep vein thrombosis (DVT), which include unilateral calf tenderness,
warmth, redness, and swelling.
\.Compartment Syndrome - Answer- Diagnosis of compartment syndrome is based on clinical
suspicion, assessment of the 6 P's (pain, poikilothermia, pallor, paresthesia, pulselessness, and
paralysis)
\.Normal Sinus Rhythm - Answer- Electrical conduction that begins in the SA node generates
a sinus rhythm. Normal sinus rhythm occurs when the electrical impulse starts at a regular rate
and rhythm in the SA node and travels through the normal conduction pathway. Normal sinus
rhythm has the following characteristics:
· Ventricular and atrial rate: 60 to 100 bpm in the adult
· Ventricular and atrial rhythm: Regular
· QRS shape and duration: Usually normal, but may be regularly abnormal
· P wave: Normal and consistent shape; always in front of the QRS
· PR interval: Consistent interval between 0.12 and 0.20 seconds
· P:QRS ratio: 1:1
\.Valve Replacement Teaching - Answer- Patients who have undergone surgical valvuloplasty
or valve replacements are admitted to the ICU. Care focuses on recovery from anesthesia and
hemodynamic stability. Vital signs are assessed every 5 to 15 minutes and as needed. After the
patient has recovered from anesthesia and sedation, is hemodynamically stable without IV
medications, and has stable physical assessment parameters, he or she usually is transferred to
a telemetry unit, typically within 24 to 72 hours of surgery. The nurse educates the patient
about anticoagulant therapy, explaining the need for frequent follow-up appointments and
blood laboratory studies.
, \.Engorgement Teaching - Answer- Suggesting a sandwich technique to insert the mother's
breast into the newborn's mouth to elicit sucking might be helpful for the mother with large
breasts. In the sandwich technique, the mother is taught to grasp her breast by making a "C"
with her thumb and index finger. The thumb stabilizes the top of the breast while the remaining
four fingers support her breast from below. Massage or pumping the breast may soften and
extend the nipple for easier infant latch-on.
\.Rhogam Refusal - Answer- Jehovah's Witnesses and others who belong to religions
prohibiting the use of blood products should decide based on their conscience and possibly
ecclesiastical leaders about the use of RhoGAM. Nurses need to respect whatever the mother's
decision is.
\.24 Hour Jaundice - Answer- Physiologic jaundice is very common in newborns, with the
majority demonstrating yellowish skin, mucous membranes, and sclera within the first 3 days of
life.
Advise mothers to nurse their infants at least eight to 12 times per day for the first several days
\.Variable Decelerations - Answer- Variable decelerations present as visually apparent abrupt
decreases in FHR below baseline and have an unpredictable shape on the FHR baseline, possibly
demonstrating no consistent relationship to uterine contractions. Variable decelerations are
associated with cord compression
Turn the client on her left or right lateral, knee-chest, or hands and knees to increase placental
perfusion or relieve cord compression.
\.Normal Fetal Heart Rate - Answer- The normal baseline FHR ranges between 110 and 160
beats per minute (bpm)
\.IUGR What is it? & What are NST Results? - Answer- intrauterine growth restriction
