HESI MID CURRICULAR EXAM
if the nurse suspects abuse (child vs adult) - ANSWERS-legally
responsible to report all suspected cases of child abuse.
if in adult then it is the adults decision and the nurse must support
decision but document objective assessment data and clients words
indicators of child abuse (top 3) and interventions - ANSWERS-1.
injuries not congruent with developmental age/skills
2. injury not congruent with story
3. delay in seeking medical care
Nx:
-report
-take color pictures
-document objective statements
Alcohol withdrawal sx - ANSWERS-Anxiety
Nausea
Tremors
Hyperalertness
Restlessness
^VS
Delirium Tremens (12-36 hours After last drink)
,Tx:
—seizure precautions (greatest risk 48-72 hours)
—high protein diet/B vitamins(malnourished)
—fluids (dehydrates)
—reduce stimuli
—monitor I/O's; VS; electrolytes
Disulfiram (Antabuse) - ANSWERS-Tx alcoholism causing straight
to hungover effect if alcohol consumed (severe side effects) used as a
deterrent
If they consume alcohol with this:
-N/V
-rapid pulse /RR
-flushed face/blood shot eyes
-hypotension
-confusion
-can die
ED:
—inhalation of paint fumes could cause reaction; no cough medicine
—sx of reaction if alcohol consumed
What basic needs take priority when working with chemically
dependent clients ? - ANSWERS-nutrition is a priority, alcohol and
drug intake has superseded the intake of food for these clients
,Nursing interventions for delusional client - ANSWERS--encourage
recognition of distorted reality
-do not agree with or support the delusion
-change focus from delusion to reality; do not permit rumination on
false ideas
-be matter-of-fact
Nursing interventions for hallucinating client - ANSWERS--protect
from injury that might result from command hallucinations
-pay attention to content
-don't argue or deny hallucination
-discuss your observations (I see ___)
Echolalia - ANSWERS-Constantly repeating what is heard
Neologism - ANSWERS-Creating new words
Blueler's 4 A's of Schizophrenia - ANSWERS-Autism (preoccupied
with self)
Affect (flat)
Associations (loose)
Ambivalence (difficulty making decisions)
Valproic Acid (Depakote) - ANSWERS-Tx bipolar (can use with
lithium)
, Admin with food
Monitor blood levels (therapeutic = 50-125)
Monitor for A/E (GI distress, N/V, hepatotoxicity, tremor, sedation)
Carbamazepine (Tegretol) - ANSWERS-Tx bipolar (alternative to
lithium)
Monitor serum level (8-12)
W/hold if WBC count <3000
Monitor CBC and hepatic/renal function
Lamotrigine (Lamictal) - ANSWERS-Anticonvulsant Tx bipolar
A/E =
Stevens Johnson syndrome
HA
Dizzy/double vision
Activities appropriate for a manic client - ANSWERS-Non-
competitive physical activities that require large muscle groups
An important nursing intervention for a depressed client is -
ANSWERS-To sit quietly with the client offering support with your
presence
Common side effects of anti anxiety meds - ANSWERS-Sedation and
drowsiness
if the nurse suspects abuse (child vs adult) - ANSWERS-legally
responsible to report all suspected cases of child abuse.
if in adult then it is the adults decision and the nurse must support
decision but document objective assessment data and clients words
indicators of child abuse (top 3) and interventions - ANSWERS-1.
injuries not congruent with developmental age/skills
2. injury not congruent with story
3. delay in seeking medical care
Nx:
-report
-take color pictures
-document objective statements
Alcohol withdrawal sx - ANSWERS-Anxiety
Nausea
Tremors
Hyperalertness
Restlessness
^VS
Delirium Tremens (12-36 hours After last drink)
,Tx:
—seizure precautions (greatest risk 48-72 hours)
—high protein diet/B vitamins(malnourished)
—fluids (dehydrates)
—reduce stimuli
—monitor I/O's; VS; electrolytes
Disulfiram (Antabuse) - ANSWERS-Tx alcoholism causing straight
to hungover effect if alcohol consumed (severe side effects) used as a
deterrent
If they consume alcohol with this:
-N/V
-rapid pulse /RR
-flushed face/blood shot eyes
-hypotension
-confusion
-can die
ED:
—inhalation of paint fumes could cause reaction; no cough medicine
—sx of reaction if alcohol consumed
What basic needs take priority when working with chemically
dependent clients ? - ANSWERS-nutrition is a priority, alcohol and
drug intake has superseded the intake of food for these clients
,Nursing interventions for delusional client - ANSWERS--encourage
recognition of distorted reality
-do not agree with or support the delusion
-change focus from delusion to reality; do not permit rumination on
false ideas
-be matter-of-fact
Nursing interventions for hallucinating client - ANSWERS--protect
from injury that might result from command hallucinations
-pay attention to content
-don't argue or deny hallucination
-discuss your observations (I see ___)
Echolalia - ANSWERS-Constantly repeating what is heard
Neologism - ANSWERS-Creating new words
Blueler's 4 A's of Schizophrenia - ANSWERS-Autism (preoccupied
with self)
Affect (flat)
Associations (loose)
Ambivalence (difficulty making decisions)
Valproic Acid (Depakote) - ANSWERS-Tx bipolar (can use with
lithium)
, Admin with food
Monitor blood levels (therapeutic = 50-125)
Monitor for A/E (GI distress, N/V, hepatotoxicity, tremor, sedation)
Carbamazepine (Tegretol) - ANSWERS-Tx bipolar (alternative to
lithium)
Monitor serum level (8-12)
W/hold if WBC count <3000
Monitor CBC and hepatic/renal function
Lamotrigine (Lamictal) - ANSWERS-Anticonvulsant Tx bipolar
A/E =
Stevens Johnson syndrome
HA
Dizzy/double vision
Activities appropriate for a manic client - ANSWERS-Non-
competitive physical activities that require large muscle groups
An important nursing intervention for a depressed client is -
ANSWERS-To sit quietly with the client offering support with your
presence
Common side effects of anti anxiety meds - ANSWERS-Sedation and
drowsiness
