HESI Milestone #2 ACTUAL EXAM 3 LATEST VERSIONS (V1, V2 AND V3) EACH VERSION CONTAINS 100 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED A+ Acute renal failure priority - ✔✔✔ ANSWER -✔✔✔ o Maintain fluids o Avoid fluid excess o Renal replacement therapy o Reduce metabolic rate o Promote pulmonary function Acute Respiratory distress priority findings - ✔✔✔ ANSWER -✔✔✔ o Hypoxia o Intercostal retract ions o Crackles o BNP levels (alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction) End of life plan of care - ✔✔✔ ANSWER -✔✔✔ o Signs and symptoms of impending death are recognized and communicated in deve lopmentally 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 Cushing Syndrome - ✔✔✔ ANSWER -✔✔✔ o 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 Valve replacement teaching - ✔✔✔ ANSWER -✔✔✔ o Anticoagulant therapy (frequent follow -up/lab tests) § Pt on warfarin has specific normal ratios o Prevent infection o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!! Cancer intractable pain plan of care - ✔✔✔ ANSWER -✔✔✔ o Pain, other symptoms and side effects are managed based on the best avail able evidence, with attention to disease -specific pain and symptoms, which are skillfully and systematically applied. ?????? Schizophrenia nursing diagnoses and interventions - ✔✔✔ ANSWER -
✔✔✔ - Dx: 2 or more S&S for over 6 mo (Positive= delusions, hallucina tions, 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 antip sych Grief process therapeutic response - ✔✔✔ ANSWER -✔✔✔ Allow the 5 steps of grieving (DABDA), active listening and offer a supportive presence Dementia action refusing ADLs - ✔✔✔ ANSWER -✔✔✔ Encourage finger foods, distraction, speak therapeutically Alcohol with drawal - ✔✔✔ 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 Methadone overdose - ✔✔✔ ANSWER -✔✔✔ S&S= constricted pupils, resp. depression, circul. depression, LOC decreased Give naloxone Domestic violence screening tool - ✔✔✔ ANSWER -✔✔✔ - Don't probe, write evidence down verbatim, provide a safe environment - Increase in violence during pregnancy
✔✔✔ - Dx: 2 or more S&S for over 6 mo (Positive= delusions, hallucina tions, 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 antip sych Grief process therapeutic response - ✔✔✔ ANSWER -✔✔✔ Allow the 5 steps of grieving (DABDA), active listening and offer a supportive presence Dementia action refusing ADLs - ✔✔✔ ANSWER -✔✔✔ Encourage finger foods, distraction, speak therapeutically Alcohol with drawal - ✔✔✔ 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 Methadone overdose - ✔✔✔ ANSWER -✔✔✔ S&S= constricted pupils, resp. depression, circul. depression, LOC decreased Give naloxone Domestic violence screening tool - ✔✔✔ ANSWER -✔✔✔ - Don't probe, write evidence down verbatim, provide a safe environment - Increase in violence during pregnancy
