HESI Mid Curricular – A+ Questions and 100% Graded Answers
Nursing process - CORRECT ANSWER-assess
diagnose
outcome/planning
implement
evaluate
techniques of physical assessment - CORRECT ANSWER-inspection
palpation
percussion
auscultation
start physical assessment with - CORRECT ANSWER-general survey assess for
-appearance
-behavior
-height/weight/BMI
-nutritional status
-waist circumference which can indicate obesity
when assessing the integumentary system you are looking for - CORRECT ANSWER-erythema
- indicating fever/inflammation
cyanosis - indicating O2 loss
jaundice - ^ billiruben
pallor - low on blood
ecchymosis
petechiae
lesions
integumentary assessment - CORRECT ANSWER-palpate for temperature, moisture, turgor,
edema
and inspect
adventitious breath sounds - CORRECT ANSWER-wheeze - high pitch indicating airway
obstruction
crackles - bubbling on in/ex
stridor - harsh high pitch sound on inhale
ronchi - sonourus , coarse low pitch
friction rub
extra heart sounds - CORRECT ANSWER-s3-normal in children
s4- normal in older adults
order to listen to heart sounds - CORRECT ANSWER-APETM
aortic, pulmonic, erbs point, tricuspid, mitral
assessing the abdomen what order - CORRECT ANSWER-inspect
auscultate
percussion
palpate
bowel sounds should occur - CORRECT ANSWER-every 5-35 seconds
gurgling
if no sounds for 5 minutes = silent ileus
, bruits - CORRECT ANSWER-abnormal bowel sound auscultated during abdominal assessment
sounds like a swishing noise and indicates obstruction
neurovascular assessment - CORRECT ANSWER-6 P's
1. pain
2. pallor
3. peripheral pulses
4. paresthesia
5. paralysis
6. pressure
cranial nerve 5 - CORRECT ANSWER-trigeminal
-motor/sensation
CHEWING
cranial nerve 7 - CORRECT ANSWER-facial
SMILE
cranial nerve 9 - CORRECT ANSWER-glossopharyngeal
SWALLOWING
cranial nerve 12 - CORRECT ANSWER-tongue
STICK YOUR TONGUE OUT AT ME
when to assess VS - CORRECT ANSWER-on admission
based on policy
with CHANGE in condition
loss of consciousness
before/after invasive procedure
before/after med admin
heat production measures the body takes - CORRECT ANSWER-shivering
piloerection
vasoconstriction
increased metabolism
heat losing measures the body takes - CORRECT ANSWER-sweating
vasodilation
increased respirations
jellinek curve - CORRECT ANSWER-phase 1 - pre alcoholic - using to relieve every day stress
phase 2 - early alcoholic - blackouts/needs it, secretive about it gulps 1st drink
phase 3 - crucial phase - lost control and gets defensive
phase 4 - chronic phase -
greatest risk for seizures in alcohol withdrawal is - CORRECT ANSWER-within 7-48 hours of
last drink
CIWA-AR - CORRECT ANSWER-monitors pt response to tx; determines need for medication,
prevents seizures. use ciwa-ar every 2 hours then 4 hours
alcoholism medications that promote sobriety - CORRECT ANSWER-- Disulfiram (antabuse) -
causes severe neg. reaction to alcohol can lead to death even if only around paint fumes.
-Naltrexone (ReVia) - reduces cravings by blocking the effects of alcohol PRN or monthly inj.
-acamprosate (campral) - reduces want/craving can't be used for pt with renal failure (2 tab
3x/day)
3 groups of laxatives and their functions - CORRECT ANSWER-1. chemical laxatives
(stimulate/irritate lining of GI
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