Exam (elaborations)
HESI mid curricular Exam 2024 Questions & Answers ( A+ Graded 100% Verified)
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HESI mid curricular Exam 2024 Questions & Answers ( A+ Graded 100% Verified)
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HESI mid curricularnursing process - ANS assess
diagnose
outcome/planning
implement
evaluate
techniques of physical assessment - ANS inspection
palpation
percussion
auscultation
start physical assessment with - ANS 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 - ANS erythema - indicating
fever/inflammation
cyanosis - indicating O2 loss
jaundice - ^ bilirubin
pallor - low on blood
ecchymosis
petechiae
lesions
integumentary assessment - ANS palpate for temperature, moisture, turgor, edema
and inspect
adventitious breath sounds - ANS wheeze - high pitch indicating airway obstruction
crackles - bubbling on in/ex
stridor - harsh high pitch sound on inhale
rhonchi - sonorous , coarse low pitch
friction rub
extra heart sounds - ANS s3-normal in children
s4- normal in older adults
order to listen to heart sounds - ANS APETM
,aortic, pulmonic, erbs point, tricuspid, mitral
assessing the abdomen what order - ANS inspect
auscultate
percussion
palpate
bowel sounds should occur - ANS every 5-35 seconds
gurgling
if no sounds for 5 minutes = silent ileus
bruits - ANS abnormal bowel sound auscultated during abdominal assessment sounds like a
swishing noise and indicates obstruction
neurovascular assessment - ANS 6 P's
1. pain
2. pallor
3. peripheral pulses
4. paresthesia
5. paralysis
6. pressure
cranial nerve 5 - ANS trigeminal
-motor/sensation
CHEWING
cranial nerve 7 - ANS facial
SMILE
cranial nerve 9 - ANS glossopharyngeal
SWALLOWING
cranial nerve 12 - ANS tongue
STICK YOUR TONGUE OUT AT ME
when to assess VS - ANS 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 - ANS shivering
piloerection
, vasoconstriction
increased metabolism
heat losing measures the body takes - ANS sweating
vasodilation
increased respirations
jellinek curve - ANS 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 - ANS within 7-48 hours of last drink
CIWA-AR - ANS 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 - ANS - 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 - ANS 1. chemical laxatives (stimulate/irritate lining of
GI
2. bulk laxatives (causes feces to ^ in bulk by ^ water content)
3. lubricant (move more smoothly)
medications that cause diarrhea - ANS antibiotics
magnesium
medications that cause constipation - ANS opioids
antacids
iron sulfate
anticholinergics
GI bleed stool will be - ANS black if bleed is high in GI tract
red/pink if bleed is closer to rectum
chemical stimulant laxatives - ANS caster oil
cascara
senna
bisacodyl
-used to evacuate bowel for diagnostic procedures
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