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Exam (elaborations)

HESI Milestone 2 Questions And Answers Well Illustrated.

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HESI Milestone 2 Questions And Answers Well Illustrated. -Chemo Side Effects - correct answer.o Nausea/vomiting (24-48 hr, can be delayed up to 1 week) Meningitis first step - correct answer.o Antibiotics - penicillin (ampicillin) AND cephalosporin o Corticosteroids Multiple scl...

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  • September 14, 2024
  • 14
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • HESI Milestone
  • HESI Milestone
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HESI Milestone 2 Questions And Answers
Well Illustrated.


-Chemo Side Effects - correct answer.o Nausea/vomiting (24-48 hr, can be delayed up
to 1 week)

Meningitis first step - correct answer.o Antibiotics - penicillin (ampicillin) AND
cephalosporin
o Corticosteroids

Multiple sclerosis and urinary retention - correct answer.o Sensation of void heeded
immediately (bed pan/urinal @ bedside)
o Voiding schedule (start 1/5-2hr then extend)
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
o Self-catherization

Acute renal failure priority - correct 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 - correct answer.o Hypoxia
o Intercostal retractions
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 - correct answer.o Signs and symptoms of impending death are
recognized and communicated in developmentally 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 - correct 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 - correct 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 - correct answer.o Pain, other symptoms and side
effects are managed based on the best available evidence, with attention to disease-
specific pain and symptoms, which are skillfully and systematically applied. ??????

Schizophrenia nursing diagnoses and interventions - correct answer.- Dx: 2 or more
S&S for over 6 mo (Positive= delusions, hallucinations, 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 antipsych

Grief process therapeutic response - correct answer.Allow the 5 steps of grieving
(DABDA), active listening and offer a supportive presence

Dementia action refusing ADLs - correct answer.Encourage finger foods, distraction,
speak therapeutically

Alcohol withdrawal - correct 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 - correct answer.S&S= constricted pupils, resp. depression,
circul. depression, LOC decreased

Give naloxone

Domestic violence screening tool - correct answer.- Don't probe, write evidence down
verbatim, provide a safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon

Aggression response - correct answer.5-phase cycle= Triggering (event), Escalation
(movement toward a loss of control), Crisis (loss of control), Recovery (regain control),
Postcrisis (reconciliation)

***Hx = likely to occur again

Violence handling - correct answer.- Engage in dialogue to prevent escalation,
intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy

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