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HESI Milestone #2 Exam Questions with correct Answers 2024( A+ GRADED 100% VERIFIED).
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HESI Milestone #2 Exam Questions with correct Answers 2024( A+ GRADED 100% VERIFIED).
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HESIMilestone
#2
-Chemo
Side
Effects
-
ANS
o
Nausea/vomiting
(24-48
hr,
can
be
delayed
up
to
1
week)
Meningitis
first
step
-
ANS
o
Antibiotics
-
penicillin
(ampicillin)
AND
cephalosporin
o
Corticosteroids
Multiple
sclerosis
and
urinary
retention
-
ANS
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-catheterization
Acute
renal
failure
priority
-
ANS
o
Maintain
fluids
o
Avoid
fluid
excess
o
Renal
replacement
therapy
o
Reduce
metabolic
rate
o
Promote
pulmonary
function
Acute
Respiratory
distress
priority
findings
-
ANS
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
-
ANS
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
-
ANS
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
-
ANS
o
Anticoagulant
therapy
(frequent
follow-up/lab
tests)
§
Pt
on
warfarin
has
specific
normal
ratios
o
Prevent
infection
o
ANTIBIOTIC
PROPHYLAXIS
FOR
DENTAL
PROCEDURES!!!
Cancer
intractable
pain
plan
of
care
-
ANS
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
-
ANS
-
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
-
ANS
Allow
the
5
steps
of
grieving
(DABDA),
active
listening
and
offer
a
supportive
presence
Dementia
action
refusing
ADLs
-
ANS
Encourage
finger
foods,
distraction,
speak
therapeutically
Alcohol
withdrawal
-
ANS
-
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
-
ANS
S&S=
constricted
pupils,
resp.
depression,
circul.
depression,
LOC
decreased
Give
naloxone
Domestic
violence
screening
tool
-
ANS
-
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
-
ANS
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
-
ANS
-
Engage
in
dialogue
to
prevent
escalation,
intervene
early
in
the
cycle
-
Approach
as
non
threatening,
calm
manner
and
convey
empathy
-
Encourage
the
client
to
express
their
anger,
build
trust,
anticipate
need
for
meds,
be
consistent
Medication
adverse
reactions
care
(schizophrenia)
-
ANS
Constipation
is
a
common
side
effect
of
anti
psych
meds,
polydipsia
occurs
after
years
of
treatment
Nurse
can
help
minimize
effects
of
delusions
with
distraction
techniques,
music,
tv,
writing
and
talking
to
friends,
positive
self-talk
and
positive
thinking
Self
care
Maslow
-
ANS
-
Physiologic,
safety,
love
and
belonging,
self
esteem,
self-actualization
-
Basic
drive
and
needs
that
motivate
people
Anxiety
Suicide
Risks:
-
ANS
Restless,
difficulty
concentrating,
irritability
-
"Have
you
had
any
suicidal
thoughts
since
starting
bupropion?"
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