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HESI MILESTONE 2 VERSION A BLUEPRINT 2025.pdf
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Schizophrenia care- Establish trust and rapport, encourage the client to talk with you, be consistent in setting expectations, explain the procedures and be certain the client understands, give positive feedback for the client successes, show empathy, do not be judgemental, never convey to the client that you accept their delusions as reality. Grief therapeutic response- Allow the 5 steps of grieving: Denial, Anger, Bargaining, Depression, and Acceptance (DABDA), active listening, and offering a supportive presence. Nursing Plans and Interventions: A. If needed, refer to grief counseling or a support group. B. Encourage activities that allow the individual to use past coping strategies to promote a feeling of self-worth and increased self-esteem. C. Encourage the individual to share his or her feelings. D. Encourage socialization with family peers and reminisce about significant life experiences. Delirium care- Know usual mental status and if changes noted are long-term, it probably represents dementia; if they are sudden/acute in onset, it is more likely to be delirium. Recognize and report symptoms immediately. Treatment of underlying causes is important - if untreated, it can lead to permanent, irreversible brain damage and death. The primary goals of nursing care for clients with delirium are: PROTECTION FROM INJURY, MANAGEMENT OF CONFUSION, AND MEETING PHYSIOLOGICAL AND PSYCHOLOGICAL NEEDS.
Ensure patient safety (fall risk) and manage behavioral problems. Alert the prescriber of nonessential medications. Nutritional and fluid intake must be monitored. A quiet and calm environment. Encourage visitors to touch and talk to patients. Assess/manage pain. Alzheimer's hallucination- Occurs in the late-middle to later stages of the disease process and is treated with antipsychotics such as Haldol Alcohol withdrawal- Symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. Symptoms include coarse hand tremors, sweating, elevated pulse, and blood pressure, insomnia, anxiety, and nausea or vomiting. Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium, called delirium tremors. Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however, and withdrawal may take 1 to 2 weeks. Safe withdrawal is usually accomplished with the administration of benzodiazepines, such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium), to suppress the withdrawal symptoms. Nursing Plans and Interventions A. Maintain safety, nutrition, hygiene, and rest. B. Obtain a BAL on admission or when a client appears intoxicated after admission. C. Implement suicide precautions if assessment indicates risk. D. In general
The nurse must protect others from these clients' manipulative or aggressive behaviors. At the beginning of treatment, he or she must set limits on unacceptable behavior. The limit setting involves the following three steps: Inform clients of the rule or limits. Explain the consequences if clients exceed the limit. State expected behavior. Nursing Plans and Interventions: Conduct and Defiant Disorders A. Assess verbal and nonverbal cues for escalating behavior so as to decrease outbursts. B. Use a nonauthoritarian approach. C. Avoid asking "why" questions. D. Initiate a "show of force" with a child who is out of control. E. Use a "quiet room" when external control is needed. F. Clarify expressions or jargon if meanings are unclear. G. Teach to redirect angry feelings to safe alternative, such as a pillow or punching bag. H. Implement behavior modification therapy if indicated. I. Role-play new coping strategies with client. Duty to warn- The obligation of a healthcare provider to warn third parties of potential threats or harm aimed at them by another individual. Schizophrenia- treatment evaluation- 1.) Clients should have decreased agitation, combativeness, and psychomotor activity. 2.) Decreased psychotic behaviors such as decreased hallucinations and delusions. Anxiety drugs risk-
Most of these drugs are benzodiazepines, which are commonly prescribed for anxiety. Benzodiazepines have a high potential for abuse and dependence, so their use should be short-term, ideally no longer than 4 to 6 weeks. One chief problem encountered with benzodiazepines is their tendency to cause physical dependence. Significant discontinuation symptoms occur when the drug is stopped; these symptoms often resemble the original symptoms for which the client sought treatment. This is especially a problem for clients with long-term benzodiazepine use, such as those with panic or generalized anxiety disorder. I am 100% convinced that this is the fact that three weeks after starting an anxiolytic, a patient is at a significantly higher risk of suicide due to increased energy and not wanting to go back to feeling anxious or depressed. It's mentioned both in Realize It and in the HESI prep ADHD exam-
Therapeutic communication abuse victim-
D. Determine the availability of the method chosen. If the method is readily available, the attempt is more likely. Example: The client has a loaded shotgun in the bedroom, so it is readily available. Appendicitis pre op prep- The nurse prepares the patient for surgery, which includes
F. Assess for headache, edema, nocturia, nosebleeds, and vision changes (may be asymptomatic). G. Assess stress level and source (related to job, economics, family). H. Assess personality type (i.e., determine whether client exhibits perfectionist behavior). HESI Hint Remember the risk factors for HTN: heredity, race, age, alcohol abuse, increased salt intake, obesity, and use of oral contraceptives. Hypothyroidism-
vi. Weakness vii. Hepatomegaly i. Ascites Small bowel obstruction actions- Nursing interventions:
area, causing interstitial overhydration; may also be seen with ascites and third-spacing. Hypertonic solutions a. 5% dextrose in lactated Ringer’s (D5LR) b. 5% dextrose in 0.45% saline c. 5% dextrose in 0.9% saline (D5NS) d. 3% Na e. 5% NaCl f. 10% dextrose in water (D10W) g. 20% Dextrose in water (20W) acts as osmotic diuretic h. 50% Dextrose in water (50% DW) Rheumatoid arthritis diagnosis- A doctor will use blood tests, X-rays, and ultrasound to determine if you have RA. The goal of treatment at all phases of the RA disease process is to
C. Hot shower in the morning
Symptoms a. Tenderness b. Distension c. Rigidity d. Anorexia e. N/V f. Fever Asthma triggers - Airway irritants (air pollutants, occupational exposure); Food (shellfish, nut); hormonal factors; medications; viral respiratory tract infections. A. Infections like sinusitis, colds, and the flu. B. Allergens such as pollens, mold, pet dander, and dust mites. C. Cockroaches D. Irritants like strong odors from perfumes or cleaning solutions E. Air pollution F. Tobacco smoke G. Exercise H. Cold air or changes in the weather, such as temperature or humidity. I. Gastroesophageal reflux disease (GERD) J. Strong emotions such as anxiety, laughter, sadness, or stress Ulcerative colitis symptoms- The predominant symptoms of ulcerative colitis include diarrhea, with the passage of mucus, pus, or blood; left lower quadrant abdominal pain; and intermittent tenesmus. The bleeding may be mild or severe, and pallor, anemia, and fatigue result. The patient may have anorexia, weight loss, fever, vomiting, dehydration, cramping, and the passage of six or more liquid stools daily. Nursing Assessment
A. Diarrhea B. Abdominal pain and cramping C. Intermittent tenesmus (anal contractions) and rectal bleeding D. Liquid stools containing blood, mucus, and pus (may pass 10 to 20 liquid stools per day) E. Weakness and fatigue F. Anemia (I don't see how this question can be anything other than the fact that UC has bloody diarrhea associated with it) Arterial insufficiency diabetic - Diabetes affects the lining around cells in the blood vessels. Blood vessels are not as flexible as needed to help blood flow smoothly. PAD happens when buildup on the walls of blood vessels causes narrowing, commonly affecting diabetics prone to hyperlipidemia and heart disease. Nursing Interventions A. Monitor extremities at designated intervals.