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Milestone HESI Retake Questions and
Correct Answers
Levels of Health Promotion - ✔ primary, secondary, tertiary Application Examples of Levels of Promotion - ✔ primary- weight loss, diet, smoking cessation Secondary- papsmears, mammograms, testicular exams Tertiary- medication therapy, surgical treatment, physical therapy, teaching foot care education to diabetic care Primary - ✔ promotes health and preventing development of disease process or injury Secondary - ✔ screening for early detection of disease Tertiary - ✔ begins after illness is diagnosed and treatment. Aims to prevent long- term consequences of chronic illnesses or disabilities Nursing Assessments - ✔ Comprehensive- (Head to Toe) = Can be done inpatient and through primary care (Physical assessment- annual exam) Focused- Health and physical hx of specific problem.- ex. Sick visit Emergency- crisis, life threatening. ex. airway, breathing, injury, disability, exposure, med reconciliation Phases of Interview process - ✔ Pre-interaction, beginning, working (open and close ended questions), closing
Data sources - ✔ Primary- individual patient Secondary- chart info, family members Purposes of Documentation - ✔ verbal communication, SBAR, written document Lifespan Nutritional Considerations - Nutrition: Pregnant Women - ✔ need additional 300 - 500 cal/day (whole foods Lifespan Nutritional Considerations - Nutrition: infants/children - ✔ infants/children: whole milk for ages 2-5 fat intake-brain development Lifespan Nutritional Considerations - Nutrition: Older - ✔ BMR declines, Vitamin D supplements, Problems: decreased thirst, increase risk for osteoarthritis, osteoporosis, dementia, obesity, social isolation General Survey - ✔ mental note of overall health (hygiene/appearance). Assessing pain: documentation, OLDCARTS/OPQRST. Aggravating and alleviating factors, pain goal and funtional goal Assessing Pain - Documentation - ✔ Acute vs. Chronic-Location Priority - ✔ Priority pain: stones (kidney, gallbladder, calcium and/or struvite), myocardial infarcation (HA), burns and sickle cell Heart Rate Elevated - ✔ above 100 beats per minute Blood Pressure- Normal - ✔ above systolic- 120 - 129, diastolic- less than 80, Blood Pressure- elevated - ✔ Hypertension: Stage 1: 130-139 or 80-89, Stage Hypertension 2: more than 140, or greater than or equal to 90
instrument sound MULTIPLE sounds- mainly heard in expiration CONDITION: PNEUMONIA abnormal lung sounds: stridor - ✔ airway obstruction, high pitch whispering or gas (CROUP, EMERGENCY, EPIGLOTTIS) Abnormal lung sounds: Crackles - ✔ coarse(low pitch, wet sound) fine (high pitch, doesnt clear w/cough, crackling of fire sound) CONDITION:RESPIRATORY EDEMA/OBSTRUCTIVE DISEASE Abnormal lung sounds: Pleural Friction Rub - ✔ Pleural friction rub (low pitch, harsh grating sound) Assessment of the Respiratory System - ✔ tachypnea- rapid breathing bradypnea- slow breathing Normally, respirations are quiet and nonlabored, and occur at a rate of 12 to 20 times each minute in healthy adults. Note any flaring of the nostrils, muscular retractions, Heart Function System - ✔ Abnormal size or location of the PMI or the presence of vibrations can indicate heart failure, myocardial infarction, disease of the heart valves, or other cardiac diseases. Abdominal Assessment - ✔ Inspect, auscultate, percussion, and palpate. Nurse assess lumps, masses or tenderness Musculoskeletal System - Pronation & Supination - ✔ prone- plank (face downward), supine- on the back, Disorder: osteoporosis- break down of bone (weight bearing activity is encouraged) Secondary osteoporosis- steroids' aka bones porous and bone prone to fractures
Compression fracture- changing position slowly, tenderness of palpitation of spine, in pain Neuro Assessment- Cranial Nerves - ✔ Olfactory (smell),Cranial Nerve 2: optic, cranial nerve 3: oculomotor, cranial nerve 4: Trochlear, cranial nerve 5: Trigeminal nerve, Cranial nerve 6: abducens cranial nerve 7: facial nerve cranial nerve 8: acoustic, cranial nerve 9: Glossopharyngeal cranial nerve 10: vagus cranial nerve 11: accessory cranial nerve 12: hypoglossal Full Description - ✔ (Cranial Nerve 1: Olfactory (smell),Cranial Nerve 2: confrontational field (cover up eye in fields in all fields) and visual acuity (Snellen Chart) reading at 20 feet from the chart. Cranial Nerve III: oculomotor- nystagmus- moving penlight in 6 cardinal fields of gaze, Cranial nerve IV: Trochlear: assess pupil constriction (normal: 3-5 mm), PERRLA and Cranial nerve VI: Abducens , Cranial nerve 5: Trigeminal nerve- mastification (feel temporal and masseter muscle)open and close mouth against resistance, cranial nerve 7: facial nerve (open and close eyes, frown, smile, Cranial nerve 8: occlude ears and whisper word and pt repeat, Cranial nerve 9: Glossopharyngeal-test gag reflex, vagus nerve- pt able to speak and swallow, cranial nerve 11- accessory- shrug shoulders w/ease, Hypoglossal: pt moves tongue from side to side Confusion Causes - ✔ underlying infections, dehydration, electrolyte imbalances Preventive Screening and Symptom Assessment - Tools & Uses - ✔ Braden pressure ulcer scale (Sensory perception, moisture, activity, mobility, nutrition, friction and shear), fall risk assessment Heart Sounds - Technique & Representation of Sounds - ✔ S1- louder than S2 S1- "lub", S2- "dub"= Systole S3- "dub", S4- "lub" = diastole
