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HESI Milestone Retake 48 Questions
and Answers Latest Study Guide Latest
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
When should BP be taken? - ✔️ after patient rests for 5 minutues or 30 minutes after caffeine, smoking
Assessment of the Head and Neck - ✔️ Inspect, palpate, auscultate
Infection - ✔️ If nodes are palpable, warm, tender = infection
✔️ 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
Murmur - ✔️ Murmur- blowing or swooshing sound due to cardio or circulatory disturbance. Ex. anemia, pregnancy
Adults - ✔️ aortic stenosis, mitral insufficiency
Abdominal Assessment - ✔️ Inspect, auscultate, percuss, palpate. Feel for lumps, masses or tenderness
Pronation - ✔️ plank (face downward
Supination - ✔️ on the back
Musculoskeletal System Disorder - ✔️ osteoporosis- break down of bone (weight bearing activity is encouraged
Secondary osteoporosis - ✔️ steroids' aka bones porous and prone to fractures
Compression fracture - ✔️ changing position slowly, tenderness of palpitation of spine, in pain
Muscle Spasticity - ✔️ involuntary contraction of muscle. painful or tightening of muscle. muscle strength 5/5 with no pain, spasms or contractions
