HESI MILESTONE #2QUESTIONS AND CORRECT
DETAILED ANSWERS AGRADE
RATED
A nurse is preparing a client for the termination phase of the nurse-client relationship.The nurse prepares to implement which nursing task appropriate for this phase? - ANSWER✔✔Making appropriate referrals Which features are prominent in anorexia nervosa? - ANSWER✔✔-Amenorrhea for three cycles -Perfectionism -Powerlessness -Rigid food rituals Describe the clinical symptoms of anorexia nervosa: - ANSWER✔✔Weight loss of at least 15% of ideal or original body weight; hair loss; dry skin; irregular heart rate; decreased pulse; decreased BP; amenorrhea; dehydration; electrolyte imbalance A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is discharged. What nursing intervention is appropriate in addressing this behavior? - ANSWER✔✔Discuss activities that don't involve food that can take place after discharge. Discuss the cookbooks with the treatment team, and if the treatment plan so indicates, take the books from the client.Bizarre social behavior - ANSWER✔✔- assess physical needs, suicide risk, ensure safety at all time 1 / 3
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
Complication Hypertension Risk - ANSWER✔✔Elevated BUN = kidney dysfunction = associated with hypertension The nurse is reviewing blood pressure readings for a group of client's on a medical unit.Which client is at the highest risk for complications related to hypertension? - ANSWER ✔✔B. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL Hypothyroidism - Sleep/ Depression - ANSWER✔✔- Depression can result from untreated hypo
- falling/staying asleep difficult = avoid sedation
- frequent rest but stay action
Diverticulosis S/S - ANSWER✔✔LLQ abdominal pain (descending/sigmoid colon) Bloating Fever Nausea/Vomiting Constipation alt. w/ diarrhea Anorexia 2 / 3
Gout Medication- Allopurinol - ANSWER✔✔- bone marrow depression, vomiting, abd.pain
- avoid starting/increasing med during active flare up
- AFTER MEALS!
Gout Medication- Allopurinol teaching - ANSWER✔✔- avoid alcohol
- purine-rich foods (red meat/shellfish/fructose drinks)
- increase fluids
- reduce stress
Diabetes Mellitus- Poor compliance - ANSWER✔✔- The patient may use a urine dipstick (Ketostix or Chemstrip uK) to detect ketonuria. The reagent pad on the strip turns purple when ketones are present. → unmanaged diabetes or control over DM is deteriorating
DKA: complication of type 1 diabetes, serum glucose >250, ketonuria in large amounts Left-Sided Heart Failure - ANSWER✔✔(Left is LUNG) congestion, dyspnea, crackles, fatigue, pink/frothy sputum Right-Sided Heart Failure - ANSWER✔✔(Systemic) congestion, peripheral edema, ascities, jugular vein distention, hepatomegaly Osteoarthritis Exercise - ANSWER✔✔- Use correct posture/body mechanics, use of assistive devices, walking, physical therapy, strength training, yoga, tai chi.
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