HESI MILESTONE 2 VERSION A BLUEPRINT with Actual Exam Hints from a Professor Latest Version Updated 2023 Graded A+

HESI MILESTONE 2 VERSION A BLUEPRINT with Actual Exam Hints from a
Professor Latest Version Updated 2023 Graded A+
1 / 35

1. 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.
2. 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.
3. 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.
4. Alzheimer’s hallucination-: Occurs in the late-middle to later stages of the
   disease process and is treated with antipsychotics such as Haldol
5. 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 accom-

HESI MILESTONE 2 VERSION A BLUEPRINT with Actual Exam Hints from a
Professor Latest Version Updated 2023 Graded A+
2 / 35
plished 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

1. Monitor vital signs, input and output (I&O), and electrolytes.
2. Observe for impending DTs.
3. Prevent aspiration; implement seizure precautions.
4. Reduce environmental stimuli.
5. Medicate with antianxiety medication, usually chlordiazepoxide (Librium) or
   lorazepam
   (Ativan)
6. Provide high-protein diet and adequate fluid intake (limit caffeine).
7. Provide vitamin supplements, especially vitamins B1 and B complex.
8. Provide emotional support.
9. Methadone-: Detoxification and maintenance therapy for opioid use disorder.
   Suppression of withdrawal symptoms during detox related to opioids such as
   heroin.
   It can cause respiratory depression.
   Do not give it to patients with acute or severe bronchial asthma.
   It is contraindicated for patients taking MAOIs.
   Methadone Overdose:
   A). Physical Assessment
   -Constricted pupils

• Respiratory depression leading to respiratory arrest
  -Circulatory depression leading to cardiac arrest
  -Unconsciousness leading to coma
  -Death
  B). General Appearance
  -General physical and mental deterioration
  -Rapid tolerance-overdose likely if not monitored.
  -Impaired judgment

1. Aggression response-: 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:

HESI MILESTONE 2 VERSION A BLUEPRINT with Actual Exam Hints from a
Professor Latest Version Updated 2023 Graded A+
3 / 35
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.

8. Duty to warn-: The obligation of a healthcare provider to warn third parties of
   potential threats or harm aimed at them by another individual.
9. Schizophrenia- treatment evaluation-: 1.) Clients should have decreased agitation, combativeness, and psychomotor activity.
   2.) Decreased psychotic behaviors such as decreased hallucinations and delusions.
10. 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
11. ADHD exam-: – Failure to listen/follow direction

• Difficulty playing quietly/sitting still
• Disruptive, impulsive behavior

HESI MILESTONE 2 VERSION A BLUEPRINT with Actual Exam Hints from a
Professor Latest Version Updated 2023 Graded A+
4 / 35

• Distractibility to external stimuli
• Excessive talking
• Shifting from one unfinished task to another.
• Underachievement in school performance

1. Obsessive compulsive disorder-Nursing Diagnosis: Nursing Diagnosis
   Ineffective Coping
   Inability to form a valid appraisal of the stressor
   Inadequate choices of practiced responses and/or
   Inability to use available resources.
   Nursing Assessment

• Recurring, intrusive thoughts and repetitive behaviors that interfere with normal
  functioning
  . Ambivalence regarding decisions or choices
• Disturbances in normal functioning due to obsessive thoughts or compulsive
  behaviors (loss of job, loss of/or alienation of family members, etc.)
• Inability to tolerate deviations from standards
• Rumination
• Low self-esteem
• Feelings of worthlessness
  . Lack of insight
  Nursing interventions
  A. Actively listen to the client’s obsessive themes.
  B. Acknowledge the effects that ritualistic acts have on the client.
  C. Demonstrate empathy.
  D.Avoid being judgmental.
  E. Provide for client’s physical needs.
  F.Allow performance of the compulsive activity with attention given to safety (e.g.,
  skin integrity of a hand washer).
  G. Explore meaning and purpose of the behavior with client.
  H. Avoid punishing and criticizing.
  I. Establish routine to avoid anxiety-producing changes.
  J. Assist client with learning alternative methods of dealing with stress.
  K. Avoid reinforcing compulsive behavior.
  L. Limit the amount of time for performance of ritual and encourage client to
  gradually decrease the time.
  M. Administer antianxiety medications as prescribed
  N. Administer SSRIs or tricyclic antidepressants as prescribed

1. Therapeutic communication abuse victim-: -Listen.
   -Believe what the person says.