HESI Milestone Version 3 Retake Exam
with Complete Solutions
Levels of Health Promotion - Correct Answer-primary, secondary, tertiary
Application
... [Show More] Examples of Levels of Promotion - Correct Answer-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 - Correct Answer-promotes health and preventing development of disease
process or injury
Secondary - Correct Answer-screening for early detection of disease
Tertiary - Correct Answer-begins after illness is diagnosed and treatment. Aims to
prevent long-term consequences of chronic illnesses or disabilities
Nursing Assessments - Correct Answer-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 - Correct Answer-Pre-interaction, beginning, working (open
and close ended questions), closing
Data sources - Correct Answer-Primary- individual patient
Secondary- chart info, family members
Purposes of Documentation - Correct Answer-verbal communication, SBAR, written
document
Lifespan Nutritional Considerations - Nutrition: Pregnant Women - Correct Answer-need
additional 300-500 cal/day (whole foods
Lifespan Nutritional Considerations - Nutrition: infants/children - Correct Answerinfants/children: whole milk for ages 2-5 fat intake-brain development
Lifespan Nutritional Considerations - Nutrition: Older - Correct Answer-BMR declines,
Vitamin D supplements, Problems: decreased thirst, increase risk for osteoarthritis,
osteoporosis, dementia, obesity, social isolation
General Survey - Correct Answer-mental note of overall health (hygiene/appearance).
Assessing pain: documentation, OLDCARTS/OPQRST. Aggravating and alleviating
factors, pain goal and funtional goal
Assessing Pain - Documentation - Correct Answer-Acute vs. Chronic-Location
Priority - Correct Answer-Priority pain: stones (kidney, gallbladder, calcium and/or
struvite), myocardial infarcation (HA), burns and sickle cell
Heart Rate Elevated - Correct Answer-above 100 beats per minute
Blood Pressure- Normal - Correct Answer-above systolic- 120-129, diastolic- less than
80,
Blood Pressure- elevated - Correct Answer-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? - Correct Answer-after patient rests for 5 minutues or 30
minutes after caffeine, smoking
Assessment of the Head and Neck - Correct Answer-Inspect, palpate, auscultate
Infection - Correct Answer-If nodes are palpable, warm, tender = infection
Assessment of the Ear - Techniques - Correct Answer-Adults: up and back
Children: down and back
Assessment of the Ear - Techniques Part 2 - Correct Answer-observe behavioral
responses to speech, inspect ear formation (size, shape & any malformation to the
auricle, condition)
Perform whisper test & Rinne test. Pt plug one ear at a time
Perform weber test (evaluate unilateral hearing loss
Assessing the Chest - Correct Answer-inspect, palpate, percuss, auscultate
Assessing Lung Sounds - Technique - Correct Answer-IPPA- inspect, palpate, percuss,
auscultate
Normal Lung Sounds - Correct Answer-Normal: bronchial (heard anteriorly) over larynx
and trachea (INSPIRIATION slightly shorter than expiration),
Bronchiovesicular (heard anteriorly and posteriorly)INSPIRATION AND EXPIRATION
EQUAL ,
Vesicular (heard both) lower lungs, low pitch, INSPIRATION GREATER THAN
EXPIRATION) [Show Less]