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HESI A2 - Critical Thinking QUESTIONS AND
CORRECT DETAILED ANSWERS
Save
Terms in this set (220)
1. The nurse is working in the Rationale
emergency department (ED) of a
children's medical center. Which Correct - 3-The child hit by a car should be
client should the nurse assess first? assessed first because he or she may have life-
1. The 1-month-old infant who has threatening injuries that must be assessed and
developed colic and is crying. treated promptly.
2. The 2-year-old toddler who was
bitten by another child at the day-
care center. 3. The 6-year-old
school-age child who was hit by a
car while riding a bicycle.
4. The 14-year-old adolescent whose
mother suspects her child is sexually
active.
,1. In an interview, the nurse may find it A) Note-taking may impede the nurse's observation
necessary to take notes to aid his or of the patient's nonverbal behaviors.
her memory later. Which statement is
true regarding note-taking? Page: 31 Some use of history forms and note-taking
may be unavoidable. But be aware that note-taking
A) Note-taking may impede the during the interview has disadvantages. It breaks
nurse's observation of the patient's eye contact too often, and it shifts attention away
nonverbal behaviors. from the patient, which diminishes his or her sense of
B) Note-taking allows the patient to importance. It also may interrupt the patient's
continue at his or her own pace as narrative flow, and it impedes the observation of
the nurse records what is said. the patient's nonverbal behavior.
C) Note-taking allows the nurse to
shift attention away from the patient,
resulting in an increased comfort
level.
D) Note-taking allows the nurse to
break eye contact with the patient,
which may increase his or her level of
comfort.
2. The 8-year-old client diagnosed Rationale
with a vaso-occlusive sickle cell Correct - 2-Because the client is complaining of a
crisis is complaining of a severe headache, the nurse should first rule out
headache. Which intervention should cerebrovascular accident (CVA) by assess- ing the
the nurse implement first? client's neurological status and then determine
1. Administer 6 L of oxygen via nasal whether it is a headache that can be treated with
cannula. medication.
2. Assess the client's neurological
status.
3. Administer a narcotic analgesic by
intravenous push (IVP). 4. Increase
the client's intravenous (IV) rate.
,2. During an interview, the nurse D) Open-ended question
states, "You mentioned shortness of
breath. Tell me more about that." Page: 32 The open-ended question asks for
Which verbal skill is used with this narrative information. It states the topic to be
statement? discussed but only in general terms. The nurse
should use it to begin the interview, to introduce a
A) Reflection new section of questions, and whenever the person
B) Facilitation introduces a new topic.
C) Direct question
D) Open-ended question
3. The 6-year-old client who has Rationale
undergone abdominal surgery is
attempting to make a pinwheel spin Correct -1. The nurse should always praise the child
by blowing on it with the nurse's for attempts at cooperation even if the child did not
assistance. The child starts crying accomplish what the nurse asked.
because the pinwheel won't spin.
Which action should the nurse
implement first?
1. Praise the child for the attempt to
make the pinwheel spin.
2. Notify the respiratory therapist to
implement incentive spirometry. 3.
Encourage the child to turn from side
to side and cough.
4. Demonstrate how to make the
pinwheel spin by blowing on it.
, 3. A nurse is taking complete health C) using biased or leading questions.
histories on all of the patients
attending a wellness workshop. On Page: 36 This is an example of using leading or
the history form, one of the written biased questions. Asking, "You don't smoke, do
questions asks, "You don't smoke, you?" implies that one answer is "better" than
drink, or take drugs, do you?" This another. If the person wants to please someone, he
question is an example of: or she is either forced to answer in a way
corresponding to their implied values or is made to
A) talking too much. feel guilty when admitting the other answer.
B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with
distasteful topics.
4. The nurse is caring for clients on Rationale
the pediatric medical unit. Which
client should the nurse assess first? Correct - 4. A pulse oximeter reading of less than
1. The child diagnosed with type 1 93% is significant and indicates hypoxia, which is life
diabetes who has a blood glucose threatening; therefore, this child should be assessed
level first.
of 180 mg/dL.
2. The child diagnosed with
pneumonia who is coughing and has
a temperature of
100°F.
3. The child diagnosed with
gastroenteritis who has a potassium
(K+) level
of 3.9 mEq/L.
4. The child diagnosed with cystic
fibrosis who has a pulse oximeter
reading of 90%.
HESI A2 - Critical Thinking QUESTIONS AND
CORRECT DETAILED ANSWERS
Save
Terms in this set (220)
1. The nurse is working in the Rationale
emergency department (ED) of a
children's medical center. Which Correct - 3-The child hit by a car should be
client should the nurse assess first? assessed first because he or she may have life-
1. The 1-month-old infant who has threatening injuries that must be assessed and
developed colic and is crying. treated promptly.
2. The 2-year-old toddler who was
bitten by another child at the day-
care center. 3. The 6-year-old
school-age child who was hit by a
car while riding a bicycle.
4. The 14-year-old adolescent whose
mother suspects her child is sexually
active.
,1. In an interview, the nurse may find it A) Note-taking may impede the nurse's observation
necessary to take notes to aid his or of the patient's nonverbal behaviors.
her memory later. Which statement is
true regarding note-taking? Page: 31 Some use of history forms and note-taking
may be unavoidable. But be aware that note-taking
A) Note-taking may impede the during the interview has disadvantages. It breaks
nurse's observation of the patient's eye contact too often, and it shifts attention away
nonverbal behaviors. from the patient, which diminishes his or her sense of
B) Note-taking allows the patient to importance. It also may interrupt the patient's
continue at his or her own pace as narrative flow, and it impedes the observation of
the nurse records what is said. the patient's nonverbal behavior.
C) Note-taking allows the nurse to
shift attention away from the patient,
resulting in an increased comfort
level.
D) Note-taking allows the nurse to
break eye contact with the patient,
which may increase his or her level of
comfort.
2. The 8-year-old client diagnosed Rationale
with a vaso-occlusive sickle cell Correct - 2-Because the client is complaining of a
crisis is complaining of a severe headache, the nurse should first rule out
headache. Which intervention should cerebrovascular accident (CVA) by assess- ing the
the nurse implement first? client's neurological status and then determine
1. Administer 6 L of oxygen via nasal whether it is a headache that can be treated with
cannula. medication.
2. Assess the client's neurological
status.
3. Administer a narcotic analgesic by
intravenous push (IVP). 4. Increase
the client's intravenous (IV) rate.
,2. During an interview, the nurse D) Open-ended question
states, "You mentioned shortness of
breath. Tell me more about that." Page: 32 The open-ended question asks for
Which verbal skill is used with this narrative information. It states the topic to be
statement? discussed but only in general terms. The nurse
should use it to begin the interview, to introduce a
A) Reflection new section of questions, and whenever the person
B) Facilitation introduces a new topic.
C) Direct question
D) Open-ended question
3. The 6-year-old client who has Rationale
undergone abdominal surgery is
attempting to make a pinwheel spin Correct -1. The nurse should always praise the child
by blowing on it with the nurse's for attempts at cooperation even if the child did not
assistance. The child starts crying accomplish what the nurse asked.
because the pinwheel won't spin.
Which action should the nurse
implement first?
1. Praise the child for the attempt to
make the pinwheel spin.
2. Notify the respiratory therapist to
implement incentive spirometry. 3.
Encourage the child to turn from side
to side and cough.
4. Demonstrate how to make the
pinwheel spin by blowing on it.
, 3. A nurse is taking complete health C) using biased or leading questions.
histories on all of the patients
attending a wellness workshop. On Page: 36 This is an example of using leading or
the history form, one of the written biased questions. Asking, "You don't smoke, do
questions asks, "You don't smoke, you?" implies that one answer is "better" than
drink, or take drugs, do you?" This another. If the person wants to please someone, he
question is an example of: or she is either forced to answer in a way
corresponding to their implied values or is made to
A) talking too much. feel guilty when admitting the other answer.
B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with
distasteful topics.
4. The nurse is caring for clients on Rationale
the pediatric medical unit. Which
client should the nurse assess first? Correct - 4. A pulse oximeter reading of less than
1. The child diagnosed with type 1 93% is significant and indicates hypoxia, which is life
diabetes who has a blood glucose threatening; therefore, this child should be assessed
level first.
of 180 mg/dL.
2. The child diagnosed with
pneumonia who is coughing and has
a temperature of
100°F.
3. The child diagnosed with
gastroenteritis who has a potassium
(K+) level
of 3.9 mEq/L.
4. The child diagnosed with cystic
fibrosis who has a pulse oximeter
reading of 90%.
