HESI A2 - Critical Thinking
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1. 1. The nurse is working in the Rationale
emergency department (ED)
of a children's medical center. Correct - 3-The child hit by a car should be assessed first
Which client should the nurse because he or she may have life- threatening injuries that
assess first? must be assessed and treated promptly.
1. The 1-month-old infant who
has developed colic and is cry-
ing.
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 rid-
ing a bicycle.
4. The 14-year-old adolescent
whose mother suspects her
child is sexually active.
2. 1. In an interview, the nurse A) Note-taking may impede the nurse's observation of the
may find it necessary to take patient's nonverbal behaviors.
notes to aid his or her memory
later. Which statement is true Page: 31 Some use of history forms and note-taking may be
regarding note-taking? unavoidable. But be aware that note-taking during the inter-
view has disadvantages. It breaks eye contact too often, and
A) Note-taking may impede it shifts attention away from the patient, which diminishes his
the nurse's observation of or her sense of importance. It also may interrupt the patient's
the patient's nonverbal behav- narrative flow, and it impedes the observation of the patient's
iors. nonverbal behavior.
B) Note-taking allows the pa-
tient to continue at his or her
own pace as the nurse records
what is said.
, HESI A2 - Critical Thinking
Study online at https://quizlet.com/_jg1vtc
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 in-
crease his or her level of com-
fort.
3. 2. The 8-year-old client diag- Rationale
nosed with a vaso-occlusive Correct - 2-Because the client is complaining of a headache,
sickle cell crisis is complaining the nurse should first rule out cerebrovascular accident (CVA)
of a severe headache. Which by assess- ing the client's neurological status and then de-
intervention should the nurse termine whether it is a headache that can be treated with
implement first? medication.
1. Administer 6 L of oxygen via
nasal cannula.
2. Assess the client's neurolog-
ical status.
3. Administer a narcotic anal-
gesic by intravenous push
(IVP). 4. Increase the client's in-
travenous (IV) rate.
4. 2. During an interview, the D) Open-ended question
nurse states, "You mentioned
shortness of breath. Tell me Page: 32 The open-ended question asks for narrative infor-
more about that." Which ver- mation. It states the topic to be discussed but only in general
bal skill is used with this state- terms. The nurse should use it to begin the interview, to in-
ment? troduce a new section of questions, and whenever the person
introduces a new topic.
, HESI A2 - Critical Thinking
Study online at https://quizlet.com/_jg1vtc
A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question
5. 3. The 6-year-old client who Rationale
has undergone abdominal
surgery is attempting to make Correct -1. The nurse should always praise the child for at-
a pinwheel spin by blowing tempts at cooperation even if the child did not accomplish
on it with the nurse's assis- what the nurse asked.
tance. The child starts crying
because the pinwheel won't
spin. Which action should the
nurse implement first?
1. Praise the child for the at-
tempt to make the pinwheel
spin.
2. Notify the respiratory ther-
apist 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.
6. 3. A nurse is taking com- C) using biased or leading questions.
plete health histories on all of
the patients attending a well- Page: 36 This is an example of using leading or biased
ness workshop. On the history questions. Asking, "You don't smoke, do you?" implies that
form, one of the written ques- one answer is "better" than another. If the person wants to
tions asks, "You don't smoke, please someone, he or she is either forced to answer in a way
, HESI A2 - Critical Thinking
Study online at https://quizlet.com/_jg1vtc
drink, or take drugs, do you?" corresponding to their implied values or is made to feel guilty
This question is an example when admitting the other answer.
of:
A) talking too much.
B) using confrontation.
C) using biased or leading
questions.
D) using blunt language to
deal with distasteful topics.
7. 4. The nurse is caring for Rationale
clients on the pediatric med-
ical unit. Which client should Correct - 4. A pulse oximeter reading of less than 93% is
the nurse assess first? significant and indicates hypoxia, which is life threatening;
1. The child diagnosed with therefore, this child should be assessed first.
type 1 diabetes who has a
blood glucose level
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%.
8.
Study online at https://quizlet.com/_jg1vtc
1. 1. The nurse is working in the Rationale
emergency department (ED)
of a children's medical center. Correct - 3-The child hit by a car should be assessed first
Which client should the nurse because he or she may have life- threatening injuries that
assess first? must be assessed and treated promptly.
1. The 1-month-old infant who
has developed colic and is cry-
ing.
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 rid-
ing a bicycle.
4. The 14-year-old adolescent
whose mother suspects her
child is sexually active.
2. 1. In an interview, the nurse A) Note-taking may impede the nurse's observation of the
may find it necessary to take patient's nonverbal behaviors.
notes to aid his or her memory
later. Which statement is true Page: 31 Some use of history forms and note-taking may be
regarding note-taking? unavoidable. But be aware that note-taking during the inter-
view has disadvantages. It breaks eye contact too often, and
A) Note-taking may impede it shifts attention away from the patient, which diminishes his
the nurse's observation of or her sense of importance. It also may interrupt the patient's
the patient's nonverbal behav- narrative flow, and it impedes the observation of the patient's
iors. nonverbal behavior.
B) Note-taking allows the pa-
tient to continue at his or her
own pace as the nurse records
what is said.
, HESI A2 - Critical Thinking
Study online at https://quizlet.com/_jg1vtc
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 in-
crease his or her level of com-
fort.
3. 2. The 8-year-old client diag- Rationale
nosed with a vaso-occlusive Correct - 2-Because the client is complaining of a headache,
sickle cell crisis is complaining the nurse should first rule out cerebrovascular accident (CVA)
of a severe headache. Which by assess- ing the client's neurological status and then de-
intervention should the nurse termine whether it is a headache that can be treated with
implement first? medication.
1. Administer 6 L of oxygen via
nasal cannula.
2. Assess the client's neurolog-
ical status.
3. Administer a narcotic anal-
gesic by intravenous push
(IVP). 4. Increase the client's in-
travenous (IV) rate.
4. 2. During an interview, the D) Open-ended question
nurse states, "You mentioned
shortness of breath. Tell me Page: 32 The open-ended question asks for narrative infor-
more about that." Which ver- mation. It states the topic to be discussed but only in general
bal skill is used with this state- terms. The nurse should use it to begin the interview, to in-
ment? troduce a new section of questions, and whenever the person
introduces a new topic.
, HESI A2 - Critical Thinking
Study online at https://quizlet.com/_jg1vtc
A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question
5. 3. The 6-year-old client who Rationale
has undergone abdominal
surgery is attempting to make Correct -1. The nurse should always praise the child for at-
a pinwheel spin by blowing tempts at cooperation even if the child did not accomplish
on it with the nurse's assis- what the nurse asked.
tance. The child starts crying
because the pinwheel won't
spin. Which action should the
nurse implement first?
1. Praise the child for the at-
tempt to make the pinwheel
spin.
2. Notify the respiratory ther-
apist 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.
6. 3. A nurse is taking com- C) using biased or leading questions.
plete health histories on all of
the patients attending a well- Page: 36 This is an example of using leading or biased
ness workshop. On the history questions. Asking, "You don't smoke, do you?" implies that
form, one of the written ques- one answer is "better" than another. If the person wants to
tions asks, "You don't smoke, please someone, he or she is either forced to answer in a way
, HESI A2 - Critical Thinking
Study online at https://quizlet.com/_jg1vtc
drink, or take drugs, do you?" corresponding to their implied values or is made to feel guilty
This question is an example when admitting the other answer.
of:
A) talking too much.
B) using confrontation.
C) using biased or leading
questions.
D) using blunt language to
deal with distasteful topics.
7. 4. The nurse is caring for Rationale
clients on the pediatric med-
ical unit. Which client should Correct - 4. A pulse oximeter reading of less than 93% is
the nurse assess first? significant and indicates hypoxia, which is life threatening;
1. The child diagnosed with therefore, this child should be assessed first.
type 1 diabetes who has a
blood glucose level
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%.
8.
