HESI A2 Critical Thinking Latest Update (HESIA2)

Exam (elaborations) HESI A2 Critical Thinking Latest Update (HESIA2) Critical Thinking 1. The Patient: A 65-year- old male. The Situation: The family brings the patient to the emergency room because he just took an entire bottle of pills. The Question: What action should the nurse take first? Answer – Determine the patient’s level of consciousness. 2. The Patient: An 80 year-old male who has used continuous oxygen for the past three years. The Situation: While making a home visit, the wife tells the nurse that her husband was doing well on 2 litres of oxygen per minute until late last night when he developed severe shortness of breath on the way to the bathroom. The Question: What action should the nurse take first? Answer – Assess the patient’s oxygen saturation by pulse oximeter. 3. The Patient: A 41-year-old male. The Situation: The patient is complaining of severe stomach pain and states that he has been “vomiting all the time.” The Question: What should the nurse do first? Answer – Administer a prescribed pain medication. 4. The Patient: The wife of a wealthy owner of the town’s bank. The Situation: The patient and her husband arrive on the unit. While orienting the patient to the hospital room, the nurse notices that the patient has placed a large amount of cash and some expensive earrings in the drawer of the bedside table. The Question: What is the best action for the nurse to take? Answer – Advise the patient to have her husband take the items home when he leaves. 5. The Patient: A 45-year-old female who is 5’ 2” tall, weighs 200 pounds, and has smoked since age 21. The Situation: The patient comes to the clinic with a complaint of “leg pain.” The Question: It is most important for the nurse to obtain information about which previous occurrence? Answer – A previous blood clot in the leg. HESI A2 Critical Thinking Latest Update 6. The Patient: A 61-year-old female. The Situation: The patient has a fever of unknown origin. The nurse administered a fever-reducing medication 30 minutes ago. At this time there has been no decrease in the patient’s fever. The Question: What action would be best for the nurse to take? Answer – Sponge the patient with cool water. 7. The Patient: A 70-year-old male who is relatively healthy. The Situation: A liquid mediation is prescribed for this patient. The Question: Prior to administering the prescribed medication, what intervention has the highest priority? Answer – Determine if the patient is allergic to the medication. 8. The Patient: A fifty-eight-year-old female. The Situation: While the nurse is offering the patient her morning medications, she tells the nurse that she does not recall ever taking a pill that was pink-colored. The Question: What should the nurse do in response to this patient’s comment? Answer – Withhold the mediation until the patient’s prescription is verify. 9. The Patients: 1. A 63-year-old with a burn on the left lower leg who is complaining of pain. 2. A 45-year-old with pneumonia, complaining of shortness of breath. 3. A 31-year-old with abdominal pain who has just vomited blood. 4. An 88-year-old who has right-sided paralysis and wants to be helped to the bathroom immediately. The Situation: The nurse is caring for these patients. The Question: Who should the nurse see first? Answer – The 45-years old with pneumonia and shortness of breath. 10. The Patients: 1. A 13-year-old female with a kidney infection who reports that there is “lots of blood” in her urine. 2. An 18-year-old male with acute alcohol poisoning who is seeing “bugs on the walls.” 3. A 21-year-old female with inflammatory bowel disease who has soaked a dressing three hours after surgery. 4. A 25-year old male who is sobbing in his room after being told that he has testicular cancer. The Situation: The nurse is caring for these four patients. The Question: Who should the nurse see first? Answer – The 21-years old who is three hours postoperative and has a soaked dressing. 11. The Patients: 1. A 42-year-old with diabetes who is blind and is asking to get up and moved to a chair. 2. An 88-year-old with lower body paralysis who wants to be turned in bed. 3. A 17-year-old with asthma who smokes and has been in the bathroom for 30 minutes. 4. A 55-year-old with cardiac disease who tells the nurse, “Get the TV fixed or I am leaving this place.” The Situation: The nurse is caring for these four patients. The Question: Which patient should the nurse see first? Answer – The 17-year old with asthma who may be smoking in the bathroom. 12. The Patient: An elderly female accompanied by her middle-aged son. The Situation: The patient is being discharged after 15-day stay on the medical unit, and the son offers the nurse a box of candy as a gesture of thanks for caring for his mother. The Question: What should the nurse do in response to the offer of this gift? Answer – Sincerely thank the son, and share the candy with all staff member on the unit. 13. The Patient: A 25-year-old female who has smoked since age 12. The Situation: The patient is complaining of “skipped heart beats.” The Question: Which instruction is most important for the nurse to provide this patient? Answer – Call for assistance if she feels weak or dizzy when getting out of bed. 14. The Patient: A frail 88-year-old male who has recently become slightly confused. The Situation: The nurse is making a home visit and assesses the safety features of the home environment. The Question: Which suggestion would be most important for the nurse to provide the family? Answer – Eliminate any throw rugs from floor. 15. The Patient: A 55-year-old female with a family history of hypertension. The Situation: The patient is concerned about her health and states, “I have had severe headaches for the last six months. I think I might have high blood pressure.” The nurse determines that the woman’s blood pressure is 138/86 (high normal). The Question: What action would be best for the nurse to take? Answer – Ask the patient about the frequency, timing and quality of her headaches. 16. The Patient: A 35-year-old female with a history of asthma. The Situation: The patient has been using a steroid inhaler because she is short of breath. However, she states that her shortness of breath is “no better.” The Question: What is the most important information for the nurse to obtain? Answer – Method of using the inhaler. 17. The Patient: An older confused male. The Situation: At 3 a.m. the patient, who thinks he is in the bathroom, defecates in the bed. The bed needs to be changed. However, there are no bed sheets on the nursing unit. The Question: What action should the nurse take first? Answer – Ask a nursing assistant to go to another unit and borrow linen. 18. The Patient: A 25-year-old female hospitalized for anorexia. The Situation: The charge nurse denies the patient permission to pass dinner trays. The Question: What is the most important reason for the nurse to deny this anorexic patient permission to pass the dinner trays? Answer – Treatment protocol for anorexics mandates that they avoid preoccupation with food. 19. The Patient: A 75-year-old male who had a heart attack four years ago. The Situation: The patient tells the nurse, “Even though I stopped smoking 10 years ago, I have a terrible cough.” The Question: What action should the nurse take first? Answer – Auscultate all lung fields 20. The Patient: A 70-year-old man dying of prostate cancer. The Situation: Nurse “A,” who is charge of a medical unit, notices that a dying patient continues to moan in pain after receiving intravenous injections of morphins whenever Nurse “B” is caring for him. Nurse “A” suspects that Nurse “B” may be diluting the patient’s dose and taking the morphine to feed an addiction. The Question: What should Nurse “A” do in this situation? Answer – Notify the shift supervisor and unit director of the circumstances before taking action 21. The Patient: A 29-year-old male. The Situation: A lower leg cast was applied yesterday to a fractured leg. Today the patient tells the nurse that he is in “terrible pain.” The Question: Which action is most important for the nurse to take? Answer – Check the patient’s toes for adequate circulation. 22. The Patient: A 54-year-old male who weighs 275 pounds. He is 5’ 10” tall and has many family members who have died of heart disease. The Situation: He comes to the clinic stating that he has had several episodes of “chest pain” in the last week. The Question: What is the most important action for the nurse to take? Answer – Ask the patient to describe the chest pain. 23. The Patient: A 7-year-old child. The Situation: A nurse arrives with an injection containing preoperative sedation that must be given to the child now. The child asks the nurse if the shot will hurt. The Question: What response should the nurse offer to this child? Answer – “Yes, but it won’t last very long and soon you will be sleepy” 24. The Patient: A 35-year-old female. The Situation: The patient is admitted with a diagnosis of abdominal pain and diarrhea. The Question: Which action should the nurse take first? Answer – Initiate Intravenous fluids. 25. The Patient: A 51-year-old male. The Situation: The patient is pale, has dark circles under his eyes, and responds to questions with a soft, low voice. He tells the nurse that he has not slept well for months, but denies any type of pain. The Question: What information is most important for the nurse to obtain? Answer – The existence of a significant life in the last year that has caused anxiety. 26. The Patient: A 19-year-old male who has previously been healthy. The Situation: The patient complains that he is losing weight despite “eating all the time.” The Question: Considering this patient’s age and complaint, which diagnostic test is likely to provide the most important information? Answer – A fingerstick for blood sugar level. 27.