The nurse is working in the emergency department (ED) of a children's medical center. Which client should the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6-year-old sc...
HESI A2 - Critical Thinking Exam
with 100% Correct Answers 2023
1. The nurse is working in the emergency department (ED) of a
children's medical center. Which client should the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
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. - Correct Answer-Rationale
Correct - 3-The child hit by a car should be assessed first because he or she
may have life- threatening injuries that must be assessed and treated
promptly.
1. In an interview, the nurse may find it necessary to take notes to
aid his or her memory later. Which statement is true regarding note-
taking?
A) Note-taking may impede the nurse's observation of the patient's
nonverbal behaviors.
B) Note-taking allows the patient to continue at his or her own pace as
the nurse records what is said.
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. - Correct Answer-A) Note-
taking may impede the nurse's observation of the patient's nonverbal
behaviors.
Page: 31 Some use of history forms and note-taking may be unavoidable.
But be aware that note-taking during the interview has disadvantages. It
breaks eye contact too often, and it shifts attention away from the patient,
which diminishes his or her sense of importance. It also may interrupt the
patient's narrative flow, and it impedes the observation of the patient's
nonverbal behavior.
2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is
complaining of a severe headache. Which intervention should the nurse
implement first?
1. Administer 6 L of oxygen via nasal
cannula. 2. Assess the client's
neurological status.
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the
client's intravenous (IV) rate. - Correct Answer-Rationale
Correct - 2-Because the client is complaining of a headache, the nurse
,should first rule out cerebrovascular accident (CVA) by assess- ing the
client's neurological status and then determine whether it is a headache
that can be treated with medication.
,2. During an interview, the nurse states, "You mentioned shortness of
breath. Tell me more about that." Which verbal skill is used with this
statement?
A)
Reflection
B)
Facilitation
C) Direct question
D) Open-ended question - Correct Answer-D) Open-ended question
Page: 32 The open-ended question asks for narrative information. It states
the topic to be discussed but only in general terms. The nurse should use it
to begin the interview, to introduce a new section of questions, and
whenever the person introduces a new topic.
3. The 6-year-old client who has undergone abdominal surgery is attempting
to make a pinwheel spin by blowing on it with the nurse's assistance. The
child starts crying 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. -
Correct Answer- Rationale
Correct -1. The nurse should always praise the child for attempts at
cooperation even if the child did not accomplish what the nurse asked.
3. A nurse is taking complete health histories on all of the patients attending
a wellness workshop. On the history form, one of the written questions
asks, "You don't smoke, drink, or take drugs, do you?" This question is an
example of:
A) talking too
much. B) using
confrontation.
C) using biased or leading questions.
D) using blunt language to deal with distasteful topics. - Correct Answer-C)
using biased or leading questions.
Page: 36 This is an example of using leading or biased questions. Asking,
"You don't smoke, do you?" implies that one answer is "better" than another.
If the person wants to please someone, he or she is either forced to answer
in a way corresponding to their implied values or is made to feel guilty when
admitting the other answer.
4. The nurse is caring for clients on the pediatric medical unit. Which client
should the nurse assess first?
1. The child diagnosed with 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.
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