Exam (elaborations)
HESI A2 - CRITICAL THINKING QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
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HESI A2 - CRITICAL THINKING QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
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HESI A2 - CRITICAL THINKINGQUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
1.MTheMnurseMisMworkingMinMtheMemergencyMdepartmentM(ED)MofMaMchildren'sMmedicalMcenter.MWhichMcli
entMshouldMtheMnurseMassessMfirst?
1.MTheM1-month-oldMinfantMwhoMhasMdevelopedMcolicMandMisMcrying.
2.MTheM2-year-oldMtoddlerMwhoMwasMbittenMbyManotherMchildMatMtheMday-careMcenter.M3.MTheM6-year-
oldMschool-ageMchildMwhoMwasMhitMbyMaMcarMwhileMridingMaMbicycle.
4.MTheM14-year-oldMadolescentMwhoseMmotherMsuspectsMherMchildMisMsexuallyMactive.M-
MANSWERMRationaleM
CorrectM-M3-TheMchildMhitMbyMaMcarMshouldMbeMassessedMfirstMbecauseMheMorMsheMmayMhaveMlife-
MthreateningMinjuriesMthatMmustMbeMassessedMandMtreatedMpromptly.
1.MInManMinterview,MtheMnurseMmayMfindMitMnecessaryMtoMtakeMnotesMtoMaidMhisMorMherMmemoryMlater.MW
hichMstatementMisMtrueMregardingMnote-taking?M
A)MNote-takingMmayMimpedeMtheMnurse'sMobservationMofMtheMpatient'sMnonverbalMbehaviors.
B)MNote-
takingMallowsMtheMpatientMtoMcontinueMatMhisMorMherMownMpaceMasMtheMnurseMrecordsMwhatMisMsaid.
C)MNote-
takingMallowsMtheMnurseMtoMshiftMattentionMawayMfromMtheMpatient,MresultingMinManMincreasedMcomfortMl
evel.
D)MNote-
takingMallowsMtheMnurseMtoMbreakMeyeMcontactMwithMtheMpatient,MwhichMmayMincreaseMhisMorMherMlevelM
ofMcomfort.M-MANSWERMA)MNote-
takingMmayMimpedeMtheMnurse'sMobservationMofMtheMpatient'sMnonverbalMbehaviors.
Page:M31MSomeMuseMofMhistoryMformsMandMnote-takingMmayMbeMunavoidable.MButMbeMawareMthatMnote-
takingMduringMtheMinterviewMhasMdisadvantages.MItMbreaksMeyeMcontactMtooMoften,MandMitMshiftsMattentio
nMawayMfromMtheMpatient,MwhichMdiminishesMhisMorMherMsenseMofMimportance.MItMalsoMmayMinterruptMth
eMpatient'sMnarrativeMflow,MandMitMimpedesMtheMobservationMofMtheMpatient'sMnonverbalMbehavior.
,2.MTheM8-year-oldMclientMdiagnosedMwithMaMvaso-
occlusiveMsickleMcellMcrisisMisMcomplainingMofMaMsevereMheadache.MWhichMinterventionMshouldMtheMnurse
MimplementMfirst?
1.MAdministerM6MLMofMoxygenMviaMnasalMcannula.
2.MAssessMtheMclient'sMneurologicalMstatus.
3.MAdministerMaMnarcoticManalgesicMbyMintravenousMpushM(IVP).M4.MIncreaseMtheMclient'sMintravenousM(IV
)Mrate.M-MANSWERMRationaleM
CorrectM-M2-
BecauseMtheMclientMisMcomplainingMofMaMheadache,MtheMnurseMshouldMfirstMruleMoutMcerebrovascularMacc
identM(CVA)MbyMassess-
MingMtheMclient'sMneurologicalMstatusMandMthenMdetermineMwhetherMitMisMaMheadacheMthatMcanMbeMtreat
edMwithMmedication.
2.MDuringManMinterview,MtheMnurseMstates,M"YouMmentionedMshortnessMofMbreath.MTellMmeMmoreMaboutMt
hat."MWhichMverbalMskillMisMusedMwithMthisMstatement?
A)MReflection
B)MFacilitation
C)MDirectMquestion
D)MOpen-endedMquestionM-MANSWERMD)MOpen-endedMquestion
Page:M32MTheMopen-
endedMquestionMasksMforMnarrativeMinformation.MItMstatesMtheMtopicMtoMbeMdiscussedMbutMonlyMinMgener
alMterms.MTheMnurseMshouldMuseMitMtoMbeginMtheMinterview,MtoMintroduceMaMnewMsectionMofMquestions,M
andMwheneverMtheMpersonMintroducesMaMnewMtopic.
3.MTheM6-year-
oldMclientMwhoMhasMundergoneMabdominalMsurgeryMisMattemptingMtoMmakeMaMpinwheelMspinMbyMblowing
MonMitMwithMtheMnurse'sMassistance.MTheMchildMstartsMcryingMbecauseMtheMpinwheelMwon'tMspin.MWhichMa
ctionMshouldMtheMnurseMimplementMfirst?
1.MPraiseMtheMchildMforMtheMattemptMtoMmakeMtheMpinwheelMspin.
2.MNotifyMtheMrespiratoryMtherapistMtoMimplementMincentiveMspirometry.M3.MEncourageMtheMchildMtoMtur
nMfromMsideMtoMsideMandMcough.
4.MDemonstrateMhowMtoMmakeMtheMpinwheelMspinMbyMblowingMonMit.M-MANSWERMRationaleM
,CorrectM-
1.MTheMnurseMshouldMalwaysMpraiseMtheMchildMforMattemptsMatMcooperationMevenMifMtheMchildMdidMnotMa
ccomplishMwhatMtheMnurseMasked.
3.MAMnurseMisMtakingMcompleteMhealthMhistoriesMonMallMofMtheMpatientsMattendingMaMwellnessMworkshop.
MOnMtheMhistoryMform,MoneMofMtheMwrittenMquestionsMasks,M"YouMdon'tMsmoke,Mdrink,MorMtakeMdrugs,Mdo
Myou?"MThisMquestionMisManMexampleMof:
A)MtalkingMtooMmuch.
B)MusingMconfrontation.
C)MusingMbiasedMorMleadingMquestions.
D)MusingMbluntMlanguageMtoMdealMwithMdistastefulMtopics.M-
MANSWERMC)MusingMbiasedMorMleadingMquestions.
Page:M36MThisMisManMexampleMofMusingMleadingMorMbiasedMquestions.MAsking,M"YouMdon'tMsmoke,MdoMyou
?"MimpliesMthatMoneManswerMisM"better"MthanManother.MIfMtheMpersonMwantsMtoMpleaseMsomeone,MheMor
MsheMisMeitherMforcedMtoManswerMinMaMwayMcorrespondingMtoMtheirMimpliedMvaluesMorMisMmadeMtoMfeelMg
uiltyMwhenMadmittingMtheMotherManswer.
4.MTheMnurseMisMcaringMforMclientsMonMtheMpediatricMmedicalMunit.MWhichMclientMshouldMtheMnurseMasses
sMfirst?
1.MTheMchildMdiagnosedMwithMtypeM1MdiabetesMwhoMhasMaMbloodMglucoseMlevel
ofM180Mmg/dL.
2.MTheMchildMdiagnosedMwithMpneumoniaMwhoMisMcoughingMandMhasMaMtemperatureMof
100°F.
3.MTheMchildMdiagnosedMwithMgastroenteritisMwhoMhasMaMpotassiumM(K+)Mlevel
ofM3.9MmEq/L.
4.MTheMchildMdiagnosedMwithMcysticMfibrosisMwhoMhasMaMpulseMoximeterMreadingMofM90%.M-
MANSWERMRationaleM
, CorrectM-
M4.MAMpulseMoximeterMreadingMofMlessMthanM93%MisMsignificantMandMindicatesMhypoxia,MwhichMisMlifeMthre
atening;Mtherefore,MthisMchildMshouldMbeMassessedMfirst.
4.MDuringManMinterview,MaMparentMofMaMhospitalizedMchildMisMsittingMinManMopenMposition.MAsMtheMintervi
ewerMbeginsMtoMdiscussMhisMson'sMtreatment,Mhowever,MheMsuddenlyMcrossesMhisMarmsMagainstMhisMchest
MandMcrossesMhisMlegs.MThisMwouldMsuggestMthatMtheMparentMis:
A)MjustMchangingMpositions.
B)MmoreMcomfortableMinMthisMposition.
C)MtiredMandMneedsMaMbreakMfromMtheMinterview.
D)MuncomfortableMtalkingMaboutMhisMson'sMtreatment.M-
MANSWERMD)MuncomfortableMtalkingMaboutMhisMson'sMtreatment.
Page:M37MNoteMtheMperson'sMposition.MAnMopenMpositionMwithMtheMextensionMofMlargeMmuscleMgroupsMs
howsMrelaxation,MphysicalMcomfort,MandMaMwillingnessMtoMshareMinformation.MAMclosedMpositionMwithMth
eMarmsMandMlegsMcrossedMtendsMtoMlookMdefensiveMandManxious.MNoteManyMchangeMinMposture.MIfMaMper
sonMinMaMrelaxedMpositionMsuddenlyMtenses,MitMsuggestsMpossibleMdiscomfortMwithMtheMnewMtopic.
5.MTheMnurseMhasMreceivedMtheMa.m.MshiftMreportMforMclientsMonMaMpediatricMunit.MWhichMmedicationMsh
ouldMtheMnurseMadministerMfirst?
1.MTheMthirdMdoseMofMtheMaminoglycosideMantibioticMtoMtheMchildMdiagnosedMwith
methicillin-resistantMStaphylococcusMaureusM(MRSA).
2.MTheMIVPMsteroidMmethylprednisoloneM(Solu-Medrol)MtoMtheMchildMdiagnosedMwith
asthma.
3.MTheMslidingMscaleMinsulinMtoMtheMchildMdiagnosedMwithMtypeM1MdiabetesMmellitus.
4.MTheMstimulantMmethylphenidateM(Ritalin)MtoMaMchildMdiagnosedMwithMattention
deficit-hyperactivityMdisorderM(ADHD).M-MANSWERMRationaleM
CorrectM-M3-
SlidingMscaleMinsulinMisMorderedMac,MwhichMisMbeforeMmeals;Mtherefore,MthisMmedicationMmustMbeMadmini
steredMfirstMafterMreceivingMtheMa.m.MshiftMreport.
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