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HESI A2 - Critical Thinking Questions With Complete Solutions
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HESI A2 - Critical Thinking Questions With Complete Solutions
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HESI A2 - Critical Thinking Questions With CompleteSolutions
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.
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.
10. During an assessment, the nurse notices that a patient is
handling a small charm that is tied to a leather strip around his
neck. Which action by the nurse is appropriate?
A) Ask the patient about the item and its significance.
B) Ask the patient to lock the item with other valuables in the
hospital's safe.
C) Tell the patient that a family member should take valuables
home.
D) No action is necessary. Correct Answer A) Ask the patient
about the item and its significance.
Page: 21 The nurse should inquire about the amulet's meaning.
Amulets, such as charms, are often seen as an important means
of protection from "evil spirits" by some cultures.
10. Which data would warrant immediate intervention from the
pediatric nurse? 1. Proteinuria for the child diagnosed with
nephrotic syndrome.
2. Petechiae for the child diagnosed with leukemia.
3. Drooling for a child diagnosed with acute epiglottitis.
,4. Elevated temperature in a child diagnosed with otitis media.
Correct Answer Rationale
Correct - 3-Drooling indicates the child is having trouble
swallowing, and the epiglottis is at risk of completely occluding
the air- way. This warrants immediate interven- tion. The nurse
should notify the HCP and obtain an emergency tracheostomy
tray for the bedside.
100. The nurse is reviewing an assessment of a patient's
peripheral pulses and notices that the documentation states that
the radial pulses are "2+." The nurse recognizes that this reading
indicates what type of pulse?
A) Bounding
B) Normal
C) Weak
D) Absent Correct Answer B) Normal
Pages: 506-507. When documenting the force, or amplitude, of
pulses, 3+ indicates an increased, full, or bounding pulse, 2+
indicates a normal pulse, 1+ indicates a weak pulse, and 0
indicates an absent pulse.
101. The nurse is percussing the seventh right intercostal space
at the midclavicular line over the liver. Which sound should the
nurse expect to hear?
A) Dullness
B) Tympany
C) Resonance
D) Hyperresonance Correct Answer A) Dullness
, Page: 541. The liver is located in the right upper quadrant and
would elicit a dull percussion note.
102. Which structure is located in the left lower quadrant of the
abdomen?
A) Liver
B) Duodenum
C) Gallbladder
D) Sigmoid colon Correct Answer D) Sigmoid colon
Page: 530. The sigmoid colon is located in the left lower
quadrant of the abdomen.
103. The nurse suspects that a patient has a distended bladder.
How should the nurse assess for this condition?
A) Percuss and palpate in the lumbar region.
B) Inspect and palpate in the epigastric region.
C) Auscultate and percuss in the inguinal region.
D) Percuss and palpate the midline area above the suprapubic
bone. Correct Answer D) Percuss and palpate the midline area
above the suprapubic bone.
Pages: 539-540. Dull percussion sounds would be elicited over a
distended bladder, and the hypogastric area would seem firm to
palpation.
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