HESI A2 - Critical Thinking latest update with correct answers A+ guaranteed.
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.
...
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. -
answers 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. - answers 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. - answers 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 - answers 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. - answers 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. - answers 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.
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%. -
answers Rationale
Correct - 4. A pulse oximeter reading of less than 93% is significant and indicates
hypoxia, which is life threatening; therefore, this child should be assessed first.
4. During an interview, a parent of a hospitalized child is sitting in an open position. As
the interviewer begins to discuss his son's treatment, however, he suddenly crosses his
arms against his chest and crosses his legs. This would suggest that the parent is:
A) just changing positions.
B) more comfortable in this position.
C) tired and needs a break from the interview.
D) uncomfortable talking about his son's treatment. - answers D) uncomfortable talking
about his son's treatment.
Page: 37 Note the person's position. An open position with the extension of large
muscle groups shows relaxation, physical comfort, and a willingness to share
information. A closed position with the arms and legs crossed tends to look defensive
and anxious. Note any change in posture. If a person in a relaxed position suddenly
tenses, it suggests possible discomfort with the new topic.
5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which
medication should the nurse administer first?
1. The third dose of the aminoglycoside antibiotic to the child diagnosed with
methicillin-resistant Staphylococcus aureus (MRSA).
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with
asthma.
3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention
deficit-hyperactivity disorder (ADHD). - answers Rationale
Correct - 3-Sliding scale insulin is ordered ac, which is before meals; therefore, this
medication must be administered first after receiving the a.m. shift report.
4-Routine medications have a 1-hour leeway before and after the scheduled time;
therefore, this medication does not have to be adminis- tered first.
5. The nurse is interviewing a patient who has a hearing impairment. What techniques
would be most beneficial in communicating with this patient?
, A) Determine the communication method he prefers.
B) Avoid using facial and hand gestures because most hearing-impaired people find this
degrading.
C) Request a sign language interpreter before meeting with him to help facilitate the
communication.
D) Speak loudly and with exaggerated facial movement when talking with him because
this helps with lip reading. - answers A) Determine the communication method he
prefers.
Pages: 40-41 The nurse should ask the deaf person the preferred way to communicate
—by signing, lip reading, or writing. If the person prefers lip reading, then the nurse
should be sure to face him or her squarely and have good lighting on the nurse's face.
The nurse should not exaggerate lip movements because this distorts words. Similarly,
shouting distorts the reception of a hearing aid the person may wear. The nurse should
speak slowly and should supplement his or her voice with appropriate hand gestures or
pantomime.
6. The nurse enters the client's room and realizes the 9-month-old infant is not breath-
ing. Which interventions should the nurse implement? Prioritize the nurse's actions from
first (1) to last (5).
1. Perform cardiac compression 30:2.
2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Determine
unresponsiveness.
5. Open the infant's airway. - answers Rationale
Correct Answer: 4, 5, 3, 2, 1
4. The nurse must first determine the
infant's responsiveness by thumping the
baby's feet.
5. The nurse should then open the child's
airway using the head-tilt chin-lift tech- nique, with care taken not to hyperextend the
neck. Then the nurse should look, listen, and feel for respirations.
3. The nurse then administers quick puffs of air while covering the child's mouth and
nose, preferably with a rescue mask.
2. The nurse should determine whether the infant has a pulse by checking the brachial
artery.
1. If the infant has no pulse, the nurse should begin chest compressions using two
fingers at a rate of 30:2.
6. The nurse is performing a health interview on a patient who has a language barrier,
and no interpreter is available. Which is the best example of an appropriate question for
the nurse to ask in this situation?
A) "Do you take medicine?"
B) "Do you sterilize the bottles?"
C) "Do you have nausea and vomiting?"
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