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HESI A2 - Critical Thinking practice
questions with verified solutions
Qs
- The nurse is working in the emergency department (ED) of a children's medical center. Which client should the nurse assess first?
- The 1-month-old infant who has developed colic and is crying.
- 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.
- The 14-year-old adolescent whose mother suspects her child is sexually active. - n Ans✔ 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. Qs
- 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. - n Ans✔
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. Qs
- 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?
- Administer 6 L of oxygen via nasal cannula.
- Assess the client's neurological status.
- Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's intravenous (IV) rate. - n Ans✔ 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. Qs
- 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 - n Ans✔
Ans✔ 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. Qs
- The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess first?
- The child diagnosed with type 1 diabetes who has a blood glucose level of 180 mg/dL.
- The child diagnosed with pneumonia who is coughing and has a temperature of 100°F.
- The child diagnosed with gastroenteritis who has a potassium (K+) level of 3.9 mEq/L.
- The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%. - n Ans✔ 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. Qs
- 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. - n Ans✔ 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. Qs
- The nurse has received the a.m. shift report for clients on a pediatric unit. Which medication should the nurse administer first?
- The third dose of the aminoglycoside antibiotic to the child diagnosed with methicillin-resistant Staphylococcus aureus (MRSA).
- The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with asthma.
- The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
- The stimulant methylphenidate (Ritalin) to a child diagnosed with attention deficit-hyperactivity disorder (ADHD). - n Ans✔ 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.
- Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4. Determine unresponsiveness.
- Open the infant's airway. - n Ans✔ Rationale Correct Answer: 4, 5, 3, 2, 1
- The nurse must first determine the infant's responsiveness by thumping the baby's feet.
- 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.
- The nurse then administers quick puffs of air while covering the child's mouth and nose, preferably with a rescue mask.
- The nurse should determine whether the infant has a pulse by checking the brachial artery.
- If the infant has no pulse, the nurse should begin chest compressions using two fingers at a rate of 30:2. Qs
- 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?" D) "You have been taking your medicine, haven't you?" - n Ans✔
A) "Do you take medicine?" Page: 46 In a situation where there is a language barrier and no interpreter available, use simple words avoiding medical jargon. Avoid using contractions and pronouns. Use nouns repeatedly and discuss one topic at a time. Qs
- A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? A) A trained interpreter B) A male family member C) A female family member D) A volunteer college student from the foreign language studies department - n Ans✔ A) A trained interpreter Page: 46 whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is preferred when possible. Qs
- The 3-year-old client has been admitted to the pediatric unit. Which task should the nurse instruct the unlicensed assistive personnel (UAP) to perform first?
- Orient the parents and child to the room.
- Obtain an admission kit for the child.
- Post the child's height and weight at the HOB. 4. Provide the child with a meal tray. - n Ans✔
B) They allow for self-expression. C) They build and enhance rapport. F) They are used when narrative information Page: 32 Open-ended questions allow for self-expression, build rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions. Qs
- The nurse is writing a care plan for the 5-year-old child diagnosed with gastroenteritis. Which client problem is priority?
- Imbalanced nutrition.
- Fluid volume deficit.
- Knowledge deficit. 4. Risk for infection. - n Ans✔ Rationale Correct - 2-The child diagnosed with gastroenteritis is at high risk for hypovolemic shock resulting from vomiting and diarrhea; therefore, maintaining fluid and elec- trolyte homeostasis is priority. Qs
- The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply. A) Collect the patient's data in a direct, face-to-face manner. B) Enter all the data as the patient states it. C) Ask the patient to wait as the nurse enters data. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing. - n
Ans✔ A) Collect the patient's data in a direct, face-to-face manner. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing. Page: 32 The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient's narrative story in a direct face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it. Qs
- Which data would warrant immediate intervention from the pediatric nurse? 1. Proteinuria for the child diagnosed with nephrotic syndrome.
- Petechiae for the child diagnosed with leukemia.
- Drooling for a child diagnosed with acute epiglottitis.
- Elevated temperature in a child diagnosed with otitis media. - n Ans✔ 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. Qs
- 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.
A) have less efficient immune systems and are often ill. B) consider these symptoms a part of normal living, not symptoms of ill health. C) come from Mexico and coughing is normal and healthy there. D) are usually in a lower socioeconomic group and are more likely to be sick. - n Ans✔ B) consider these symptoms a part of normal living, not symptoms of ill health. Page: 27 The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health. Qs
- The pediatric clinic nurse is triaging telephone calls. Which client's parent should the nurse call first?
- The 4-month-old child who had immunizations yesterday and the parent is report- ing a high-pitched cry and a 103°F fever.
- The 8-month-old whose parent is reporting the child is pulling on the right ear and has a fever.
- The 2-year-old child who has patent ductus arteriosis whose parent reports running out of digoxin.
- The 3-year-old child whose mother called and reported her daughter may have chickenpox. - n Ans✔ Rationale Correct 1-A high fever and high-pitched crying may indicate a reaction to the immunizations; therefore, this parent needs to be called first to bring the child to the clinic. Qs
- Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief? A) A person is able to work and produce. B) A person is happy, stable, and feels good. C) All aspects of the person are in perfect balance. D) A person is able to care for others and function socially. - n Ans✔ C) All aspects of the person are in perfect balance. Page: 21 Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory. Qs
- The parent of a 12-year-old male child with a left below-the-knee cast calls the pedi- atric clinic nurse and tells the nurse, "My son's foot is cold and he told me it feels like his foot is asleep." Which action should the nurse implement first?
- Prepare to bifurcate the left below-the-knee cast.
- Tell the parent to bring the child to the office.
- Instruct the parent to elevate the left leg on two pillows.
- Notify the child's orthopedist of the situation. - n Ans✔ Rationale Correct - 3. The nurse should first take care of the client's body by having the parent elevate the left leg. Qs
seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers. Qs
- Which child requires the nurse to notify the healthcare provider?
- The 1-year-old child with iron deficiency anemia who has dark-colored stool.
- The 3-year-old child with phenylketonuria (PKU) whose parent does not feed the child any meat or milk products.
- The 5-year-old child with rheumatic heart fever who is having difficulty breathing.
- The 7-year-old child diagnosed with acute glomerulonephritis who has dark "tea"-colored urine. - n Ans✔ Rationale Correct - 3-A complication of rheumatic heart disease is valvular disorders that may be mani- fested by respiratory problems; therefore, the nurse should notify the child's health- care provider. Qs
- The pediatric nurse on the surgical unit has just received a.m. shift report. Which client should the nurse assess first?
- The 3-week-old child 1 day postoperative with surgical repair of a myelomeningo- cele who has bulging fontanels.
- The 3-month-old child 2 days postoperative temporary colostomy secondary to Hirschsprung's disease who has a moist, pink stoma.
- The 9-month-old child with a cleft palate repair who is spitting up formula and refusing to eat.
- The 4-year-old child 1 day postoperative for repair of hypospadias who has clear amber urine draining from indwelling catheter. - n
Ans✔ Rationale Correct - 1-Bulging fontanels is a sign of increased intracranial pressure, which is a compli- cation of neurological surgery; therefore, this child should be assessed first. Qs
- An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would: A) contact the hospital administrator about the best course of action. B) automatically get a curandero for her because it is not culturally appropriate for her to request one. C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. D) ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families. - n Ans✔ C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. Pages: 22-23 In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept). Qs
- The charge nurse has assigned a staff nurse to care for an 8-year-old client diagnosed with cerebral palsy. Which nursing action by the staff nurse would warrant immediate intervention by the charge nurse?
- The nurse and the unlicensed assistive personnel (UAP) are caring for clients on the pediatric unit. Which action by the nurse indicates appropriate delegation?
- The nurse requests the UAP to check the circulation on the child with a cast.
- The nurse asks the UAP to feed an infant who has just had a cleft palate repair.
- The nurse has the UAP demonstrate a catheterization for a child with a neurogenic bladder.
- The nurse checks to make sure the UAP's delegated tasks have been completed. - n Ans✔ Rationale Correct - 4. The last step of delegating to a UAP is for the nurse to evaluate and determine whether the delegated tasks have been completed and performed correctly. This indicates the nurse has delegated appropriately. Qs
- The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: A) children have spiritual needs that are influenced by their stages of development. B) children have spiritual needs that are direct reflections of what is occurring in their homes. C) religious beliefs rarely affect the parents' perceptions of the illness. D) parents are often the decision makers, and they have no knowledge of their children's spiritual needs. - n Ans✔ A) children have spiritual needs that are influenced by their stages of development. Page: 20. Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct.
Qs
- The nurse on a pediatric unit has received the a.m. shift report and tells the unli- censed assistive personnel (UAP) to keep the 2-year-old child NPO for a procedure. At 0830, the nurse observes the mother feeding the child. Which action should the nurse implement first?
- Determine what the UAP did not understand about the instruction.
- Tell the HCP the UAP did not follow the nurse's direction.
- Ask the mother why she was feeding her child if the child was NPO.
- Notify the dietary department to hold the child's meal trays. - n Ans✔ Rationale Correct - 1.Communication to the UAP must be clear, concise, correct, and complete. The nurse must determine why there was a lack of communication, which resulted in the child receiving food; therefore, this action should be implemented first. Qs
- When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an elderly American Indian patient? A) "Are you of the Christian faith?" B) "Do you want to see a medicine man?" C) "How often do you seek help from medical providers?" D) "What cultural or spiritual beliefs are important to you?" - n Ans✔ D) "What cultural or spiritual beliefs are important to you?"
