HESI A2 CRICTICAL THINKING EXAM WITH BEST SOLUTIONS

HESI A2 CRICTICAL THINKING EXAM WITH BEST SOLUTIONS

1.   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.

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.

2.   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.

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.

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%. - Correct Answer-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. - Correct Answer-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). - Correct Answer-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.