HESI A2 CRICTICAL THINKING (HESI A2 MULTI-VERSIONS) EXAMS WITH BEST SOLUTIONS

HESI A2 CRICTICAL THINKING (HESI A2 MULTI-VERSIONS)
EXAMS WITH BEST SOLUTIONS
1. The 8-year-oldclientdiagnosed withavaso-occlusive sicklecell crisis is complaining of
a severe headache. Which intervention should the nurse implement first?
1. Administer 6 Lofoxygen vianasal cannula.
2. Assess theclient'sneurological status.
3. Administeranarcotic analgesic byintravenous push(IVP).4. Increasetheclient'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. Duringaninterview, thenursestates, "You mentioned shortness of breath. Tell me
more about that." Which verbal skill is used with this statement?
A) Reflection
B) Facilitation
C) Directquestion
D) Open-ended question - Correct Answer-D) Open-ended question
Page: 32 Theopen-ended question asks fornarrativeinformation. Itstates thetopic to be
discussed butonly ingeneral terms. Thenurseshould useit to begin theinterview, to
introduce a new section of questions, and whenever the person introduces a new topic.
1. Thenurse is workingintheemergencydepartment (ED) of achildren's medical
center. Which client should the nurse assess first?
1. The1-month-oldinfant whohasdevelopedcolicandiscrying.
2. The2-year-old toddler who was bitten byanother child at theday-care center. 3. The 6-
year-old school-age child who was hit by a car while riding a bicycle.
4. The14-year-old adolescent whose mother suspectsher childis sexually active. - Correct
Answer-Rationale
Correct - 3-Thechild hitby acar should beassessed first becauseheor she mayhave lifethreatening injuries that must be assessed and treated promptly.
2. In aninterview, thenurse may finditnecessary to takenotes toaid hisor her
memory later. Which statement is true regarding note-taking?
A) Note-taking may impedethenurse's observationof thepatient'snonverbal
behaviors.
B) Note-taking allowsthepatient tocontinueat hisorherownpaceas thenurse
records what is said.
C) Note-taking allows thenursetoshiftattention away from thepatient, resulting inan
increased comfort level.
D) Note-taking allows the nurse to break eye contact with the patient, which may
increasehis or her level ofcomfort. - Correct Answer-A) Note-taking may impedethe
nurse's observation of the patient's nonverbal behaviors.
Page: 31 Someuseofhistory forms andnote-taking maybeunavoidable. Butbeaware that
note-taking duringtheinterview has disadvantages. It breaks eye contact toooften, 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 makea
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. Praisethechild for theattempt to makethepinwheel spin.
2. Notify therespiratory therapist toimplement incentivespirometry. 3.Encouragethe
child to turn from side to side and cough.
4. Demonstratehow to make thepinwheel spinbyblowingonit. - Correct Answer- Rationale
Correct -1. Thenurseshould always praisethechild for attempts atcooperation evenif the
child did not accomplish what the nurse asked.
3. A nurseis taking complete health histories onall of thepatients 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) talkingtoo much.
B) usingconfrontation.
C) usingbiasedorleadingquestions.
D) usingblunt language todeal 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 oneanswer is "better" thananother. If theperson 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. Thenurse is caringfor clients on thepediatric medicalunit. Whichclient should the
nurse assess first?
1. Thechild diagnosed with type1diabetes who has ablood glucoselevel of
180 mg/dL.
2. Thechild diagnosed with pneumonia whois coughing andhas atemperature of
100°F.
3. Thechilddiagnosed withgastroenteritis whohasapotassium (K+) level of
3.9 mEq/L.
4. Thechilddiagnosed withcystic fibrosis whohasapulseoximeter reading of 90%. -
Correct Answer-Rationale
Correct -4. A pulseoximeter readingof less than 93% is significant andindicates 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 todiscuss his son's treatment,however,hesuddenly crosseshis arms
against his chest and crosses his legs. This would suggest that the parent is:
A) justchanging positions.
B) morecomfortable inthis position.
C) tiredandneedsabreak from theinterview.
D) uncomfortabletalking abouthis 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 withthearmsand legs crossed tends to lookdefensive 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. Thenursehas received thea.m. shift report for clientsonapediatric unit. Which
medication should the nurse administer first?
1. Thethirddoseof theaminoglycosideantibiotic to thechild diagnosed with
methicillin-resistant Staphylococcus aureus (MRSA).
2. TheIVP steroid methylprednisolone(Solu-Medrol) tothechild diagnosed with
asthma.
3. Thesliding scaleinsulin tothechild diagnosed with type1diabetes mellitus.
4. Thestimulant methylphenidate(Ritalin) toachilddiagnosed withattention
deficit-hyperactivity disorder (ADHD). - Correct Answer-Rationale
Correct - 3-Slidingscale insulin isordered ac, which is before meals; therefore, this
medication must be administered first after receiving the a.m. shift report.
4-Routine medications havea1-hour leewaybeforeand after thescheduled time; therefore,
this medication does not have to be adminis- tered first.
5. Thenurseis interviewing apatient whohasahearingimpairment. What techniques
would be most beneficial in communicating with this patient?
A) Determinethecommunication methodheprefers.
B) Avoid using facial and handgestures because mosthearing-impaired peoplefindthis
degrading.
C) Requestasignlanguage interpreterbefore meeting with him tohelp facilitate the
communication.
D) Speak loudlyand with exaggerated facial movement when talking withhim because this
helps with lip reading. - Correct Answer-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. Thenurseshouldspeak slowlyandshould
supplementhisorher voice with appropriate hand gestures or pantomime.