HESI A2 - Critical Thinking
Questions with Accurate Answers
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.
104. While examining a patient, the nurse observes abdominal pulsations
between the xiphoid and umbilicus. The nurse would suspect that these are:
A) pulsations of the renal arteries.
B) pulsations of the inferior vena cava.
Questions with Accurate Answers
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.
104. While examining a patient, the nurse observes abdominal pulsations
between the xiphoid and umbilicus. The nurse would suspect that these are:
A) pulsations of the renal arteries.
B) pulsations of the inferior vena cava.
