HESI A2 - Critical Thinking Exam
Questions with Complete
Solutions
The nurse is performing a functional assessment on an 82-year-old patient who recently
had a stroke. Which of these questions would be most important to ask?
A. "Do you wear glasses?"
B. "Are you able to dress yourself?"
C. "Do you have any thyroid problems?"
D. "How many times a day do you have a bowel movement?" - Answer- B. "Are you
able to dress yourself?"
Rationale
Functional assessment measures how a person manages day-to-day activities. For the
older person, the meaning of health becomes those activities that they can or cannot
do. The other responses do not relate to functional assessment.
78. A 65-year-old patient with a history of heart failure comes to the clinic with
complaints of "being awakened from sleep with shortness of breath." Which action by
the nurse is most appropriate?
A) Obtain a detailed history of the patient's allergies and history of asthma.
B) Tell the patient to sleep on his or her right side to facilitate ease of respirations.
C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
D) Assure the patient that this is normal and will probably resolve within the next week. -
Answer- C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
Pages: 419-420. The patient is experiencing paroxysmal nocturnal dyspnea: being
awakened from sleep with shortness of breath and the need to be upright to achieve
comfort.
The nurse is preparing to do a mental status examination. Which statement is true
regarding the mental status examination?
A) A patient's family is the best resource for information about the patient's coping skills.
B) It is usually sufficient to gather mental status information during the health history
interview.
C) It takes an enormous amount of extra time to integrate the mental status examination
into the health history interview.
,D) It is usually necessary to perform a complete mental status examination to get a
good idea of the patient's level of functioning. - Answer- B) It is usually sufficient to
gather mental status information during the health history interview.
Rationale
The full mental status examination is a systematic check of emotional and cognitive
functioning. The steps described here, though, rarely need to be taken in their entirety.
Usually, one can assess mental status through the context of the health history
interview.
79. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile
fremitus most intensely over which location?
A) Between the scapulae
B) Third intercostal space, MCL
C) Fifth intercostal space, MAL
D) Over the lower lobes, posterior side - Answer- A) Between the scapulae
Page: 424. Normally, fremitus is most prominent between the scapulae and around the
sternum. These are sites where the major bronchi are closest to the chest wall.
Fremitus normally decreases as one progress down the chest because more tissue
impedes sound transmission.
The nurse is conducting a developmental history on a 5-year-old child. Which questions
are appropriate to ask the parents for this part of the assessment? Select all that apply.
A. "How much junk food does your child eat?"
B. "How many teeth has he lost, and when did he lose them?"
C. "Is he able to tie his shoelaces?"
D. "Does he take a children's vitamin?"
E. "Can he tell time?"
F. "Does he have any food allergies?" - Answer- B. "How many teeth has he lost, and
when did he lose them?"
C. "Is he able to tie his shoelaces?"
E. "Can he tell time?"
Rationale
Questions about tooth loss, ability to tell time, and ability to tie shoelaces are
appropriate questions for a developmental assessment. Questions about junk food
intake and vitamins are part of a nutritional history. Questions about food allergies are
not part of a developmental history.
80. The nurse is reviewing the technique of palpating for tactile fremitus with a new
graduate. Which statement by the graduate nurse reflects a correct understanding of
tactile fremitus? "Tactile fremitus:
,A) is caused by moisture in the alveoli."
B) indicates that there is air in the subcutaneous tissues."
C) is caused by sounds generated from the larynx."
D) reflects the blood flow through the pulmonary arteries." - Answer- C) is caused by
sounds generated from the larynx."
Pages: 422-423. Fremitus is a palpable vibration. Sounds generated from the larynx are
transmitted through patent bronchi and the lung parenchyma to the chest wall where
they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.
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 - Answer-
A) A trained interpreter
Rationale
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.
81. When auscultating the lungs of an adult patient, the nurse notes that over the
posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being
longer than expiration. The nurse interprets that these are:
A) sounds normally auscultated over the trachea.
B) bronchial breath sounds and are normal in that location.
C) vesicular breath sounds and are normal in that location.
D) bronchovesicular breath sounds and are normal in that location. - Answer- C)
vesicular breath sounds and are normal in that location.
Pages: 428-429. Vesicular breath sounds are low-pitched, soft sounds with inspiration
being longer than expiration. These breath sounds are expected over peripheral lung
fields where air flows through smaller bronchioles and alveoli.
When the nurse is evaluating the reliability of a patient's responses, which of these
statements would be correct? The patient:
A. has a history of drug abuse and therefore is not reliable.
B. provided consistent information and therefore is reliable.
C. smiled throughout interview and therefore is assumed reliable.
D. would not answer questions concerning stress and therefore is not reliable. - Answer-
B. provided consistent information and therefore is reliable.
, Rationale
A reliable person always gives the same answers, even when questions are rephrased
or are repeated later in the interview. The other statements are not correct.
82. The nurse is percussing over the lungs of a patient with pneumonia. The nurse
knows that percussion over an area of atelectasis in the lungs would reveal:
A) dullness.
B) tympany.
C) resonance.
D) hyperresonance. - Answer- A) dullness.
Pages: 424-425. A dull percussion note signals an abnormal density in the lungs, as
with pneumonia, pleural effusion, atelectasis, or tumor.
83. The nurse knows that auscultation of fine crackles would most likely be noticed in:
A) a healthy 5-year-old child.
B) a pregnant woman.
C) the immediate newborn period.
D) association with a pneumothorax. - Answer- C) the immediate newborn period.
Pages: 436-437. Fine crackles are commonly heard in the immediate newborn period
as a result of the opening of the airways and clearing of fluid. Persistent fine crackles
would be noticed with pneumonia, bronchiolitis, or atelectasis.
The nurse is conducting an interview. Which of these statements is true regarding open-
ended questions? Select all that apply.
A) They elicit cold facts.
B) They allow for self-expression.
C) They build and enhance rapport.
D) They leave interactions neutral.
E) They call for short one- to two-word answers.
F) They are used when narrative information is needed. - Answer- B) They allow for
self-expression.
C) They build and enhance rapport.
F) They are used when narrative information
Rationale
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.
When planning a cultural assessment, the nurse should include which component?
Questions with Complete
Solutions
The nurse is performing a functional assessment on an 82-year-old patient who recently
had a stroke. Which of these questions would be most important to ask?
A. "Do you wear glasses?"
B. "Are you able to dress yourself?"
C. "Do you have any thyroid problems?"
D. "How many times a day do you have a bowel movement?" - Answer- B. "Are you
able to dress yourself?"
Rationale
Functional assessment measures how a person manages day-to-day activities. For the
older person, the meaning of health becomes those activities that they can or cannot
do. The other responses do not relate to functional assessment.
78. A 65-year-old patient with a history of heart failure comes to the clinic with
complaints of "being awakened from sleep with shortness of breath." Which action by
the nurse is most appropriate?
A) Obtain a detailed history of the patient's allergies and history of asthma.
B) Tell the patient to sleep on his or her right side to facilitate ease of respirations.
C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
D) Assure the patient that this is normal and will probably resolve within the next week. -
Answer- C) Assess for other signs and symptoms of paroxysmal nocturnal dyspnea.
Pages: 419-420. The patient is experiencing paroxysmal nocturnal dyspnea: being
awakened from sleep with shortness of breath and the need to be upright to achieve
comfort.
The nurse is preparing to do a mental status examination. Which statement is true
regarding the mental status examination?
A) A patient's family is the best resource for information about the patient's coping skills.
B) It is usually sufficient to gather mental status information during the health history
interview.
C) It takes an enormous amount of extra time to integrate the mental status examination
into the health history interview.
,D) It is usually necessary to perform a complete mental status examination to get a
good idea of the patient's level of functioning. - Answer- B) It is usually sufficient to
gather mental status information during the health history interview.
Rationale
The full mental status examination is a systematic check of emotional and cognitive
functioning. The steps described here, though, rarely need to be taken in their entirety.
Usually, one can assess mental status through the context of the health history
interview.
79. When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile
fremitus most intensely over which location?
A) Between the scapulae
B) Third intercostal space, MCL
C) Fifth intercostal space, MAL
D) Over the lower lobes, posterior side - Answer- A) Between the scapulae
Page: 424. Normally, fremitus is most prominent between the scapulae and around the
sternum. These are sites where the major bronchi are closest to the chest wall.
Fremitus normally decreases as one progress down the chest because more tissue
impedes sound transmission.
The nurse is conducting a developmental history on a 5-year-old child. Which questions
are appropriate to ask the parents for this part of the assessment? Select all that apply.
A. "How much junk food does your child eat?"
B. "How many teeth has he lost, and when did he lose them?"
C. "Is he able to tie his shoelaces?"
D. "Does he take a children's vitamin?"
E. "Can he tell time?"
F. "Does he have any food allergies?" - Answer- B. "How many teeth has he lost, and
when did he lose them?"
C. "Is he able to tie his shoelaces?"
E. "Can he tell time?"
Rationale
Questions about tooth loss, ability to tell time, and ability to tie shoelaces are
appropriate questions for a developmental assessment. Questions about junk food
intake and vitamins are part of a nutritional history. Questions about food allergies are
not part of a developmental history.
80. The nurse is reviewing the technique of palpating for tactile fremitus with a new
graduate. Which statement by the graduate nurse reflects a correct understanding of
tactile fremitus? "Tactile fremitus:
,A) is caused by moisture in the alveoli."
B) indicates that there is air in the subcutaneous tissues."
C) is caused by sounds generated from the larynx."
D) reflects the blood flow through the pulmonary arteries." - Answer- C) is caused by
sounds generated from the larynx."
Pages: 422-423. Fremitus is a palpable vibration. Sounds generated from the larynx are
transmitted through patent bronchi and the lung parenchyma to the chest wall where
they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.
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 - Answer-
A) A trained interpreter
Rationale
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.
81. When auscultating the lungs of an adult patient, the nurse notes that over the
posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being
longer than expiration. The nurse interprets that these are:
A) sounds normally auscultated over the trachea.
B) bronchial breath sounds and are normal in that location.
C) vesicular breath sounds and are normal in that location.
D) bronchovesicular breath sounds and are normal in that location. - Answer- C)
vesicular breath sounds and are normal in that location.
Pages: 428-429. Vesicular breath sounds are low-pitched, soft sounds with inspiration
being longer than expiration. These breath sounds are expected over peripheral lung
fields where air flows through smaller bronchioles and alveoli.
When the nurse is evaluating the reliability of a patient's responses, which of these
statements would be correct? The patient:
A. has a history of drug abuse and therefore is not reliable.
B. provided consistent information and therefore is reliable.
C. smiled throughout interview and therefore is assumed reliable.
D. would not answer questions concerning stress and therefore is not reliable. - Answer-
B. provided consistent information and therefore is reliable.
, Rationale
A reliable person always gives the same answers, even when questions are rephrased
or are repeated later in the interview. The other statements are not correct.
82. The nurse is percussing over the lungs of a patient with pneumonia. The nurse
knows that percussion over an area of atelectasis in the lungs would reveal:
A) dullness.
B) tympany.
C) resonance.
D) hyperresonance. - Answer- A) dullness.
Pages: 424-425. A dull percussion note signals an abnormal density in the lungs, as
with pneumonia, pleural effusion, atelectasis, or tumor.
83. The nurse knows that auscultation of fine crackles would most likely be noticed in:
A) a healthy 5-year-old child.
B) a pregnant woman.
C) the immediate newborn period.
D) association with a pneumothorax. - Answer- C) the immediate newborn period.
Pages: 436-437. Fine crackles are commonly heard in the immediate newborn period
as a result of the opening of the airways and clearing of fluid. Persistent fine crackles
would be noticed with pneumonia, bronchiolitis, or atelectasis.
The nurse is conducting an interview. Which of these statements is true regarding open-
ended questions? Select all that apply.
A) They elicit cold facts.
B) They allow for self-expression.
C) They build and enhance rapport.
D) They leave interactions neutral.
E) They call for short one- to two-word answers.
F) They are used when narrative information is needed. - Answer- B) They allow for
self-expression.
C) They build and enhance rapport.
F) They are used when narrative information
Rationale
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.
When planning a cultural assessment, the nurse should include which component?
