HESIghnA2ghn-ghnCriticalghnThinking
1.ghnTheghnnurseghnisghnworkingghninghntheghnemergencyghndepartmentghn(ED)ghnofgh
naghnchildren'sghnmedicalghncenter.ghnWhichghnclientghnshouldghntheghnnurseghnasse
ssghnfirst?
1.ghnTheghn1-month-
oldghninfantghnwhoghnhasghndevelopedghncolicghnandghnisghncrying.
2.ghnTheghn2-year-
oldghntoddlerghnwhoghnwasghnbittenghnbyghnanotherghnchildghnatghntheghnday-
careghncenter.ghn3.ghnTheghn6-year-oldghnschool-
ageghnchildghnwhoghnwasghnhitghnbyghnaghncarghnwhileghnridingghnaghnbicycle.
4.ghnTheghn14-year-
oldghnadolescentghnwhoseghnmotherghnsuspectsghnherghnchildghnisghnsexuallyghnacti
ve.ghn-ghnCORRECTghnANSWER✔Rationaleghn
Correctghn-ghn3-
Theghnchildghnhitghnbyghnaghncarghnshouldghnbeghnassessedghnfirstghnbecauseghnheghnorgh
nsheghnmayghnhaveghnlife-
ghnthreatening ghninjuriesghnthatghnmustghnbeghnassessedghnandghntreatedghnpromptly
.
1.ghnInghnanghninterview,ghntheghnnurseghnmayghnfindghnitghnnecessaryghntoghntakeghnno
tesghntoghnaidghnhisghnorghnherghnmemoryghnlater.ghnWhichghnstatementghnisghntrueghnre
gardingghnnote-taking?ghn
,A)ghnNote-
takingghnmayghnimpedeghntheghnnurse'sghnobservationghnofghntheghnpatient'sghnnonv
erbalghnbehaviors.
B)ghnNote-
takingghnallowsghntheghnpatientghntoghncontinueghnatghnhisghnorghnherghnownghnpaceghna
sghntheghnnurseghnrecordsghnwhatghnisghnsaid.
C)ghnNote-
takingghnallowsghntheghnnurseghntoghnshiftghnattentionghnawayghnfromghntheghnpatient
,ghnresultingghninghnanghnincreasedghncomfortghnlevel.
D)ghnNote-
takingghnallowsghntheghnnurseghntoghnbreakghneyeghncontactghnwithghntheghnpatient,ghn
whichghnmayghnincreaseghnhisghnorghnherghnlevelghnofghncomfort.ghn-
ghnCORRECTghnANSWER✔A)ghnNote-
takingghnmayghnimpedeghntheghnnurse'sghnobservationghnofghntheghnpatient'sghnnonv
erbalghnbehaviors.
Page:ghn31ghnSomeghnuseghnofghnhistoryghnformsghnandghnnote-
takingghnmayghnbeghnunavoidable.ghnButghnbeghnawareghnthatghnnote-
takingghnduringghntheghninterviewghnhasghndisadvantages.ghnItghnbreaksghneyeghnco
ntactghntooghnoften,ghnandghnitghnshiftsghnattentionghnawayghnfromghntheghnpatient,ghn
whichghndiminishesghnhisghnorghnherghnsenseghnofghnimportance.ghnItghnalsoghnmayghni
nterruptghntheghnpatient'sghnnarrativeghnflow,ghnandghnitghnimpedesghntheghnobservat
ionghnofghntheghnpatient'sghnnonverbalghnbehavior.
2.ghnTheghn8-year-oldghnclientghndiagnosedghnwithghnaghnvaso-
occlusiveghnsickleghncellghncrisisghnisghncomplainingghnofghnaghnsevereghnheadache.g
hnWhichghnintervention ghnshouldghntheghnnurseghnimplementghnfirst?
1.ghnAdministerghn6ghnLghnofghnoxygenghnviaghnnasalghncannula.
2.ghnAssessghntheghnclient'sghnneurologicalghnstatus.
,3.ghnAdministerghnaghnnarcoticghnanalgesicghnbyghnintravenousghnpushghn(IVP).ghn4
.ghnIncreaseghntheghnclient'sghnintravenousghn(IV)ghnrate.ghn-
ghnCORRECTghnANSWER✔Rationaleghn
Correctghn-ghn2-
Becauseghntheghnclientghnisghncomplainingghnofghnaghnheadache,ghntheghnnurseghnsho
uldghnfirstghnruleghnoutghncerebrovascularghnaccidentghn(CVA)ghnbyghnassess-
ghningghntheghnclient's ghnneurologicalghnstatusghnandghnthenghndetermine ghnwhetherg
hnitghnisghnaghnheadacheghnthatghncanghnbeghntreatedghnwithghnmedication.
2.ghnDuringghnanghninterview,ghntheghnnurseghnstates,ghn"Youghnmentionedghnshortn
essghnofghnbreath.ghnTellghnmeghnmoreghnaboutghnthat."ghnWhichghnverbalghnskillghnisg
hnusedghnwithghnthisghnstatement?
A)ghnReflection
B)ghnFacilitation
C)ghnDirectghnquestion
D)ghnOpen-endedghnquestionghn-ghnCORRECTghnANSWER✔D)ghnOpen-
endedghnquestion
Page:ghn32ghnTheghnopen-
endedghnquestionghnasksghnforghnnarrativeghninformation.ghnItghnstatesghntheghntopic
ghntoghnbeghndiscussedghnbutghnonlyghninghngeneralghnterms.ghnTheghnnurseghnshouldghn
useghnitghntoghnbeginghntheghninterview,ghntoghnintroduceghnaghnnewghnsectionghnofghnq
uestions,ghnandghnwheneverghntheghnpersonghnintroducesghnaghnnewghntopic.
3.ghnTheghn6-year-
oldghnclientghnwhoghnhasghnundergoneghnabdominalghnsurgeryghnisghnattemptingghnt
, oghnmakeghnaghnpinwheelghnspinghnbyghnblowingghnonghnitghnwithghntheghnnurse'sghnass
istance.ghnTheghnchildghnstartsghncryingghnbecauseghntheghnpinwheelghnwon'tghnspin
.ghnWhichghnactionghnshouldghntheghnnurseghnimplementghnfirst?
1.ghnPraiseghntheghnchildghnforghntheghnattemptghntoghnmakeghntheghnpinwheelghnspin.
2.ghnNotifyghntheghnrespiratoryghntherapistghntoghnimplementghnincentiveghnspirom
etry.ghn3.ghnEncourageghntheghnchildghntoghnturnghnfromghnsideghntoghnsideghnandghncou
gh.
4.ghnDemonstrateghnhowghntoghnmakeghntheghnpinwheelghnspinghnbyghnblowingghnong
hnit.ghn-ghnCORRECTghnANSWER✔Rationaleghn
Correctghn-
1.ghnTheghnnurseghnshouldghnalwaysghnpraiseghntheghnchildghnforghnattemptsghnatghnco
operationghnevenghnifghntheghnchildghndidghnnotghnaccomplishghnwhatghntheghnnurseghn
asked.
3.ghnAghnnurseghnisghntakingghncompleteghnhealthghnhistoriesghnonghnallghnofghntheghnpa
tientsghnattendingghnaghnwellnessghnworkshop.ghnOnghntheghnhistoryghnform,ghnonegh
nofghntheghnwrittenghnquestionsghnasks,ghn"Youghndon'tghnsmoke,ghndrink,ghnorghntake
ghndrugs,ghndoghnyou?"ghnThisghnquestionghnisghnanghnexampleghnof:
A)ghntalkingghntooghnmuch.
B)ghnusingghnconfrontation.
C)ghnusingghnbiasedghnorghnleadingghnquestions.
D)ghnusingghnbluntghnlanguageghntoghndealghnwithghndistastefulghntopics.ghn-
ghnCORRECTghnANSWER✔C)ghnusingghnbiasedghnorghnleadingghnquestions.
1.ghnTheghnnurseghnisghnworkingghninghntheghnemergencyghndepartmentghn(ED)ghnofgh
naghnchildren'sghnmedicalghncenter.ghnWhichghnclientghnshouldghntheghnnurseghnasse
ssghnfirst?
1.ghnTheghn1-month-
oldghninfantghnwhoghnhasghndevelopedghncolicghnandghnisghncrying.
2.ghnTheghn2-year-
oldghntoddlerghnwhoghnwasghnbittenghnbyghnanotherghnchildghnatghntheghnday-
careghncenter.ghn3.ghnTheghn6-year-oldghnschool-
ageghnchildghnwhoghnwasghnhitghnbyghnaghncarghnwhileghnridingghnaghnbicycle.
4.ghnTheghn14-year-
oldghnadolescentghnwhoseghnmotherghnsuspectsghnherghnchildghnisghnsexuallyghnacti
ve.ghn-ghnCORRECTghnANSWER✔Rationaleghn
Correctghn-ghn3-
Theghnchildghnhitghnbyghnaghncarghnshouldghnbeghnassessedghnfirstghnbecauseghnheghnorgh
nsheghnmayghnhaveghnlife-
ghnthreatening ghninjuriesghnthatghnmustghnbeghnassessedghnandghntreatedghnpromptly
.
1.ghnInghnanghninterview,ghntheghnnurseghnmayghnfindghnitghnnecessaryghntoghntakeghnno
tesghntoghnaidghnhisghnorghnherghnmemoryghnlater.ghnWhichghnstatementghnisghntrueghnre
gardingghnnote-taking?ghn
,A)ghnNote-
takingghnmayghnimpedeghntheghnnurse'sghnobservationghnofghntheghnpatient'sghnnonv
erbalghnbehaviors.
B)ghnNote-
takingghnallowsghntheghnpatientghntoghncontinueghnatghnhisghnorghnherghnownghnpaceghna
sghntheghnnurseghnrecordsghnwhatghnisghnsaid.
C)ghnNote-
takingghnallowsghntheghnnurseghntoghnshiftghnattentionghnawayghnfromghntheghnpatient
,ghnresultingghninghnanghnincreasedghncomfortghnlevel.
D)ghnNote-
takingghnallowsghntheghnnurseghntoghnbreakghneyeghncontactghnwithghntheghnpatient,ghn
whichghnmayghnincreaseghnhisghnorghnherghnlevelghnofghncomfort.ghn-
ghnCORRECTghnANSWER✔A)ghnNote-
takingghnmayghnimpedeghntheghnnurse'sghnobservationghnofghntheghnpatient'sghnnonv
erbalghnbehaviors.
Page:ghn31ghnSomeghnuseghnofghnhistoryghnformsghnandghnnote-
takingghnmayghnbeghnunavoidable.ghnButghnbeghnawareghnthatghnnote-
takingghnduringghntheghninterviewghnhasghndisadvantages.ghnItghnbreaksghneyeghnco
ntactghntooghnoften,ghnandghnitghnshiftsghnattentionghnawayghnfromghntheghnpatient,ghn
whichghndiminishesghnhisghnorghnherghnsenseghnofghnimportance.ghnItghnalsoghnmayghni
nterruptghntheghnpatient'sghnnarrativeghnflow,ghnandghnitghnimpedesghntheghnobservat
ionghnofghntheghnpatient'sghnnonverbalghnbehavior.
2.ghnTheghn8-year-oldghnclientghndiagnosedghnwithghnaghnvaso-
occlusiveghnsickleghncellghncrisisghnisghncomplainingghnofghnaghnsevereghnheadache.g
hnWhichghnintervention ghnshouldghntheghnnurseghnimplementghnfirst?
1.ghnAdministerghn6ghnLghnofghnoxygenghnviaghnnasalghncannula.
2.ghnAssessghntheghnclient'sghnneurologicalghnstatus.
,3.ghnAdministerghnaghnnarcoticghnanalgesicghnbyghnintravenousghnpushghn(IVP).ghn4
.ghnIncreaseghntheghnclient'sghnintravenousghn(IV)ghnrate.ghn-
ghnCORRECTghnANSWER✔Rationaleghn
Correctghn-ghn2-
Becauseghntheghnclientghnisghncomplainingghnofghnaghnheadache,ghntheghnnurseghnsho
uldghnfirstghnruleghnoutghncerebrovascularghnaccidentghn(CVA)ghnbyghnassess-
ghningghntheghnclient's ghnneurologicalghnstatusghnandghnthenghndetermine ghnwhetherg
hnitghnisghnaghnheadacheghnthatghncanghnbeghntreatedghnwithghnmedication.
2.ghnDuringghnanghninterview,ghntheghnnurseghnstates,ghn"Youghnmentionedghnshortn
essghnofghnbreath.ghnTellghnmeghnmoreghnaboutghnthat."ghnWhichghnverbalghnskillghnisg
hnusedghnwithghnthisghnstatement?
A)ghnReflection
B)ghnFacilitation
C)ghnDirectghnquestion
D)ghnOpen-endedghnquestionghn-ghnCORRECTghnANSWER✔D)ghnOpen-
endedghnquestion
Page:ghn32ghnTheghnopen-
endedghnquestionghnasksghnforghnnarrativeghninformation.ghnItghnstatesghntheghntopic
ghntoghnbeghndiscussedghnbutghnonlyghninghngeneralghnterms.ghnTheghnnurseghnshouldghn
useghnitghntoghnbeginghntheghninterview,ghntoghnintroduceghnaghnnewghnsectionghnofghnq
uestions,ghnandghnwheneverghntheghnpersonghnintroducesghnaghnnewghntopic.
3.ghnTheghn6-year-
oldghnclientghnwhoghnhasghnundergoneghnabdominalghnsurgeryghnisghnattemptingghnt
, oghnmakeghnaghnpinwheelghnspinghnbyghnblowingghnonghnitghnwithghntheghnnurse'sghnass
istance.ghnTheghnchildghnstartsghncryingghnbecauseghntheghnpinwheelghnwon'tghnspin
.ghnWhichghnactionghnshouldghntheghnnurseghnimplementghnfirst?
1.ghnPraiseghntheghnchildghnforghntheghnattemptghntoghnmakeghntheghnpinwheelghnspin.
2.ghnNotifyghntheghnrespiratoryghntherapistghntoghnimplementghnincentiveghnspirom
etry.ghn3.ghnEncourageghntheghnchildghntoghnturnghnfromghnsideghntoghnsideghnandghncou
gh.
4.ghnDemonstrateghnhowghntoghnmakeghntheghnpinwheelghnspinghnbyghnblowingghnong
hnit.ghn-ghnCORRECTghnANSWER✔Rationaleghn
Correctghn-
1.ghnTheghnnurseghnshouldghnalwaysghnpraiseghntheghnchildghnforghnattemptsghnatghnco
operationghnevenghnifghntheghnchildghndidghnnotghnaccomplishghnwhatghntheghnnurseghn
asked.
3.ghnAghnnurseghnisghntakingghncompleteghnhealthghnhistoriesghnonghnallghnofghntheghnpa
tientsghnattendingghnaghnwellnessghnworkshop.ghnOnghntheghnhistoryghnform,ghnonegh
nofghntheghnwrittenghnquestionsghnasks,ghn"Youghndon'tghnsmoke,ghndrink,ghnorghntake
ghndrugs,ghndoghnyou?"ghnThisghnquestionghnisghnanghnexampleghnof:
A)ghntalkingghntooghnmuch.
B)ghnusingghnconfrontation.
C)ghnusingghnbiasedghnorghnleadingghnquestions.
D)ghnusingghnbluntghnlanguageghntoghndealghnwithghndistastefulghntopics.ghn-
ghnCORRECTghnANSWER✔C)ghnusingghnbiasedghnorghnleadingghnquestions.
