HESI A2 - Cr itical Thinking Exam Questions w ith
100% Ver ifi ed Cor r ect Answ er s
1. 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; 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. 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, result-
ing 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 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. 2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is
complaining of a severe headache. Which intervention should the nurse im-
plement 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 Rationale
Correct - 2-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident
(CVA) by assessing the client's neurological status and then determine whether it is a headache that can be treated with
medication.
,4. 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 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.
5. 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. Encour-
age the child to turn from side to side and cough.
4. Demonstrate how to make the pinwheel spin by blowing on it.
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.
6. 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 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.
7. 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.
100% Ver ifi ed Cor r ect Answ er s
1. 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; 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. 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, result-
ing 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 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. 2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is
complaining of a severe headache. Which intervention should the nurse im-
plement 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 Rationale
Correct - 2-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident
(CVA) by assessing the client's neurological status and then determine whether it is a headache that can be treated with
medication.
,4. 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 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.
5. 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. Encour-
age the child to turn from side to side and cough.
4. Demonstrate how to make the pinwheel spin by blowing on it.
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.
6. 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 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.
7. 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.
