HESI A2 Critical Thinking

HESI A2 Critical Thinking 1. The Patient: An adult with diabetes mellitus who was just given a morning does of insulin which lowers the blood sugar. The Situation: The patient’s breakfast tray arrives, and the nurse notices that the pancake syrup and sugar packets have not been substituted with products containing artificial sweeteners. The Question: What should the nurse do first in this situation? Answer – Remove foods containing sugar and offer sugar substitutes. 2. The Patient: A terminally ill male. The Situation: Nurse “A” and an unidentified woman ride the elevator to the fifth floor, Nurse “B” joins them on the elevator and exclaims that a code has just been called on a male patient on the fifth floor, and he is not expected to live. The Question: What should Nurse “A” do in this situation? Answer – Tell Nurse B stop discussing the client’s situation in a public place. 3. The Patient: An elderly confused female in a semi-private room on a hospital medical unit. The Situation: The patient is yelling loudly at 3:30a.m. and awakens her roommate, who calls the nurse for assistance. The Question: What should the nurse do first in this situation? Answer – Assess the confused patient for causes of her behaviour. 4. The Patient: A 75-year-old male. The Situation: The family brings the patient to the emergency room because they witnessed him have a seizure. The patient is hallucinating, and loudly cries out to the nurse, “Get those dogs out of here!” The nurse places the patient in a cubicle where he can be seen from the nurse’s station. The Question: What action would be best for the nurse to take? Answer – Ask the family to remain with the patient. The Patient: A 65-year- old male. The Situation: The family brings the patient to the emergency room because he just took an entire bottle of pills. The Question: What action should the nurse take first? Answer – Determine the patient’s level of consciousness. 5. The Patient: An 80 year-old male who has used continuous oxygen for the past three years. The Situation: While making a home visit, the wife tells the nurse that her husband was doing well on 2 litres of oxygen per minute until late last night when he developed severe shortness of breath on the way to the bathroom. The Question: What action should the nurse take first? Answer – Assess the patient’s oxygen saturation by pulse oximeter.