Test Bank For Critical Thinking, 13th Edition All Chapters - 9781260241020.pdf

HESIA2 Critical Thinking ExamTest Bank j j j j j j




1. The nurse is working in the emergency department (ED) of a children's medical cent
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er. Which client should the nurse assess first?
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1. The 1-month-old infant who has developed colic and is crying.
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2. The 2-year-old toddler who was bitten by another child at the day-care center.
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3. The 6-year-old school-age child who was hit by a car while riding a bicycle.
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4. The 14-year- j



old adolescent whose mother suspects her child is sexually active. (ANS- Rationale
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Correct – 3-The child hit by a car should be assessed first because he or she may have life-
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threatening injuries that must be assessed and treated promptly.
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1. In an interview, the nurse may find it necessary to take notes to aid his or her mem
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ory later. Which statement is true regarding note-taking?
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A) Note-
taking may impede the nurse's observation of the patient's nonverbal behaviors.
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B) Note-
taking allows the patient to continue at his or her own pace as the nurse records what i
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s said.
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C) Note-
taking allows the nurse to shift attention away from the patient, resulting in an increase
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d comfort level.
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D) Note-
taking allows the nurse to break eye contact with the patient, which may increase his o
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r her level of comfort.
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(ANS- A) Note- j j



taking may impede the nurse's observation of the patient's nonverbal behaviors.
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,Page: 31 Some use of history forms and note-
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taking may be unavoidable. But be aware that note-
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taking during the interview has disadvantages. It breaks eye contact too often, and it sh
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ifts attention away from the patient, which diminishes his or her sense of importance. It
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also may interrupt the patient's narrative flow, and it impedes the observation of the pa
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tient's nonverbal behavior.
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2. The 8-year-old client diagnosed with a vaso-
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occlusive sickle cell crisis is complaining of a severe headache. Which intervention sho
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uld the nurse implement first?
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1. Administer 6 L of oxygen via nasal cannula. j j j j j j j



2. Assess the client's neurological status. j j j j



3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the clie j j j j j j j j j j j



nt's intravenous (IV) rate.
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(ANS-
Correct - 2- j j



Rationale ;
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Because the client is complaining of a headache, the nurse should first rule out cerebrov
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ascular accident (CVA) by assess- j j j j



ing the client's neurological status and then determine whether it is a headache that can b
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e treated with medication.
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2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me
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more about that." Which verbal skill is used with this statement?
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A) Reflection
B) Facilitation
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D) Open-ended question j

,(ANS- D) Open-ended question j j j




Page: 32 The open- j j j



ended question asks for narrative information. It states the topic to be discussed but only
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in general terms. The nurse should use it to begin the interview, to introduce a new sectio
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n of questions, and whenever the person introduces a new topic.
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3. The 6-year- j



old client who has undergone abdominal surgery is attempting to make a pinwheel spin
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by blowing on it with the nurse's assistance. The child starts crying because the pinwhe
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el won't spin. Which action should the nurse implement first?
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1. Praise the child for the attempt to make the pinwheel spin. j j j j j j j j j j



2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage the
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child to turn from side to side and cough.
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4. Demonstrate how to make the pinwheel spin by blowing on it. (A
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NS-


Correct - j



1. Rationale ;
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The nurse should always praise the child for attempts at cooperation even if the child did
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not accomplish what the nurse asked.
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3. A nurse is taking complete health histories on all of the patients attending a wellne
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ss workshop. On the history form, one of the written questions asks, "You don't smok
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e, drink, or take drugs, do you?" This question is an example of:
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A) talking too much. j j

, B) using confrontation. j



C) using biased or leading questions. j j j j



D) using blunt language to deal with distasteful topics. (A
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NS- C) using biased or leading questions.
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Page: 36 This is an example of using leading or biased questions. Asking, "You don't s
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moke, do you?" implies that one answer is "better" than another. If the person wants to
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please someone, he or she is either forced to answer in a way corresponding to their im
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plied values or is made to feel guilty when admitting the other answer.
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4. The nurse is caring for clients on the pediatric medical unit. Which client should the n
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urse assess first?
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1. The child diagnosed with type 1 diabetes who has a blood glucose level of 1
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80 mg/dL.
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2. The child diagnosed with pneumonia who is coughing and has a temperature of 100°
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F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) level of 3
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.9 mEq/L.
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4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%
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.(ANS


Correct - 4. j j



- Rationale ;
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A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is l
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ife threatening; therefore, this child should be assessed first.
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