HESI A2 Critical Thinking Exam Questions And Answers

HESI A2 Critical Thinking Exam Questions And Answers ."E" - Answer-establish and maintain eye contact ."L" - Answer-lean forward toward the patient ."L" "E" "A" "R" "N" - Answer-Listen to others Explain your understanding Acknowledge and discuss Recommend alternative action Negotiate agreement ."O" - Answer-open posture ."R" - Answer-relax ."s" - Answer-sit or staqnd facing patient .(T or F) Nursing interventions are sometimes suggested by the problem label instead of the etiology. - Answer-True .(T or F) The nurse should choose the NIC intervention labels and activites best suited to your patients needs - Answer-T .`What is ethical knowledge? - Answer-refers to the knowledge of professional standards of conduct .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, resulting 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. - Answer-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. .1.Write the Diagnosis in Terms of Response Rather than Need - Answer--INCORRECT: Needs adequate nutrition; needs frequent turning -CORRECT: Risk for altered nutrition: greater than body requirements r/t excessive caloric intake; Impaired physical mobility r/t pain .10. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? A) Ask the patient about the item and its significance. B) Ask the patient to lock the item with other valuables in the hospital's safe. C) Tell the patient that a family member should take valuables home. D) No action is necessary. - Answer-A) Ask the patient about the item and its significance. Page: 21 The nurse should inquire about the amulet's meaning. Amulets, such as charms, are often seen as an important means of protection from "evil spirits" by some cultures. .10.The tendency to write the nursing diagnosis as a paraphrased medical diagnosis - Answer--INCORRECT: Ineffective airway clearance r/t obstructive pulmonary disease Congestive Heart Failure -CORRECT: Ineffective airway clearance r/t retained secretions; Noncompliance (cardiac meds) r/t lack of knowledge (action and dose of meds) .100. The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? A) Bounding B) Normal C) Weak D) Absent - Answer-B) Normal Pages: 506-507. When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse. .101. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) Hyperresonance - Answer-A) Dullness Page: 541. The liver is located in the right upper quadrant and would elicit a dull percussion note. .102. Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon - Answer-D) Sigmoid colon Page: 530. The sigmoid colon is located in the left lower quadrant of the abdomen. .103. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region. B) Inspect and palpate in the epigastric region. C) Auscultate and percuss in the inguinal region. D) Percuss and palpate the midline area above the suprapubic bone. - Answer-D) Percuss and palpate the midline area above the suprapubic bone. Pages: 539-540. Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation. .104. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction. - Answer-C) normal abdominal aortic pulsations. Pages: 538-539. Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation. .105. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis. - Answer-B) peritonitis. Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.