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47. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these
factors is most likely to affect the nutritional status of an elderly person?
A) Increase in taste and smell
B) Living alone on a fixed income
C) Change in cardiovascular status
D) Increase in gastrointestinal motility and absorption - CORRECT ANSWERS B) Living
alone on a fixed income
Page: 176. Socioeconomic conditions frequently affect the nutritional status of the aging adult;
these factors should be closely evaluated. Physical limitations, income, and social isolation are
frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste
and smell and decreased gastrointestinal motility and absorption occur with aging.
Cardiovascular status is not a factor that affects an elderly person's nutritional status.
49. The fire alarm on the pediatric unit has just started sounding. Which action should the
charge nurse implement first?
1. Call the hospital operator to find out the location of the fire.
2. Ensure that all visitors and clients are in the room with the door closed.
3. Prepare to evacuate the clients and visitors down the stairs. 4. Make a list of which clients
are not currently on the unit. - CORRECT ANSWERS 1.The charge nurse must first make
sure that clients and visitors are safe. Someone will notify the charge nurse about the location
of the fire.
**2.Safety of the clients and visitors is prior- ity; therefore, ensuring that they are in a room
with the door closed is the first intervention.
3.The charge nurse may need to prepare for evacuation, but it is not the first intervention.
,HESI A2 - CRITICAL THINKING EXAM QUESTIONS AND
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4. Although making a list of clients not cur- rently on the unit is an appropriate interven- tion,
the charge nurse must first ensure the safety of the clients and visitors who are on the pediatric
unit.
48. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are
evaluated, which is important for the nurse to remember?
A) These measurements are no longer necessary for the elderly.
B) Derived weight measures may be difficult to interpret because of wide ranges of normal.
C) These measurements may not be accurate because of changes in skin and fat distribution.
D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least
90 degrees. - CORRECT ANSWERS C) These measurements may not be accurate
because of changes in skin and fat distribution.
Page: 191
Accurate mid-upper arm circumference and triceps skinfold measurements are difficult to
obtain and interpret in older adults because of sagging skin, changes in fat distribution, and
declining muscle mass. Body mass index and waist-to-hip ratio are better indicators of obesity
in the elderly.
50. A nurse overhears two other nurses talking about a client in the hospital dining room.
Which action should the nurse implement first?
1. Notify the HIPAA officer about the breach of confidentiality.
2. Immediately report the two nurses to their clinical manager.
3. Document the situation in writing and submit to the Chief Nursing Officer (CNO). 4. Tell the
two nurses they are violating the client's confidentiality. - CORRECT ANSWERS 1. .The
,HESI A2 - CRITICAL THINKING EXAM QUESTIONS AND
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HIPAA officer can be notified of the breach of confidentiality, but the nurse must first confront
the two nurses and correct the behavior.
2. The nurses can be reported to their clinical manager, but the nurse must first confront the
two nurses and correct the behavior.
3. The situation can be documented in writing and turned into the HIPAA officer (not the CNO),
but the nurse must first confront the two nurses and correct the behavior.
**4. This is a violation of HIPAA; therefore, the nurse must first confront the two nurses and
correct the behavior.
49. The nurse needs to perform anthropometric measures of an 80-year-old man who is
confined to a wheelchair. Which of the following is true in this situation?
A) Changes in fat distribution will affect the waist-to-hip ratio.
B) Height measurements may not be accurate because of changes in bone.
C) Declining muscle mass will affect the triceps skinfold measure.
D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity. - CORRECT
ANSWERS B) Height measurements may not be accurate because of changes in bone.
Page: 191. Height measures may not be accurate in individuals confined to a bed or wheelchair
or those over 60 years of age because of osteoporotic changes.
51. The nurse is caring for newborns in the nursery. Which newborn warrants immediate
intervention by the nurse?
1. The 8-hour-old newborn who has not passed meconium.
2. The 15-hour-old newborn who is slightly jaundiced.
, HESI A2 - CRITICAL THINKING EXAM QUESTIONS AND
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3. The 4-hour-old newborn who is jittery and irritable. 4. The 10-hour-old newborn who will not
stop crying. - CORRECT ANSWERS 1.The nurse would not be concerned about not
passing meconium until at least 24 hours after delivery.
2. The nurse would not be concerned about a newborn who is slightly jaundiced until after 24
hours after delivery, at which point the HCP would investigate to determine whether the
jaundice is pathological.
**3. A newborn who is jittery and irritable needs to be assessed first for possible hypoglycemia.
The nurse could feed the newborn glucose water or provide more frequent, regular feedings.
4. Although the nurse should determine why the newborn will not stop crying, the new- born
who is showing signs of hypoglycemia warrants immediate intervention.
50. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse
knows that physiological changes that directly affect the nutritional status of the elderly
include:
A) slowed gastrointestinal motility.
B) hyperstimulation of the salivary glands.
C) an increased sensitivity to spicy and aromatic foods.
D) decreased gastrointestinal absorption causing esophageal reflux. - CORRECT
ANSWERS A) slowed gastrointestinal motility.
Page: 176. Normal physiological changes in aging adults that affect nutritional status include
slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory
and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.
53. The nurse who has never worked on the maternity ward has been pulled from the surgical
unit to work in the newborn nursery. Which assignment would be most appropriate for the
nurse to accept?
ANSWERS LATEST DOWNLOADED 2025/2026 A
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47. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these
factors is most likely to affect the nutritional status of an elderly person?
A) Increase in taste and smell
B) Living alone on a fixed income
C) Change in cardiovascular status
D) Increase in gastrointestinal motility and absorption - CORRECT ANSWERS B) Living
alone on a fixed income
Page: 176. Socioeconomic conditions frequently affect the nutritional status of the aging adult;
these factors should be closely evaluated. Physical limitations, income, and social isolation are
frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste
and smell and decreased gastrointestinal motility and absorption occur with aging.
Cardiovascular status is not a factor that affects an elderly person's nutritional status.
49. The fire alarm on the pediatric unit has just started sounding. Which action should the
charge nurse implement first?
1. Call the hospital operator to find out the location of the fire.
2. Ensure that all visitors and clients are in the room with the door closed.
3. Prepare to evacuate the clients and visitors down the stairs. 4. Make a list of which clients
are not currently on the unit. - CORRECT ANSWERS 1.The charge nurse must first make
sure that clients and visitors are safe. Someone will notify the charge nurse about the location
of the fire.
**2.Safety of the clients and visitors is prior- ity; therefore, ensuring that they are in a room
with the door closed is the first intervention.
3.The charge nurse may need to prepare for evacuation, but it is not the first intervention.
,HESI A2 - CRITICAL THINKING EXAM QUESTIONS AND
ANSWERS LATEST DOWNLOADED 2025/2026 A
COMPLETE SOLUTION WITH 100% CORRECT DETAILED
ANSWERS BEST GRADED TO SCORE A+ FOR SUCCESS
4. Although making a list of clients not cur- rently on the unit is an appropriate interven- tion,
the charge nurse must first ensure the safety of the clients and visitors who are on the pediatric
unit.
48. When the mid-upper arm circumference and triceps skinfold of an 82-year-old man are
evaluated, which is important for the nurse to remember?
A) These measurements are no longer necessary for the elderly.
B) Derived weight measures may be difficult to interpret because of wide ranges of normal.
C) These measurements may not be accurate because of changes in skin and fat distribution.
D) Measurements may be difficult to obtain if the patient is unable to flex his elbow to at least
90 degrees. - CORRECT ANSWERS C) These measurements may not be accurate
because of changes in skin and fat distribution.
Page: 191
Accurate mid-upper arm circumference and triceps skinfold measurements are difficult to
obtain and interpret in older adults because of sagging skin, changes in fat distribution, and
declining muscle mass. Body mass index and waist-to-hip ratio are better indicators of obesity
in the elderly.
50. A nurse overhears two other nurses talking about a client in the hospital dining room.
Which action should the nurse implement first?
1. Notify the HIPAA officer about the breach of confidentiality.
2. Immediately report the two nurses to their clinical manager.
3. Document the situation in writing and submit to the Chief Nursing Officer (CNO). 4. Tell the
two nurses they are violating the client's confidentiality. - CORRECT ANSWERS 1. .The
,HESI A2 - CRITICAL THINKING EXAM QUESTIONS AND
ANSWERS LATEST DOWNLOADED 2025/2026 A
COMPLETE SOLUTION WITH 100% CORRECT DETAILED
ANSWERS BEST GRADED TO SCORE A+ FOR SUCCESS
HIPAA officer can be notified of the breach of confidentiality, but the nurse must first confront
the two nurses and correct the behavior.
2. The nurses can be reported to their clinical manager, but the nurse must first confront the
two nurses and correct the behavior.
3. The situation can be documented in writing and turned into the HIPAA officer (not the CNO),
but the nurse must first confront the two nurses and correct the behavior.
**4. This is a violation of HIPAA; therefore, the nurse must first confront the two nurses and
correct the behavior.
49. The nurse needs to perform anthropometric measures of an 80-year-old man who is
confined to a wheelchair. Which of the following is true in this situation?
A) Changes in fat distribution will affect the waist-to-hip ratio.
B) Height measurements may not be accurate because of changes in bone.
C) Declining muscle mass will affect the triceps skinfold measure.
D) Mid-arm circumference is difficult to obtain because of loss of skin elasticity. - CORRECT
ANSWERS B) Height measurements may not be accurate because of changes in bone.
Page: 191. Height measures may not be accurate in individuals confined to a bed or wheelchair
or those over 60 years of age because of osteoporotic changes.
51. The nurse is caring for newborns in the nursery. Which newborn warrants immediate
intervention by the nurse?
1. The 8-hour-old newborn who has not passed meconium.
2. The 15-hour-old newborn who is slightly jaundiced.
, HESI A2 - CRITICAL THINKING EXAM QUESTIONS AND
ANSWERS LATEST DOWNLOADED 2025/2026 A
COMPLETE SOLUTION WITH 100% CORRECT DETAILED
ANSWERS BEST GRADED TO SCORE A+ FOR SUCCESS
3. The 4-hour-old newborn who is jittery and irritable. 4. The 10-hour-old newborn who will not
stop crying. - CORRECT ANSWERS 1.The nurse would not be concerned about not
passing meconium until at least 24 hours after delivery.
2. The nurse would not be concerned about a newborn who is slightly jaundiced until after 24
hours after delivery, at which point the HCP would investigate to determine whether the
jaundice is pathological.
**3. A newborn who is jittery and irritable needs to be assessed first for possible hypoglycemia.
The nurse could feed the newborn glucose water or provide more frequent, regular feedings.
4. Although the nurse should determine why the newborn will not stop crying, the new- born
who is showing signs of hypoglycemia warrants immediate intervention.
50. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse
knows that physiological changes that directly affect the nutritional status of the elderly
include:
A) slowed gastrointestinal motility.
B) hyperstimulation of the salivary glands.
C) an increased sensitivity to spicy and aromatic foods.
D) decreased gastrointestinal absorption causing esophageal reflux. - CORRECT
ANSWERS A) slowed gastrointestinal motility.
Page: 176. Normal physiological changes in aging adults that affect nutritional status include
slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory
and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.
53. The nurse who has never worked on the maternity ward has been pulled from the surgical
unit to work in the newborn nursery. Which assignment would be most appropriate for the
nurse to accept?
