HESI A2 Critical Thinking Exam Test Bank b b b b b b
1. The nurse is working in the emergency department (ED) of a children's medical c
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enter. Which client should the nurse assess first?
b b b b b b b
1. The 1-month-old infant who has developed colic and is crying.
b b b b b b b b b
2. The 2-year-old toddler who was bitten by another child at the day-care center.
b b b b b b b b b b b b
3. The 6-year-old school-age child who was hit by a car while riding a bicycle.
b b b b b b b b b b b b b
4. The 14-year- b
old adolescent whose mother suspects her child is sexually active. (ANS- Rationale
b b b b b b b b b b b
Correct – 3- b b
The child hit by a car should be assessed first because he or she may have life-
b b b b b b b b b b b b b b b b
threatening injuries that must be assessed and treated promptly.
b b b b b b b b b
1. In an interview, the nurse may find it necessary to take notes to aid his or her m
b b b b b b b b b b b b b b b b b
emory later. Which statement is true regarding note-taking?
b b b b b b b
A) Note-
taking may impede the nurse's observation of the patient's nonverbal behaviors.
b b b b b b b b b b
B) Note-
taking allows the patient to continue at his or her own pace as the nurse records wh
b b b b b b b b b b b b b b b b
at is said.
b b
C) Note-
taking allows the nurse to shift attention away from the patient, resulting in an incre
b b b b b b b b b b b b b b
ased comfort level. b b
D) Note-
taking allows the nurse to break eye contact with the patient, which may increase hi
b b b b b b b b b b b b b b
s or her level of comfort.
b b b b b
(ANS- A) Note- b b
,taking may impede the nurse's observation of the patient's nonverbal behaviors.
b b b b b b b b b b
,Page: 31 Some use of history forms and note-
b b b b b b b b
taking may be unavoidable. But be aware that note-
b b b b b b b b
taking during the interview has disadvantages. It breaks eye contact too often, and it
b b b b b b b b b b b b b b
shifts attention away from the patient, which diminishes his or her sense of importa
b b b b b b b b b b b b b
nce. It also may interrupt the patient's narrative flow, and it impedes the observation
b b b b b b b b b b b b b
of the patient's nonverbal behavior.
b b b b b
2. The 8-year-old client diagnosed with a vaso-
b b b b b b
occlusive sickle cell crisis is complaining of a severe headache. Which intervention s
b b b b b b b b b b b b
hould the nurse implement first?
b b b b
1. Administer 6 L of oxygen via nasal cannula. b b b b b b b
2. Assess the client's neurological status.
b b b b
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the c
b b b b b b b b b b b
lient's intravenous (IV) rate.
b b b
(ANS-
Correct - 2- b b
Rationale ;
b b
Because the client is complaining of a headache, the nurse should first rule out cerebr
b b b b b b b b b b b b b b
ovascular accident (CVA) by assess- b b b b
ing the client's neurological status and then determine whether it is a headache that ca
b b b b b b b b b b b b b b b
n be treated with medication.
b b b b
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell m
b b b b b b b b b b b b
e more about that." Which verbal skill is used with this statement?
b b b b b b b b b b b
A) Reflection
B) Facilitation
C) Direct question b
D) Open-ended question b
, (ANS- D) Open-ended question
b b b
Page: 32 The open-b b b
ended question asks for narrative information. It states the topic to be discussed but o
b b b b b b b b b b b b b b
nly in general terms. The nurse should use it to begin the interview, to introduce a ne
b b b b b b b b b b b b b b b b
w section of questions, and whenever the person introduces a new topic.
b b b b b b b b b b b
3. The 6-year- b
old client who has undergone abdominal surgery is attempting to make a pinwheel s
b b b b b b b b b b b b b
pin by blowing on it with the nurse's assistance. The child starts crying because the p
b b b b b b b b b b b b b b b
inwheel won't spin. Which action should the nurse implement first?
b b b b b b b b b
1. Praise the child for the attempt to make the pinwheel spin.
b b b b b b b b b b
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage t
b b b b b b b b b b
he child to turn from side to side and cough.
b b b b b b b b b
4. Demonstrate how to make the pinwheel spin by blowing on it. (
b b b b b b b b b b b b
ANS-
Correct - b
1. Rationale ;
b b
The nurse should always praise the child for attempts at cooperation even if the child
b b b b b b b b b b b b b b b
did not accomplish what the nurse asked.
b b b b b b
3. A nurse is taking complete health histories on all of the patients attending a well
b b b b b b b b b b b b b b
ness workshop. On the history form, one of the written questions asks, "You don't s
b b b b b b b b b b b b b b
moke, drink, or take drugs, do you?" This question is an example of:
b b b b b b b b b b b b
A) talking too much. b b
1. The nurse is working in the emergency department (ED) of a children's medical c
b b b b b b b b b b b b b
enter. Which client should the nurse assess first?
b b b b b b b
1. The 1-month-old infant who has developed colic and is crying.
b b b b b b b b b
2. The 2-year-old toddler who was bitten by another child at the day-care center.
b b b b b b b b b b b b
3. The 6-year-old school-age child who was hit by a car while riding a bicycle.
b b b b b b b b b b b b b
4. The 14-year- b
old adolescent whose mother suspects her child is sexually active. (ANS- Rationale
b b b b b b b b b b b
Correct – 3- b b
The child hit by a car should be assessed first because he or she may have life-
b b b b b b b b b b b b b b b b
threatening injuries that must be assessed and treated promptly.
b b b b b b b b b
1. In an interview, the nurse may find it necessary to take notes to aid his or her m
b b b b b b b b b b b b b b b b b
emory later. Which statement is true regarding note-taking?
b b b b b b b
A) Note-
taking may impede the nurse's observation of the patient's nonverbal behaviors.
b b b b b b b b b b
B) Note-
taking allows the patient to continue at his or her own pace as the nurse records wh
b b b b b b b b b b b b b b b b
at is said.
b b
C) Note-
taking allows the nurse to shift attention away from the patient, resulting in an incre
b b b b b b b b b b b b b b
ased comfort level. b b
D) Note-
taking allows the nurse to break eye contact with the patient, which may increase hi
b b b b b b b b b b b b b b
s or her level of comfort.
b b b b b
(ANS- A) Note- b b
,taking may impede the nurse's observation of the patient's nonverbal behaviors.
b b b b b b b b b b
,Page: 31 Some use of history forms and note-
b b b b b b b b
taking may be unavoidable. But be aware that note-
b b b b b b b b
taking during the interview has disadvantages. It breaks eye contact too often, and it
b b b b b b b b b b b b b b
shifts attention away from the patient, which diminishes his or her sense of importa
b b b b b b b b b b b b b
nce. It also may interrupt the patient's narrative flow, and it impedes the observation
b b b b b b b b b b b b b
of the patient's nonverbal behavior.
b b b b b
2. The 8-year-old client diagnosed with a vaso-
b b b b b b
occlusive sickle cell crisis is complaining of a severe headache. Which intervention s
b b b b b b b b b b b b
hould the nurse implement first?
b b b b
1. Administer 6 L of oxygen via nasal cannula. b b b b b b b
2. Assess the client's neurological status.
b b b b
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the c
b b b b b b b b b b b
lient's intravenous (IV) rate.
b b b
(ANS-
Correct - 2- b b
Rationale ;
b b
Because the client is complaining of a headache, the nurse should first rule out cerebr
b b b b b b b b b b b b b b
ovascular accident (CVA) by assess- b b b b
ing the client's neurological status and then determine whether it is a headache that ca
b b b b b b b b b b b b b b b
n be treated with medication.
b b b b
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell m
b b b b b b b b b b b b
e more about that." Which verbal skill is used with this statement?
b b b b b b b b b b b
A) Reflection
B) Facilitation
C) Direct question b
D) Open-ended question b
, (ANS- D) Open-ended question
b b b
Page: 32 The open-b b b
ended question asks for narrative information. It states the topic to be discussed but o
b b b b b b b b b b b b b b
nly in general terms. The nurse should use it to begin the interview, to introduce a ne
b b b b b b b b b b b b b b b b
w section of questions, and whenever the person introduces a new topic.
b b b b b b b b b b b
3. The 6-year- b
old client who has undergone abdominal surgery is attempting to make a pinwheel s
b b b b b b b b b b b b b
pin by blowing on it with the nurse's assistance. The child starts crying because the p
b b b b b b b b b b b b b b b
inwheel won't spin. Which action should the nurse implement first?
b b b b b b b b b
1. Praise the child for the attempt to make the pinwheel spin.
b b b b b b b b b b
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage t
b b b b b b b b b b
he child to turn from side to side and cough.
b b b b b b b b b
4. Demonstrate how to make the pinwheel spin by blowing on it. (
b b b b b b b b b b b b
ANS-
Correct - b
1. Rationale ;
b b
The nurse should always praise the child for attempts at cooperation even if the child
b b b b b b b b b b b b b b b
did not accomplish what the nurse asked.
b b b b b b
3. A nurse is taking complete health histories on all of the patients attending a well
b b b b b b b b b b b b b b
ness workshop. On the history form, one of the written questions asks, "You don't s
b b b b b b b b b b b b b b
moke, drink, or take drugs, do you?" This question is an example of:
b b b b b b b b b b b b
A) talking too much. b b
