HESI A2 CRITICAL THINKING EXAM QUESTIONS & ANSWERS WITH RATIONALES LATEST UPATED

HESI A2 - Critical Thinking k k k k




1. 1. The nurse is working in the emergency department (ED) of a children'sme
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dical center. 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-
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care center. 3.The 6-year-old school-
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age child who was hit by a car while riding abicycle.
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4. The 14-year-
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old adolescent whose mother suspects her child is sexuallyactive.: Rationale
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Correct - 3- k k




The child hit by a car should be assessed first because he or she mayhave life-
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threatening injuries that must be assessed and treated promptly.
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,2. 1. In an interview, the nurse may find it necessary to take notes to aid hisor
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her memory 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 nonver-
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bal behaviors.
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B) Note-

taking allows the patient to continue at his or her own pace as thenurse reco
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rds what is said.
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C) Note-

taking allows the nurse to shift attention away from the patient,resulting i
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n an increased comfort level.
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D) Note-

taking allows the nurse to break eye contact with the patient, whichmay incre
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ase his or her level of comfort.: A) Note-
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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 eyecontact too often, and i
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,t shifts attention away from the patient, which diminisheshis or her sense of import
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ance. It also may interrupt the patient's narrative flow,and it impedes the observati
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on of the patient's nonverbal behavior.
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3. 2. The 8-year-old client diagnosed with a vaso-
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occlusive sickle cell crisisis complaining of a severe headache. Which interv
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ention should the nurseimplement first?
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1. Administer 6 L of oxygen via nasal cannula. k k k k k k k




2. Assess the client's neurological status.
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3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase thecl
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ient's intravenous (IV) rate.: Rationale
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Correct - 2- k k




Because the client is complaining of a headache, the nurse should firstrule out cerebr
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ovascular accident (CVA) by assess- ing the client's neurological
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, status and then determine whether it is a headache that can be treated withme
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dication.

4. 2. During an interview, the nurse states, "You mentioned shortness of bre
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ath. Tell me more about that." Which verbal skill is used with this state-
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ment?
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A) Reflection

B) Facilitation

C) Direct question k




D) Open-ended question: D) Open-ended question k k k k




Page: 32 The open- k k k




ended question asks for narrative information. It states the topic to be discussed but
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only in general terms. The nurse should use it to beginthe interview, to introduce a ne
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w section of questions, and whenever the personintroduces a new topic.
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5. 3. The 6-year-old client who has undergone abdominal surgery is attempt-
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ing to make a pinwheel spin by blowing on it with the nurse's assistance.Thechi
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ld starts crying because the pinwheel won't spin.Which action should thenurs
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e implement first?
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