HESI A2 - Critical Thinking Questions and Answers
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. - ansA) 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. The nurse is working in the emergency department (ED) of a children's medical center. Which client should
the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6-year-old school-age
child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually active. - ansRationale
Correct - 3-The child hit by a car should be assessed first because he or she may have life- threatening injuries
that must be assessed and treated promptly.
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. - ansA) 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. Which data would warrant immediate intervention from the pediatric nurse? 1. Proteinuria for the child
diagnosed with nephrotic syndrome.
2. Petechiae for the child diagnosed with leukemia.
3. Drooling for a child diagnosed with acute epiglottitis.
4. Elevated temperature in a child diagnosed with otitis media. - ansRationale
Correct - 3-Drooling indicates the child is having trouble swallowing, and the epiglottis is at risk of completely
occluding the air- way. This warrants immediate interven- tion. The nurse should notify the HCP and obtain an
emergency tracheostomy tray for the bedside.
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 - ansB) 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 - ansA) 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 - ansD) 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. - ansD) 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. - ansC) 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. - ansB) 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.
106. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers
to:
A) a loud continuous hum.
B) a peritoneal friction rub.
C) hypoactive bowel sounds.
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. - ansA) 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. The nurse is working in the emergency department (ED) of a children's medical center. Which client should
the nurse assess first?
1. The 1-month-old infant who has developed colic and is crying.
2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6-year-old school-age
child who was hit by a car while riding a bicycle.
4. The 14-year-old adolescent whose mother suspects her child is sexually active. - ansRationale
Correct - 3-The child hit by a car should be assessed first because he or she may have life- threatening injuries
that must be assessed and treated promptly.
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. - ansA) 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. Which data would warrant immediate intervention from the pediatric nurse? 1. Proteinuria for the child
diagnosed with nephrotic syndrome.
2. Petechiae for the child diagnosed with leukemia.
3. Drooling for a child diagnosed with acute epiglottitis.
4. Elevated temperature in a child diagnosed with otitis media. - ansRationale
Correct - 3-Drooling indicates the child is having trouble swallowing, and the epiglottis is at risk of completely
occluding the air- way. This warrants immediate interven- tion. The nurse should notify the HCP and obtain an
emergency tracheostomy tray for the bedside.
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 - ansB) 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 - ansA) 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 - ansD) 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. - ansD) 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. - ansC) 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. - ansB) 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.
106. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers
to:
A) a loud continuous hum.
B) a peritoneal friction rub.
C) hypoactive bowel sounds.
