HESI A2 - Critical Thinking latest update with correct answers A+ guaranteed.
1. The nurse is working in the emergency department
... [Show More] (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. - answers Rationale
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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.
2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first?
1. Administer 6 L of oxygen via nasal cannula.
2. Assess the client's neurological status.
3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's intravenous (IV) rate. - answers Rationale
2. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement?
A) Reflection
B) Facilitation
C) Direct question
D) Open-ended question -
3. The 6-year-old client who has undergone abdominal surgery is attempting to make a pinwheel spin by blowing on it with the nurse's assistance. The child starts crying because the pinwheel won't spin. Which action should the nurse implement first?
1. Praise the child for the attempt to make the pinwheel spin.
2. Notify the respiratory therapist to implement incentive spirometry. 3. Encourage the child to turn from side to side and cough.
4. Demonstrate how to make the pinwheel spin by blowing on it. - answers Rationale
3. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of:
A) talking too much.
B) using confrontation.
C) using biased or leading questions.
D) using blunt language to deal with distasteful topics. -
4. The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess first?
1. The child diagnosed with type 1 diabetes who has a blood glucose level
of 180 mg/dL.
2. The child diagnosed with pneumonia who is coughing and has a temperature of
100°F.
3. The child diagnosed with gastroenteritis who has a potassium (K+) level
of 3.9 mEq/L.
4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%. - answers Rationale
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4. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is:
A) just changing positions.
B) more comfortable in this position.
C) tired and needs a break from the interview.
D) uncomfortable talking about his son's treatment. -
5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medication should the nurse administer first?
1. The third dose of the aminoglycoside antibiotic to the child diagnosed with
methicillin-resistant Staphylococcus aureus (MRSA).
2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with
asthma.
3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.
4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention
deficit-hyperactivity disorder (ADHD). -
5. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient?
A) Determine the communication method he prefers.
B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading.
C) Request a sign language interpreter before meeting with him to help facilitate the communication.
D) Speak loudly and with exaggerated facial movement when talking with him because this helps with lip reading. -
6. The nurse enters the client's room and realizes the 9-month-old infant is not breath- ing. Which interventions should the nurse implement? Prioritize the nurse's actions from first (1) to last (5).
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