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HESI A2 - Critical Thinking Questions and Answers Already Passed

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HESI A2 - Critical Thinking Questions and Answers Already Passed 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-yearold 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. ✔✔Rationale Correct - 3-The child hit by a car should be assessed first because he or she may have lifethreatening injuries that must be assessed and treated promptly. 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. ✔✔A) 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 notetaking 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. 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. ✔✔Rationale Correct - 2-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident (CVA) by assess- ing the client's neurological status and then determine whether it is a headache that can be treated with medication. 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 ✔✔D) Open-ended question Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. 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 pinwhee

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