2024-2025 HESI A2 Critical Thinking with Answers (124 Solved Questions)

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HESIA2-CriticalThinking100% VERIFIED ANSWERS2024/2025 ALREADYPASSED1. The nurse is working in theemergency department (ED) of a children's medicalcenter. 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. The6-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.RationaleCorrect-3-The child hit by a car should be assessed first because he or she may havelife-threatening 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 hermemory later. Which statement is true regarding note-taking?A) Note-taking may impede the nurse's observation of the patient's nonverbalbehaviors.B) Note-taking allows the patient to continue at his or her own pace as the nurserecords what is said.C) Note-taking allows the nurse to shift attention away from the patient, resultingin an increased comfort level.D) Note-taking allows the nurse to break eye contact with the patient, which mayincrease his or her level of comfort.

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A) Note-taking may impede the nurse's observation of the patient's nonverbalbehaviors.Page: 31 Some use of history forms andnote-taking may be unavoidable. But be awarethat 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 ofimportance. It also may interrupt the patient's narrative flow, and it impedes theobservation of the patient's nonverbal behavior.2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis iscomplaining of a severe headache. Which intervention should the nurseimplement 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 theclient's intravenous (IV) rate.RationaleCorrect-2-Because the client is complaining of a headache, the nurse should first ruleout cerebrovascular accident (CVA) by assess-ing the client's neurological status andthen determine whether it is a headache that can be treated with medication.2. During an interview, the nurse states,"You mentioned shortness of breath. Tellme more about that." Which verbal skill is used with this statement?A) ReflectionB) FacilitationC) Direct questionD) Open-ended questionD) Open-ended questionPage: 32 The open-ended question asks for narrative information. It states the topic to

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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 newtopic.3. The 6-year-old client who has undergone abdominal surgery is attempting tomake a pinwheel spin by blowing on it with the nurse's assistance. The childstarts crying because the pinwheel won't spin. Which action should the nurseimplement first?1. Praise the child for the attempt to make thepinwheel 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.RationaleCorrect-1. The nurse should alwayspraise the child for attempts at cooperation even ifthe child did not accomplish what the nurse asked.3. A nurse is taking complete health histories on all of the patients attending awellness workshop. On the history form, one of the written questionsasks, "Youdon'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.C) using biased or leading questions.Page: 36 This is an example of using leading or biased questions. Asking, "You don'tsmoke, do you?" implies that one answer is "better" than another. If the person wants toplease someone, he or she is either forced to answer in a way corresponding to theirimplied values or is made to feel guilty when admitting the other answer.

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4. The nurse is caring for clients on the pediatric medical unit. Which clientshould the nurse assess first?1. The child diagnosed with type 1 diabetes who has a blood glucose levelof 180 mg/dL.2. The child diagnosed with pneumonia who is coughing and has a temperatureof100°F.3. The child diagnosed with gastroenteritis who has a potassium (K+) levelof 3.9 mEq/L.4. The child diagnosed with cystic fibrosis who hasa pulse oximeter reading of90%.RationaleCorrect-4. A pulse oximeter reading of less than 93% is significant and indicateshypoxia, which is life threatening; therefore, this child should be assessed first.4. During an interview, a parent of a hospitalized child is sitting in an openposition. As the interviewer begins to discuss his son's treatment, however, hesuddenly crosses his arms against his chest and crosses his legs. This wouldsuggest 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.D) uncomfortable talking about his son's treatment.Page: 37 Note the person's position. An open position with the extensionof largemuscle groups shows relaxation, physical comfort, and a willingness to shareinformation. A closed position with the arms and legs crossed tends to look defensive

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and anxious. Note any change in posture. If a person in a relaxed position suddenlytenses, it suggests possible discomfort with the new topic.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 withmethicillin-resistant Staphylococcus aureus (MRSA).2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed withasthma.3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus.4. The stimulantmethylphenidate (Ritalin) to a child diagnosed with attentiondeficit-hyperactivity disorder (ADHD).RationaleCorrect-3-Sliding scale insulin is ordered ac, which is before meals; therefore, thismedication must be administered first after receiving the a.m. shift report.4-Routine medications have a 1-hour leeway before and after the scheduled time;therefore, this medication does not have to be adminis-tered first.5. The nurse is interviewing a patient who has a hearing impairment. Whattechniques 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 peoplefind this degrading.C) Request a sign language interpreter before meeting with him to help facilitatethe communication.D) Speak loudly and with exaggerated facial movement when talking with himbecause this helps with lip reading.A) Determine the communication method he prefers.

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Pages: 40-41 The nurse should ask the deaf person the preferred way tocommunicate—by signing, lip reading, or writing. If the person prefers lip reading, thenthe nurse should be sure to face him or her squarely and have good lighting on thenurse's face. The nurse should not exaggerate lip movements because this distortswords. Similarly, shouting distorts the reception of a hearing aid the person may wear.The nurse should speak slowly and should supplementhis or her voice with appropriatehand gestures or pantomime.6. The nurse enters the client's room and realizes the 9-month-old infant is notbreath-ing. Which interventions should the nurse implement? Prioritize thenurse's actions from first (1) to last (5).1. Perform cardiac compression 30:2.2. Check the infant's brachial pulse. 3. Administer two puffs to the infant. 4.Determine unresponsiveness.5. Open the infant's airway.RationaleCorrect Answer: 4, 5, 3, 2, 14. The nurse must first determine theinfant's responsiveness by thumping thebaby's feet.5. The nurse should then open the child'sairway using the head-tilt chin-lift tech-nique, with care taken not to hyperextend theneck. Then the nurse should look, listen, and feel for respirations.3. The nurse then administers quick puffs of air while covering the child's mouth andnose, preferably with a rescue mask.2. The nurse should determine whether the infant has a pulse by checking the brachialartery.1. If the infant has no pulse, the nurse should begin chest compressions using twofingers at a rate of 30:2.

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6. The nurse is performing a health interview on a patient who has a languagebarrier, and no interpreter is available. Which is the best example of anappropriate question for the nurse to ask in this situation?A) "Do you take medicine?"B) "Do you sterilize the bottles?"C) "Do you have nausea and vomiting?"D) "You have been taking your medicine, haven't you?"A) "Do you take medicine?"Page: 46 In a situation where there is a language barrier and no interpreter available,use simple words avoiding medical jargon. Avoid using contractions and pronouns. Usenouns repeatedly and discuss one topic at a time.7. A female patient does not speak English well, and the nurse needs to choosean interpreter. Which of the following would be the most appropriate choice?A) A trained interpreterB) A male family memberC) A female family memberD) A volunteer college student from the foreign language studies departmentA) A trained interpreterPage: 46 whenever possible, the nurse should use a trained interpreter, preferably onewho knows medical terminology. In general, an older, more mature interpreter ispreferred to a younger, less experienced one, and the same gender is preferred whenpossible.7. The 3-year-old client has been admitted to the pediatric unit. Which task shouldthe nurse instruct the unlicensed assistive personnel (UAP) to perform first?1. Orient the parents and child to the room.

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2. Obtain an admission kit for the child.3.Post the child's height and weight at the HOB. 4. Provide the child with a mealtray.RationaleCorrect-1.The first intervention after the child is ad-mitted to the unit is to orient theparents and child to the room, the call system, and the hospitalrules, such as notleaving the child alone in the room.8. The clinic nurse is preparing to administer an intramuscular (IM) injection tothe 2-year-old toddler. Which intervention should the nurse implement first?1. Immobilize the child's leg.2. Explain the procedure to the child.3. Cleanse the area with an alcohol swab. 4. Administer the medication in thethigh.RationaleCorrect-2-The nurse must explain any procedure in words the child can understand. Itdoes not matter how old the child is.8. Thenurse is conducting an interview. Which of these statements is trueregarding open-ended questions? Select all that apply.A) They elicit cold facts.B) They allow for self-expression.C) They build and enhance rapport.D) They leave interactions neutral.E) They call for short one-to two-word answers.F) They are used when narrative information is needed.B) They allow for self-expression.C) They build and enhance rapport.

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F) They are used when narrative informationPage: 32 Open-ended questions allowfor self-expression, build rapport, and obtainnarrative information. These features enhance communication during an interview. Theother statements are appropriate for closed or direct questions.9. The nurse is writing a care plan for the 5-year-old child diagnosed withgastroenteritis. Which client problem is priority?1. Imbalanced nutrition.2. Fluid volume deficit.3. Knowledge deficit. 4. Risk for infection.RationaleCorrect-2-The child diagnosed with gastroenteritis is at high risk for hypovolemic shockresulting from vomiting and diarrhea; therefore, maintaining fluid and elec-trolytehomeostasis is priority.9. The nurse is conducting an interview in an outpatient clinic and is using acomputer to record data. Which is the best use of the computer in this situation?Select all that apply.A) Collect the patient's data in a direct, face-to-face manner.B) Enter all the data as the patient states it.C) Ask the patient to wait as the nurse enters data.D) Type the data into the computer after the narrative is fully explored.E) Allow the patient to see the monitor during typing.A) Collect the patient's data in a direct, face-to-face manner.D) Type the data into the computer after the narrative is fully explored.E) Allow the patient to see themonitor during typing.Page: 32 The use of a computer can become a barrier. The nurse should begin theinterview as usual by greeting the patient, establishing rapport, and collecting the

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patient's narrative story in a direct face-to-face manner. Only after the narrative is fullyexplored should the nurse type data into the computer. When typing, the nurse shouldposition the monitor so that the patient can see it.10. Which data would warrant immediate intervention from the pediatric nurse? 1.Proteinuriafor 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.RationaleCorrect-3-Droolingindicates the child is having trouble swallowing, and the epiglottis isat risk of completely occluding the air-way. This warrants immediate interven-tion. Thenurse should notify the HCP and obtain an emergency tracheostomy tray for thebedside.10. During an assessment, the nurse notices that a patient is handling a smallcharm that is tied to a leather strip around his neck. Which action by the nurse isappropriate?A) Ask the patient about the item and its significance.B) Ask the patient to lock theitem 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.A) Ask the patient about the item and its significance.Page: 21 The nurse should inquire about the amulet'smeaning. Amulets, such ascharms, are often seen as an important means of protection from "evil spirits" by somecultures.11. Which client should the pediatric nurse assess first after receiving the a.m.shift report? 1. The 6-month old child diagnosed with bacterial meningitis who is

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irritable andcrying.2. The 9-month old child diagnosed with tetralogy of Fallot (TOF) who has edemaofthe face.3. The 11-month old child diagnosed with Reye syndrome who is lethargic andvomiting.4. The 13-month-old child diagnosed with diarrhea who has sunken eyeballs anddecreased urine output.RationaleCorrect-4. Sunken eyeballs and decreased urine out-put are signs of dehydration,which is a life-threatening complication of diarrhea; therefore, this child shouldbeassessed first.11. In the majority culture of America, coughing, sweating, and diarrhea aresymptoms of an illness. For some individuals of Mexican-American origin,however, these symptoms are a normal part of living. The nurse recognizes thatthis istrue, probably because Mexican-Americans:A) have less efficient immune systems and are often ill.B) consider these symptoms a part of normal living, not symptoms of ill health.C) come from Mexico and coughing is normal and healthy there.D) are usuallyin a lower socioeconomic group and are more likely to be sick.B) consider these symptoms a part of normal living, not symptoms of ill health.Page: 27 The nurse needs to identify the meaning of health to the patient, rememberingthat concepts are derived, in part, from the way in which members of the cultural groupdefine health.12. The pediatric clinic nurse is triaging telephone calls. Which client's parentshould the nurse call first?

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1. The 4-month-old child who had immunizations yesterday and the parent isreport-ing a high-pitched cry and a 103°F fever.2. The 8-month-old whose parent is reporting the child is pulling on the right earand has a fever.3. The 2-year-old child who has patent ductus arteriosis whose parent reportsrunning out of digoxin.4. The 3-year-old child whose mother called and reported her daughter may havechickenpox.RationaleCorrect 1-A high fever and high-pitched crying may indicate a reaction to theimmunizations; therefore, this parent needs to be called first to bringthe child to theclinic.12. Among many Asians there is a belief in the yin/yang theory, rooted in theancient Chinese philosophy of Tao. The nurse recognizes which statement thatmost accurately reflects "health" in an Asian with this belief?A) A person is able to work and produce.B) A person is happy, stable, and feels good.C) All aspects of the person are in perfect balance.D) A person is able to care for others and function socially.C) All aspects of the person are in perfect balance.Page: 21 Many Asians believe in the yin/yang theory, in which health is believed to existwhen all aspects of the person are in perfect balance. The other statements do notdescribe this theory.13. The parent of a 12-year-old male child with a left below-the-knee cast calls thepedi-atric clinic nurse and tells the nurse, "My son's foot is cold and he told me itfeels like his foot is asleep." Which action should the nurse implement first?1. Prepare to bifurcate the left below-the-knee cast.

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2. Tell theparent to bring the child to the office.3. Instruct the parent to elevate the left leg on two pillows.4. Notify the child's orthopedist of the situation.RationaleCorrect-3. The nurse should first take care of the client's body by having the parentelevate the left leg.13. An individual who takes the magicoreligious perspective of illness anddisease is likely to believe that his or her illness was caused by:A) germs and viruses.B) supernatural forces.C) eating imbalanced foods.D) an imbalance within his or her spiritual nature.B) supernatural forces.Page: 21 The basic premise of the magicoreligious perspective is that the world is seenas an arena in which supernatural forces dominate. The fate of the world and those in itdepends on the actions of supernatural forces for good or evil. The other answers donot reflect the magicoreligious perspective.14. If an American Indian has come to the clinic to seek help with regulating herdiabetes, the nurse can expect that she:A) will comply with the treatment prescribed.B) has obviously given up her beliefs in naturalistic causes of disease.C) may also be seeking the assistance of a shaman or medicine man.D) will need extra help in dealing with her illness and may be experiencing a crisisof faith.

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C) may also be seeking the assistance of a shaman or medicine man.Page: 23 When self-treatment is unsuccessful, the individual may turn to the lay or folkhealing systems, to spiritual or religious healing, or to scientific biomedicine. In additiontoseeking help from a biomedical or scientific health care provider, patients may alsoseek help from folk or religious healers.14. Which child requires the nurse to notify the healthcare provider?1. The 1-year-old child with iron deficiency anemia who has dark-colored stool.2. The 3-year-old child with phenylketonuria (PKU) whose parent does not feedthechild any meat or milk products.3. The 5-year-old child with rheumatic heart fever who is having difficultybreathing.4. The 7-year-old child diagnosed with acute glomerulonephritis who has dark"tea"-colored urine.RationaleCorrect-3-A complication of rheumatic heart disease is valvular disorders that may bemani-fested by respiratory problems; therefore, the nurse should notify the child'shealth-care provider.15. The pediatric nurse on the surgical unit has just received a.m. shift report.Which client should the nurse assess first?1. The 3-week-old child 1 day postoperative with surgical repair of amyelomeningo-cele who has bulging fontanels.2. The 3-month-old child 2 days postoperative temporary colostomy secondary toHirschsprung's disease who has a moist, pink stoma.3. The 9-month-old child with a cleft palate repair who is spitting up formula andrefusing to eat.4. The 4-year-old child1 day postoperative for repair of hypospadias who has

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clearamber urine draining from indwelling catheter.RationaleCorrect-1-Bulging fontanels is a sign of increased intracranial pressure, which is acompli-cation of neurological surgery; therefore,this child should be assessed first.15. An elderly Mexican-American woman with traditional beliefs has beenadmitted to an inpatient care unit. A culturally-sensitive nurse would:A) contact the hospital administrator about the best course of action.B)automatically get a curandero for her because it is not culturally appropriatefor her to request one.C) further assess the patient's cultural beliefs and offer the patient assistance incontacting a curandero or priest if she desires.D) ask the family what they would like to do because Mexican-Americanstraditionally give control of decisions to their families.C) further assess the patient's cultural beliefs and offer the patient assistance incontacting a curandero or priest if she desires.Pages: 22-23 In addition to seeking help from the biomedical/scientific health careprovider, patients may also seek help from folk or religious healers. Some people, suchas those of Mexican-American or American Indian origins, may believe that the cure isincomplete unless the body, mind, and spirit are also healed (although the division ofthe person into parts is a Western concept).16. The charge nurse has assigned a staff nurse to care for an 8-year-old clientdiagnosed with cerebral palsy. Which nursing actionby the staff nurse wouldwarrant immediate intervention by the charge nurse?1. The staff nurse performs gentle range-of-motion (ROM) exercises toextremities. 2. The staff nurse puts the client's bed in the lowest positionpossible.

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3. The staff nurse takes the client in a wheelchair to the activity room.4. The staff nurse places the child in semi-Fowler's position to eat lunch.RationaleCorrect-4-The child should be positioned upright to prevent aspiration during meals;there-fore, this action wouldrequire the charge nurse to intervene.16. The nurse is reviewing concepts of cultural aspects of pain. Which statementis true regarding pain?A) All patients will behave the same way when in pain.B) Just as patients vary in their perceptions of pain,so will they vary in theirexpressions of pain.C) Cultural norms have very little to do with pain tolerance, because paintolerance is always biologically determined.D) A patient's expression of pain is largely dependent on the amount of tissueinjury associated with the pain.B) Just as patients vary in their perceptions of pain, so will they vary in their expressionsof pain.Page: 25 In addition to expecting variations in pain perception and tolerance, the nurseshould expect variations in the expression of pain. It is well known that individuals turnto their social environment for validation and comparison. The other statements areincorrect.17. The nurse and the unlicensed assistive personnel (UAP) are caring for clientson the pediatric unit. Which action by the nurse indicates appropriate delegation?1. The nurse requests the UAP to check the circulation on the child with a cast.2. The nurse asks the UAP to feed an infant who has just had a cleft palate repair.3. The nurse has the UAP demonstrate a catheterization for a child with aneurogenicbladder.

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4. The nurse checks to make sure the UAP's delegated tasks have beencompleted.RationaleCorrect-4. The last step of delegating to a UAP is for the nurse to evaluate anddetermine whether the delegated tasks have been completed and performed correctly.This indicates the nurse has delegated appropriately.17. The nurse recognizes that working with children with a different culturalperspective may be especially difficult because:A) children have spiritual needs that are influenced by their stages ofdevelopment.B) children have spiritual needs that are direct reflections of what is occurring intheir homes.C) religious beliefs rarely affect the parents' perceptions of the illness.D) parents are often the decision makers, and they have no knowledge of theirchildren's spiritual needs.A) children have spiritual needs that are influenced by their stages of development.Page: 20. Illness during childhood may be an especially difficult clinical situation.Children, as well as adults, have spiritual needs that vary according to the child'sdevelopmental level and the religious climate that exists in the family. The otherstatements are not correct.18. The nurse on a pediatric unit has received the a.m. shift report and tells theunli-censed assistive personnel (UAP) to keep the 2-year-old child NPO for aprocedure. At 0830, the nurse observes the mother feeding the child. Whichaction should the nurse implement first?1. Determine what the UAP did not understand about the instruction.2. Tell the HCP the UAP did not follow the nurse's direction.

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3. Ask the mother why she was feeding her child if the child was NPO.4. Notify the dietary department tohold the child's meal trays.RationaleCorrect-1.Communication to the UAP must be clear, concise, correct, and complete.The nurse must determine why there was a lack of communication, which resulted inthe child receiving food; therefore, this action should be implemented first.18. When providing culturally competent care, nurses must incorporate culturalassessments into their health assessments. Which statement is most appropriateto use when initiating an assessment of cultural beliefs with an elderly AmericanIndian patient?A) "Are you of the Christian faith?"B) "Do you want to see a medicine man?"C) "How often do you seek help from medical providers?"D) "What cultural or spiritual beliefs are important to you?"D) "What cultural or spiritual beliefs are important to you?"Page: 17. The nurse needs to assess the cultural beliefs and practices of the patient.American Indians may seek assistance from a medicine man or shaman, but the nurseshould not assume this. An open-ended question regardingcultural and spiritual beliefsis best used initially when performing a cultural assessment.19. The charge nurse on the six-bed pediatric burn unit is making shiftassignments and has one registered nurse (RN), one scrub technician, oneunlicensed assistive personnel (UAP), and a unit secretary. Which client careassignment indicates the best use of the hospital personnel?1. The RN performs daily whirlpool dressing changes.2. The unit secretary transcribes the HCP's orders.3. The scrub technician medicates the client prior to dressing changes. 4. TheUAP places the current laboratory results on the chart.

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1-The scrub technician is assigned to perform daily whirlpool dressing changes, whichis a lengthy procedure. Therefore, assigning the one RN to thistask would beinappropriate because he or she cannot be unavailable for an extended period of time.**2-One of the responsibilities of the unit secretary is to transcribe the HCP's orders, butthe licensed nurse retains total responsibility for the correctness and accuracy of thetranscribed orders.3-The scrub technician cannot administer medications.4-The unit secretary and laboratory personnel are responsible for posting laboratorydata into the client's charts. The UAP should be on the unit taking careof the clients.19. When planning a cultural assessment, the nurse should include whichcomponent?A) Family historyB) Chief complaintC) Medical historyD) Health-related beliefsD) Health-related beliefsPages: 19-20. Health-related beliefs and practices are one component of a culturalassessment. The other items reflect other aspects of the patient's history.20. The RN and the UAP are caring for clients on a pediatric surgical unit. Whichtasks would bemost appropriate to delegate to the UAP? Select all that apply.1. Pass dietary trays to the clients.2. Obtain routine vital signs on the clients.3. Complete the preoperative checklist.4. Change linens on the clients' beds.5. Document the clients' intake and output.1, 2, 4, and 5 are correct.1. The UAP can pass the dietary trays to

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the clients because it does not requirejudgment.2. One of the responsibilities of the UAP istaking routine vital signs on clients.3. The nurse must complete the preoperative checklist because it requires nursing judg-ment to determine whether the client is ready for surgery.4. One of the responsibilities of the UAP is changing bed linens.5. The UAP can document the client's in-take and output, but the UAP cannot evaluatethe numbers.20. When the nurse is evaluating the reliability of a patient's responses, which ofthese statements would be correct? The patient:A. has a history of drug abuse and therefore is not reliable.B. provided consistent information and therefore is reliable.C. smiled throughout interview and therefore is assumed reliable.D. would not answer questions concerning stress and therefore is not reliable.B. provided consistent information and therefore is reliable.Page: 50. A reliable person always gives the same answers, even when questions arerephrased or are repeated later in the interview. The other statements are not correct.21. Which client should the charge nurse on the pediatric unit assign to the mostexperienced nurse?1. The 4-year-old child diagnosed with hemophilia receiving factor VIII.2. The 8-year-old child with headaches who is scheduled for a CT scan.3. The 6-year-old child recovering from a sickle cell crisis.4. The 11-year-old child newly diagnosed with rheumatoid arthritis.1-The administration of blood products does not require the most experienced nurse.2-Preparing a child for a routine procedure does not require the most experiencednurse.

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3-The child recovering from a sickle cell crisis would not require the most experiencednurse.**4-The child newly diagnosed with a chronic disease, which will have acute exacerba-tions, requires extensive teaching; there-fore, the most experienced nurse should beassigned to this child and family.21. In recording the childhood illnesses of a patient who denies having had any,which note by the nurse would be most accurate?A. Patient denies usual childhood illnesses.B. Patient states he was a "very healthy" child.C. Patient states sister had measles, but he didn't.D. Patientdenies measles, mumps, rubella, chickenpox, pertussis, and strepthroat.D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.Page: 51. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis,and strep throat. Avoid recording "usual childhood illnesses" because an illnesscommon in the person's childhood may be unusual today (e.g., measles).22. The charge nurse is making shift assignments on a pediatric oncology unit.Which delegation/assignment would bemost appropriate?1. Delegate the unlicensed assistive personnel (UAP) to obtain routine blood workfrom the central line.2. Instruct the licensed practical nurse (LPN) to contact the leukemia supportgroup.3. Assign the chemotherapy-certified RN to administer chemotherapeuticmedication.4. Have the dietitian check the meal trays for the amount eaten.1-Only an RN can withdraw blood from acentral line.

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2. The social worker or case manager is respon-sible for referring clients to support groups. This isnot an expected responsibility of afloor nurse/LPN.**3. Only chemotherapy-certified RNs can administer antineoplastic, chemothera-peuticmedications. This is a national minimal standard of care according to the OncologyNursing Society.4. The dietician is responsible for ensuring that the proper food is provided along withevalu-ating the child's nutritional intake, not checking the amount of food eaten—this isthe responsibility of the nursing staff.22. The mother of a 16-month-old toddler tells thenurse that her daughter has anearache. What would be an appropriate response?A. "Maybe she is just teething."B. "I will check her ear for an ear infection."C. "Are you sure she is really having pain?"D. "Please describe what she is doing to indicateshe is having pain."D. "Please describe what she is doing to indicate she is having pain."Page: 60. With a very young child, ask the parent, "How do you know the child is inpain?" Pulling at ears alerts parent to ear pain. The statements about teething andquestioning whether the child is really having pain do not explore the symptoms, whichshould be done before a physical examination.23. The nurse observes the unlicensed assistive personnel (UAP) bringing acartoon video to a 6-year-old female childon bed rest so that she can watch it onthe television. Which action should the nurse take?1. Tell the UAP that the child should not be watching videos.2. Explain that this is the responsibility of the child life therapist.3. Praise the UAP for providing the child with an appropriate activity. 4. Notify thecharge nurse that the UAP gave the child videos to watch.

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1. A 6 year old child on best rest needs an appropriate activity to help with distraction; acartoon video would be an age appropriate activity.2. The child life therapist is responsible forrecreational and developmental activity for the hospitalized child, but any staff membershould address the child's psychosocial needs.**3. Part of the delegation process is to evaluate the UAP's performance of duties, andthe nurse should praise any initiative on the part of the UAP in being a client advocate.4. Videos are one of the few age-appropriate activities to occupy a 6-year-old on bedrest; therefore, there is no reason to notify the charge nurse.23. A 5-year-old boy is being admitted to the hospital to have his tonsils removed.Which information should the nurse collect before this procedure?A. The child's birth weightB. The age at which he crawledC. Whether he has had the measlesD. Reactions to previous hospitalizationsD. Reactions to previous hospitalizationsAssess how the child reacted to hospitalization and any complications. If the childreacted poorly, he or she may be afraid now and will need special preparation for theexamination that is to follow. The other items are not significant for the procedure.24. Which newborn should the nurse in the neonatal intensive care unit (NICU)assign to a new graduate who has just completed an NICU internship?1. The 1-day-old infant diagnosedwith a myelomeningocele.2. The 2-week-old infant who was born 6 weeks premature.3. The 3-hour-old infant who is being evaluated for esophageal atresia. 4. The 1-week-old infant diagnosed with tetralogy of Fallot.1-The newborn with the myelomeningocele has a portion of the spinal cord and mem-branes protruding through the back and is at risk for hydrocephalus and meningitis; this

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client should be assigned to a more experi-enced nurse.**2-The new graduate who has completed the NICU internship should beable to carefor a premature infant because care is primarily supportive.3-Esophageal atresia, a congenital anomaly in which the esophagus does notcompletely develop, is a clinical and surgical emergency. It puts the newborn at risk foraspiration be-cause the upper esophagus ends in a blind pouch with the lower part ofthe esophagus connected to the trachea. This newborn should be assigned to a moreexperienced nurse.4-Tetralogy of Fallot is a cyanotic, congenital anomaly. It includes a combination offourdefects of the heart, all of which result in unoxygenated blood being pumped into thesystemic circulation. This newborn must be assigned to an experienced nurse.24. The nurse is preparing to do a functional assessment. Which statement bestdescribesthe purpose of a functional assessment?A. It assesses how the individual is coping with life at home.B. It determines how children are meeting developmental milestones.C. It can identify any problems with memory the individual may be experiencing.D.It helps to determine how a person is managing day-to-day activities.D. It helps to determine how a person is managing day-to-day activities.Page: 67. The functional assessment measures how a person manages day-to-dayactivities. The other answers do not reflect the purpose of a functional assessment.25. The newly hired nurse is working on a pediatric unit and needs the unlicensedassistive personnel (UAP) to obtain a urine specimen on an 11-month-old infant.Which statement made to the UAP indicates the nurse understands thedelegation process?1. "Be sure to weigh the diaper when obtaining the urine specimen."2. "Do you know how to apply the urine collection bag?"

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3. "Use a small indwelling catheter when obtaining the urine specimen." 4. "I needfor you to get a urine specimen on the infant."1-Weighing the diaper is the procedure for de-termining the infant's urinary output andis not part of the procedure for obtaining a urine specimen.**2-The NCSBN position paper in 1995 defined delegation as transferring to acompetent individual the authority to perform a selected nursing task in a se-lectedsituation. The nurse retains the accountability for the delegation. The nurse mustdetermine whether the UAP has the ability and knowledge to perform a task. Thisquestion clarifies whether the UAP has the ability to obtain a urine specimen.3-Obtaining a urine specimen with an in-dwelling catheter on an 11-month-old infantwould require more expertise than a UAP would have on the pediatric unit.Furthermore, it does not determine whether the UAP understands how to do theprocedure.4. This statement does not determine whether the UAP understands how to perform theprocedure of obtaining a urine specimen from an 11-month-old infant.25. The nurse is performing a functional assessment on an 82-year-old patientwho recently had a stroke. Which of these questions would be most important toask?A. "Do you wear glasses?"B. "Are you able to dress yourself?"C. "Do you have any thyroid problems?"D. "How many times a day do you have a bowel movement?"B. "Are you able to dress yourself?"Page: 67. Functional assessment measures how a person manages day-to-dayactivities. For the older person, the meaning of health becomes those activities that theycan or cannot do. The other responses do not relate to functional assessment.

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26. Which task is most appropriate for the pediatric nurse to delegate to theunlicensed assistive personnel (UAP)?1. Ask the UAP to orient the parents and child to the room.2. Tell the UAP to prepare the child for an endoscopy.3. Request the UAP to log roll the client who had a spinal surgery. 4. Instruct theUAP to assess the child's developmental level.**1-The UAP can orient the parents and child to the room, and demonstrate how to usethe call light, how the bed works, or how the television works.2-The UAP cannot prepare a child for en-doscopy; this requires assessment andevaluation to determine if the child is ready for the procedure.3-There must be at least two people to log roll achild, and the UAP cannot do thisprocedure alone.4-The nurse cannot delegate assessment to the UAP.26. The nurse is conducting a developmental history on a 5-year-old child. Whichquestions are appropriate to ask the parents for this part of the assessment?Select all that apply.A. "How much junk food does your child eat?"B. "How many teeth has he lost, and when did he lose them?"C. "Is he able to tie his shoelaces?"D. "Does he take a children's vitamin?"E. "Can he tell time?"F. "Does he have any food allergies?"B. "How many teeth has he lost, and when did he lose them?"C. "Is he able to tie hisshoelaces?"E. "Can he tell time?"Page: 61. Questions about tooth loss, ability to tell time, and ability to tie shoelaces areappropriate questions for a developmental assessment. Questions about junk food

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intake and vitamins are part of a nutritionalhistory. Questions about food allergies arenot part of a developmental history.27. Which behavior by the unlicensed assistive personnel (UAP) warrantsintervention by the nurse?1. The UAP weighs the child's diaper on a scale and records the urine outputonthe intake & output (I&O) sheet.2. The UAP sits with the child while the parent goes down to the cafeteria to getsomething to eat.3. The UAP bathes the child with congenital dislocated hip with the Pavlikharness on the child.4. The UAP applies wrist restraints on the 7-month-old who is 1 day postoperativecleft palate repair.1-The UAP can weigh the diapers and obtain urine output. The nurse must evaluate theoutput.2-A child under 12 years of age cannot be left alone in the room, and the UAP couldstay with the child while the parent gets some-thing to eat.3-The Pavlik harness should not be removed, so bathing the child in the harness isappro-priate and does not warrant intervention.**4-The 7-month-old should have elbow restraints, not wristrestraints. Elbow restraintsprevent the child from putting fingers into the mouth, but allow the child to move thearms.27. During an examination, the nurse can assess mental status by which activity?A) Examining the patient's electroencephalogramB)Observing the patient as he or she performs an IQ testC) Observing the patient and inferring health or dysfunctionD) Examining the patient's response to a specific set of questionsC) Observing the patient and inferring health or dysfunction

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Page: 71. Mental status cannot be scrutinized directly like the characteristics of skin orheart sounds. Its functioning is inferred through assessment of an individual's behaviors,such as consciousness, language, mood and affect, and other aspects.28. The nurse isassessing a 75-year-old man. As the nurse begins the mentalstatus portion of the assessment, the nurse expects that this patient:A) will have no decrease in any of his abilities, including response time.B) will have difficulty on tests of remote memory because this typically decreaseswith age.C) may take a little longer to respond, but his general knowledge and abilitiesshould not have declined.D) will have had a decrease in his response time because of language loss and adecrease in general knowledge.C) may take a little longer to respond, but his general knowledge and abilities should nothave declined.Page: 72. The aging process leaves the parameters of mental status mostly intact.There is no decrease in general knowledge and little or no loss in vocabulary. Responsetime is slower than in youth. It takes a bit longer for the brain to process information andto react to it. Recent memory, which requires some processing is somewhat decreasedwith aging, but remote memory is not affected.28. The nurse is caring for pediatric clients. Which tasks are most appropriate toassign to an unlicensed assistive personnel (UAP) and/or a licensed vocationalnurse (LPN)? Select all that apply.1. Instruct the LPN to teach the parent of a child new diagnosed with type1 diabetes.2. Tell the UAP to apply an ice collar to the child who is 1 day postoperativetonsillectomy.3. Ask the UAP to place ointment on a child's diaper rash around the anal area.

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4. Request the LPN to double-check the medication dose forthe child receivinganantibiotic.5. Tell the LPN to transcribe the healthcare provider's orders for the child withcystic fibrosis.2, 3, 4, and 5 are correct.1. The nurse cannot assign teaching to the LPN.2. The UAP can apply an ice collar since theclient is stable.3. The UAP can apply ointment to a diaperrash—it is a medication but it can beapplied by the UAP.4. The LPN can double-check a dose ofmedication. The nurse can assign med-ication administration to an LPN.5. The LPN can transcribe ahealthcareprovider's orders.29. The nurse is discharging a 4-month-old child with a temporary colostomy.Which intervention should the nurse implement?1. Request the UAP to complete the discharge written documentation.2. Tell the LPN to show the parenthow to irrigate the colostomy.3. Ask the UAP to remove the child's intravenous catheter. 4. Request the UAP toescort the parent and child to the car.1-The nurse cannot delegate teaching to the UAP.2-The LPN could teach a client how to irrigate a colostomy, but a 4-month-old is inconti-nent of stool; therefore, irrigating the colostomy is not done.3-The LPN or nurse should remove the IV catheter of a 4-month-old child, not the UAP.**4-The UAP can escort the child and parents to the car.

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29. The nurseis preparing to do a mental status examination. Which statement istrue regarding the mental status examination?A) A patient's family is the best resource for information about the patient'scoping skills.B) It is usually sufficient to gather mental status information during the healthhistory interview.C) It takes an enormous amount of extra time to integrate the mental statusexamination into the health history interview.D) It is usually necessary to perform a complete mental status examination to geta good idea of the patient's level of functioning.B) It is usually sufficient to gather mental status information during the health historyinterview.Page: 73. The full mental status examination is a systematic check of emotional andcognitive functioning. The steps described here, though, rarely need to be taken in theirentirety. Usually, one can assess mental status through the context of the health historyinterview.30. The unlicensed assistive personnel (UAP) tells the nurse the child with Downsyndrome who is 2 days postoperative appendectomy is having pain. Whichintervention should the nurse implement first?1. Tell the UAP to check the child's vital signs.2. Assess the child's abdominal dressing and pain immediately.3. Notify the healthcareprovider.4. Check the MAR for last time pain medication was administered.1-The UAP can take vital signs but the nurse should assess the child to determinewhether this is routine postoperative pain (expected), or whether a complication isoccurring.**2. A rule of thumb—if anyone else gives the nurse information about a client, the

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