HESI A2 Critical Thinking Questions
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HESI A2 Critical Thinking Questions
Terms in this set (124)
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 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.
HESI A2 Critical Thinking Questions Study
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. 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.
C) using biased or leading questions.
Page: 36 This is an example of using leading or
biased questions. Asking, "You don't smoke, do
you?" implies that one answer is "better" than
another. If the person wants to please someone, he
or she is either forced to answer in a way
corresponding to their implied values or is made to
feel guilty when admitting the other answer.
HESI A2 Critical Thinking Questions Study
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.
D) uncomfortable talking about his son's treatment.
Page: 37 Note the person's position. An open
position with the extension of large muscle groups
shows relaxation, physical comfort, and a
willingness to share information. A closed position
with the arms and legs crossed tends to look
defensive and anxious. Note any change in posture.
If a person in a relaxed position suddenly tenses, it
suggests possible discomfort with the new topic.
HESI A2 Critical Thinking Questions Study
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.
A) Determine the communication method he
prefers.
Pages: 40-41 The nurse should ask the deaf person
the preferred way to communicate—by signing, lip
reading, or writing. If the person prefers lip reading,
then the nurse should be sure to face him or her
squarely and have good lighting on the nurse's face.
The nurse should not exaggerate lip movements
because this distorts words. Similarly, shouting
distorts the reception of a hearing aid the person
may wear. The nurse should speak slowly and
should supplement his or her voice with appropriate
hand gestures or pantomime.
HESI A2 Critical Thinking Questions Study
6. The nurse is performing a
health interview on a patient
who has a language barrier,
and no interpreter is available.
Which is the best example of
an appropriate 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. Use nouns repeatedly
and discuss one topic at a time.
7. A female patient does not
speak English well, and the
nurse needs to choose an
interpreter. Which of the
following would be the most
appropriate choice?
A) A trained interpreter
B) A male family member
C) A female family member
D) A volunteer college student
from the foreign language
studies department
A) A trained interpreter
Page: 46 whenever possible, the nurse should use a
trained interpreter, preferably one who knows
medical terminology. In general, an older, more
mature interpreter is preferred to a younger, less
experienced one, and the same gender is preferred
when possible.
HESI A2 Critical Thinking Questions Study
8. The nurse is conducting an
interview. Which of these
statements is true regarding
open-ended questions? Select
all that apply.
A) They elicit cold facts.
B) They allow for selfexpression.
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.
F) They are used when narrative information
Page: 32 Open-ended questions allow for selfexpression, build rapport, and obtain narrative
information. These features enhance communication
during an interview. The other statements are
appropriate for closed or direct questions.
HESI A2 Critical Thinking Questions Study
9. The nurse is conducting an
interview in an outpatient clinic
and is using a computer 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 the monitor during
typing.
Page: 32 The use of a computer can become a
barrier. The nurse should begin the interview as
usual by greeting the patient, establishing rapport,
and collecting the patient's narrative story in a
direct face-to-face manner. Only after the narrative
is fully explored should the nurse type data into the
computer. When typing, the nurse should position
the monitor so that the patient can see it.
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.
A) 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.
HESI A2 Critical Thinking Questions Study
11. In the majority culture of
America, coughing, sweating,
and diarrhea are symptoms of
an illness. For some individuals
of Mexican-American origin,
however, these symptoms are a
normal part of living. The nurse
recognizes that this is true,
probably because MexicanAmericans:
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 usually in 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, remembering that concepts
are derived, in part, from the way in which members
of the cultural group define health.
HESI A2 Critical Thinking Questions Study
12. Among many Asians there is
a belief in the yin/yang theory,
rooted in the ancient Chinese
philosophy of Tao. The nurse
recognizes which statement
that most 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 exist when all aspects
of the person are in perfect balance. The other
statements do not describe this theory.
13. An individual who takes the
magicoreligious perspective of
illness and disease 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 seen as an arena in
which supernatural forces dominate. The fate of the
world and those in it depends on the actions of
supernatural forces for good or evil. The other
answers do not reflect the magicoreligious
perspective.
HESI A2 Critical Thinking Questions Study
14. If an American Indian has
come to the clinic to seek help
with regulating her diabetes,
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 crisis of
faith.
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 folk healing
systems, to spiritual or religious healing, or to
scientific biomedicine. In addition to seeking help
from a biomedical or scientific health care provider,
patients may also seek help from folk or religious
healers.
HESI A2 Critical Thinking Questions Study
15. An elderly MexicanAmerican woman with
traditional beliefs has been
admitted 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 appropriate for
her to request one.
C) further assess the patient's
cultural beliefs and offer the
patient assistance in contacting
a curandero or priest if she
desires.
D) ask the family what they
would like to do because
Mexican-Americans
traditionally give control of
decisions to their families.
C) further assess the patient's cultural beliefs and
offer the patient assistance in contacting a
curandero or priest if she desires.
Pages: 22-23 In addition to seeking help from the
biomedical/scientific health care provider, patients
may also seek help from folk or religious healers.
Some people, such as those of Mexican-American
or American Indian origins, may believe that the
cure is incomplete unless the body, mind, and spirit
are also healed (although the division of the person
into parts is a Western concept).
HESI A2 Critical Thinking Questions Study
16. The nurse is reviewing
concepts of cultural aspects of
pain. Which statement is 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 their expressions of
pain.
C) Cultural norms have very
little to do with pain tolerance,
because pain tolerance is
always biologically
determined.
D) A patient's expression of
pain is largely dependent on
the amount of tissue injury
associated with the pain.
B) Just as patients vary in their perceptions of pain,
so will they vary in their expressions of pain.
Page: 25 In addition to expecting variations in pain
perception and tolerance, the nurse should expect
variations in the expression of pain. It is well known
that individuals turn to their social environment for
validation and comparison. The other statements
are incorrect.
HESI A2 Critical Thinking Questions Study
17. The nurse recognizes that
working with children with a
different cultural perspective
may be especially difficult
because:
A) children have spiritual needs
that are influenced by their
stages of development.
B) children have spiritual needs
that are direct reflections of
what is occurring in their
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 their
children'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's developmental level and the religious
climate that exists in the family. The other statements
are not correct.
HESI A2 Critical Thinking Questions Study
18. When providing culturally
competent care, nurses must
incorporate cultural
assessments into their health
assessments. Which statement
is most appropriate to use
when initiating an assessment
of cultural beliefs with an
elderly American Indian
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 nurse should not assume this. An
open-ended question regarding cultural and
spiritual beliefs is best used initially when
performing a cultural assessment.
19. When planning a cultural
assessment, the nurse should
include which component?
A) Family history
B) Chief complaint
C) Medical history
D) Health-related beliefs
D) Health-related beliefs
Pages: 19-20. Health-related beliefs and practices
are one component of a cultural assessment. The
other items reflect other aspects of the patient's
history.
HESI A2 Critical Thinking Questions Study
20. When the nurse is
evaluating the reliability of a
patient's responses, which of
these 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 are rephrased or are
repeated later in the interview. The other statements
are not correct.
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. Patient denies measles,
mumps, rubella, chickenpox,
pertussis, and strep throat.
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 illness common in the person's
childhood may be unusual today (e.g., measles).
HESI A2 Critical Thinking Questions Study
22. The mother of a 16-monthold toddler tells the nurse that
her daughter has an earache.
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 indicate she 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 in pain?" Pulling at
ears alerts parent to ear pain. The statements about
teething and questioning whether the child is really
having pain do not explore the symptoms, which
should be done before a physical examination.
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 weight
B. The age at which he crawled
C. Whether he has had the
measles
D. Reactions to previous
hospitalizations
D. Reactions to previous hospitalizations
Assess how the child reacted to hospitalization and
any complications. If the child reacted poorly, he or
she may be afraid now and will need special
preparation for the examination that is to follow. The
other items are not significant for the procedure.
HESI A2 Critical Thinking Questions Study
24. The nurse is preparing to
do a functional assessment.
Which statement best
describes the 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-day activities. The other
answers do not reflect the purpose of a functional
assessment.
25. The nurse is performing a
functional assessment on an
82-year-old patient who
recently had a stroke. Which of
these questions would be most
important to ask?
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-day activities. For the older
person, the meaning of health becomes those
activities that they can or cannot do. The other
responses do not relate to functional assessment.
HESI A2 Critical Thinking Questions Study
26. The nurse is conducting a
developmental history on a 5-
year-old child. Which questions
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 his shoelaces?"
E. "Can he tell time?"
Page: 61. Questions about tooth loss, ability to tell
time, and ability to tie shoelaces are appropriate
questions for a developmental assessment.
Questions about junk food intake and vitamins are
part of a nutritional history. Questions about food
allergies are not part of a developmental history.
27. During an examination, the
nurse can assess mental status
by which activity?
A) Examining the patient's
electroencephalogram
B) Observing the patient as he
or she performs an IQ test
C) Observing the patient and
inferring health or dysfunction
D) Examining the patient's
response to a specific set of
questions
C) Observing the patient and inferring health or
dysfunction
Page: 71. Mental status cannot be scrutinized
directly like the characteristics of skin or heart
sounds. Its functioning is inferred through
assessment of an individual's behaviors, such as
consciousness, language, mood and affect, and
other aspects.
HESI A2 Critical Thinking Questions Study
28. The nurse is assessing a 75-
year-old man. As the nurse
begins the mental status
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 decreases with
age.
C) may take a little longer to
respond, but his general
knowledge and abilities should
not have declined.
D) will have had a decrease in
his response time because of
language loss and a decrease
in general knowledge.
C) may take a little longer to respond, but his
general knowledge and abilities should not have
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. Response time is slower than in youth. It
takes a bit longer for the brain to process
information and to react to it. Recent memory, which
requires some processing is somewhat decreased
with aging, but remote memory is not affected.
HESI A2 Critical Thinking Questions Study
29. The nurse is preparing to do
a mental status examination.
Which statement is true
regarding the mental status
examination?
A) A patient's family is the best
resource for information about
the patient's coping skills.
B) It is usually sufficient to
gather mental status
information during the health
history interview.
C) It takes an enormous
amount of extra time to
integrate the mental status
examination into the health
history interview.
D) It is usually necessary to
perform a complete mental
status examination to get a
good idea of the patient's level
of functioning.
B) It is usually sufficient to gather mental status
information during the health history interview.
Page: 73. The full mental status examination is a
systematic check of emotional and cognitive
functioning. The steps described here, though,
rarely need to be taken in their entirety. Usually, one
can assess mental status through the context of the
health history interview.
HESI A2 Critical Thinking Questions Study
30. During a mental status
examination, the nurse wants to
assess a patient's affect. The
nurse should ask the patient
which question?
A) "How do you feel today?"
B) "Would you please repeat
the following words?"
C) "Have these medications
had any effect on your pain?"
D) "Has this pain affected your
ability to get dressed by
yourself?"
A) "How do you feel today?"
Page: 74. Judge mood and affect by body language
and facial expression and by asking directly, "How
do you feel today?" or "How do you usually feel?"
The mood should be appropriate to the person's
place and condition and should change
appropriately with topics.
31. During a mental status
assessment, which question by
the nurse would best assess a
person's judgment?
A) "Do you feel that you are
being watched, followed, or
controlled?"
B) "Tell me about what you
plan to do once you are
discharged from the hospital."
C) "What does the statement,
'People in glass houses
shouldn't throw stones,' mean
to you?"
D) "What would you do if you
found a stamped, addressed
envelope lying on the
sidewalk?"
B) "Tell me about what you plan to do once you are
discharged from the hospital."
Pages: 76-77. A person exercises judgment when he
or she can compare and evaluate the alternatives in
a situation and reach an appropriate course of
action. Rather than testing the person's response to
a hypothetical situation (as illustrated in the option
with the envelope), the nurse should be more
interested in the person's judgment about daily or
long-term goals, the likelihood of acting in
response to delusions or hallucinations and the
capacity for violent or suicidal behavior.
HESI A2 Critical Thinking Questions Study
32. The nurse is performing a
mental status examination.
Which statement is true
regarding the assessment of
mental status?
A) Mental status assessment
diagnoses specific psychiatric
disorders.
B) Mental disorders occur in
response to everyday life
stressors.
C) Mental status functioning is
inferred through assessment of
an individual's behaviors.
D) Mental status can be
assessed directly, just like other
systems of the body (e.g.,
cardiac and breath sounds).
C) Mental status functioning is inferred through
assessment of an individual's behaviors.
Page: 71. Mental status functioning is inferred
through assessment of an individual's behaviors. It
cannot be assessed directly like characteristics of
the skin or heart sounds.
33. When performing a
physical assessment, the
technique the nurse will always
use first is:
A) palpation.
B) inspection.
C) percussion.
D) auscultation.
B) inspection.
Pages: 115-116. The skills requisite for the physical
examination are inspection, palpation, percussion,
and auscultation. The skills are performed one at a
time and in this order (with the exception of the
abdominal assessment, where auscultation takes
place before palpation and percussion). The
assessment of each body system begins with
inspection. A focused inspection takes time and
yields a surprising amount of information.
HESI A2 Critical Thinking Questions Study
34. The nurse is assessing a
patient's skin during an office
visit. What is the best technique
to use to best assess the
patient's skin temperature? Use
the:
A) fingertips because they're
more sensitive to small
changes in temperature.
B) dorsal surface of the hand
because the skin is thinner than
on the palms.
C) ulnar portion of the hand
because there is increased
blood supply that enhances
temperature sensitivity.
D) palmar surface of the hand
because it is most sensitive to
temperature variations because
of increased nerve supply in
this area.
B) dorsal surface of the hand because the skin is
thinner than on the palms.
The dorsa (backs) of hands and fingers are best for
determining temperature because the skin there is
thinner than on the palms. Fingertips are best for
fine, tactile discrimination; the other responses are
not useful for palpation.
HESI A2 Critical Thinking Questions Study
35. The nurse is preparing to
assess a patient's abdomen by
palpation. How should the
nurse proceed?
A) Avoid palpation of reported
"tender" areas because this
may cause the patient pain.
B) Quickly palpate a tender
area to avoid any discomfort
that the patient may
experience.
C) Begin the assessment with
deep palpation, encouraging
the patient to relax and take
deep breaths.
D) Start with light palpation to
detect surface characteristics
and to accustom the patient to
being touched.
D) Start with light palpation to detect surface
characteristics and to accustom the patient to being
touched.
Pages: 115-116. Light palpation is performed initially
to detect any surface characteristics and to
accustom the person to being touched. Tender
areas should be palpated last, not first.
36. The nurse would use
bimanual palpation technique
in which situation?
A) Palpating the thorax of an
infant
B) Palpating the kidneys and
uterus
C) Assessing pulsations and
vibrations
D) Assessing the presence of
tenderness and pain
B) Palpating the kidneys and uterus
Pages: 115-116. Bimanual palpation requires the use
of both hands to envelop or capture certain body
parts or organs such as the kidneys, uterus, or
adnexa. The other situations are not appropriate for
bimanual palpation.
HESI A2 Critical Thinking Questions Study
37. When percussing over the
liver of a patient, the nurse
notices a dull sound. The nurse
should:
A) consider this a normal
finding.
B) palpate this area for an
underlying mass.
C) reposition the hands and
attempt to percuss in this area
again.
D) consider this an abnormal
finding and refer the patient for
additional treatment.
A) consider this a normal finding.
Pages: 116-117. Percussion over relatively dense
organs, such as the liver or spleen, will produce a
dull sound. The other responses are not correct.
38. The nurse is unable to
palpate the right radial pulse
on a patient. The best action
would be to:
A) auscultate over the area with
a fetoscope.
B) use a goniometer to
measure the pulsations.
C) use a Doppler device to
check for pulsations over the
area.
D) check for the presence of
pulsations with a stethoscope.
C) use a Doppler device to check for pulsations
over the area.
Page: 120. Doppler devices are used to augment
pulse or blood pressure measurements.
Goniometers measure joint range of motion. A
fetoscope is used to auscultate fetal heart tones.
Stethoscopes are used to auscultate breath, bowel,
and heart sounds.
HESI A2 Critical Thinking Questions Study
39. When performing a physical
examination, safety must be
considered to protect the
examiner and the patient
against the spread of infection.
Which of these statements
describes the most
appropriate action the nurse
should take when performing a
physical examination?
A) There is no need to wash
one's hands after removing
gloves, as long as the gloves
are still intact.
B) Wash hands before and after
every physical patient
encounter.
C) Wash hands between the
examination of each body
system to prevent the spread
of bacteria from one part of
the body to another.
D) Wear gloves throughout the
entire examination to
demonstrate to the patient
concern regarding the spread
of infectious diseases.
B) Wash hands before and after every physical
patient encounter.
Page: 120. The nurse should wash his or her hands
before and after every physical patient encounter;
after contact with blood, body fluids, secretions,
and excretions; after contact with any equipment
contaminated with body fluids; and after removing
gloves. Hands should be washed after gloves have
been removed, even if the gloves appear to be
intact. Gloves should be worn when there is
potential contact with any body fluids.
HESI A2 Critical Thinking Questions Study
40. The nurse is examining an
infant and prepares to elicit the
Moro reflex at which time
during the examination?
A) When the infant is sleeping
B) At the end of the
examination
C) Before auscultation of the
thorax
D) Halfway through the
examination
B) At the end of the examination
Page: 123. Elicit the Moro or "startle" reflex at the
end of the examination because it may cause the
infant to cry.
HESI A2 Critical Thinking Questions Study
41. A 6-month-old infant has
been brought to the well-child
clinic for a check-up. She is
currently sleeping. What
should the nurse do first when
beginning the examination?
A) Auscultate the lungs and
heart while the infant is still
sleeping.
B) Examine the infant's hips
because this procedure is
uncomfortable.
C) Begin with the assessment
of the eye and continue with
the remainder of the
examination in a head-to-toe
approach.
D) Wake the infant before
beginning any portion of the
examination to obtain the most
accurate assessment of body
systems.
A) Auscultate the lungs and heart while the infant is
still sleeping.
Pages: 122-124. When the infant is quiet or sleeping
is an ideal time to assess the cardiac, respiratory,
and abdominal systems. Assessment of the eye, ear,
nose, and throat are invasive procedures and should
be performed at the end of the examination.
HESI A2 Critical Thinking Questions Study
42. The nurse is assessing an
80-year-old male patient.
Which assessment findings
would be considered normal?
A) An increase in body weight
from younger years
B) Additional deposits of fat on
the thighs and lower legs
C) The presence of kyphosis
and flexion in the knees and
hips
D) A change in overall body
proportion, a longer trunk, and
shorter extremities
C) The presence of kyphosis and flexion in the
knees and hips
Page: 149. Changes that occur in the aging person
include more prominent bony landmarks,
decreased body weight (especially in males), a
decrease in subcutaneous fat from the face and
periphery, and additional fat deposited on the
abdomen and hips. Postural changes of kyphosis
and slight flexion in the knees and hips also occur.
43. When assessing the force,
or strength, of a pulse, the
nurse recalls that it:
A) is usually recorded on a 0-
to 2-point scale.
B) demonstrates elasticity of
the vessel wall.
C) is a reflection of the heart's
stroke volume.
D) reflects the blood volume in
the arteries during diastole.
C) is a reflection of the heart's stroke volume.
Page: 134. The heart pumps an amount of blood (the
stroke volume) into the aorta. The force flares the
arterial walls and generates a pressure wave, which
is felt in the periphery as the pulse.
HESI A2 Critical Thinking Questions Study
44. When assessing the quality
of a patient's pain, the nurse
should ask which question?
A) "When did the pain start?"
B) "Is the pain a stabbing pain?"
C) "Is it a sharp pain or dull
pain?"
D) "What does your pain feel
like?"
D) "What does your pain feel like?"
Page: 164. To assess the quality of a person's pain,
have the patient describe the pain in his or her own
words.
45. The nurse is providing care
for a 68-year-old woman who
is complaining of constipation.
What concern exists regarding
her nutritional status?
A) The absorption of nutrients
may be impaired.
B) The constipation may
represent a food allergy.
C) She may need emergency
surgery for the problem.
D) The gastrointestinal problem
will increase her caloric
demand.
A) The absorption of nutrients may be impaired.
Page: 182. Gastrointestinal symptoms such as
vomiting, diarrhea, or constipation may interfere
with nutrient intake or absorption. The other
responses are not correct.
HESI A2 Critical Thinking Questions Study
46. During a nutritional
assessment, why is it important
for the nurse to ask a patient
what medications he or she is
taking?
A) Certain drugs can affect the
metabolism of nutrients.
B) The nurse needs to assess
the patient for allergic
reactions.
C) Medications need to be
documented on the record for
the physician's review.
D) Medications can affect one's
memory and ability to identify
food eaten in the last 24 hours.
A) Certain drugs can affect the metabolism of
nutrients.
Page: 183
Analgesics, antacids, anticonvulsants, antibiotics,
diuretics, laxatives, antineoplastic drugs, steroids,
and oral contraceptives are drugs that can interact
with nutrients, impairing their digestion, absorption,
metabolism, or use. The other responses are not
correct.
47. The nurse is reviewing the
nutritional assessment of an 82-
year-old patient. Which of
these factors is most likely to
affect the nutritional status of
an elderly person?
A) Increase in taste and smell
B) Living alone on a fixed
income
C) Change in cardiovascular
status
D) Increase in gastrointestinal
motility and absorption
B) Living alone on a fixed income
Page: 176. Socioeconomic conditions frequently
affect the nutritional status of the aging adult; these
factors should be closely evaluated. Physical
limitations, income, and social isolation are frequent
problems that interfere with the acquisition of a
balanced diet. A decrease in taste and smell and
decreased gastrointestinal motility and absorption
occur with aging. Cardiovascular status is not a
factor that affects an elderly person's nutritional
status.
HESI A2 Critical Thinking Questions Study
48. When the mid-upper arm
circumference and triceps
skinfold of an 82-year-old man
are evaluated, which is
important for the nurse to
remember?
A) These measurements are no
longer necessary for the
elderly.
B) Derived weight measures
may be difficult to interpret
because of wide ranges of
normal.
C) These measurements may
not be accurate because of
changes in skin and fat
distribution.
D) Measurements may be
difficult to obtain if the patient
is unable to flex his elbow to at
least 90 degrees.
C) These measurements may not be accurate
because of changes in skin and fat distribution.
Page: 191
Accurate mid-upper arm circumference and triceps
skinfold measurements are difficult to obtain and
interpret in older adults because of sagging skin,
changes in fat distribution, and declining muscle
mass. Body mass index and waist-to-hip ratio are
better indicators of obesity in the elderly.
HESI A2 Critical Thinking Questions Study
49. The nurse needs to perform
anthropometric measures of an
80-year-old man who is
confined to a wheelchair.
Which of the following is true
in this situation?
A) Changes in fat distribution
will affect the waist-to-hip ratio.
B) Height measurements may
not be accurate because of
changes in bone.
C) Declining muscle mass will
affect the triceps skinfold
measure.
D) Mid-arm circumference is
difficult to obtain because of
loss of skin elasticity.
B) Height measurements may not be accurate
because of changes in bone.
Page: 191. Height measures may not be accurate in
individuals confined to a bed or wheelchair or those
over 60 years of age because of osteoporotic
changes.
HESI A2 Critical Thinking Questions Study
50. The nurse is performing a
nutritional assessment on an
80-year-old patient. The nurse
knows that physiological
changes that directly affect the
nutritional status of the elderly
include:
A) slowed gastrointestinal
motility.
B) hyperstimulation of the
salivary glands.
C) an increased sensitivity to
spicy and aromatic foods.
D) decreased gastrointestinal
absorption causing
esophageal reflux.
A) slowed gastrointestinal motility.
Page: 176. Normal physiological changes in aging
adults that affect nutritional status include slowed
gastrointestinal motility, decreased gastrointestinal
absorption, diminished olfactory and taste
sensitivity, decreased saliva production, decreased
visual acuity, and poor dentition.
51. The nurse keeps in mind that
a thorough skin assessment is
very important because the
skin holds information about a
person's:
A) support systems.
B) circulatory status.
C) socioeconomic status.
D) psychological wellness.
B) circulatory status.
Page: 211. The skin holds information about the
body's circulation, nutritional status, and signs of
systemic diseases as well as topical data on the
integument itself.
HESI A2 Critical Thinking Questions Study
52. A patient tells the nurse that
he has noticed that one of his
moles has started to burn and
bleed. When assessing his skin,
the nurse would pay special
attention to the danger signs
for pigmented lesions and
would be concerned with
which additional finding?
A) Color variation
B) Border regularity
C) Symmetry of lesions
D) Diameter less than 6 mm
A) Color variation
Pages: 212-213. Abnormal characteristics of
pigmented lesions are summarized in the mnemonic
ABCD: asymmetry of pigmented lesion, border
irregularity, color variation, and diameter greater
than 6 mm.
53. An elderly woman is
brought to the emergency
department after being found
lying on the kitchen floor 2
days, and she is extremely
dehydrated. What would the
nurse expect to see upon
examination?
A) Smooth mucous membranes
and lips
B) Dry mucous membranes and
cracked lips
C) Pale mucous membranes
D) White patches on the
mucous membranes
B) Dry mucous membranes and cracked lips
Page: 215. With dehydration, mucous membranes
look dry and lips look parched and cracked. The
other responses are not found in dehydration.
HESI A2 Critical Thinking Questions Study
54. A 65-year-old man with
emphysema and bronchitis has
come to the clinic for a followup appointment. On
assessment, the nurse might
expect to see which
assessment finding?
A) Anasarca
B) Scleroderma
C) Pedal erythema
D) Clubbing of the nails
D) Clubbing of the nails
Pages: 217-218. Clubbing of the nails occurs with
congenital cyanotic heart disease, neoplastic, and
pulmonary diseases. The other responses are
assessment findings not associated with pulmonary
diseases.
55. The nurse has discovered
decreased skin turgor in a
patient and knows that this is an
expected finding in which of
these conditions?
A) Severe obesity
B) Childhood growth spurts
C) Severe dehydration
D) Connective tissue disorders
such as scleroderma
C) Severe dehydration
Page: 215. Decreased skin turgor is associated with
severe dehydration or extreme weight loss.
HESI A2 Critical Thinking Questions Study
56. A 40-year-old woman
reports a change in mole size,
accompanied by color
changes, itching, burning, and
bleeding over the past month.
She has a dark complexion and
has no family history of skin
cancer, but she has had many
blistering sunburns in the past.
The nurse would:
A) tell the patient to watch the
lesion and report back in 2
months.
B) refer the patient because of
the suspicion of melanoma on
the basis of her symptoms.
C) ask additional questions
regarding environmental
irritants that may have caused
this condition.
D) suspect that this is a
compound nevus, which is very
common in young to middleaged adults.
B) refer the patient because of the suspicion of
melanoma on the basis of her symptoms.
The ABCD danger signs of melanoma are
asymmetry, border irregularity, color variation, and
diameter. In addition, individuals may report a
change in size, development of itching, burning,
bleeding, or a new-pigmented lesion. Any of these
signs raise suspicion of malignant melanoma and
warrant immediate referral.
HESI A2 Critical Thinking Questions Study
57. The nurse is assessing for
clubbing of the fingernails and
would expect to find:
A) a nail base that is firm and
slightly tender.
B) curved nails with a convex
profile and ridges across the
nail.
C) a nail base that feels spongy
with an angle of the nail base
of 150 degrees.
D) an angle of the nail base of
180 degrees or greater with a
nail base that feels spongy.
D) an angle of the nail base of 180 degrees or
greater with a nail base that feels spongy.
Pages: 217-218. The normal nail is firm at its base and
has an angle of 160 degrees. In clubbing, the angle
straightens to 180 degrees or greater and the nail
base feels spongy.
58. A patient has been
admitted for severe psoriasis.
The nurse can expect to see
what finding in the patient's
fingernails?
A) Splinter hemorrhages
B) Paronychia
C) Pitting
D) Beau lines
C) Pitting
Pages: 248-250. Pitting nails are characterized by
sharply defined pitting and crumbling of the nails
with distal detachment, and they are associated with
psoriasis. See Table 12-13 for descriptions of the
other terms.
HESI A2 Critical Thinking Questions Study
59. The nurse suspects that a
patient has hyperthyroidism
and laboratory data indicate
that the patient's thyroxine and
tri-iodothyronine hormone
levels are elevated. Which of
these findings would the nurse
most likely find on
examination?
A) Tachycardia
B) Constipation
C) Rapid dyspnea
D) Atrophied nodular thyroid
A) Tachycardia
Thyroxine and tri-iodothyronine are thyroid
hormones that stimulate the rate of cellular
metabolism, resulting in tachycardia. With an
enlarged thyroid as in hyperthyroidism, the nurse
might expect to find diffuse enlargement (goiter) or
a nodular lump, but not an atrophied gland.
Dyspnea and constipation are not findings
associated with hyperthyroidism.
60. During an examination, the
nurse knows that Paget's
disease would be indicated by
which of these assessment
findings?
A) Positive Macewen sign
B) Premature closure of the
sagittal suture
C) Headache, vertigo, tinnitus,
and deafness
D) Elongated head with heavy
eyebrow ridge
C) Headache, vertigo, tinnitus, and deafness
Paget's disease occurs more often in males and is
characterized by bowed long bones, sudden
fractures, and enlarging skull bones that press on
cranial nerves causing symptoms of headache,
vertigo, tinnitus, and progressive deafness.
HESI A2 Critical Thinking Questions Study
61. A woman comes to the
clinic and states, "I've been sick
for so long! My eyes have
gotten so puffy, and my
eyebrows and hair have
become coarse and dry." The
nurse will assess for other signs
and symptoms of:
A) cachexia.
B) Parkinson's syndrome.
C) myxedema.
D) scleroderma.
C) myxedema.
Pages: 276-277. Myxedema (hypothyroidism) is a
deficiency of thyroid hormone that, when severe,
causes a nonpitting edema or myxedema. The
patient will have a puffy edematous face especially
around eyes (periorbital edema), coarse facial
features, dry skin, and dry, coarse hair and
eyebrows. See Table 13-4, Abnormal Facial
Appearances with Chronic Illnesses, for
descriptions of the other responses.
62. The physician reports that a
patient with a neck tumor has a
tracheal shift. The nurse is
aware that this means that the
patient's trachea is:
A) pulled to the affected side.
B) pushed to the unaffected
side.
C) pulled downward.
D) pulled downward in a
rhythmic pattern.
B) pushed to the unaffected side.
Pages: 262-263. The trachea is pushed to the
unaffected side with an aortic aneurysm, a tumor,
unilateral thyroid lobe enlargement, and
pneumothorax. The trachea is pulled to the affected
side with large atelectasis, pleural adhesions, or
fibrosis. Tracheal tug is a rhythmic downward pull
that is synchronous with systole and occurs with
aortic arch aneurysm.
HESI A2 Critical Thinking Questions Study
63. During an assessment of an
infant, the nurse notes that the
fontanels are depressed and
sunken. The nurse suspects
which condition?
A) Rickets
B) Dehydration
C) Mental retardation
D) Increased intracranial
pressure
B) Dehydration
Pages: 265-266. Depressed and sunken fontanels
occur with dehydration or malnutrition. Mental
retardation and rickets have no effect on fontanels.
Increased intracranial pressure would cause tense
or bulging, and possibly pulsating fontanels.
64. The nurse is performing an
assessment on a 7-year-old
child who has symptoms of
chronic watery eyes, sneezing,
and clear nasal drainage. The
nurse notices the presence of a
transverse line across the
bridge of the nose, dark blue
shadows below the eyes, and a
double crease on the lower
eyelids. These findings are
characteristic of:
A) allergies.
B) a sinus infection.
C) nasal congestion.
D) an upper respiratory
infection.
A) allergies.
Page: 275. Chronic allergies often develop chronic
facial characteristics. These include blue shadows
below the eyes, a double or single crease on the
lower eyelids, open-mouth breathing, and a
transverse line on the nose.
HESI A2 Critical Thinking Questions Study
65. A mother asks when her
newborn infant's eyesight will
be developed. The nurse
should reply:
A) "Vision is not totally
developed until 2 years of
age."
B) "Infants develop the ability
to focus on an object at around
8 months."
C) "By about 3 months, infants
develop more coordinated eye
movements and can fixate on
an object."
D) "Most infants have
uncoordinated eye movements
for the first year of life."
C) "By about 3 months, infants develop more
coordinated eye movements and can fixate on an
object."
Page: 284. Eye movements may be poorly
coordinated at birth, but by 3 to 4 months of age,
the infant should establish binocularity and should
be able to fixate on a single image with both eyes
simultaneously.
66. The nurse is performing an
eye assessment on an 80-yearold patient. Which of these
findings is considered
abnormal?
A) A decrease in tear
production
B) Unequal pupillary
constriction in response to
light
C) The presence of arcus senilis
seen around the cornea
D) Loss of the outer hair on the
eyebrows due to a decrease in
hair follicles
B) Unequal pupillary constriction in response to
light
Pages: 305-308. Pupils are small in old age, and the
pupillary light reflex may be slowed, but pupillary
constriction should be symmetric. The assessment
findings in the other responses are considered
normal in older persons.
HESI A2 Critical Thinking Questions Study
67. The nurse notices the
presence of periorbital edema
when performing an eye
assessment on a 70-year-old
patient. The nurse should:
A) check for the presence of
exophthalmos.
B) suspect that the patient has
hyperthyroidism.
C) ask the patient if he or she
has a history of heart failure.
D) assess for blepharitis
because this is often
associated with periorbital
edema.
C) ask the patient if he or she has a history of heart
failure.
Page: 312. Periorbital edema occurs with local
infections, crying, and systemic conditions such as
heart failure, renal failure, allergy, and
hypothyroidism. Periorbital edema is not associated
with blepharitis.
HESI A2 Critical Thinking Questions Study
68. A patient comes to the
emergency department after a
boxing match, and his left eye
is swollen almost shut. He has
bruises on his face and neck.
He says he is worried because
he "can't see well" from his left
eye. The physician suspects
retinal damage. The nurse
recognizes that signs of retinal
detachment include:
A) loss of central vision.
B) shadow or diminished vision
in one quadrant or one half of
the visual field.
C) loss of peripheral vision.
D) sudden loss of pupillary
constriction and
accommodation.
B) shadow or diminished vision in one quadrant or
one half of the visual field.
Page: 316. With retinal detachment, the person has
shadows or diminished vision in one quadrant or
one half of the visual field. The other responses are
not signs of retinal detachment.
HESI A2 Critical Thinking Questions Study
69. A 68-year-old woman is in
the eye clinic for a checkup.
She tells the nurse that she has
been having trouble with
reading the paper, sewing, and
even seeing the faces of her
grandchildren. On examination,
the nurse notes that she has
some loss of central vision but
her peripheral vision is normal.
These findings suggest that:
A) she may have macular
degeneration.
B) her vision is normal for
someone her age.
C) she has the beginning
stages of cataract formation.
D) she has increased
intraocular pressure or
glaucoma.
A) she may have macular degeneration.
Page: 285. Macular degeneration is the most
common cause of blindness. It is characterized by
loss of central vision. Cataracts would show lens
opacity. Chronic open-angle glaucoma, the most
common type of glaucoma, involves a gradual loss
of peripheral vision.
70. An ophthalmic examination
reveals papilledema. The nurse
is aware that this finding
indicates:
A) retinal detachment.
B) diabetic retinopathy.
C) acute-angle glaucoma.
D) increased intracranial
pressure.
D) increased intracranial pressure.
Pages: 319-320. Papilledema, or choked disk, is a
serious sign of increased intracranial pressure,
which is caused by a space-occupying mass such as
a brain tumor or hematoma. This pressure causes
venous stasis in the globe, showing redness,
congestion, and elevation of the optic disc, blurred
margins, hemorrhages, and absent venous
pulsations. Papilledema is not associated with the
conditions in the other responses.
HESI A2 Critical Thinking Questions Study
71. During an examination, a
patient states that she was
diagnosed with open-angle
glaucoma 2 years ago. The
nurse assesses for
characteristics of open-angle
glaucoma. Which of these are
characteristics of open-angle
glaucoma? Select all that
apply.
A) The patient may experience
sensitivity to light, nausea, and
halos around lights.
B) The patient experiences
tunnel vision in late stages.
C) Immediate treatment is
needed.
D) Vision loss begins with
peripheral vision.
E) It causes sudden attacks of
increased pressure that cause
blurred vision.
F) There are virtually no
symptoms.
B) The patient experiences tunnel vision in late
stages.
D) Vision loss begins with peripheral vision.
F) There are virtually no symptoms.
Pages: 308-309. Open-angle glaucoma is the most
common type of glaucoma; there are virtually no
symptoms. Vision loss begins with the peripheral
vision, which often goes unnoticed because
individuals learn to compensate intuitively by
turning their heads. The other characteristics are
those of closed-angle glaucoma.
HESI A2 Critical Thinking Questions Study
72. The nurse is taking the
history of a patient who may
have a perforated eardrum.
What would be an important
question in this situation?
A) "Do you ever notice ringing
or crackling in your ears?"
B) "When was the last time you
had your hearing checked?"
C) "Have you ever been told
you have any type of hearing
loss?"
D) "Was there any relationship
between the ear pain and the
discharge you mentioned?"
D) "Was there any relationship between the ear pain
and the discharge you mentioned?"
Pages: 327-328. Typically with perforation, ear pain
occurs first, stopping with a popping sensation, and
then drainage occurs.
73. The nurse is performing an
ear examination of an 80-yearold patient. Which of these
would be considered a normal
finding?
A) A high-tone frequency loss
B) Increased elasticity of the
pinna
C) A thin, translucent
membrane
D) A shiny, pink tympanic
membrane
A) A high-tone frequency loss
Pages: 337-338. A high-tone frequency hearing loss
is apparent for those affected with presbycusis, the
hearing loss that occurs with aging. The pinna loses
elasticity, causing earlobes to be pendulous. The
eardrum may be whiter in color and more opaque
and duller than in the young adult.
HESI A2 Critical Thinking Questions Study
74. During an examination, the
patient states he is hearing a
buzzing sound and says that it
is "driving me crazy!" The nurse
recognizes that this symptom
indicates:
A) vertigo.
B) pruritus.
C) tinnitus.
D) cholesteatoma.
C) tinnitus.
Pages: 328-329. Tinnitus is a sound that comes from
within a person; it can be a ringing, crackling, or
buzzing sound. It accompanies some hearing or ear
disorders.
75. The nurse is testing the
hearing of a 78-year-old man
and keeps in mind the changes
in hearing that occur with
aging include which of the
following? Select all that apply.
A) Hearing loss related to
aging begins in the mid 40s.
B) The progression is slow.
C) The aging person has lowfrequency tone loss.
D) The aging person may find it
harder to hear consonants than
vowels.
E) Sounds may be garbled and
difficult to localize.
F) Hearing loss reflects nerve
degeneration of the middle
ear.
B) The progression is slow.
D) The aging person may find it harder to hear
consonants than vowels.
E) Sounds may be garbled and difficult to localize.
Page: 326. Presbycusis is a type of hearing loss that
occurs with aging and is found in 60% of those
older than 65 years. It is a gradual sensorineural loss
caused by nerve degeneration in the inner ear or
auditory nerve, and it slowly progresses after age
50. The person first notices a high-frequency tone
loss; it is harder to hear consonants (high-pitched
components of speech) than vowels. This makes
words sound garbled. The ability to localize sound
is impaired also.
HESI A2 Critical Thinking Questions Study
76. When assessing a patient's
lungs, the nurse recalls that the
left lung:
A) consists of two lobes.
B) is divided by the horizontal
fissure.
C) consists primarily of an
upper lobe on the posterior
chest.
D) is shorter than the right lung
because of the underlying
stomach.
A) consists of two lobes.
Pages: 413-414. The left lung has two lobes, and the
right lung has three lobes. The right lung is shorter
than the left lung because of the underlying liver.
The left lung is narrower than the right lung
because the heart bulges to the left. The posterior
chest is almost all lower lobe.
77. During an assessment, the
nurse knows that expected
assessment findings in the
normal adult lung include the
presence of:
A) adventitious sounds and
limited chest expansion.
B) increased tactile fremitus
and dull percussion tones.
C) muffled voice sounds and
symmetrical tactile fremitus.
D) absent voice sounds and
hyperresonant percussion
tones.
C) muffled voice sounds and symmetrical tactile
fremitus.
Pages: 429-430. Normal lung findings include
symmetric chest expansion, resonant percussion
tones, vesicular breath sounds over the peripheral
lung fields, muffled voice sounds, and no
adventitious sounds.
HESI A2 Critical Thinking Questions Study
78. A 65-year-old patient with a
history of heart failure comes
to the clinic with complaints of
"being awakened from sleep
with shortness of breath."
Which action by the nurse is
most appropriate?
A) Obtain a detailed history of
the patient's allergies and
history of asthma.
B) Tell the patient to sleep on
his or her right side to facilitate
ease of respirations.
C) Assess for other signs and
symptoms of paroxysmal
nocturnal dyspnea.
D) Assure the patient that this is
normal and will probably
resolve within the next week.
C) Assess for other signs and symptoms of
paroxysmal nocturnal dyspnea.
Pages: 419-420. The patient is experiencing
paroxysmal nocturnal dyspnea: being awakened
from sleep with shortness of breath and the need to
be upright to achieve comfort.
79. When assessing tactile
fremitus, the nurse recalls that
it is normal to feel tactile
fremitus most intensely over
which location?
A) Between the scapulae
B) Third intercostal space, MCL
C) Fifth intercostal space, MAL
D) Over the lower lobes,
posterior side
A) Between the scapulae
Page: 424. Normally, fremitus is most prominent
between the scapulae and around the sternum.
These are sites where the major bronchi are closest
to the chest wall. Fremitus normally decreases as
one progress down the chest because more tissue
impedes sound transmission.
HESI A2 Critical Thinking Questions Study
80. The nurse is reviewing the
technique of palpating for
tactile fremitus with a new
graduate. Which statement by
the graduate nurse reflects a
correct understanding of
tactile fremitus? "Tactile
fremitus:
A) is caused by moisture in the
alveoli."
B) indicates that there is air in
the subcutaneous tissues."
C) is caused by sounds
generated from the larynx."
D) reflects the blood flow
through the pulmonary
arteries."
C) is caused by sounds generated from the larynx."
Pages: 422-423. Fremitus is a palpable vibration.
Sounds generated from the larynx are transmitted
through patent bronchi and the lung parenchyma to
the chest wall where they are felt as vibrations.
Crepitus is the term for air in the subcutaneous
tissues.
HESI A2 Critical Thinking Questions Study
81. When auscultating the lungs
of an adult patient, the nurse
notes that over the posterior
lower lobes low-pitched, soft
breath sounds are heard, with
inspiration being longer than
expiration. The nurse interprets
that these are:
A) sounds normally
auscultated over the trachea.
B) bronchial breath sounds and
are normal in that location.
C) vesicular breath sounds and
are normal in that location.
D) bronchovesicular breath
sounds and are normal in that
location.
C) vesicular breath sounds and are normal in that
location.
Pages: 428-429. Vesicular breath sounds are lowpitched, soft sounds with inspiration being longer
than expiration. These breath sounds are expected
over peripheral lung fields where air flows through
smaller bronchioles and alveoli.
82. The nurse is percussing
over the lungs of a patient with
pneumonia. The nurse knows
that percussion over an area of
atelectasis in the lungs would
reveal:
A) dullness.
B) tympany.
C) resonance.
D) hyperresonance.
A) dullness.
Pages: 424-425. A dull percussion note signals an
abnormal density in the lungs, as with pneumonia,
pleural effusion, atelectasis, or tumor.
HESI A2 Critical Thinking Questions Study
83. The nurse knows that
auscultation of fine crackles
would most likely be noticed
in:
A) a healthy 5-year-old child.
B) a pregnant woman.
C) the immediate newborn
period.
D) association with a
pneumothorax.
C) the immediate newborn period.
Pages: 436-437. Fine crackles are commonly heard
in the immediate newborn period as a result of the
opening of the airways and clearing of fluid.
Persistent fine crackles would be noticed with
pneumonia, bronchiolitis, or atelectasis.
84. During auscultation of the
lungs of an adult patient, the
nurse notices the presence of
bronchophony. The nurse
should assess for signs of
which condition?
A) Airway obstruction
B) Emphysema
C) Pulmonary consolidation
D) Asthma
C) Pulmonary consolidation
Page: 446. Pathologic conditions that increase lung
density, such as pulmonary consolidation, will
enhance transmission of voice sounds, such as
bronchophony. See Table 18-7.
HESI A2 Critical Thinking Questions Study
85. The nurse is listening to the
breath sounds of a patient with
severe asthma. Air passing
through narrowed bronchioles
would produce which of these
adventitious sounds?
A) Wheezes
B) Bronchial sounds
C) Bronchophony
D) Whispered pectoriloquy
A) Wheezes
Page: 445. Wheezes are caused by air squeezed or
compressed through passageways narrowed almost
to closure by collapsing, swelling, secretions, or
tumors, such as with acute asthma or chronic
emphysema.
86. An adult patient with a
history of allergies comes to
the clinic complaining of
wheezing and difficulty in
breathing when working in his
yard. The assessment findings
include tachypnea, use of
accessory neck muscles,
prolonged expiration,
intercostal retractions,
decreased breath sounds, and
expiratory wheezes. The nurse
interprets that these
assessment findings are
consistent with:
A) asthma.
B) atelectasis.
C) lobar pneumonia.
D) heart failure.
A) asthma.
Page: 451. Asthma is allergic hypersensitivity to
certain inhaled particles that produces inflammation
and a reaction of bronchospasm, which increases
airway resistance, especially during expiration.
Increased respiratory rate, use of accessory
muscles, retraction of intercostal muscles,
prolonged expiration, decreased breath sounds,
and expiratory wheezing are all characteristic of
asthma. See Table 18-8 for descriptions of the other
conditions.
HESI A2 Critical Thinking Questions Study
87. During auscultation of
breath sounds, the nurse
should use the stethoscope
correctly, in which of the
following ways?
A) Listen to at least one full
respiration in each location.
B) Listen as the patient inhales
and then go to the next site
during exhalation.
C) Have the patient breathe in
and out rapidly while the nurse
listens to the breath sounds.
D) If the patient is modest,
listen to sounds over his or her
clothing or hospital gown.
A) Listen to at least one full respiration in each
location.
Pages: 426-427. During auscultation of breath
sounds with a stethoscope, it is important to listen
to one full respiration in each location. During the
examination, the nurse should monitor the breathing
and offer times for the person to breathe normally
to prevent possible dizziness.
88. During palpation of the
anterior chest wall, the nurse
notices a coarse, crackling
sensation over the skin surface.
On the basis of these findings,
the nurse suspects:
A) tactile fremitus.
B) crepitus.
C) friction rub.
D) adventitious sounds.
B) crepitus.
Page: 424. Crepitus is a coarse, crackling sensation
palpable over the skin surface. It occurs in
subcutaneous emphysema when air escapes from
the lung and enters the subcutaneous tissue, as
after open thoracic injury or surgery.
HESI A2 Critical Thinking Questions Study
89. The nurse is auscultating the
lungs of a patient who had
been sleeping and notices
short, popping, crackling
sounds that stop after a few
breaths. The nurse recognizes
that these breath sounds are:
A) atelectatic crackles, and that
they are not pathologic.
B) fine crackles, and that they
may be a sign of pneumonia.
C) vesicular breath sounds.
D) fine wheezes.
A) atelectatic crackles, and that they are not
pathologic.
Pages: 429-430. One type of adventitious sound,
atelectatic crackles, is not pathologic. They are
short, popping, crackling sounds that sound like fine
crackles but do not last beyond a few breaths.
When sections of alveoli are not fully aerated (as in
people who are asleep or in the elderly), they
deflate slightly and accumulate secretions. Crackles
are heard when these sections are expanded by a
few deep breaths. Atelectatic crackles are heard
only in the periphery, usually in dependent portions
of the lungs, and disappear after the first few
breaths or after a cough.
HESI A2 Critical Thinking Questions Study
90. The nurse is assessing voice
sounds during a respiratory
assessment. Which of these
findings indicates a normal
assessment? Select all that
apply.
A) Voice sounds are faint,
muffled, and almost inaudible
when the patient whispers
"one, two, three" in a very soft
voice.
B) As the patient says "ninetynine" repeatedly, the examiner
hears the words "ninety-nine"
clearly.
C) When the patient speaks in a
normal voice, the examiner can
hear a sound but cannot
distinguish exactly what is
being said.
D) As the patient says a long
"ee-ee-ee" sound, the examiner
also hears a long "ee-ee-ee"
sound.
E) As the patient says a long
"ee-ee-ee" sound, the examiner
hears a long "aaaaaa" sound.
A) Voice sounds are faint, muffled, and almost
inaudible when the patient whispers "one, two,
three" in a very soft voice.
C) When the patient speaks in a normal voice, the
examiner can hear a sound but cannot distinguish
exactly what is being said.
D) As the patient says a long "ee-ee-ee" sound, the
examiner also hears a long "ee-ee-ee" sound.
Page: 446. As a patient says "ninety-nine"
repeatedly, normally, the examiner hears sound but
cannot distinguish what is being said. If a clear
"ninety-nine" is auscultated, then it could indicate
increased lung density, which enhances transmission
of voice sounds. This is a measure of bronchophony.
When a patient says a long "ee-ee-ee" sound,
normally the examiner also hears a long "ee-ee-ee"
sound through auscultation. This is a measure of
egophony. If the examiner hears a long "aaaaaa"
sound instead, this could indicate areas of
consolidation or compression. With whispered
pectoriloquy, as when a patient whispers a phrase
such as "one-two-three," the normal response when
auscultating voice sounds is to hear sounds that are
faint, muffled, and almost inaudible. If the examiners
hears the whispered voice clearly, as if the patient is
speaking through the stethoscope, then
consolidation of the lung fields may exist.
HESI A2 Critical Thinking Questions Study
91. During an assessment of a
68-year-old man with a recent
onset of right-sided weakness,
the nurse hears a blowing,
swishing sound with the bell of
the stethoscope over the left
carotid artery. This finding
would indicate:
A) a valvular disorder.
B) blood flow turbulence.
C) fluid volume overload.
D) ventricular hypertrophy.
B) blood flow turbulence.
Page: 471. A bruit is a blowing, swishing sound
indicating blood flow turbulence; normally none is
present.
92. During an assessment of a
healthy adult, where would the
nurse expect to palpate the
apical impulse?
A) Third left intercostal space
at the midclavicular line
B) Fourth left intercostal space
at the sternal border
C) Fourth left intercostal space
at the anterior axillary line
D) Fifth left intercostal space at
the midclavicular line
D) Fifth left intercostal space at the midclavicular
line
Pages: 473-474. The apical impulse should occupy
only one intercostal space, the fourth or fifth, and it
should be at or medial to the midclavicular line.
HESI A2 Critical Thinking Questions Study
93. The nurse is preparing to
auscultate for heart sounds.
Which technique is correct?
A) Listen to the sounds at the
aortic, tricuspid, pulmonic, and
mitral areas.
B) Listen by inching the
stethoscope in a rough Z
pattern, from the base of the
heart across and down, then
over to the apex.
C) Listen to the sounds only at
the site where the apical pulse
is felt to be the strongest.
D) Listen for all possible
sounds at a time at each
specified area.
B) Listen by inching the stethoscope in a rough Z
pattern, from the base of the heart across and
down, then over to the apex.
Pages: 475-476. Do not limit auscultation of breath
sounds to only four locations. Sounds produced by
the valves may be heard all over the precordium.
Inch the stethoscope in a rough Z pattern from the
base of the heart across and down, then over to the
apex. Or, start at the apex and work your way up.
See Figure 19-22. Listen selectively to one sound at
a time.
94. The nurse is assessing a
patient's apical impulse. Which
of these statements is true
regarding the apical impulse?
A) It is palpable in all adults.
B) It occurs with the onset of
diastole.
C) Its location may be
indicative of heart size.
D) It should normally be
palpable in the anterior axillary
line.
C) Its location may be indicative of heart size.
Page: 473 | Page: 492. The apical impulse is
palpable in about 50% of adults. It is located in the
fifth left intercostal space in the midclavicular line.
Horizontal or downward displacement of the apical
impulse may indicate an enlargement of the left
ventricle.
HESI A2 Critical Thinking Questions Study
95. During an assessment of an
older adult, the nurse should
expect to notice which finding
as a normal physiologic
change associated with the
aging process?
A) Hormonal changes causing
vasodilation and a resulting
drop in blood pressure
B) Progressive atrophy of the
intramuscular calf veins,
causing venous insufficiency
C) Peripheral blood vessels
growing more rigid with age,
producing a rise in systolic
blood pressure
D) Narrowing of the inferior
vena cava, causing low blood
flow and increases in venous
pressure resulting in
varicosities
C) Peripheral blood vessels growing more rigid with
age, producing a rise in systolic blood pressure
Pages: 504-505. Peripheral blood vessels grow
more rigid with age, resulting in a rise in systolic
blood pressure. Aging produces progressive
enlargement of the intramuscular calf veins, not
atrophy. The other options are not correct.
96. During an assessment, the
nurse uses the "profile sign" to
detect:
A) pitting edema.
B) early clubbing.
C) symmetry of the fingers.
D) insufficient capillary refill.
B) early clubbing.
Page: 506. The nurse should use the profile sign
(viewing the finger from the side) to detect early
clubbing.
HESI A2 Critical Thinking Questions Study
97. When performing a
peripheral vascular assessment
on a patient, the nurse is
unable to palpate the ulnar
pulses. The patient's skin is
warm and capillary refill time is
normal. The nurse should next:
A) check for the presence of
claudication.
B) refer the individual for
further evaluation.
C) consider this a normal
finding and proceed with the
peripheral vascular evaluation.
D) ask the patient if he or she
has experienced any unusual
cramping or tingling in the arm.
C) consider this a normal finding and proceed with
the peripheral vascular evaluation.
Pages: 506-507. It is not usually necessary to
palpate the ulnar pulses. The ulnar pulses are often
not palpable in the normal person. The other
responses are not correct.
HESI A2 Critical Thinking Questions Study
98. The nurse is attempting to
assess the femoral pulse in an
obese patient. Which of these
actions would be most
appropriate?
A) Have the patient assume a
prone position.
B) Ask the patient to bend his
or her knees to the side in a
froglike position.
C) Press firmly against the
bone with the patient in a semiFowler position.
D) Listen with a stethoscope
for pulsations because it is very
difficult to palpate the pulse in
an obese person.
B) Regular "lub, dub" pattern
Pages: 510-511. To help expose the femoral area,
particularly in obese people, the nurse should ask
the person to bend his or her knees to the side in a
froglike position.
99. When using a Doppler
ultrasonic stethoscope, the
nurse recognizes arterial flow
when which sound is heard?
A) Low humming sound
B) Regular "lub, dub" pattern
C) Swishing, whooshing sound
D) Steady, even, flowing sound
C) Swishing, whooshing sound
Pages: 515-516. When using the Doppler ultrasonic
stethoscope, the pulse site is found when one hears
a swishing, whooshing sound.
HESI A2 Critical Thinking Questions Study
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
B) 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
A) 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
D) Sigmoid colon
Page: 530. The sigmoid colon is located in the left
lower quadrant of the abdomen.
HESI A2 Critical Thinking Questions Study
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.
D) 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.
C) 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.
HESI A2 Critical Thinking Questions Study
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.
B) 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.
D) hyperactive bowel sounds.
D) hyperactive bowel sounds.
Pages: 539-540. Borborygmi is the term used for
hyperperistalsis when the person actually feels his
or her stomach growling.
107. During an abdominal
assessment, the nurse would
consider which of these
findings as normal?
A) The presence of a bruit in
the femoral area
B) A tympanic percussion note
in the umbilical region
C) A palpable spleen between
the ninth and eleventh ribs in
the left midaxillary line
D) A dull percussion note in the
left upper quadrant at the
midclavicular line
B) A tympanic percussion note in the umbilical
region
Pages: 539-540. Tympany should predominate in all
four quadrants of the abdomen because air in the
intestines rises to the surface when the person is
supine. Vascular bruits are not usually present.
Normally the spleen is not palpable. Dullness would
not be found in the area of lung resonance (left
upper quadrant at the midclavicular line).
HESI A2 Critical Thinking Questions Study
108. During an abdominal
assessment, the nurse is unable
to hear bowel sounds in a
patient's abdomen. Before
reporting this finding as "silent
bowel sounds" the nurse
should listen for at least:
A) 1 minute.
B) 5 minutes.
C) 10 minutes.
D) 2 minutes in each quadrant.
B) 5 minutes.
Pages: 539-540. Absent bowel sounds are rare. The
nurse must listen for 5 minutes before deciding
bowel sounds are completely absent.
109. A patient is suspected of
having inflammation of the
gallbladder, or cholecystitis.
The nurse should conduct
which of these techniques to
assess for this condition?
A) Obturator test
B) Test for Murphy's sign
C) Assess for rebound
tenderness
D) Iliopsoas muscle test
B) Test for Murphy's sign
Page: 551. Normally, palpating the liver causes no
pain. In a person with inflammation of the
gallbladder, or cholecystitis, pain occurs as the
descending liver pushes the inflamed gallbladder
onto the examining hand during inspiration
(Murphy's test). The person feels sharp pain and
abruptly stops inspiration midway.
HESI A2 Critical Thinking Questions Study
110. During an assessment the
nurse notices that a patient's
umbilicus is enlarged and
everted. It is midline, and there
is no change in skin color. The
nurse recognizes that the
patient may have which
condition?
A) Intra-abdominal bleeding
B) Constipation
C) Umbilical hernia
D) An abdominal tumor
C) Umbilical hernia
Page: 537. The umbilicus is normally midline and
inverted, with no signs of discoloration. With an
umbilical hernia, the mass is enlarged and everted.
The other responses are incorrect.
111. The nurse suspects that a
patient has appendicitis. Which
of these procedures are
appropriate for use when
assessing for appendicitis or a
perforated appendix? Select
all that apply.
A) Test for Murphy's sign.
B) Test for Blumberg's sign.
C) Test for shifting dullness.
D) Perform iliopsoas muscle
test.
E) Test for fluid wave.
B) Test for Blumberg's sign.
D) Perform iliopsoas muscle test.
Pages: 543-544 | Page: 551. Testing for Blumberg's
sign (rebound tenderness) and performing the
iliopsoas muscle test should be used to assess for
appendicitis. Murphy's sign is used to assess for an
inflamed gallbladder or cholecystitis. Testing for a
fluid wave and shifting dullness is done to assess for
ascites.
HESI A2 Critical Thinking Questions Study
112. When assessing muscle
strength, the nurse observes
that a patient has complete
range of motion against gravity
with full resistance. What Grade
should the nurse record using
a 0 to 5 point scale?
A) 2
B) 3
C) 4
D) 5
D) 5
Pages: 578-579. Complete range of motion against
gravity is normal muscle strength and is recorded as
Grade 5 muscle strength.
113. The nurse is assessing the
joints of a woman who has
stated, "I have a long family
history of arthritis, and my
joints hurt." The nurse suspects
that she has osteoarthritis.
Which of these are symptoms
of osteoarthritis? Select all that
apply.
A) Symmetric joint involvement
B) Asymmetric joint
involvement
C) Pain with motion of affected
joints
D) Affected joints are swollen
with hard, bony protuberances
E) Affected joints may have
heat, redness, and swelling
B) Asymmetric joint involvement
C) Pain with motion of affected joints
D) Affected joints are swollen with hard, bony
protuberances
Page: 608. In osteoarthritis, asymmetric joint
involvement commonly affects hands, knees, hips,
and lumbar and cervical segments of the spine.
Affected joints have stiffness, swelling with hard
bony protuberances, pain with motion, and
limitation of motion. The other options reflect signs
of rheumatoid arthritis.
HESI A2 Critical Thinking Questions Study
114. During an assessment of an
80-year-old patient, the nurse
notices the following: inability
to identify vibrations at the
ankle and to identify position
of big toe, slower and more
deliberate gait, and slightly
impaired tactile sensation. All
other neurologic findings are
normal. The nurse should
interpret that these findings
indicate:
A) cranial nerve dysfunction.
B) lesion in the cerebral cortex.
C) normal changes due to
aging.
D) demyelinization of nerves
due to a lesion.
C) normal changes due to aging.
Page: 629. Some aging adults show a slower
response to requests, especially for those calling
for coordination of movements. The findings listed
are normal in the absence of other significant
abnormal findings. The other responses are
incorrect.
HESI A2 Critical Thinking Questions Study
115. In obtaining a history on a
74-year-old patient the nurse
notes that he drinks alcohol
daily and that he has noticed a
tremor in his hands that affects
his ability to hold things. With
this information, what should
the nurse's response be?
A) "Does your family know you
are drinking every day?"
B) "Does the tremor change
when you drink the alcohol?"
C) "We'll do some tests to see
what is causing the tremor."
D) "You really shouldn't drink
so much alcohol; it may be
causing your tremor."
B) "Does the tremor change when you drink the
alcohol?"
Page: 632. Intention tremor/ senile tremor is
relieved by alcohol, although this is not a
recommended treatment. The nurse should assess
whether the person is abusing alcohol in an effort to
relieve the tremor.
HESI A2 Critical Thinking Questions Study
116. During the neurologic
assessment of a "healthy" 35-
year-old patient, the nurse asks
him to relax his muscles
completely. The nurse then
moves each extremity through
full range of motion. Which of
these results would the nurse
expect to find?
A) Firm, rigid resistance to
movement
B) Mild, even resistance to
movement
C) Hypotonic muscles as a
result of total relaxation
D) Slight pain with some
directions of movement
B) Mild, even resistance to movement
Page: 637. Tone is the normal degree of tension
(contraction) in voluntarily relaxed muscles. It shows
a mild resistance to passive stretch. Normally, the
nurse will notice a mild, even resistance to
movement. The other responses are not correct.
117. When the nurse asks a 68-
year-old patient to stand with
feet together and arms at his
side with his eyes closed, he
starts to sway and moves his
feet farther apart. The nurse
would document this finding as
a(n):
A) ataxia.
B) lack of coordination.
C) negative Homans' sign.
D) positive Romberg sign.
D) positive Romberg sign.
Page: 638. Abnormal findings for Romberg test
include swaying, falling, and widening base of feet
to avoid falling. Positive Romberg sign is loss of
balance that is increased by closing of the eyes.
Ataxia is uncoordinated or unsteady gait. Homans'
sign is used to test the legs for deep vein
thrombosis.
HESI A2 Critical Thinking Questions Study
118. During the history of a 78-
year-old man, his wife states
that he occasionally has
problems with short-term
memory loss and confusion:
"He can't even remember how
to button his shirt." In doing the
assessment of his sensory
system, which action by the
nurse is most appropriate?
A) The nurse would not do this
part of the examination
because results would not be
valid.
B) The nurse would perform
the tests, knowing that mental
status does not affect sensory
ability.
C) The nurse would proceed
with the explanations of each
test, making sure the wife
understands.
D) Before testing, the nurse
would assess the patient's
mental status and ability to
follow directions at this time.
D) Before testing, the nurse would assess the
patient's mental status and ability to follow
directions at this time.
The nurse should ensure validity of the sensory
system testing by making sure the patient is alert,
cooperative, comfortable, and has an adequate
attention span. Otherwise, the nurse may obtain
misleading and invalid results.
HESI A2 Critical Thinking Questions Study
119. In assessing a 70-year-old
patient who has had a recent
cerebrovascular accident, the
nurse notices right-sided
weakness. What might the
nurse expect to find when
testing his reflexes on the right
side?
A) Lack of reflexes
B) Normal reflexes
C) Diminished reflexes
D) Hyperactive reflexes
D) Hyperactive reflexes
Hyperreflexia is the exaggerated reflex seen when
the monosynaptic reflex arc is released from the
influence of higher cortical levels. This occurs with
upper motor neuron lesions (e.g., a cerebrovascular
accident). The other responses are incorrect
120. During the assessment of
an 80-year-old patient, the
nurse notices that his hands
show tremors when he reaches
for something and his head is
always nodding. There is no
associated rigidity with
movement. Which of these
statements is most accurate?
A) These are normal findings
resulting from aging.
B) These could be related to
hyperthyroidism.
C) These are the result of
Parkinson disease.
D) This patient should be
evaluated for a cerebellar
lesion.
A) These are normal findings resulting from aging.
Page: 659. Senile tremors occasionally occur. These
benign tremors include an intention tremor of the
hands, head nodding (as if saying yes or no), and
tongue protrusion. Tremors associated with
Parkinson disease include rigidity, slowness, and
weakness of voluntary movement. The other
responses are incorrect.
HESI A2 Critical Thinking Questions Study
121. While the nurse is taking
the history of a 68-year-old
patient who sustained a head
injury 3 days earlier, he tells the
nurse that he is on a cruise ship
and is 30 years old. The nurse
knows that this finding is
indicative of:
A) a great sense of humor.
B) uncooperative behavior.
C) inability to understand
questions.
D) decreased level of
consciousness.
D) decreased level of consciousness.
Pages: 660-661. A change in consciousness may be
subtle. The nurse should notice any decreasing level
of consciousness, disorientation, memory loss,
uncooperative behavior, or even complacency in a
previously combative person. The other responses
are incorrect.
122. The nurse is caring for a
patient who has just had
neurosurgery. To assess for
increased intracranial pressure,
what would the nurse include
in the assessment?
A) Cranial nerves, motor
function, and sensory function
B) Deep tendon reflexes, vital
signs, and coordinated
movements
C) Level of consciousness,
motor function, pupillary
response, and vital signs
D) Mental status, deep tendon
reflexes, sensory function, and
pupillary response
C) Level of consciousness, motor function, pupillary
response, and vital signs
Pages: 660-661. Some hospitalized persons have
head trauma or a neurologic deficit from a systemic
disease process. These people must be monitored
closely for any improvement or deterioration in
neurologic status and for any indication of
increasing intracranial pressure. The nurse should
use an abbreviation of the neurologic examination
in the following sequence: level of consciousness,
motor function, pupillary response, and vital signs.
HESI A2 Critical Thinking Questions Study
123. During an assessment of a
22-year-old woman who has a
head injury from a car accident
4 hours ago, the nurse notices
the following change: pupils
were equal, but now the right
pupil is fully dilated and
nonreactive, left pupil is 4 mm
and reacts to light. What does
finding this suggest?
A) Injury to the right eye
B) Increased intracranial
pressure
C) Test was not performed
accurately
D) Normal response after a
head injury
B) Increased intracranial pressure
Pages: 662-663. In a brain-injured person, a sudden,
unilateral, dilated, and nonreactive pupil is ominous.
Cranial nerve III runs parallel to the brainstem.
When increasing intracranial pressure pushes the
brainstem down (uncal herniation), it puts pressure
on cranial nerve III, causing pupil dilation. The other
responses are incorrect.
124. The nurse knows that
determining whether a person
is oriented to his or her
surroundings will test the
functioning of which of these
structures?
A) Cerebrum
B) Cerebellum
C) Cranial nerves
D) Medulla oblongata
A) Cerebrum
Pages: 621-622 | Page: 660. The cerebral cortex is
responsible for thought, memory, reasoning,
sensation, and voluntary movement. The other
options structures are not responsible for a person's
level of consciousness.
HESI A2 Critical Thinking Questions Study