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
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Nursing Elites

HESI A2

HESI A2 Practice Test Anatomy and Physiology

1. Before a child undergoes a tonsillectomy, what information should the nurse collect?

Correct answer: D

Rationale: Before a child undergoes a tonsillectomy, it is crucial for the nurse to gather information on the child's reactions to previous hospitalizations. This data helps in assessing potential fears or anxiety and in providing the necessary support and preparation for the upcoming tonsillectomy. Understanding the child's past reactions is vital for ensuring their comfort and well-being during the hospital admission and procedure. The other options provided are not directly relevant to the child's upcoming tonsillectomy procedure. Birth weight (Choice A) is not typically a factor considered before a tonsillectomy. The age at which a child crawled (Choice B) is a developmental milestone but not pertinent to the tonsillectomy. Having had measles (Choice C) is important for overall health history but not specifically crucial before a tonsillectomy.

2. 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?

Correct answer: A

Rationale: The appropriate action for the nurse in this situation is to ask the patient about the charm and its significance. This helps the nurse understand the patient's cultural beliefs, personal values, and any potential significance the charm holds for the patient. It also shows respect for the patient's personal belongings. Asking about the charm can help establish rapport and cultural competence in the nurse-patient relationship. Choices B and C do not address the patient's attachment to the charm or provide an opportunity for cultural understanding. Choice D is incorrect as it dismisses the importance of acknowledging and respecting the patient's personal belongings.

3. 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?

Correct answer: C

Rationale: In Asian belief systems like the yin\yang theory rooted in Tao philosophy, health is seen as existing when all aspects of a person are in perfect balance. This means that physical, mental, emotional, and spiritual elements need to be harmonized for an individual to be considered healthy. The other statements do not encapsulate this holistic perspective on health.

4. When a nurse is performing a health interview on a patient with a language barrier and no interpreter is available, which of the following is the best example of an appropriate question for the nurse to ask?

Correct answer: A

Rationale: The best example of an appropriate question for the nurse to ask in this situation is 'Do you take medicine?' This question is clear, simple, and focused on one topic at a time, which is essential when there is a language barrier and no interpreter available. It follows the recommendation to use simple words, avoid medical jargon, contractions, and pronouns in such situations. Choices B, C, and D involve more complex language, unrelated topics, or assumptions about the patient's actions, making them less suitable for effective communication in this context.

5. When planning a cultural assessment, which component should be included?

Correct answer: D

Rationale: When planning a cultural assessment, the nurse should include the component of health-related beliefs. Understanding a person's cultural background and beliefs about health and wellness is crucial for providing culturally competent care. Health-related beliefs can impact a person's attitudes towards illness, treatment preferences, and adherence to medical recommendations. Therefore, assessing health-related beliefs is essential for delivering effective and respectful healthcare services. Choices A, B, and C are important components of a comprehensive patient assessment but are not specific to cultural considerations. While family history, chief complaint, and medical history are pertinent to understanding a patient's health status, health-related beliefs focus specifically on the cultural aspect that influences an individual's health perceptions and behaviors.

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