the mother of a 16 month old toddler tells the nurse that her daughter has an earache what would be an appropriate response
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Nursing Elites

HESI A2

HESI A2 Practice Test Anatomy and Physiology

1. What would be an appropriate nursing response when a mother reports that her 16-month-old toddler has an earache?

Correct answer: B

Rationale: The appropriate nursing response would be to assess the toddler's ear to determine if there is indeed an ear infection causing the earache. It is crucial to provide timely and suitable care for the child's pain and discomfort. Checking for an ear infection is a necessary step in evaluating the source of the toddler's earache. Choice A is incorrect as it assumes the earache is due to teething without proper assessment. Choice C questions the mother's report rather than focusing on the child's condition. Choice D is not as direct and focused as directly examining the ear for a possible infection.

2. When conducting an interview in an outpatient clinic using a computer to record data, what is the best use of the computer in this situation? Select all that apply.

Correct answer: A

Rationale: A. Collect the patient's data in a direct, face-to-face manner: When conducting an interview in an outpatient clinic, it is essential to engage with the patient face-to-face to establish a rapport, gather their narrative, and ensure accurate data collection. Entering all the data as the patient states it (choice B) may lead to missing important details or misinterpretation. Asking the patient to wait as the data is entered (choice C) can create a disconnect in communication and reduce patient engagement. Typing the data into the computer after establishing a connection (choice D) is not ideal as it is important to collect data actively while interacting with the patient.

3. 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.

4. During an interview, the interviewer is using open-ended questions. Which of the following statements are true regarding open-ended questions? Select all that apply.

Correct answer: B

Rationale: Open-ended questions are designed to encourage the interviewee to express themselves freely, leading to more detailed and insightful responses. These questions help build rapport by showing interest in the interviewee's thoughts and feelings. By allowing for self-expression, open-ended questions facilitate a deeper and more meaningful conversation, making them a valuable tool in conducting interviews. Choice A is incorrect because open-ended questions aim to gather detailed and subjective information, not just cold facts. Choice D is incorrect as open-ended questions often lead to more engaging interactions rather than leaving them neutral.

5. 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:

Correct answer: D

Rationale: The parent's sudden change in body language from an open position to crossing arms and legs suggests discomfort or defensiveness, particularly when discussing his son's treatment. This closed-off position indicates a lack of willingness to share information and potentially signals discomfort with the topic being discussed. Choice A is incorrect as the abrupt shift in body language indicates more than just a change in position. Choice B is incorrect because crossing arms and legs typically signal defensiveness or discomfort rather than comfort. Choice C is incorrect as there are specific body language cues indicating discomfort rather than just fatigue.

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