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質問 92
A 60-year-old male client was hospitalized 3 days ago with the diagnosis of acute anterior wall myocardial infarction. Today he has been complaining of increasing weakness and shortness of breath. Crackles in both lung bases are audible on auscultation. He is developing:
- A. Pulmonary edema
- B. An extension of his myocardial infarction
- C. Pneumonia
- D. Pulmonary emboli
正解: A
解説:
(A) Extensions of his myocardial infarction would be chest pain unrelieved with nitroglycerin, cardiac enzyme elevations, and electrocardiographic changes. (B) Persons with pneumonia may complain of weakness and shortness of breath and have crackles in their lung bases. However, they would also have sputum production and leukocytosis. (C) Persons who have had myocardial infarctions (especially anterior wall) are at risk of developing left ventricular heart failure, which is a major cause of pulmonary edema. Pulmonary edema is manifest by shortness of breath, weakness, and crackles on auscultation of the lung fields. (D) Pulmonary emboli may be accompanied by shortness of breath, weakness, and crackles. However, the pulmonary hypertension that accompanies pulmonary emboli results in signs of increased systemic venous pressure as well.
質問 93
A client tells the nurse that he has been hearing voices that tell him to kill his girlfriend because she is a spy. He further states that he is having difficulty not obeying the voices because, if he does not, his house will be burned down. The highest priority nursing diagnosis for him at this time is:
- A. Impaired verbal communication: loose associations
- B. Sensory-perceptual alteration: auditory command hallucinations
- C. Alteration in thought processes: paranoid delusions
- D. Potential for violence directed at others
正解: D
解説:
(A) Although the client is having command hallucinations, this is second in priority to real or potential violence, which can be a threat to life itself. (B) Although the client is experiencing delusions, this is also a lower priority than his potential or actual loss of control. (C) Whether real or potential, violence directed at self or others is always high priority. (D) There is no evidence of loosening of associations.
質問 94
A client who is a breast-feeding mother develops mastitis. The clinical signs and symptoms of mastitis include:
- A. Cracked nipple with complaints of soreness
- B. Marked engorgement, elevated temperature, chills, and breast pain with an area that is red and hardened
- C. Marked engorgement and breast pain
- D. Elevated temperature and general malaise
正解: B
解説:
Explanation
(A) Mastitis is a bacterial inflammation of the breast tissue found primarily in breast-feeding mothers. The bacteria usually enter the breast through a cracked nipple, or the infection results from stasis of milk behind a blocked duct. (B) With breast engorgement during breast-feeding, there may be marked breast pain. This is not necessarily a sign of infection. (C) Women may become ill during breast-feeding with other bacterial or viral infections that are not related to mastitis. (D) Improper care of the nipples or improper positioning of the infant during breastfeeding may result in cracked or sore nipples.
質問 95
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, "Why did this happen to my baby?" is:
- A. "I know your other children will be a great comfort to you."
- B. "I can see you're upset. Would you like to see and hold your baby?"
- C. "It's God's will. It was probably for the best. There was something probably wrong with your baby."
- D. "You're young. You can have other children later."
正解: B
解説:
Section: Questions Set F
Explanation:
(A) The mother and the father require support; the nurse should not minimize their grief in this situation. (B) Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. (C) Attachment to this infant occurs during the pregnancy for both the mother and father.
Siblings will not replace their feelings or minimize their loss of this infant. (D) Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ("she is bruised") and provide support.
質問 96
The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son's condition by which of the following statements?
- A. "Has anyone in your family ever had schizophrenia?"
- B. "Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship."
- C. "If your son has a twin, he probably will eventually develop schizophrenia, too."
- D. "Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain."
正解: D
解説:
Explanation
(A) The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms. (B) This statement will only create anxiety in the mother, and the genetic theory is only one of the etiological factors. (C) This statement will cause the mother much alarm, and nothing was mentioned about any other child. (D) The motherchild relationship is one of the previous theories examined, but it is not one to be emphasized, thereby causing a lot of anxiety for the mother.
質問 97
A 10-year-old has been diagnosed with acute poststreptococcal glomerulonephritis. The clinical findings were proteinuria, moderately elevated blood pressure, and periorbital edema. Which dietary plan is most appropriate for this client?
- A. Low-sodium diet
- B. High-cholesterol diet
- C. Increased fluid intake
- D. Low-protein diet
正解: A
解説:
Explanation/Reference:
Explanation:
(A) A high-protein diet is usually indicated because protein is excreted in urine. Protein restriction is usually prescribed with severe azotemia. (B) The kidneys usually enlarge in these children, and sodium and water are retained. (C) Fluid restriction may be ordered to help reduce edema; however, monitoring for dehydration is indicated. (D) A high-cholesterol diet would not be indicated for any child, especially one with elevated blood pressure.
質問 98
In teaching the client about proper umbilical cord care, the nurse recommends that:
- A. A belly binder be applied to prevent umbilical hernia
- B. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
- C. Petrolatum be placed around the cord after the sponge bath
- D. The cord clamp be left on until the cord stump separates
正解: B
解説:
Explanation/Reference:
Explanation:
(A) Petrolatum does not allow the cord to dry and will encourage infection. (B) Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. (C) Frequent applications of alcohol will facilitate drying and discourage infection. (D) The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.
質問 99
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client's obstetrical history, the nurse should record:
- A. Gravida 2 para 1
- B. Gravida 2 para 2
- C. Gravida 3 para 1
- D. Gravida 3 para 2
正解: D
解説:
Explanation
(A) This answer is an incorrect application of gravida and para. The client has had two prior deliveries of more than 20 weeks' gestation; therefore, para equals 2, not 1. (B) This answer is the correct application of gravida and para. The client is currently pregnant for the third time (G = 3), regardless of the length of the pregnancy, and has had two prior pregnancies with birth after the 20th week (P = 2), whether infant was alive or dead. (C) This answer is an incorrect application of gravida and para. The client is currently pregnant for the third time (G = 3, not 2); prior pregnancies lasted longer than 20 weeks (therefore, P = 2, not 1). (D) This is an incorrect application of gravida and para. Client is currently pregnant for third time (G = 3, not 2).
質問 100
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, "Begin oxytocin induction at 1 mU/min." The nurse should:
- A. Begin the oxytocin induction as ordered
- B. Question the order
- C. Maintain the dosage when duration of contractions is 40-60 seconds and frequency is at 212-4 minute intervals
- D. Increase the dosage by 2 mU/min increments at 15-minute intervals
正解: B
解説:
(A)
Oxytocin stimulates labor but should not be used until CPD (cephalopelvic disproportion) is ruled out in a dysfunctional labor. (B) This answer is the correct protocol for oxytocin administration, but the medication should not be used until CPD is ruled out.
(C)
This answer is the correct manner to interpret effective stimulation, but oxytocin should not be used until CPD is ruled out. (D) This answer is the appropriate nursing action because the scenario presents adysfunctional labor pattern that may be caused by CPD. Oxytocin administration is contraindicated in CPD.
質問 101
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is:
- A. Skin turgor
- B. Blood pressure
- C. Level of consciousness
- D. Fluid intake
正解: C
解説:
Explanation/Reference:
Explanation:
(A) Blood pressure can remain normotensive in a state of hypovolemia. (B) Capillary refill, alterations in sensorium, and urine output are the most reliable indicators for assessing hydration. (C) Skin turgor is not a reliable indicator for assessing hydration in a burn client. (D) Fluid intake does not indicate adequacy of fluid resuscitation in a burn client.
質問 102
A 26-year-old female client presents at 10 weeks' gestation. She currently is a G3 1-0-1-1. Her mother and grandmother have heart disease. Her grandmother also has insulin-dependent diabetes. The client's previous delivery was a term female infant weighing 9 lb 13 oz. The client is 5 ft 6 inches tall and her current weight is
130 lb. Based on her history, she is at risk for developing diabetes in pregnancy. Which of the following factors places her at risk for gestational diabetes?
- A. Maternal weight
- B. Age >25 years
- C. Previous birth of an infant weighing>9 lb
- D. Family history of heart disease
正解: C
解説:
Section: Questions Set F
Explanation:
(A) Maternal age older than 30 years is an identified risk factor for diabetes. Age younger than 30 years is insignificant for diabetes unless there is a familial history of diabetes. (B) The client's weight is appropriate for her height. Obesity or pregnancy weight >20% of the ideal weight is a contributing factor to the development of gestational diabetes. (C) The birth of an infant weighing >9 lb (4000 g) is an identified risk factor for gestational diabetes. (D) A familial history of heart disease is insignificant in the development of diabetes. However, a familial history of type II diabetes mellitus is identified as a risk factor in the development of diabetes during pregnancy.
質問 103
At 38 weeks' gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?
- A. "I feel dizzy."
- B. "I am cold."
- C. "I am nauseous."
- D. "I have a backache."
正解: A
解説:
(A)
Cold is not a symptom of hyperventilation. This could be due to the temperature of the
room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the client's position in bed.
(C)
Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain.
質問 104
A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client's return to her room, which nursing measure best demonstrates the nurse's thorough understanding of possible postthyroidectomy complications?
- A. Dressings are placed at the bedside for dressing changes, which are to be done every 2 hours to best detect postoperative bleeding.
- B. The nurse should instruct the client as soon as possible on alternative means of communication.
- C. Narcotics are readily available and administered when the client returns to her room to prevent excruciating pain.
- D. A tracheostomy set, O2, and suction are available at the bedside.
正解: D
解説:
Explanation
(A) Dressing changes are done as necessary for bleeding. However, frequently, post-thyroidectomy bleeding may not be visible on the dressing, but blood may drain down the back of the neck by gravity. (B) Narcotics are administered for acute pain as necessary. They are not necessarily given on return of the client to her room.
(C) The most serious postthyroidectomy complication is ineffective airway and breathing pattern related to tracheal compression and edema. A tracheostomy set, O2, and suction should be available at bedside for at least the first 24 hours postoperatively. (D) Impaired verbal communication may occur due to laryngeal edema or nerve damage, but most commonly, it occurs due to endotracheal intubation. The client is usually able to communicate but is hoarse.
質問 105
A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this procedure means:
- A. Removal of prostate tissue by a resectoscope that is inserted through the penile urethra
- B. Removal of the prostate tissue by an open surgical approach through an incision between the ischial tuberosities, the scrotum, and the rectum
- C. Removal of prostate tissue by an open surgical approach through a low horizontal incision, bypassing the bladder, to the prostate gland
- D. Removal of the prostate tissue by way of a lower abdominal midline incision through the bladder and into the prostate gland
正解: A
解説:
(A) This describes a suprapubic (transvesical) prostatectomy procedure. (B) This is the correct description of a TURP procedure. (C) This describes a perineal prostatectomy procedure. (D) This describes a retropubic (extravesical) prostatectomy procedure.
質問 106
Except for initial explosiveness on admission, a client diagnosed with schizophrenia stays in her room. She continues to believe other people are out to get her. A nursing intervention basic to improving withdrawn behavior is:
- A. Having her sit with the nurses while they chart
- B. Assigning her to occupational therapy
- C. Facilitating communication
- D. Helping her to make friends
正解: C
解説:
Explanation/Reference:
Explanation:
(A) The nurse does not make this assignment. (B) One-to-one observation is not appropriate. It does not focus on the client or encourage communication. (C) The client is too suspicious to accomplish this goal.
(D) The withdrawn individual must learn to communicate on a one-to-one level before moving on to more threatening situations.
質問 107
A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
- A. Advise the client to discontinue the drug at the first sign of dizziness.
- B. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
- C. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent hearing loss.
- D. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
正解: D
解説:
Explanation
(A) The first nursing measure is to instruct the client in which drug side effects to report. (B) Discontinuing the drug is not an independent nursing intervention and may compromise client care. (C) Audiometric testing will detect hearing loss, but it does not indicate a potential cause. (D) Equalizing middle ear pressure will not prevent hearing loss.
質問 108
The parents of a 9-year-old child with acute lymphocytic leukemia expressed concern about his alopecia from cranial irradiation. The nurse explains that:
- A. His hair will grow back in a few months.
- B. There are several wig makers for children.
- C. Most children select a favorite hat to protect their heads.
- D. Alopecia is an unavoidable side effect.
正解: A
解説:
Explanation/Reference:
Explanation:
(A) Alopecia has occurred, and knowing it is a side effect does not address their concern. (B) Although true, it does not give them hope for the future. (C) Although true, it does not provide them with information of the temporary nature of the situation. (D) Knowing the hair will grow back provides comfort that the alopecia is temporary.
質問 109
A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice before. She had a "miscarriage" with the first pregnancy after 6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks' gestation. One of the twins was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:
- A. 3-0-1-1-0
- B. 2-0-2-1-0
- C. 2-2-2-1-2
- D. 2-1-1-0-0
正解: A
解説:
Explanation/Reference:
Explanation:
(A) The first digit represents the total number of pregnancies. This client has been pregnant 3 times including this pregnancy. The twin pregnancy counts as only one pregnancy, and because she delivered prior to 37 weeks' gestation, the third digit is recorded as 1. (B) The first digit represents the total number of pregnancies. This client has been pregnant 3 times including this pregnancy. The second digit represents the total number of fullterm deliveries; she has lost two pregnancies before 37 weeks' gestation. At present, she has no living children, so the fifth digit is noted as 0. (C) The client is pregnant for the third time, and the first digit reflects the total number of pregnancies. She has had no full-term deliveries, because she delivered prior to 37 gestational weeks, so the second digit is recorded as 0. The third digit represents the number of preterm deliveries, and a twin pregnancy counts as only one delivery.
She lost an earlier pregnancy prior to 20 gestational weeks, and the fourth digit reflects spontaneous or elective abortions. Lastly, the fifth digit indicates the number of children currently living, and she has no living children. (D) She is pregnant for the third time, and the first digit reflects the total number of pregnancies. In the previous two pregnancies, she delivered prior to 37 gestational weeks, thus having no full-term deliveries, which is indicated by the second digit. The fourth digit represents the total number of abortions, spontaneous or elective, and she reported a spontaneous abortion with her first pregnancy.
質問 110
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her lithium level was 1 mEq/L. The nurse should:
- A. Administer the morning lithium dose as scheduled
- B. Obtain an order for benztropine (Cogentin)
- C. Notify the physician immediately
- D. Hold the morning lithium dose and continue to observe the client
正解: A
解説:
Explanation
(A) There is no need to phone the physician because the lithium level is within therapeutic range and because there are no indications of toxicity present. (B) There is no reason to withhold the lithium because the blood level is within therapeutic range. Also, it is necessary to give the medication as scheduled to maintain adequate blood levels. (C) The lab results indicate that the client's lithium level is within therapeutic range (0.2-1.4 mEq/L), so the medication should be given as ordered. (D) Benztropine is an antiparkinsonism drug frequently given to counteractextrapyramidal symptoms associated with the administration of antipsychotic drugs (not lithium).
質問 111
A 9-month-old infant is being examined in the general pediatric clinic for a routine well-child checkup. His immunizations are up to date, and his mother reports that he has had no significant illnesses or injuries. Which of the following signs would lead the nurse to believe that he has had a cerebral injury?
- A. Hyperextension of the neck with evidence of pain on flexion
- B. Significant head lag when raised to a sitting position
- C. Holding the head erect and in the midline when in a vertical position
- D. Holding the head to one side and pointing the chin toward the other side
正解: B
解説:
Explanation
(A) This position is indicative of a possible meningeal irritation or infection such as meningitis. (B) This position is seen most frequently in infants who have had an injury to the sternocleidomastoid muscle. (C) Most infants aged 4 months and older are able to maintain this position. (D) Infants older than 6 months of age should not have significant head lag. This is a sign of cerebral injury and should be referred for further evaluation.
質問 112
A 30-year-old client has a history of several recent traumatic experiences. She presents at the physician's office with a complaint of blindness. Physical exam and diagnostic testing reveal no organic cause. The nurse recognizes this as:
- A. Conversion
- B. Hallucination
- C. Delusion
- D. Illusion
正解: A
解説:
Explanation
(A) The client's blindness is real. Delusion is a false belief. (B) Illusion is the misrepresentation of a real, external sensory experience. (C) Hallucination is a false sensory perception involving any of the senses. (D) Conversion is the expression of intrapsychic conflict through sensory or motor manifestations.
質問 113
The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis:
- A. Hypothermia
- B. Seizure
- C. Constipation
- D. Sunken fontanelles
正解: B
解説:
Explanation
(A) Constipation may occur if the child is dehydrated, but it is not directly associated with meningitis. (B) It is more likely the child will have fever. (C) Seizure is often the initial sign of meningitis in children and could become frequent. (D) It is more likely the child will have bulging fontanelles.
質問 114
When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent another occurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease?
- A. "I will report any changes in bowel movements to my doctor."
- B. "I will not eat any raw or uncooked vegetables."
- C. "I will limit my alcohol to one cocktail per day."
- D. "I will look into attending Alcoholics Anonymous meetings."
正解: D
解説:
Section: Questions Set B
Explanation:
(A) Raw or uncooked vegetables are all right to eat postdischarge. (B) This client must avoid any alcohol intake. (C) The client displays awareness of the need to avoid alcohol. (D) This action would be pertinent only if fatty stools associated with chronic hepatitis were the problem.
質問 115
A client suspected of having anorexia nervosa is placed on bed rest with an IV infusion and a high- carbohydrate liquid diet. Within 72 hours, the results of her lab work show a return to normal limits. She is transferred to the psychiatric service for further treatment. A behavior modification plan is initiated. Three days after her transfer, the client tells the nurse, "I haven't exercised in 6 days. I won't be eating lunch today." This statement by her most likely reflects:
- A. Increased knowledge about personal exercise plans
- B. A manipulative technique to trick the nurse into allowing her to miss a meal
- C. A true desire to stay fit while in the hospital
- D. Her lack of internal awareness about the outcome of the behavior
正解: D
解説:
Explanation/Reference:
Explanation:
(A) Indirect self-destructive behavior such as that seen in anorexia nervosa is characterized by the client's lack of insight and the awareness that the outcome of the dieting, exercising, and weight loss will ultimately result in death if uninterrupted. (B) Although the client is knowledgeable about exercise, knowledge about the balance between nutrition, exercise, and rest is absent. (C) The client's level of denial and lack of awareness disallow this behavior as a manipulative trick. (D) The client's illness-maintaining behaviors are inconsistent with fitness.
質問 116
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
- A. Consume foods from all four food groups.
- B. Be afebrile throughout her hospital stay.
- C. Sleep or lie quietly 10 hr/day.
- D. Participate in play activities 4 hr/day.
正解: C
解説:
Section: Questions Set G
Explanation:
(A) Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. (B) Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. (C) This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. (D) If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.
質問 117
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