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質問 # 145
During an examination, the nurse notes that an infant has diaper rash on the convex surfaces of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most effective in resolving the condition?
- A. Cleaning the inflamed area thoroughly with disposable wet "wipes" at each diaper change
- B. Coating the inflamed areas with zinc oxide
- C. Using talcum powder on the inflamed areas to promote drying
- D. Removing the diaper entirely for extended periods of time
正解：D
解説：
Explanation
(A) Zinc oxide is not usually applied to inflamed areas because it contributes to sweat retention. (B) Talcum powder is of questionable benefit and poses a hazard of accidental inhalation. (C) Removing the diaper and exposing the area to air and light facilitate drying and healing. (D) Infants may be sensitive to one or more agents in the wet "wipes." It is better to simply clean with a wet cloth.
質問 # 146
A client is pregnant for the fourth time and has had three normal vaginal deliveries. She is in active labor and fully dilated. Suddenly she calls, "Nurse, the baby is coming." As the nurse responds to her call, which one of the following observations should the nurse make first?
- A. Time the contractions.
- B. Auscultate for fetal heart rate (FHR).
- C. Inspect the perineum.
- D. Prepare a sterile area for delivery.
正解：C
解説：
Explanation
(A) The nurse must assess the labor status to determine if birth is imminent. The nurse may note perineal bulging, crowning, or birth of the head to ascertain labor status. (B) Assessing uterine contractions is one intervention to ascertain labor status. Based on the client's cry, it is not the intervention of choice. (C) If delivery of the infant is imminent, preparing a clean or sterile area for delivery is appropriate, but labor status must be established, whether delivery is imminent, by perineal assessment. (D) Assessing FHR is one intervention to ascertain fetal well-being. Based on the client's cry, this is not the intervention of choice.
質問 # 147
A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?
- A. Puppets
- B. Riding toys
- C. Books with colorful pictures
- D. Music
正解：A
解説：
(A) Books increase cognition, assist with fine motor skills, and augment language development. (B) Music provides auditory stimulation and large-muscle activity. (C) Riding toys provide large-muscle activity. (D) Puppets allow expression of feelings and fears that otherwise could not be directly communicated.
質問 # 148
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
- A. Decreases the time of the client's first stage of labor
- B. Decreases the overall time of the labor process
- C. Prolongs the client's first stage of labor
- D. Prolongs the client's third stage of labor
正解：C
解説：
Explanation
(A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position.
Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered.
質問 # 149
A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?
- A. Intimacy versus isolation
- B. Identity versus role confusion
- C. Integrity versus despair
- D. Generativity versus self-absorption
正解：D
解説：
Explanation/Reference:
Explanation:
(A) Identity versus role confusion is experienced by adolescents making the transition from childhood to adulthood as they attempt to develop a sense of identity. (B) Integrity versus despair is experienced by the elderly as they reflect on their life in an attempt to find meaning. (C) Intimacy versus isolation is experienced by young adults as they establish intimate bonds of love and friendship. (D) Generativity versus self-absorption is experienced by middle-aged adults as they fulfill life goals that involve family, career, and society. The client is experiencing this crisis.
質問 # 150
A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?
- A. Small, frequent feedings of foods that can be carried
- B. Giving him a quiet place where he can sit down to eat meals
- C. Allowing him to eat when and what he wants
- D. Tube feedings with nutritional supplements
正解：A
解説：
Explanation/Reference:
Explanation:
(A) The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. (B) This type of therapy should be implemented when other methods have been exhausted. (C) The manic client should not be in control of his treatment plan. This type of client may forget to eat. (D) The manic client is unable to sit down to eat full meals.
質問 # 151
A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:
- A. Assist him to develop more effective coping mechanisms.
- B. Isolate him from stressful situations that may precipitate a depressive episode.
- C. Have him sign a "no-suicide" contract.
- D. Provide him with a safe and structured environment.
正解：A
解説：
Explanation/Reference:
Explanation:
(A) This statement represents a short-term goal. (B) Long-term therapy should be directed toward assisting the client to cope effectively with stress. (C) Suicide contracts represent short-term interventions. (D) This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.
質問 # 152
A 47-year-old client comes to the emergency department complaining of moderate flank, abdominal, and testicular pain with nausea of 4 hours' duration. After physical examination and obtaining the client's history, the physician suspects urethral obstruction by calculi. The nurse realizes that the physician will order which one of the following diagnostic studies to best confirm the diagnosis?
- A. Cystoscopy
- B. Intravenous pyelogram with excretory urogram
- C. Kidneys, ureter, bladder, x-ray of abdomen
- D. Ureterolithotomy
正解：B
解説：
Explanation
(A) Cystoscopy is an endoscopic procedure that uses an instrument (a cystoscope) to visualize the internal bladder and ureter structures and to capture and remove an obstructing stone. (B) Kidney, ureter, bladder x-ray is used to outline gross structural changes in the kidneys, ureter, and bladder and will determine the general location of a stone. (C) An intravenous pyelogram with excretory urogram is used to visualize the kidneys, kidney pelvis, ureters, and bladder. This procedure is used specifically to determine whether urethral obstruction is partial or complete; it shows the exact location of the stone and dilation of the ureter above the stone. (D) Ureterolithotomy is a surgical procedure in which the ureter is incised and the stone is manually removed because the stone is unable to pass through the ureter independently.
質問 # 153
The physician prescribes a medical regimen of isoniazid, rifampin, and vitamin B6 for a tuberculosis client.
The nurse instructs the client that B6 is given because it:
- A. Increases activity of isoniazid
- B. Improves nutritional status
- C. Increases activity of rifampin
- D. Reduces peripheral neuropathy
正解：D
解説：
Explanation
(A) Vitamin B6does not enhance the activity of isoniazid. (B) Vitamin B6does not enhance the activity of rifampin. (C) A vitamin alone does not improve nutritional status. (D) Isoniazid leads to Vitamin B6deficiency, which is manifested as peripheral neuropathy.
質問 # 154
A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?
- A. Abruptio placentae
- B. Massive uterine rupture
- C. Ectopic pregnancy
- D. Placenta previa
正解：A
解説：
Explanation
(A) Abruptio placentae, the complete or partial separation of the placenta from the uterine wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid increase in uterine size with rigidity.
(B) Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity. (C) Massive uterine rupture occurs during labor when the uterine contents are extruded through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and trauma from instruments or an obstetrical intervention. (D) Placenta previa is the condition in which the placenta is implanted in the lower uterine segment and either completely or partially covers the cervical os.
質問 # 155
When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:
- A. Leukopenic aplastic anemia
- B. Granulocytosis and nephrosis
- C. Folate deficiency
- D. Stephens-Johnson syndrome
正解：D
解説：
(A) Stephens-Johnson syndrome is a toxic effect of phenytoin. (B) Folate deficiency is a side effect of phenytoin, but not a toxic effect. (C) Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). (D) Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).
質問 # 156
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. 2-1-1-0-0
- B. 3-0-1-1-0
- C. 2-0-2-1-0
- D. 2-2-2-1-2
正解：B
解説：
(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 # 157
A 3-month-old infant has had a unilateral cleft lip repair. He has resumed feedings of oral formula. The nurse should feed the infant with:
- A. A straw and cup
- B. Nipple and bottle
- C. Syringe
- D. Gavage tube
正解：C
解説：
(A) A gavage tube may damage suture line. It is the most invasive and should be the last measure. (B) A nipple and bottle require sucking, which may damage sutures. (C) A 3month-old infant is not able to drink from a straw. (D) A syringe allows for the formula to be placed to the side and back of the mouth. This minimizes the amount of sucking needed.
質問 # 158
A mother brings her 3-year-old child who is unconscious but breathing to the ER with an apparent drug overdose. The mother found an empty bottle of aspirin next to her child in the bathroom. Which nursing action is the most appropriate?
- A. Place child on respiratory assistance.
- B. Teach mother poison prevention techniques.
- C. Put in a nasogastric tube and lavage the child's stomach.
- D. Monitor muscular status.
正解：C
解説：
Section: Questions Set B
Explanation:
(A) The immediate treatment for drug overdose is removal of the drug from the stomach by either forced emesis or gastric lavage. The child's unconscious state prohibits forced emesis. (B) Toxic amounts of salicylates directly affect the respiratory system, which could lead to respiratory failure. (C) The mother's anxiety is probably so high that preventive guidance will be ineffective. (D) Respiratory assistance is not needed if the child's respiratory function is unaltered.
質問 # 159
A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?
- A. Hepatitis B vaccine
- B. Inactivated poliovirus vaccine
- C. Oral poliovirus vaccine
- D. Tetanus toxoid
正解：D
解説：
Explanation
(A) Oral poliovirus vaccine is given to prevent polio. Polio is transmitted by direct contact with an infected person. (B) Inactivated poliovirus vaccine is given to adults and immunosuppressed individuals. Polio is transmitted by direct contact with an infected person. (C) Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds. (D) Hepatitis B vaccine prevents hepatitis B infection. Hepatitis B is transmitted through contact with infected blood or body fluids.
質問 # 160
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