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質問 # 164
Which of the following statements by a client indicates adequate understanding of preparation for a lipoprotein fractionation test?
- A. "I cannot eat or drink after midnight."
- B. "I need to ingest a lipid solution."
- C. "I cannot eat for 12 hours before the test."
- D. "I need to limit my fluid intake."
正解：C
解説：
Section: Physiological Integrity
Explanation:
For lipid fractionation, the client cannot eat for 12 hours prior to the test, but he or she can drink an unrestricted amount of water. No lipid solution is given.
Thus, the other choices are incorrect.
質問 # 165
A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse?
- A. "There is no discomfort with this test, so don't be anxious."
- B. "You can receive a sedative to help you relax during the test."
- C. "The test won't last long, so you can handle it."
- D. "There is absolutely nothing to worry about."
正解：B
解説：
Explanation/Reference:
Explanation:
This statement reassures the client that there is a solution for relief of his anxiety. The other responses minimize the client's feelings. Reduction of Risk Potential
質問 # 166
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. crisis intervention.
- B. empathetic concern.
- C. unwarranted intrusion.
- D. assessment.
正解：A
解説：
Explanation/Reference:
Explanation:
Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client's coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims. Coordinated Care
質問 # 167
Which of the following services is not part of family consultation?
- A. helping families solve problems
- B. providing information about the client's illness
- C. teaching effective communication
- D. assisting with vocational rehabilitation
正解：D
解説：
Section: Psychosocial Integrity
Explanation:
Family consultation does not involve vocational rehabilitation. It involves helping families deal with their feelings, focus, and find solutions.
Choices "providing information about the client's illness", "teaching effective communication" and "helping families solve problems" are components of family consultation.
質問 # 168
The LPN is caring for a patient with ascites related to liver failure. The patient becomes hypotensive and complains of cramps.
Which of the following is least likely related to the hypotension and cramps?
- A. recent diuretics
- B. excessive IV intake
- C. decreased renal blood flow
- D. increased aldosterone
正解：B
解説：
Section: Physiological Integrity
質問 # 169
The only time that an individual may receive medical care without giving informed consent is:
- A. when the physician is not available for discussion with the client.
- B. in an emergency, life-or-death situation.
- C. when the durable power of attorney for health care is not available.
- D. when they (clients) are not able to speak for themselves.
正解：B
解説：
Explanation/Reference:
Explanation:
Treatment may be given without consent in a life-threatening situation. Choices 1, 3, and 4 are incorrect.
All attempts to notify a durable power of attorney for health care should be made. If unavailable, the physician assumes responsibility for treatment within facility protocol. The physician is obligated to have a discussion with the client in all non-life-threatening situations. If clients are not able to speak for themselves, their power of attorney for health care or responsible party is involved in the consent process.
Coordinated Care
質問 # 170
Which of the following coping mechanisms protects an individual from anxiety?
- A. regression and displacement
- B. denial and fantasy
- C. reaction formation and projection
- D. rationalization and suppression
正解：B
解説：
Explanation/Reference:
Explanation:
Denial, rationalization, regression, and fantasy are coping mechanisms that protect persons from anxiety.
Psychosocial Integrity
質問 # 171
When caring for a client with a possible diagnosis of placenta previa, which of the following admission procedures should the nurse omit?
- A. blood specimen collection
- B. urine specimen collection
- C. perineal shave
- D. enema
正解：D
解説：
An enema could dislodge the placenta and increase bleeding.Physiological Adaptation
質問 # 172
Your 32-year-old female patient has erythema marginatum, Sydenham chorea, epistaxis, abdominal pain, fever, cardiac problems and skin nodules.
What disorder would you most likely suspect based on these signs and symptoms?
- A. Rheumatoid arthritis
- B. Histoplasmosis
- C. Leukemia
- D. Pneumocystis jirovec
正解：A
解説：
Section: Safe and Effective Care Environment
Explanation:
Erythema marginatum, Sydenham chorea, epistaxis, abdominal pain, fever, cardiac problems and skin nodules are the signs and symptoms of rheumatoid arthritis.
Some of the signs and symptoms of leukemia are fever, bleeding and bruising, shortness of breath, loss of appetite, pain in the bones or stomach and painless lumps in the neck, groin and/or underarm.
Histoplasmosis, a fungal infection, is characterized with fever, chills, cough, chest pain, joint pain, mouth sores and erythema modosum.
Lastly, the signs and symptoms of Pneumocystis jirovec, among others, can include fever, shortness of breath, rapid breathing and a dry cough.
質問 # 173
A gastroenterologist should be consulted for clients suffering from __________.
- A. nervous system diseases
- B. urinary system diseases
- C. female reproductive system diseases
- D. digestive system diseases
正解：D
解説：
Section: Safe and Effective Care Environment
Explanation:
A gastroenterologist cares for clients with digestive system diseases.
A urologist cares for clients with urinary system diseases.
A gynecologist cares for clients with female reproductive system diseases.
A neurologist cares for clients with nervous system diseases.
質問 # 174
In examining an EKG waveform, what indicates atrial contraction?
- A. T-wave
- B. P-wave
- C. QRS-complex
- D. U-wave
正解：B
解説：
Section: Physiological Integrity
質問 # 175
The most common cause of injury from a house fire is:
- A. explosion.
- B. falls from second-story windows.
- C. thermal damage to skin and body surfaces.
- D. inhalation injury.
正解：D
解説：
Inhalation is the most common cause of injury from a house fire.Accident Prevention
質問 # 176
How many daily feedings are considered normal for a newborn?
- A. 10 to 12
- B. 8 to 10
- C. 6 to 8
- D. 12 to 14
正解：A
解説：
Section: Health Promotion and Maintenance
Explanation:
An average newborn's stomach empties every 1.5 hours, so common feeding times occur about every 2 hours during a 24-hour period; therefore, 10 to 12 feedings per day is typical.
Frequent breastfeeds increase a mother's prolactin levels, and high prolactin levels are required to establish an adequate milk supply.
A higher-frequency of feedings help babies compensate for the lower caloric density of the milk.
質問 # 177
Carrying a donor card for organ donation means that:
- A. a client is considered an organ donor for only one organ or tissue.
- B. medical care is altered in the event of serious injuries to get organs for donation.
- C. a client is allowed to revoke his decision for organ donation at any time.
- D. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation.
正解：C
解説：
Revocation of the decision for organ donation may occur at any time, by either the client or his responsible party. When organ donation is considered, as many organs as the donor wished to donate are considered and accepted for donation if found appropriate. Medical care for an individual during immediate care and/or resuscitation is not altered to declare a client dead and ready for organ donation.Coordinated Care
質問 # 178
How long can women lactate for?
- A. 12 to 18 months
- B. Indefinitely
- C. 18 to 24 months
- D. 30 to 36 months
正解：B
解説：
Section: Health Promotion and Maintenance
Explanation:
A woman can lactate indefinitely; however, it puts them at risk of developing osteoporosis due to the calcium depletion from the bones and teeth.
Letting the baby wean itself is ideal. Ideally, all babies should be exclusively breastfed for six months with the gradual introduction of solid foods while continuing to breastfeed.
Most women in the United States stop breastfeeding following the twelfth month of life.
質問 # 179
For a client requiring total oral care, it is important for the nurse to:
- A. place client in Fowler's position, prepare the equipment, and tell the client what to do.
- B. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
- C. use gloves and clean the client's mouth, including the tongue.
- D. assemble all equipment, assist the client tosemi-Fowler's position, and place a towel on his chest.
正解：B
解説：
Explanation/Reference:
Explanation:
Assemble all equipment first; place the client in a side-lying position so that fluid can easily flow out or pool in the side of the mouth for suctioning (to prevent aspiration); and then place a towel under the client's chin and a curved basin against the chin. Gloves should be worn. Basic Care and Comfort
質問 # 180
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