美國注冊護士試卷2

美國護士資格認證(CGFNS)-2PartOneYouwillhavetwohoursand30minutestocompletePart

One.A22-year-oldclientisdiagnosedwithdependentpersonalitydisorder.Whichbehaviorismostlikelyevidenceofineffectiveindividualcoping?Inabilitytomakechoicesanddecisionswithoutadvice.Showinginterestonlyinsolitaryactivities.Avoidingdevelopingrelationships.Recurrentself-destructivebehaviorwithhistoryofdepression.正確答案:A答案解析:Individualswithdependentpersonalitydisordertypicallyshowindecisiveness,submissiveness,andclingingbehaviorssothatotherswillmakedecisionsforthem.Theseclientsfeelhelplessanduncomfortablewhenaloneanddon"tshowinterestinsolitaryactivities.Theyalsopursuerelationshipsinordertohavesomeonetotakecareofthem.Althoughclientswithdependentpersonalitydisordermaybecomedepressedandsuicidaliftheirneedsaren"tmet,thisisn"tatypicalresponse.Thenurseiscaringforaneonatewithamyelomeningocele.Theprioritynursingcareofaneonatewithamyelomeningoceleisprimarilydirectedtowardensuringadequatenutrition.preventingmotingneuraltubesacdrainage.conservingbodyheat.正確答案:B答案解析:Thenurseneedstoprovidespecialcaretotheneuraltubesactopreventinfection.Allowingthesactodrycouldresultincracksthatallowmicroorganismstoenter.Pressureonthesaccouldcauseittorupture,creatingaportalofentryformicroorganisms.Administeringantibioticsandkeepingthesacfreefromurineandstoolareothermeasurestopreventinfection.Adequatenutritionisaconcernforallneonates,includingthosewithamyelomeningocele.Likeallneonates,theneonatewithamyelomeningocelemustbekeptwarm,butcaremustbetakentoavoiddryingouttheneuraltubesacwitharadiantheaterorexertingpressureusingasheetorblanketoverthesac.Whichofthefollowingnutritionaldeficienciesmaydelaywoundhealing?ALackofthiamine.BLackofvitaminＣ.CLackoffolate.DLackofvitaminＡ.正確答案:B答案解析:VitaminsC,B6,andB12arenecessaryforcollagensynthesisthattakesplaceduringwoundhealing.Folateenablesoxygentransport.VitaminAisneededforreversalofeffectsoftheglucocorticoids.Thiamineisrequiredforcarbohydratemetabolism.Thenurseispreparingtoremoveapreviouslyappliedtopicalmedicationfromaclient.Therationaleforremovingpreviouslyappliedtopicalmedicationsbeforeapplyingnewmedicationsistodecreasethepossibilityofabsorptiononthenurse"sskin.allowdistributionofmedication.preventsoilingoftheclient"sclothes.avoidadministeringmorethantheprescribeddose.正確答案:D答案解析:Thenurseshouldremovepreviouslyappliedtopicalmedicationsbeforeapplyingnewmedicationstopreventaccumulationofmedicationthatexceedstheprescribeddose.Wearinggloveswilldecreasethepossibilityofabsorptiononthenurse"sskin.Spreadingtopicalmedicationsevenlywillallowfordistributionofmedication.Placingadressing,ifallowable,overthemedicationwillpreventsoilingofclient"sclothes.Thenurseiscaringforaclientwithadultrespiratorydistresssyndrome(ARDS).Whatisthemostlikelylaboratoryfindingintheearlystagesofthisdisease?Increasedcarboxyhemoglobin.Decreasedpartialpressureofarterialoxygen(PaO2).Increasedpartialpressureofarterialcarbondioxide(PaCO2).Decreasedbicarbonate([*]).正確答案:B答案解析:DecreasedPaO2indicateshypoxemia,whichisauniversalfindinginARDS.ThePaO2levelislowearlyinthediseaseduetohyperventilationandthenelevateslaterinthediseaseduetofatigueandworseningclinicalstatus.The[*]levelmaybelowinARDSandisrelatedtoreducedtissueoxygenation.Thecarboxyhemoglobinlevelwillbeincreasedinaclientwithaninhalationinjury,whichcommonlyprogressesintoARDS.Thisisn"tacommoncauseofARDS.Thenurseisprovidingcareforapregnant16-year-oldclient.Theclientsaysthatshe"sconcernedshemaygaintoomuchweightandwantstostartdieting.Thenurseshouldrespondbysaying."Nowisn"tagoodtimetobegindietingbecauseyouareeatingfortwo.""Let"sexploreyourfeelingsfurther.""Nutritionisimportantbecausedeprivingyourbabyofnutrientscancausedevelopmentalandgrowthproblems.""Theprenatalvitaminsshouldensurethebabygetsallthenecessarynutrients."正確答案:C答案解析:Deprivingthedevelopingfetusofnutrientscancauseseriousproblems,andthenurseshoulddiscussthiswiththeclient.Theclientisn"teatingfortwo;thisisamisconception.Exploringfeelingshelpstheclientunderstandherconcerns,butsheneedstobeawareoftherisksatthistime.Thevitaminsaresupplementsanddon"tcontaineverythingamotherorneonateneeds;theyworkincongruencewithabalanceddiet.Thenurseispreparingtodischargeachildwhohasrheumaticfever.Whichofthefollowingmedicationsisprescribedtopreventrecurrenceofrheumaticfever?Glucocorticoids.Digoxin.Antibiotics.Anti-inflammatorymedications.正確答案:C答案解析:Becausethechildwithrheumaticfeverisatriskforarecurrence,especiallyiftheconditioniscomplicatedbycarditis,long-termantibiotictherapyisnecessaryintoadulthood,maybeevenforlife.Digoxinmaybeprescribedtotreatheartfailure,butitdoesn"tpreventtherecurrenceofrheumaticfever.Corticosteroidsandanti-inflammatorymedicationsreduceinflammationinrheumaticfeverbutwon"tpreventarecurrence.Thenursesuspectsthata68-year-oldclienthasdigoxintoxicity.Thenurseshouldassessforhearingloss.visionchanges.decreasedurineoutput.gaitinstability.正確答案:B答案解析:Visionchanges,suchashalosaroundobjects,aresignsofdigoxintoxicity.Hearinglosscanbedetectedthroughhearingassessment;however,itisn"tacommonsignofdigoxintoxicity.Intakeandoutputaren"taffectedunlessthere"snephrotoxicity,butthatsituationisuncommon.Gaitchangesarealsouncommon.Thenurseisassessinga15-year-oldfemalewhoisbeingadmittedfortreatmentofanorexianervosa.Whichclinicalmanifestationisthenursemostlikelytofind?Tachycardia.Warm,flushedextremities.Parotidglandtenderness.Coarsehairgrowth.正確答案:C答案解析:Frequentvomitingcausestendernessandswellingoftheparotidglands.Thereducedmetabolismthatoccurswithsevereweightlossproducesbradycardiaandcoldextremities.Soft,downlikehair(calledlanugo)maycovertheextremities,shoulders,andfaceofananorexicclient.Thenurseisassessinga71-year-oldfemaleclientwithulcerativecolitis.Whichassessmentfindingrelatedtothefamilywillhavethegreatestimpactontheclient"srehabilitationafterdischarge?Thefamily"sabilitytotakecareoftheclient"sspecialdietneeds.Thefamily"sexpectationthattheclientwillresumeresponsibilitiesandrole-relatedactivities.Emotionalsupportfromthefamily.Thefamily"sabilitytounderstandtheupsanddownsoftheillness.正確答案:C答案解析:Emotionalsupportfromthefamilyisthemainneed.Aspecialdietdoesn"tfocusonemotionalneeds.Roleexpectationsdon"taddressthemainissue,butemotionalsupportwhiletheclientisfulfillingtheserolesisimportant.Thefamily"sabilitytounderstandtheupsanddownsoftheillnesswillhelpthembutnottheclient.Thenurseistakingthehealthhistoryofan85-year-oldclient.Whichinformationwillbemostusefultothenurseforplanningcare?Generalhealthforthelast10years.Currenthealthpromotionactivities.Familyhistoryofdiseases.Maritalstatus.正確答案:B答案解析:Recognizinganindividual"spositivehealthmeasuresisveryuseful.Generalhealthintheprevious10yearsisimportant;however,thecurrentactivitiesofan85-year-oldclientaremostsignificantinplanningcare.Familyhistoryofdiseaseforaclientinlateryearsisofminorsignificance.Maritalstatusinformationmaybeimportantfordischargeplanningbutisn"tassignificantforaddressingtheimmediatemedicalproblem.A35-year-oldclientisundergoingabraincomputedtomography(CT)scanbecauseofcontinuedmigraineheadaches.He"splacedintheCTscannerandsuddenlybeginstocomplainofpalpitations,sweating,shortnessofbreath,andshaking.Theclientismostlikelyexperiencinganallergicreaction.amyocardialinfarction(MI).apanicattack.ahypoglycemicepisode.正確答案:C答案解析:Consideringthecircumstancessurroundingthesesymptoms,theymostprobablysignalapanicattack,whichisaperiodofintensefearordiscomfortthatdevelopsabruptly,andpeaksin10minutes.Anallergicreactionwouldhaveaprecipitatingcauseandmayalsoincludeacutaneousreactionoredema.AnMIwouldinvolvechestpainorcardiaccompromise.Hypoglycemiararelyincludesshortnessofbreathbutwouldneedtobedifferentiatedbyobtainingtheclient"sbloodglucoselevel.Whichnursingactiontakesprioritywhenadmittingaelientwithrightlowerlobepneumonia?Elevatingtheheadofthebed45to90degrees.Auscultatingthechestforadventitioussounds.Obtainingasputumspecimenforculture.Notifyingthephysicianoftheclient"sadmission.正確答案:A答案解析:ClientswithpneumoniabreatheeasierinFowler"sorsemi-Fowler"spositionbecausegravityfacilitatesdiaphragmaticmovement.Theothernursingactionsareimportantbutdon"ttakefirstpriority.Thenurseisteachingapsychiatricclientaboutherprescribeddrugs,chlorpromazineandbenztropine.Whyisbenztropineadministered?Toreducepsychoticsymptoms.Toreduceextrapyramidalsymptoms.Tocontrolnauseaandvomiting.Torelieveanxiety.正確答案:B答案解析:Benztropineisananticholinergicmedication,administeredtoreducetheextrapyramidaladverseeffectsofchlorpromazineandotherantipsyehoticmedications.Benztropinedoesn"treducepsychoticsymptoms,relieveanxiety,orcontrolnauseaandvomiting.Thenurseiscaringforaclientwho"shypoglycemic.Thisclientwillhaveabloodglucoselevelbelow70mg/dL.between70and120mg/dL.between120and180mg/dL.above180mg/dL.正確答案:A答案解析:Abloodglucoselevelbelow70mg/dLisconsideredhypoglycemic.Anormalbloodglucoselevelisbetween70and120mg/dL.Above120mg/dLindicateshyperglycemia.Thenurseiscaringforaclientwithotosclerosisscheduledtoundergoastapedectomy.Theclientasksthenursewhenherhearingwillimprove.Whichresponsebythenurseismostappropriate?Yourhearingmaynotimprovebutyou"llnolongerbebotheredbytinnitus.Yourhearingmaybedramaticallyimprovedrightaftersurgery.Youmaynoticeimprovedhearingwithin1to2weeks.Yourhearingmayimprove3to6weeksaftersurgery.正確答案:D答案解析:Afterstapedectomy,itcantakeaslongas6weeksforhearingtoimprove.Theclientmaynotnoticeanyimprovementinthefirst2weeksaftersurgery.Aftersurgery,hearingmayinitiallyworsenbecauseofswellingandfluidaccumulationintheear.Tinnitusmaynotresolve.Aclientinher7thmonthofpregnancyhasbeencomplainingofbackpainandwantstoknowwhatcanbedonetorelieveit.Whichofthefollowingresponsesbythenurseismosteffective?"Youneedtoliedownmoreduringthedaytogetoffyourfeet.""Avoidliftingheavyloads,andtryusingthepelvictiltexercise.""Haveotherspickthingsupforyousoyoudon"thavetobendoversomuch.""Yourbackpainwillgoawayafterthebabyisborn."正確答案:B答案解析:Thepelvictiltexercise,whichcanbedonestandingaswellaslyingdown,cangreatlyrelievebackdiscomfort.Asthepregnancyprogressesintothelasttrimester,womentypicallydevelopa"swayback"curvatureofthespinetocounterbalancetheenlargingfetus.Tiltingofthepelvisalignsthespine,decreasingpressureandbackdiscomfort.Lyingdownmoreduringthedaymaynotbepossibleorconvenientforsomeclients.Also,thesupinepositionmaynotbecomfortableforsomeclientsandmaycausevenacavasyndrome(dizzinessonrisinganddecreasedcirculationtothefetus).Avoidingbendingoverasmuchmaynotberealisticfortheclient"scircumstances,nordoesitaddressbackpainaseffectivelyasthepelvictilt.Thelastresponsedoesn"thelptorelievetheclient"sdiscomfort.Thenurseadministersracemicepinephrinetoachild.Tenminutesafteradministration,thenurseshouldbealertforrespiratoryfoundtachycardia.signsofimprovedoxygenation.diminishedcyanosis.正確答案:A答案解析:Areboundeffectfromracemicepinephrinecanoccurupto4hoursaftertreatmentwithsignsofrespiratorydistress(tachypnea,restlessness,cyanosis).Tachycardiamayinitiallyfollowtreatmentwithracemicepinephrineaswellasimprovementinclientstatus(improvedoxygenationandimprovedcolor).Aclientwithaneurogenicbladderisbeginningbladdertraining.Whichofthefollowingnursingactionsismostimportant?Setupspecifictimestoemptythebladder.Forcefluids.Provideadequateroughage.Encouragetheuseofanindwellingurinarycatheter.正確答案:A答案解析:Clientsaretaughttowritedowntheirvoidingpatternandtoemptythebladderatthesametimeseachday.Forcingfluids(morethan2L/day)increasesurineproductionandcomplicatestheinitialbladder-trainingprocess.Roughageisunnecessaryforbladdertraining.Anindwellingurinarycatheterisusedonlywhenothermethodsofcontroldon"twork.Thenurseisadministeringwarfarin(Coumadin)toaclientwithdeepveinthrombophlebitis.Whichlaboratoryvalueindicateswarfarinisattherapeuticlevels?Partialthromboplastintime(PTT)[*]to2timesthecontrol.Prothrombintime(PT)[*]to2timesthecontrol.Internationalnormalizedratio(INR)of3to4.Hematocritof32%.正確答案:B答案解析:Warfarinisattherapeuticlevelswhentheclient"sPTis[*]to2timesthecontrol.Highervaluesindicateincreasedriskofbleedingandhemorrhage;whereaslowervaluesindicateincreasedriskofbloodclotformation.Heparin--notwarfarin--prolongsPTT.TheINRmayalsobeusedtodetermineifwarfarinisatatherapeuticlevel.AnINRof2to3isconsideredtherapeutic.Hematocritdoesn"tprovideinformationontheeffectivenessofwarfarin;however,afallinghematocritinaclienttakingwarfarinmaybeasignofhemorrhage.Whenprioritizingaclient"scareplanbasedonMaslow"shierarchyofneeds,thenurse"sfirstprioritywouldbeallowingthefamilytoseeanewlyadmittedclient.ambulatingtheclientinthehallway.administeringpainmedication.placingwristrestraintsontheclient.正確答案:C答案解析:InMaslow"shierarchyofneeds,painreliefisonthefirstlayer.Activityisonthesecondlayer.Safetyisonthethirdlayer.Loveandbelongingareonthefourthlayer.Thenurseisteachingaclientaboutusingvaginalmedications.Thenurseshouldinstructtheclienttouseatamponafterinsertiontoincreasemedicationabsorption.releaseandpullupontheapplicatorbeforeremoval.neverrefrigeratesuppositories.useonlyawater-solublelubricantwheninsertingasuppository.正確答案:D答案解析:Thenurseshouldinstructtheclienttouseonlyawater-solublelubricantwheninsertingasuppository.Tamponsshouldn"tbeusedbecausethetamponwillabsorbsomemedication,makingthemedicationlesseffective.Whenremovingtheapplicator,theclientshouldkeeptheplungerdepressed.Suppositoriesmayberefrigeratedtokeeptheirform.Whichofthefollowingpositionsismostappropriateforaneonatewithcongenitalhipdislocation?Semi-Fowler"swithbothlegsflexed.Legsadductedwithheadelevated.Swaddledinababycarrier.Pronepositionwithhipsabducted.正確答案:D答案解析:Abductionplacesthefemoralheadintotheacetabulumforcorrectalignment.Placingtheclientinsemi-Fowler"spositionwithbothlegsflexedorwithhislegsadductedandhisheadelevatedwon"thelpcorrecttheproblem.Swaddlingtheclientinababycarrierwouldworsenthedislocation.Thenurseispreparingatreatmentplanforaclienttakingoralcorticosteroidstocontrolseverechronicasthma.Whichstatementindicatesthattheclientunderstandshistreatmentplan?"Ishouldtakecorticosteroidsonanemptystomach.""Ineedtotakecorticosteroidstohelpbuildupmyimmunesystem.""IshouldstoptakingcorticosteroidsifIhaven"thadanasthmaattackfor1week.""I"lltellmyotherhealthcareprovidersthatI"mtakingacorticosteroid."正確答案:D答案解析:Theclient"sotherhealthcareprovidersneedtoknowthattheclientistakingacorticosteroidbecausethesedrugscansuppressinflammatoryandimmuneresponses.ToreduceGIsymptoms,clientsshouldtakeeorticosteroidswithfoodormilk,neveronanemptystomach.Corticosteroidssuppress,ratherthanbuildup,theimmunesystem.Clientsshouldnevertakecorticosteroidswithoutconsultingwithaphysician.Topreventanadrenalcrisis,corticosteroidusemustbediscontinuedbygraduallyreducingdrugdosage,especiallywhentheclienthasbeenonlong-termcorticosteroidtherapy.Aprimigravidainlaborfor13hoursclenchesherfists,tightenshermuscles,andscreamsduringeverycontraction.Herreactiontolaborseemsexaggeratedcomparedtothecontractionpatternrecordingfromtheelectronicfetalmonitor(EFM).What"sthenurse"sbestresponse?ExplaintotheclientthattheEFMshowsmildcontractions,sosheshouldjustrelaxandletthecontractionswork.Takeoverashercoachbecauseherhusbandisn"thelpingherproperly.Ignoreherreactions,realizingthatthisisherfirsttimeinlaborandherreactionswillsoonmatchtheintensityofcontractionsshownontheEFM.Palpateherabdomentodeterminetheintensityoflaborcontractionsasthey"retakingplace.正確答案:D答案解析:Internalandexternalfetalmonitorsarehelpfulinassessingthedurationandfrequencyofcontractions,buttheexternalmonitordoesn"taccuratelyportraytheintensityofthecontraction.Thelaborroomnursemustevaluatethisbypalpation.Takingoverashercoach,ignoringherreactions,andtellinghertorelaxfailtorecognizetheneedforpalpation.A10-year-oldgirlvisitstheclinicforacheckupbeforeenteringschool.Thechild"smotherquestionsthenurseaboutwhattoexpectofherdaughter"sgrowthanddevelopmentatthisstage.Whichresponseismostappropriate?"Herphysicaldevelopmentwillberapidatthisstage,andrapiddevelopmentwillcontinuefromnowon.""She"llbecomemoreindependentandwon"trequireparentalsupervision.""Don"tanticipateanychangesatthisstageinhergrowthanddevelopment.""Friendswillbeveryimportanttoher,andshe"lldevelopaninterestintheoppositesex."正確答案:D答案解析:Friendsbecomeveryimportantatthisage.Childrenusuallybeginhavinganinterestintheoppositesexaroundthisage,althoughtheyaren"talwayswillingtoadmitit.Herphysicaldevelopmenttowardsmaturitycontinues,butitisn"tasrapidatthisstageasinpreviousyears.Althoughindependenceincreasesatthisstage,childrencontinuetoneedparentalsupervision.Growthanddevelopmentslowdown,butgradualchangescontinuetooccur.Amultigravidainher34thweekofgestationpresentsintheemergencydepartmentcomplainingofvaginalbleeding.Whichofthefollowingshouldbethenurse"sfirstaction?EstablishIVaccess.Assessfetalheartrate(FHR)andmaternalbloodpressure.Preparetheclientforacesareandelivery.Assessmaternalheartrateandrespiratoryrate.正確答案:B答案解析:FHRandmaternalbloodpressurewillprovideimportantdataontheconditionsofmotherandfetus.AnIVshouldbestartedafterthematernal-fetaldyadisassessed.Preparingtheclientforacesareandeliverybeforedeterminingthecauseofthevaginalbleedingwouldbepremature.Maternalheartrateandrespiratoryratearen"tthebestindicatorsofmaternalhealthstatusandprovidenoinformationaboutfetalhealth.A2-month-oldneonatewithdiarrheaandvomitinghasbeenreceivingIVfluidsforthepast24hours.Thespecificgravityoftheneonate"surineis1.012.Whatshouldthenursedonext?Checktheneonate"sbloodpressure.Checkthespecificgravityagainassoonaspossible.Notifythephysician.ContinuetheorderedIVflowrate.正確答案:D答案解析:Theneonate"surinespecificgravityiswithinnormallimits,indicatingthathe"sbeingadequatelyhydrated.Theotheroptionsaren"tnecessary.A34-year-oldclientat32weeks"gestationtellsthenursethatherbabywillbesickbecauseshesawadeaddogontheroadyesterday.What"sthebestresponsebythenurse?"Yourbabywillbefine.That"sjustsuperstition.""Don"tworry.We"llmakesureyourbabyisokay.""Icanseethatyouareconcerned.Let"stalkaboutwhat"sbotheringyou.""Perhapsso.Yourbabyshouldbeseenbyaphysicianassoonasit"sborn."正確答案:C答案解析:Someculturesholdthatifapregnantwomanlooksuponadeadanimal,thefetusisexposedtotherealmofthedeadandmaylaterbecomeillasababy.Thenurse"sresponseissensitivetothemother"sbeliefsandeasesthewayforthemothertobegintotalkaboutherconcern.OptionAdiscountsthemother"sbeliefs.OptionBdismissesthemother"sconcernsandoffersfalsereassurance.OptionDcarriesempathyoverintofalsevalidationandoverreaction,yetitfailstosetupanydialoguewiththeclient.Whichofthefollowingassessmentsindicatesfetaldistress?FetalscalppHof7.14.Fetalheartrate(FHR)of144beats/minute.AccelerationofFHRwithcontractions.Long-termvariability.正確答案:A答案解析:AscalppHoflessthan7.25indicatesacidosisandfetalhypoxia.Theotheroptionsarenormalresponsesofahealthyfetustolabor.Aclientwithacuterespiratoryfailureisintubatedandplacedonmechanicalventilation.Whichinterventionismostappropriatewhensuctioningtheclient?Insertthesuctioncatheterwhileapplyingsuction.Applysuctionuntilallthesecretionshavebeenremoved.Usethesamecathetertofirstsuctionthemouth,thentheendotraehealtube.Preoxygenatewith100%oxygenbeforesuctioning.正確答案:D答案解析:Preoxygenatetheclientwith100%oxygenbeforesuctioningtopreventthehypoxiathatoccurswhentheclientisdisconnectedfromtheoxygensourceandoxygenisremovedfromtheairwayduringsuctioning.Toavoidhypoxiaandtraumatothetrachea,suctionshouldn"tbeappliedwheninsertingthecatheter.Topreventhypoxia,neversuctionlongerthan15seconds.Asuctioncatheterthathasbeenusedtosuctionthemouthshouldbeconsideredcontaminatedandshouldn"tbeusedtosuctiontheendotrachealtube.Thenurseiscaringforaclientwithafracturedhip.Theclientiscombativeandconfused,andhe"stryingtogetoutofbed.Thenurseshouldleavetheclientandgethelp.obtainaphysician"sordertorestraintheclient.readthefacility"spolicyonrestraints.ordersoftrestraintsfromthestoreroom.正確答案:B答案解析:It"smandatoryinmostsettingstohaveaphysician"sorderbeforerestrainingaclient.Aclientshouldneverbeleftalonewhilethenursesummonsassistance.Allstaffmembersrequireannualinstructionontheuseofrestraints,andthenurseshouldbefamiliarwiththefacility"spolicy.Shortlyafterbeingadmittedtothecoronarycareunitwithanacutemyocardialinfarction(MI),aclientreportsmidsternalchestpainradiatingdowntheleftarm.Thenursenoticesthattheclientisrestlessandslightlydiaphoretic,andmeasuresatemperatureof99.6°F(37.6℃),aheartrateof102beats/minute;regular,slightlylaboredrespirationsat26breaths/minute;andabloodpressureof150/90mmHg.Whichnursingdiagnosistakeshighestpriority?Riskforimbalancedbodytemperature.Decreasedcardiacoutput.Anxiety.Acutepain.正確答案:D答案解析:ThenursingdiagnosisofAcutepaintakeshighestprioritybecausepainincreasestheclient"spulseandbloodpressure.DuringanacutephaseofanMI,low-gradefeverisanexpectedresultofthebody"sresponsetothemyocardialtissuenecrosis.ThismakesRiskforimbalancedbodytemperatureanincorrectanswer.Theclient"sbloodpressureandheartratedon"tsuggestanursingdiagnosisofDecreasedcardiacoutput.Anxietycouldbeanappropriatenursingdiagnosisbutitmaybecorrectedbyaddressingthepriorityconcern-pain.Aclientwithcholecystitisisreceivingpropanthelinebromide.Theclientisgiventhismedicationbecauseitreducesgastricsolutionproductionandhypermobility.slowsemptyingofthestomachandreduceschymeintheduodenum.inhibitscontractionofthebileductandgallbladder.decreasesbilesecretions.正確答案:C答案解析:PropanthelinebromideisclassifiedasaGIanticholinergic;themedicationinhibitsmuscarinicactionsofacetylcholineatpostganglionicparasympatheticneuroeffectorsites.Forgallbladderdisease,propanthelinehasanantispasmodiceffectonthebileductandgallbladder.Althoughthemedicationreducesproductionofgastricsolutionsandalsoreduceshypermobility,itisn"tthemainreasonforthemedication.Thedrugdoesn"tslowemptyingofthestomachorreducechymeintheduodenum.Thenursehasaclientat30weeks"gestationwhohastestedpositiveforthehumanimmunodeficiencyvirus(HIV).Whatshouldthenursetelltheclientwhenshesaysthatshewantstobreast-feedherneonate?Encouragebreas-feedingsothatshecangetherrestandgethealthier.Encouragebreast-feedingbecauseit"shealthierfortheneonate.Encouragebreast-feedingtofacilitatebonding.Discouragebreast-feedingbecauseHIVcanbetransmittedthroughbreastmilk.正確答案:D答案解析:TransmissionofHIVcanoccurthroughbreastmilk,sobreast-feedingshouldbediscouragedinthiscase.Whichclienthasthehighestriskofovariancancer?30-year-oldwomantakingoralcontraceptivepills.45-year-oldwomanwhohasneverbeenpregnant.40-year-oldwomanwiththreechildren.36-year-oldwomanwhohadherfirstchildatage22.正確答案:B答案解析:Theincidenceofovariancancerincreasesinwomenwhohaveneverbeenpregnant,areinfertile,orhavemenstrualirregularitiesandaftermenopause.Otherriskfactorsincludeapersonalorfamilyhistoryofovarian,breast,bowel,orendometrialcancer.Theriskofovariancancerisreducedinwomenwhohavetakenoralcontraceptives,havehadmultiplebirths,orhavehadafirstchildatayoungage.Thenurseisprovidingpostoperativecareforaclientrecoveringfromabdominalsurgery.Theclientisreceivingmorphinethroughaclient-controlledanalgesiapump.Whichfindingwouldindicatethattheclientisobtainingadequatepainrelief?Awakeningseveraltimesduringthenighttoredose.Respiratoryrateof10breaths/minute.Painratingof2or3onascaleof0to10.Complaintofitchingasanadverseeffectoftheanalgesia.正確答案:C答案解析:Aratingof2or3onascaleof0to10isconsideredmildpain,whichistobeexpectedafterabdominalsurgery.Redosingduringthenight,whichdisruptssleep,isadisadvantageofthismethodanddoesn"