2023年CGNS美國(guó)海外護(hù)士資格認(rèn)證歷年高頻考題帶答案難題附詳解

2023年CGNS美國(guó)海外護(hù)士資格認(rèn)證歷年高頻考題帶答案難題附詳解（圖片大小可自由調(diào)整）第1卷一.Comprehensivetestcenter(共50題)1.A20-year-oldwomanhasjustbeendiagnosedwithCrohn'sdisease.Shehaslost10lb(4.5kg)andhascrampsandoccasionaldiarrhea.Thenurseshouldincludewhichofthefollowingwhendoinganutritionalassessment?A.Lettheclienteatasdesiredduringhospitalization.B.Weightheclientdaily.C.Asktheclienttolistwhatsheeatsduringatypicalday.D.PlacetheclientonI＆Ostatusanddrawbloodforelectrolytelevels.2.Whichofthefollowinglaboratorytestsshouldbemonitoredcloselybythenursewhiletheclientisreceivingheparintherapy?A.Internationalnormalizedratio(INR).B.Activatedpartialthromboplastintime(APTT).C.Prothrombintime(PT).D.Thrombintime.3.Forachildreceivingsteroidsintherapeuticdosesoveralongperiod,thenurseshouldpaymoreattentiononwhichofthefollowing?A.Monitorthechild'sserumglucoselevel.B.Decreasethechild'singestionofpotassium-richfoods.C.Givethedrugonanemptystomach.D.Monitorthechild'stemperaturetoassessforinfection.4.Duringthefirst48to72hoursoffluidresuscitationtherapyafteramajorburninjury,theintravenousinfusionratewillbeadjustedbyevaluatingwhichofthefollowingobservation?A.Dailybodyweight.B.Hourlyurineoutput.C.Hourlyurinespecificgravity.D.Hourlybodytemperature.5.Whenselectingaroomforaclientwiththediagnosisofbipolardisorder,manicphase,whoishyperactiveandtalkingnonstopinalouddemandingvoice,thenurserecognizesthatamostimportantfactorwouldbethattheA.RoomhaveapleasantviewB.AtmospherebequietandrestfulC.Locationbeclosetothenurses'stationD.Roommateshavesimilarbehavioralresponses6.Followingacystoscopythatconfirmedadiagnosisofbladdercancer,aclientisscheduledforchemotherapyandailealconduiturinarydiversion.Thenurseshouldincludewhichofthefollowingpointsintheclient'spreoperativeteaching?A.Theclient'sneedtoperformstomaself-careimmediatelyaftersurgery.B.Theclient'sneedtoremainonbedrestfor3daysfollowingsurgery.C.Theprocedurecreatesastomaandhemustwearapouchafterward.D.Theclientwillbeabletocontrolurinepassagethroughthestoma.7.A23-year-oldclientinthemanicphaseofbipolardisorderisadmittedtothefacility.Whichofthefollowingagentswouldbeappropriateforthisclient?A.Bupropion(Wellbutrin)andlithium(Lithobid).B.Lithium(Lithobid)andvalproicacid(Depakene).C.Haloperidol(Haldol)andfluphenazine(Prolixin).D.Risperidone(Risperdal)andclozapine(Clozaril).8.Whenadministeringanintramuscularinjectiontoaneonate,whichofthefollowingmuscleswouldthenurseconsiderasthebestinjectionsite?A.Deltoid.B.Dorsogluteal.C.Ventrogluteal.D.Vastuslateralis.9.Aclientbeingevaluatedintheemergencydepartmentcomplainsofchestpainthatradiatestohisneck,shoulders,back,andarms,whichdecreaseswhenhesitsupandleansforward.Basedonthisassessment,thenursesuspectsthathehasA.developedanothermyocardialinfarction(MI).B.endocarditis.C.pericarditis.D.myocarditis.10.Whichofthefollowingsignsandsymptomsisclassicforapatientwithrheumatoidarthritis?A.Jointswelling,jointstiffnessinthemorning,andbilateraljointinvolvement.B.Crepitus,developmentofHeberden'snodes,andanemia.C.Painonweight-bearing,rash,andlow-gradefever.D.Fatigue,leukopenia,andjointpain.11.Beforeatransesophagealechocardiogram,aclientisgivenanoraltopicalanestheticspray.Uponreturnfromtheprocedure,thenurseobservesthattheclienthasnoactivegagreflex.Inresponse,thenurseshouldA.insertanoralairway.B.withholdfoodandfluids.C.positiontheclientonhisside.D.introduceanasogastric(NG)tube.12.Whichoneisnotrightaboutpersonalitydisorder?A.MultiplepersonalitydisorderisdistinctandseparatepersonalitieswithinthesamepersonB.PeoplewithpersonalitydisorderoftenexperiencechildabuseortraumaticC.Onlythesymptomsofpersonalitydisorderrepresenttheperson'sstablecharacteristicsandsocialfunctioning,hecanbediagnosedpersonalitydisorderD.Paranoidandantisocialpersonalitydisordersaremorecommonlydiagnosedinwomenthanmen13.Aspartoftheannualhealthscreening,thenursevisitstheeighth-gradephysicaleducationclassesandaskseachstudenttobendforwardatthewaistwiththebackparalleltothefloorandthehandstogetheratmidline.Forwhichofthefollowingisthenurseassessing?A.Slippedepiphysis.B.Developmentaldysplasiaofhip.C.Idiopathicscoliosis.D.Physicaldexterity.14.A7-year-oldboyishospitalizedwithcysticfibrosis.Tohelphimmanagesecretionsandavoidrespiratorydistress,thenurseshouldA.performchestphysiotherapyevery4hours.B.givepancreaticenzymesasordered.C.placethechildinanoxygententandhaveoxygenadministeredcontinuously.D.serveahigh-caloriediet.15.Borderlinepersonalitydisorderinvolvescontinuousdysfunctionalbehaviorsinwhichpatientmayinjuryhimself.PredisposingfactorsofthisdisorderincludeallofthefollowingexceptA.Diagnosedwithattentiondeficithyperactivitydisorder(ADHD)everB.AbusebyhisparentsorothersinchildhoodC.HiseffortstobeautonomouswereoftenpunishedbyhisgrandmotherwhofostershimD.Noneoftheabove16.Themultidisciplinaryteamdecidestoemployabehaviormodificationapproachtoayoungfemale'sproblemwithanorexianervosa.AplannednursinginterventionthatwouldfollowthisapproachwouldhetoA.HaveclientroleplayinteractionswithherparentsB.Provideclientwithahigh-calorie,high-proteindietC.Restricttheclienttoherroomuntilshegains2poundsD.Forcetheclienttotalkaboutherfavoritefoodsfor1houraday17.AclientwhohasrecentlyhadsurgeryforprostatecancerexpressestothenursefeelingsofangertowardGod,hischurch,andtheclergy.Whichinterventionisn'tappropriateforthisclient?A.Acknowledgingtheclient'sspiritualdistress.B.Invitingtheclient'sclergymantovisithim.C.Encouragingtheclienttodiscussreligiousbeliefsandpractices.D.Encouragingtheclienttodiscussconcernswiththeclergy.18.Thenursemustassessjudgmenttodetermineaclient'smentalstatus.Whichtestbestaccomplishesthis?A.Interpretingproverbs.B.Spellingwordsbackward.C.Countingbyserialsevens.D.Discussinghypotheticalethicalsituations.19.A72-year-oldclientseekshelpforchronicconstipation.Thisisacommonproblemforelderlyclientsduetoseveralfactorsrelatedtoaging.Whichofthefollowingisonesuchfactor?A.Increasedintestinalmotility.B.Decreasedabdominalstrength.C.Increasedintestinalbacteria.D.Decreasedproductionofhydrochloricacid.20.Aclientwhoreceivedgeneralanesthesiareturnsfromsurgery.Postoperatively,whichnursingdiagnosistakeshighestpriorityforthisclient?A.Acutepainrelatedtosurgery.B.Deficientfluidvolumerelatedtobloodandfluidlossfromsurgery.C.Impairedphysicalmobilityrelatedtosurgery.D.Riskforaspirationrelatedtoanesthesia.21.Johnoftenfindsherselfdaydreamingaboutboy'sandwonderingwhatherlifewillbelikewhenshegetsmarried.AccordingtoPiaget,Johnislikelyinwhichstage?A.SensorimotorstageB.PreoperationalstageC.ConcreteoperationalstageD.Formaloperationalstage22.Thenursingcareplanforaclientaftergynecologicsurgeryincludesnursingordersintendedtohelpreducetheriskofthrombophlebitis.Whichisnotappropriateamongthefollowingnursinginterventions?A.Ambulatetheclient.B.Massagetheclient'slegs.C.Havetheclientwearelasticizedstockings.D.Havetheclientperformrange-of-motionexercisesinbed.23.AnelderlyresidentwiththediagnosisofdementiaoftheAlzheimer'stypefrequentlytalkaboutthegoodolddaysattheranchasachild.Onthebasisofanunderstandingoftheresident'sdiagnosis,thenurse'smostappropriateactionatthistimewouldbetoA.InvolvetheresidentininterestingdiversionalactivitiesinasmallgroupB.AllowtheresidenttoreminisceaboutthepastandlistenwithinteresttothestoriesC.Gentlyremindtheresidentthatthose"goodolddays"arepastandthinkingshouldfocusonthepresentD.Introducetheresidenttootherresidentsofthesameagesothattheycanmutuallysharetheirpastexperiences24.Thenurseisdevelopingateachingplanforaclientwithdiabetesmellitus.AclientwithdiabetesmellitusshouldA.usecommercialpreparationstoremovecorns.B.cuttoenailsbyroundingedges.C.washandinspectfeetdaily.D.walkbarefootatleastonceeachday.25.Thenurseisprovidingcareforapregnantclient.Theclientasksthenursehowshecanbestdealwithherfatigue.ThenurseshouldinstructhertoA.takesleepingpillsforarestfulnight'ssleep.B.trytogetmorerestbygoingtobedearlier.C.takeherprenatalvitamins.D.tellhernottoworrybecausethefatiguewillgoawaysoon.26.Whenprioritizingaclient'scareplanbasedonMaslow'shierarchyofneeds,thenurse'sfirstprioritywouldbeA.allowingthefamilytoseeanewlyadmittedclient.B.ambulatingtheclientinthehallway.C.administeringpainmedication.D.placingwristrestraintsontheclient.27.Whencaringforaclientwithamajordepression,thenurseusuallyhasthemostdifficulty,dealingwiththe:A.Client'slackofenergyB.NegativenonverbalresponsesC.Client'spsychomotorretardationD.Pervasivequalityofthedepression28.Thenurseisprovidingcareforaclientwithmultiplemyeloma,adisordercharacterizedbyepisodesofremissionsandexacerbations.Whichofthefollowingresourcescanbesthelptheclientadapttothedisease?A.Theclient'sfamily.B.Supportgroup.C.Pastoralcare.D.Hospicecare.29.Ayoungmaleclientwithanorxianervosatelephoneshomejustbeforemealtime.Theclientusesthephonecallstoavoideating.ThenursecouldevaluatethatthenursingplantosetlimitsonthisavoidancebehaviorwaseffectivewhentheclientA.OrganizesanaerobicgroupfortheclientsB.ArrivesontimeformealswithoutbeingcalledC.BeginsreadingandclippingrecipesfrommagazinesD.Contactshisfamilyfrequentlybytelephonebetweenmeals30.Aclientwithahistoryofheartfailureisexaminedintheoutpatientdepartmenttoinvestigatetherecentonsetofperipheraledemaandincreasedshortnessofbreath.Physicalfindingsincludebilateralcrackles,athirdheartsound(S3),distendedneckveins,elevatedbloodpressure,andpittingedemaoftheankles.Thenursedocumentstheseverityofpittingedemaas+1.Whatisthebestdescriptionofthistypeofedema?A.Barelydetectabledepressionwhenthethumbisreleasedfromtheswollenarea;normalfootandlegcontours.B.Detectabledepressionoflessthan5mmwhenthethumbisreleasedfromtheswollenarea;normalfootandlegcontours.C.A5-to10-mmdepressionwhenthethumbisreleasedfromtheswollenarea;footandlegswelling.D.Adepressionofmorethan1cmwhenthethumbisreleasedfromtheswollenarea;severefootandlegswelling.31.Aclientisplacedinfullleatherrestraints.Howoftenmustthenursechecktheclient'scirculation?A.Onceperhour.B.Oncepershift.C.Every10to15minutes.D.Every2hours.32.Aclientwhoagreedtobecomeanorgandonorispronounceddead.Whatisthemostimportantfactorinselectingatransplantrecipient?A.Bloodrelationship.B.Sexandsize.C.Compatiblebloodandtissuetypes.D.Need.33.Aclientwithahistoryofpanicattacksseekstoincreasesocialinteraction.Eachtimetheclienttriestogotothedayroom,shebeginstoperspireandbecomesshortofbreath.Whichactionbythenursewillhelpeasetheclient'sfeelingsofpanic?A.Haveotherclientsvolunteertoaccompanytheclient.B.Telltheclientshehastoovercomeherfear.C.Allowtheclienttostayinherroom.D.Walkwiththeclientandstaywithherwhileshe'sinthedayroom.34.Aprimigravidaat28weeks'gestationisadmittedwithadiagnosisofpretermlabor.Theclient'scontractionsareoccurringevery15to20minutes,lasting25seconds.Themembranesareintact.Whatshouldthenursedo?A.Requestassistancefromtheneonatalresuscitationteam.B.Placetheclientonbedrestonherleftside.C.Obtainequipmentforanamniotomy.D.Prepareterbutalineinanintravenoussolutionofnormalsaline.35.A4-month-oldinfantisbroughttothepediatricianbyhisparentsbecausethey'reconcernedabouthisfrequentrespiratoryinfections,poorfeedinghabits,frequentvomiting,andcolic.Thephysiciannotesthatthebabyhasfailedtogainexpectedweightandrecommendsthatthebabyhaveasweattestperformedtodetectpossiblecysticfibrosis.Topreparetheparentsforthetest,thenurseshouldexplainthatA.thebabywillneedtofastbeforethetest.B.asampleofbloodwillbenecessary.C.alow-sodiumdietisnecessaryfor24hoursbeforethetest.D.alow-intensity,painlesselectricalcurrentisappliedtotheskin.36.Thenurseiscaringforaclientwithcirrhosis.WhichmanifestationsindicatedeficientvitaminKabsorptioncausedbycirrhosis?A.Dyspneaandfatigue.B.Ascitesandorthopnea.C.Purpuraandpetechiae.D.Gynecomastiaandtesticularatrophy.37.Whichofthefollowinghomeregimensshouldthenursesuggesttorelieveitchinginchildrenwithchickenpox?A.Generousamountsoffinebabypowder.B.Oatmealpreparationbaths.C.Terryclothtowelsmoistenedwithhydrogenperoxide.D.Coolcompressesmoistenedwithaweaksaltsolution.38.Thenurseisteachingbreastself-examination(BSE)toacollegestudent.Thenurseknowsthattheclientunderstandsthebesttimetoexamineherbreastswhenshesays:A."I'llexaminemybreasts1weekaftermyperiodstarts."B."I'llperformaBSEjustbeforemyperiodstarts."C."Imustexaminemybreaststhesametimeeachday."D."EverytimeIshowerI'lldoabreastexamination."39.Aregisterednursewhousuallyworksonamedical-surgicalunitistoldtoreporttothecardiaccareunit(CCU)forthedaybecausetheCCUisshortstaffedandneedsadditionalhelptocarefortheclients.ThenursehasneverworkedintheCCU.Whichofthefollowingresponsesisthemostappropriatenursingaction?A.Callthehospitallawyer.B.ReporttotheCCUandidentifytasksthatshefeelsshecansafelyperform.C.Speaktothenursingsupervisor.D.RefusetogototheCCU.40.Whichofthefollowingwouldthenurseexpecttoassessaspresumptivesignsofpregnancy?A.Amenorrheaandquickening.B.Apositivepregnancytestandafetaloutline.C.BraxtonHickscontractionsandHegar'ssign.D.UterineenlargementandChadwick'ssign.41.Thenurseisdevelopingateachingplanforaclientwithgenitalherpes.SheshouldincludeinformationaboutA.acyclovir(Zovirax).B.penicillin.C.doxycycline.D.tetracycline.42.Whichofthefollowingsymptomswouldthenursemostlikelyobserveinaclientwithcholecystitisfromcholelithiasis?A.Blackstools.B.Decreasedwhitebloodcellcount.C.Nauseaafteringestionofhigh-fatfoods.D.Elevatedtemperatureof103°F(39.4℃).43.Themotherofanew-bornasksthenursehowoftensheshouldbreastfeedherbaby.Whichofthefollowingresponsesbythenursewouldbebest?A."Newbornsshouldbreastfedatleastevery3hoursduringtheday."B."Newbornsshouldbefedwhentheycry."C."Aslongasthebabyfeedsfourtimesaday,hewillgetenough."D."Newbornsmaybreastfeedcontinuouslyuntiltheystabilize."44.Aclientreportsasevereheadacheshortlyafteralumbarpunctureforamyelogram.Whatwouldbethenurse'sbestresponse?A.Increasetheclient'sfluidintake.B.Administerprescribedantihypertensives.C.Offerrolllensestotheclient.D.Placecoolingpacksoverthelumbarpuncturesite.45.Thenurseisassessingthepuncturesiteofaclientwhohasreceivedapurifiedproteinderivativetest.Whichfindingindicatesaneedforfurtherevaluation?A.15-mminduration.B.Reddenedarea.C.10-mmbruise.D.Blister.46.TheclientistoreceiveanIVinfusionof3000mLofdextroseandnormalsalinesolutionover24hours.Thenurseobservesthattherateis150mL/hour.Ifthesolutionrunscontinuouslyatthisrate,theinfusionwillbecompletedinA.12hours.B.20hours.C.24hours.D.50hours.47.Thenurseappliesafetalmonitortoa15-year-oldprimagravidaadmittedtothehospitalwithpossiblepregnancy-inducedhypertension.Whichmonitorpatternwouldthenurseexpecttoobserveiftheclientisexperiencinguteroplacentalinsufficiency?A.Latedeceleration.B.Earlydeceleration.C.Variabledeceleration.D.Fetalacceleration.48.Thenurseisprovidingbreastcancereducationatacommunityfacility.TheAmericanCancerSocietyrecommendsthatwomengetmammogramsA.yearlyafterage40.B.afterthebirthofthefirstchildandevery2yearsthereafter.C.afterthefirstmenstrualperiodandannuallythereafter.D.every3yearsbetweenages20and40andannuallythereafter.49.Whilemanagingamanicepisode,anursewouldNOTA.ProvideaquietenvironmentanddecreasestimuliB.ArguewithpatientabouthisdisruptivebehaviorC.Whileadministeringmedicationasadvised,observeforsideeffects,monitorlithiumbloodlevels,andmaintainfluidandsaltintakeD.Assistdressingandbathing50.Thenurseiscaringforaclientwithbipolardisorderinamanicstate.Whichofthefollowingnursinginterventionsshouldbeincludedintheplanofcare?A.Allowingtheclienttoexhibithyperactive,demanding,manipulativebehaviorwithoutsettinglimits.B.Listeningattentivelywithaneutralattitudeandavoidingpowerstruggles.C.Offeringhigh-caloriemealsandstronglyencouragingtheclienttofinishallfood.D.Insistingthattheclientremainactivethroughthedaysothathe'llsleepatnight.第1卷參考答案一.Comprehensivetestcenter1.參考答案：CWhenperforminganutritionalassessment,oneofthefirstthingsthenurseshoulddoistoassesswhattheclienttypicallyeats.Theclientshouldn'tbepermittedtoeatasdesired.Weighingtheclientdaily,placingheronI＆Ostatus,anddrawingbloodtodetermineelectrolytelevelsaren'tpartofanutritionalassessment.2.參考答案：BActivatedpartialthromboplastintime(APTT)isusedtomeasuretheclottingstatuswhentheclientisreceivingheparin.3.參考答案：ASteroidusetendstoelevateglucoselevels.Thechildshouldbemonitoredforincreases.4.參考答案：BDuringthefirst48to72hoursoffluidresuscitationtherapy,hourlyurineoutputisthemostaccessibleandgenerallyreliableindicatorofadequatefluidreplacement.Fluidvolumeisalsoassessedbymonitoringmentalstatus,vitalsigns,peripheralperfusion,andbodyweight.Pulmonaryarteryend-diastolicpressure(PAEDP)andevencentralvenouspressure(CVP)arepreferredguidestofluidadministration,buturineoutputisbestwhenPAEDPorCVParenotused.Afterthefirst48to72hours,urineoutputisaless-reliableguidetofluidneeds.Thevictimentersthediureticphaseasedemareabsorptionoccurs,andurineoutputincreasesdramatically.5.參考答案：B6.參考答案：CThenurseshouldensurethattheclientunderstandsthatastomawillbeformedandthathe'llneedtowearapouch.Thenursewillcareforthestomaimmediatelyaftersurgery;self-carewillbeginwhentheclientisphysicallyable.Theclientwillbeencouragedtogetoutofbedthefirstdayaftersurgerytopreventcomplicationsofimmobility.Urineflowcan'tbecontrolledthroughastoma.7.參考答案：BLithiumandvalproicacidarethedrugsofchoiceformanicdepression.Wellbutrinisanantidepressant,notanantimanic.Haloperidol,fluphenazine,clozapine,andrisperidoneareantipsychoticagents.8.參考答案：DThevastuslateralismuscleofthethighispreferredforadministeringintramuscularinjectionstoinfantsbecausethereislessdangerofinjuringnerves,bloodvessels,orbonystructuresatthissite.9.參考答案：CPericarditisisaninflammationofthefibroseroussacthatenvelopstheheart.UnlikethepainofanMI,pericardialpainiscommonlypleuritieandeaseswhentheheartispulledawayfromthediaphragmaticpleuraeofthelungs.Thehallmarkindicationofendocarditisisintermittentfeverandmalaiseresultingfrominfectionoftheendocardium.Myocarditishasnonspecificsymptomsthatreflecttheaccompanyingsystemicinfection.10.參考答案：AClassicsignsandsymptomsofrheumatoidarthritisincludejointpain,swelling,andwarmth.Symptomsaretypicallybilaterallysymmetric.Jointstiffnessinthemorninglastinglongerthan30minutesisanotherclassicsymptom.Rheumatoidarthritisisasystemicdisease.Othersymptomscanincludefatigue,low-gradefever,anemia,andweightloss.11.參考答案：BFollowingatransesophagealechocardiograminwhichtheclient'sthroathasbeenanesthetized,foodandfluidshouldbewithhelduntilthegagreflexreturns.Thereisnoindicationfororalairwayplacement.Theclientshouldbeintheuprightposition,andinsertinganNGtubeisunnecessary.12.參考答案：D13.參考答案：CWhenbendingforward,apersonwhohasidiopathicscoliosishasanobviousribhump.Thetwosidesofthebackatthehips,ribs,orshouldersarenotlevel.14.參考答案：AChestphysiotherapyaidsinlooseningsecretionsintheentirerespiratorytract.Pancreaticenzymesaidintheabsorptionofnecessarynutrients--notinmanagingsecretions.Oxygentherapydoesn'taidinlooseningsecretionsandcancausecarbondioxideretentionandrespiratorydistressinchildrenwithcysticfibrosis.Ahigh-caloriedietisappropriatebutdoesn'tfacilitaterespiratoryeffort.15.參考答案：D16.參考答案：C17.參考答案：BThenurseshouldn'tinvitehisclergymantovisittheclient,unlesstheclientspecificallyaskstoseethatmemberoftheclergy.Acknowledgingtheclient'sspiritualdistressmayhelpthenursebuildatherapeuticrelationshipwiththeclient.Encouragingtheclienttodiscussreligiousbeliefsandpracticesisafirststepindevelopingaplanfortheclient.Encouragingtheclienttodiscusshisconcernswiththeclergyisalsoappropriate.18.參考答案：DHypotheticalethicalsituations--suchas"Whatwouldyoudoifyoufoundawalletcontainingcreditcardsandidentification?"--areusedtotestjudgment.Proverbinterpretationteststhinking.Spellingwordsbackwardandcountingbyserialsevenstestconcentration.19.參考答案：BDecreasedabdominalstrength,muscletoneoftheintestinalwall,andmotilityallcontributetochronicconstipationintheelderly.Adecreaseinhydrochloricacidcausesadecreaseinabsorptionofiron,andanincreaseinintestinalbacteriaactuallycausesdiarrhea.20.參考答案：DRiskforaspirationrelatedtoanesthesiatakespriorityforthisclientbecausegeneralanesthesiamayimpairthegagandswallowingreflexes,possiblyleadingtoaspiration.Theotheroptions,althoughimportant,aresecondary.21.參考答案：D22.參考答案：BMassagingthelegspostoperativelyiscontraindicatedbecauseitmaydislodgesmallclotsofblood,ifpresent,andcauseevenmoreseriousproblems.23.參考答案：C24.參考答案：CDiabeticclientsshouldwashtheirfeetdailytoallowfordailyinspectionofthefeet.Theclientshouldwearnonconstrictiveshoes.Cornsshouldbetreatedbyapodiatrist,notwithcommercialpreparations.Nailsshouldbefiledstraightacross.Clientswithdiabetesmellitusshouldneverwalkbarefoot.25.參考答案：BSheshouldlistentothebody'swayoftellingherthatsheneedsmorerestandtrygoingtobedearlier.Sleepingpillsshouldn'tbeconsumedprenatallybecausetheycanharmthefetus.Vitaminswon'ttakeawayfatigue.Falsereassuranceisinappropriateanddoesn'thelpherdealwithfatiguenow.26.參考答案：CInMaslow'shierarchyofneeds,painreliefisonthefirstlayer.Activityisonthesecondlayer.Safetyisonthethirdlayer.Loveandbelongingareonthefourthlayer.27.參考答案：D28.參考答案：BSupportgroupsconsistofclientswiththesamediagnoseswhoshareexperiencesofthediseasewitheachother.Sharingexperienceshelpstheclientunderstanddisease-relatedproblemsandgiveshimaforuminwhichhecanventhisfeelings,whichareusuallysimilartothoseofthegroup.Theclient'sfamilyandclergy,althoughsupportive,can'tsharesimilardiseaseexperiences.Hospicecareisusuallyimplementedlateinthedisease,attheendoflife.29.參考答案：B30.參考答案：APittingedemaisdocumentedas+1whendepressionisbarelydetectableonreleaseofthumbpressureandwhenfootandlegcontoursarenormal.Adetectabledepressionoflessthan5mmaccompaniedbynormallegandfootcontourswarrantsa+2rating.Adeeperdepression(5to10mm)accompaniedbyfootandlegswellingisevaluatedas+3.Anevendeeperdepression(morethan1cm)accompaniedbyseverefootandlegswellingratesa+4.31.參考答案：CCirculatoryaswellasskinandnervedamagecanoccurwithin15minutes.Checkingeveryhour,2hours,or8hoursisn'toftenenoughandcouldresultinpermanentdamagetotheclient'sextremities.32.參考答案：CThedonorandrecipientmusthavecompatiblebloodandtissuetypes.Theyshouldbefairlycloseinsizeandage.Whenalivingdonorisconsidered,it'spreferabletohavearelativedonatetheorgan.Needisimportant,butitcan'tbethecriticalfactorifacompatibledonorisn'tavailable.33.參考答案：DTheclientmayfindsecurityinthepresenceofatrustedperson.Herfearsareveryrealandshe'llneedtheemotionalsupportofcaringprofessionalstoovercomethem.Tellingtheclientshehastoovercomeherfearsminimizesherfeelings.Allowingtheclienttostayinherroomdoesn'thelptheclientovercomeherfeelingsofpanic.34.參考答案：BThisclientisexperiencingearlysignsofpretermlabor.Thenurseshouldplantoplacetheclientonbedrestonherleftsidewhichpromotesuterineplacentalperfusionandincreasedoxygensupplytothefetus.35.參考答案：DBecausecysticfibrosisclientshaveelevatedlevelsofsodiumandchlorideintheirsweat,asweattestisperformedtoconfirmthisdisorder.Afterpilocarpine(acholinergicmedicationthatinducessweating)isappliedtoagauzepadandplacedonthearm,alow-intensity,painlesselectricalcurrentisappliedforseveralminutes.Thearmisthenwashedoff,andafilterpaperisplacedoverthesitewithforcepstocollectthesweat.Elevatedlevelsofsodiumandchloridearediagnosticofcysticfibrosis.Nofastingisnecessarybeforethistestandnobloodsampleisrequired.Alow-sodiumdietisn'trequiredbeforethetest.36.參考答案：CAliverdisorder,suchascirrhosis,candisrupttheliver'snormaluseofvitaminKtoproduceprothrombin(aclottingfactor).Becauseofthis,thenurseshouldmonitortheclientforsignsofbleeding,includingpurpuraandpetechiae.Dyspneaandfatiguesuggestanemia.AscitesandorthopneaareunrelatedtovitaminKabsorption.Gynecomastiaandtesti