美国护士资格认证-2

1、美国护士资格认证 (CGFNS)-2( 总分： 53.00 ，做题时间： 90 分钟 )一、 Part One ( 总题数： 30，分数： 30.00)1.During the night, a 50-year-old Vietnam veteran with posttraumatic stress syndrome wakens shaking and tells you that someone is trying to smother him. What is the appropriate response for the nurse in this situation?A. &qu

2、ot;It was a bad dream. You are safe. I'll stay here with you until you go back to sleep. "B. "We can talk about it tomorrow. Try to see if you can get back to sleep. "C. "It was only a dream. There's nothing to be frightened about. "D. "I'll call the physici

3、an and see whether I can get you medication to help you go back to sleep. /A. B.C.D.解析： The important intervention is to assist the client to feel safe. Staying with him until he's able to sleep again or listening to him if he wants to talk is the most appropriate action for the nurse to take in

4、 this situation. Talking about it in the morning won't comfort the client when he's most upset. Stating that it was only a dream trivializes his experience. Calling the physician for a sleeping aide doesn't help the client cope with stress.2.A client is admitted to the hospital with an e

5、xacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isn't answered immediately. The most appropriate response to her would be,A. "You seem angry. Would you like to talk about it?"B. "Calm down. You know that stress will make your sympto

6、ms worse. "C. "Would you like to talk about the problem with the nursing supervisor?"D. "I can see you're angry. I'll come back when you've calmed down. /A. B.C.D.解析： Verbalizing the observed behavior is a therapeutic communication technique in which thenurse acknowle

7、dges what the client is feeling. Offering to listen to the client express her anger can help the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge her feelings. Offering to

8、get the nursing supervisor also doesn't acknowledge the client's feelings. Ignoring the client's feelings suggests that the nurse has no interest in what the client has said.3.In an industrial accident, a client who weighs 155 lb (70.3 kg) sustained full-thickness burns over 40%o f his b

9、ody. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?A. A urine output consistently above 100 mL/hr.B. A weight gain of 4 lb (1.8 kg) in 24 hours.C. Body temperature readings all within normal limits.D. An electro

10、cardiogram (ECG) showing no arrhythmias.A. B.C.D.解析： In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequatelyperfused, they will produce an acceptable urine output of at l

11、east 0.5 mL/(kg· hr). Thus, theexpected urine output of a 155 lb client is 35 mL/hr, and a urine output consistently above 100 mL/hr is more than adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4 lbweight gain in 24 hours suggests third spacing. Body temperature read

12、ings and ECGi nterpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.4. A client with type 1 (insulin-dependent) diabetes mellitus has just learned she's pregnant.The nurse is teaching her about insulin requirements during pregnancy. Which guid

13、eline should the nurse provide?A. "Insulin requirements don't change during pregnancy. Continue your current regimen. "B. "Insulin requirements usually decrease during the last two trimesters. "C. "Insulin requirements usually decrease during the first trimester. "D

14、. "Insulin requirements increase greatly during labor. /A.B.C. D.解析： Maternal insulin requirements usually decrease during the first trimester due to rapid fetal growth and maternal metabolicchanges, necessitating adjustment of the insulin dosage. Maternalinsulin requirements fluctuate througho

15、ut pregnancy; after decreasing during the first trimester, they rise again during the second and third trimesters when fetal growth slows. During labor, insulin requirements diminish due to extreme maternal energy expenditure.5. Which pregnancy-related physiologic change would place the client with

16、a history of cardiac disease at the greatest risk for developing severe cardiac problems?A. Decreased heart rate.B. Decreased cardiac output.C. Increased plasma volume.D. Increased blood pressure.A.B.C. D.解析： Pregnancy increases plasma volume and expands the uterine vascular bed, possibly increasing

17、 the heart rate and cardiac output. These changes may cause cardiac stress, especially during the second trimester. Blood pressure during early pregnancy may decrease, but it gradually returns to prepregnancy levels.6. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The clie

18、nt mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium becauseA. reducing sodium promotes urea nitrogen excretion.B. reducing sodium decreases edema.C. reducing sodium improves her glomerular filtration rate.D. reducing sodium increases potassium absorptio

19、n.A.B. C.C. 解析： Reducing sodium intake reduces fluid retention. Fluid retention increases blood volume, which changes blood vessel permeability and allows plasma to move into interstitial tissue, causing edema. Urea nitrogen excretion can be increased only by improved renal function. Sodium intake d

20、oesn't affect the glomerular filtration rate. Potassium absorption is improved only by increasing the glomerular filtration rate; it isn't affected by sodium intake.7.One day after an appendectomy, a 9-year-old rates his pain at 4 out of 5 on the pain scale but is playing video games and lau

21、ghing with his friend. Which of the following would the nurse document on the child's chart?A. The child is in no apparent distress, and no pain medication is needed at this time.B. The child rates pain at 4 out of 5. Pain medication administered as prescribed.C. The child doesn't understand

22、 the pain scale. Performed teaching to help child match his pain rating to how he appears to be feeling.D. The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when he's visibly showing signs of pain.A.B. C.C. 解析： Pain is what the child says it is, and the n

23、urse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses passive coping behaviors (such as distraction and cooperation) may rate pain as more intense than children who use active coping behav

24、iors (such as crying and kicking). Nurses frequently make judgments about pain based on behavior, which can result in children being inadequately medicated for pain.8. The nurse is providing care to a 5-year-old client with a fractured femur whose nursing diagnosis is Imbalanced nutrition: less than

25、 body requirements related to impaired physical mobility. Which of the following is most likely to occur with this condition?A. Decreased protein catabolism.B. Increased calorie intake.C. Increased digestive enzymes.D. Increased carbohydrate need.A.B.C.D. 解析： Carbohydrate need increases because heal

26、ing and repair of tissue requires more carbohydrates. Increased-not decreased-protein catabolismis present. Decreased appetite-not increased-isa problem. Digestive enzymes are decreased-not increased.9. Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon

27、 return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse shouldA. insert an oral airway.B. withhold food and fluids.C. position the client on his side.D. introduce a nasogastric (NG) tube.A.B. C.C. 解析： Following a transesophageal echocardiogram

28、in which the client's throat has been anesthetized, food and fluid should be withheld until the gag reflex returns. There is no indication for oral airway placement. The client should be in the upright position, and inserting an NG tube is unnecessary.10. The nurse is caring for a primigravida w

29、ho is scheduled fora fetal acousticstimulation test(FAST). The nurse should explain to the client that the primary purpose of this test is toA. induce contractions.B. induce fetal heart rate accelerations.C. shorten the contraction stress test.D. determine fluid volume.A.B. C.D.解析： The FAST is being

30、 used more commonly. This noninvasive technique induces fetal heart rate accelerations by using low-frequency vibrations on the maternal abdomen over the fetal head. It can shorten the length of the nonstress test. The FAST isn't used to induce contractions, shorten the length of the contraction

31、 stress test, or determine fluid volume.11. The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse shouldA. encourage verbalizations about fears and stressful life situations.B. agree with the client becaus

32、e she feels a specific physical feature is awful.C. ignore the comment and talk about less threatening issues.D. compliment the client on her appearance.A. B.C.D.解析： Encouraging the client to discuss stressful life situations helps focus on the underlyingissues. The client's preoccupation with a

33、 specific physical feature is a means of not coping with life. Ignoring the client or complimenting the client won't be helpful. She won't be able to accept the compliment. Agreeing with her strengthens her problem.12. For the past few days, a client has been having calf pain and notices tha

34、t the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which of the following questions about the pain should the nurse include in the assessment?A. "Does the pain worsen in the morning upon rising?"B. "Does the pain increase with acti

35、vity and lessen with rest?"C. "Is the pain relieved by position changes?"D. "Is the pain worse with the toes pointed toward the knee?/A.B.C.D. 解析： The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes toward the knee will elicit discomfort. The time of the

36、day doesn't influence the pain associated with DVT. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. A dependent position will increase venous stasis and the pain associated with DVT.13. A client seeks care for low back painof 2 wee

37、ks' duration. Which assessment finding suggestsa herniated intervertebral disk?A. Pain that radiates down the posterior thigh.B. Back pain when the knees are flexed.C. Atrophy of the lower leg muscles.D. Positive Homans' sign.A. B.C.D.解析： Disk herniation may compress spinal nerve roots, caus

38、ing sciatic nerve inflammation, which produces pain that radiates down the leg. Slight knee flexion should relieve lower back pain.If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Pos

39、itive Homans' sign is more indicative of phlebothrombosis.14. As an adolescent is receiving care, he's inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is not a goal of the report?A. Staff

40、involved so they're reprimanded for their actions.B. Learning needs of staff to prevent recurrence of incidents.C. Patterns of client care problems.D. Facts surrounding each incident.A. B.C.D.解析： The main goal of an incident report following an adventitious event isn't punishment forthose in

41、volved in the incident. The purpose of an incident report is threefold: to identify ways to prevent recurrences of incidents, to identify patterns of care problems, and to identify facts surrounding each incident.15. A client with intrauterine growth retardation is admitted to the labor and delivery

42、 unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her plan of care?A. Carefully titrating the oxytocin based on her pattern of labor.B. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes.C. Allowi

43、ng the client to ambulate as tolerated.D. Helping the client use breathing exercises to manage her contractions.A.B.C. D.解析： Because the fetus is at risk for complications, frequent and close monitoring is necessary. Therefore, the client shouldn't be allowed to ambulate. Carefully titrating the

44、 oxytocin, monitoring vital signs, including fetal well-being, and assisting with breathing exercises are appropriate actions to include.16. The nurse is interviewing a client admitted to the facility with a diagnosis of schizophrenia. The client states, "I run apple, train, grass, window. &quo

45、t; This response by the client is known asA. echopraxia.B. a word salad.C. flight of ideas.D. neologisms.A.B. C.D.解析： A word salad is an illogical word grouping. Echopraxia is an involuntary repetition ofmovements. Flight of ideas is a rapid succession of unrelated ideas. Neologisms are bizarre word

46、s that have meaning only to the client.17. The nurse is speaking to a group of women about early detection ofbreast cancer. The averageage of the women in the group is 47. Followingthe American Cancer Society (ACS)guidelines, thenurse should recommend that the womenA. perform breast self-examination

47、 annually.B. have a mammogram annually.C. have a hormonal receptor assay annually.D. have a physician conduct a clinical examination every 2 years.A.B. C.D.解析： According to the ACS guidelines, "Womeno lder than age 40 should have a mammograma nnually and a clinical examination at least annually

48、 (not every 2 years); all women should perform breast self-examination monthly (not annually). " The hormonal receptor assay is clone on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.18. A client who has cervical cancer is scheduled to undergo intern

49、al radiation. In teaching the client about the procedure, the nurse would be most accurate in telling the clientA. she'll be in a private room with unrestricted activities.B. a bowel-cleansing procedure will precede radioactive implantation.C. she'll be expected to use a bedpan for urination

50、.D. the preferred positioning in bed will be semi-Fowler's.A.B. C.D.解析： The client will receive an enema before the procedure because bowel motility during cervical radiation implant therapy can disrupt or dislodge the implants. The client will be in a private room, and activities will be restri

51、cted in order to keep the implants in place. To keep the bladder empty, an indwelling catheter will be used. Positioning in bed shouldn't exceed a 20-degree elevation because sitting up can cause the implants to move from their intended locations.Semi-Fowler's position is 45 degrees.19. A cl

52、ient with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instructions?A. "Weigh yourself daily and report a loss of 1 lb in 1 day. "B. "Eat a high-sodium diet. "C. "Weigh yourself daily and repor

53、t a gain of 2 lb in 1 day. "D. "Maintain bedrest. /A.B.C. D.解析： COPDc auses pulmonary hypertension, leading to right ventricular failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client&#

54、39;s condition. He should eat a low-sodium diet to avoid fluid retention and should engage in moderate exercise to avoid muscle atrophy.20. A 28-year-old woman is scheduled for a glucose tolerance test (GTT). She asks the nurse what result indicates diabetes mellitus. The nurse should respond that t

55、he minimum parameter for indication of diabetes mellitus is a 2-hour blood glucose level greater thanA. 120 mg/dLB. 150 mg/dLC. 200 mg/dLD. 250 mg/dLA.B.C. D. 解析： A GTT indicates a diagnosis of diabetes mellitus when the 2-hour blood glucose level is greater than 200 mg/dL. Confirmation occurs when

56、at least one subsequent result is greater than 200 mg/dL.21. When a client experiences a loss of vibratory sense on examination, this indicatesA. injury to the cranial nerves.B. injury to the peripheral nerves.C. intact cranial nerves.D. intact peripheral nerves.A.B. C.C. 解析： Appropriate perception

57、of vibration indicates intact dorsal column tracts and peripheral nerves. If there's a loss of vibratory sense, an injury to the peripheral nerves is probable.22. The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client

58、 toA. restrict fluid intake to 1 qt (1,000 mL)/day.B. drink liquids only with meals.C. don't drink liquids 2 hours before meals.D. drink liquids only between meals.A.B.C.D. 解析： A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meal

59、s rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before me