美国护士资格认证-23

1、美国护士资格认证 (CGFNS)-23（ 总分： 53.00 ，做题时间： 90 分钟 ）一、 Part One （ 总题数： 30，分数： 30.00）1. Which of the following interventions will assist the client in taking phenytoin as prescribed?A. Calling him daily for the first week after hospital discharge.B. Having a family member monitor him to ensure compliance.C.

2、 Providing him with written and verbal instructions about the medicine.D. Emphasizing that embarrassing seizures may occur again if he does not take the medicine.A.B.C. D.解析： Providing the client with written and verbal instructions will increase understanding of the medication regimen2. Which of th

3、e following signs or symptoms would the nurse expect to see in a client with pancreatitis?A. Bradycardia.B. Hypertension.C. Decreased white blood cell count.D. Left upper quadrant abdominal pain.A.B.C.D. 解析： The most common symptom of pancreatitis is intense abdominal pain in the mid- epigastric are

4、a or the left upper quadrant. The pain may radiate to the back.3. Mrs. Wilson, a primigravida, was admitted to the hospital at 12 weeks' gestation. She is complaining of abdominal cramping, exhibits bright red vaginal spotting without cervical dilation. The nurse determines that the client is mo

5、st likely experiencing which of the following types of abortion?A. Complete.B. Threatened.C. Inevitable.D. Missed.A.B. C.D.解析： In a threatened abortion, vaginal bleeding or spotting occurs and abdominal cramping mayoccur. However, the cervix is not dilated. Termination of the pregnancy may or may no

6、t be prevented.4. The nurse is assessing a 15-year-old female who is being admitted for treatment of anorexia nervosa. Which of the following clinical manifestation is the nurse most likelyto find from theclient?A. Tachycardia.B. Coarse hair growth.C. Parotid gland tenderness.D. Warm, flushed extrem

7、ities.A.B.C. D.解析： Frequent vomiting causes tenderness and swelling of the parotid glands. The reduced metabolism that occurs with severe weight loss produces bradycardia and cold extremities. Soft, downlike hair (called lanugo) may cover the extremities, shoulders, and face of an anorexic client.5.

8、 A priority nursing diagnosis during the first 24 hours following an MI isA. Ineffective cardiac tissue perfusion.B. Risk for infection.C. Deficient fluid volume.D. Constipation.A. B.C.D.解析： Ineffective Cardiac Tissue Perfusion related to myocardial damage and inadequate cardiacoutput is a major pro

9、blem immediately after a heart attack. Therapy is directed toward improving cardiac output and decreasing myocardial workload.6. The parents of a 3-year-old boy call the clinic to report chickenpox. When teaching the parents about how to care for the lesions, the nurse would advise which of the foll

10、owing?A. Soak in a hot tub for 30 minutes three times a day.B. Take an antihistamine and use calamine lotion on the lesions.C. Take acetaminophen and use an antibiotic ointment on the lesions.D. Remove lesions crusts as they form.A.B. C.D.解析： Use of an antihistamine and calamine lotion are recommend

11、ed to help decrease the itching.7. Which of the following nursing diagnoses would be most appropriate when teaching the motherof a toddler?A. Activity intolerance.B. Risk for injury.C. Delayed growth and development.D. Impaired mobility.A.B. C.D.解析：The most appropriate nursing diagnosis would be Ris

12、k for injury because a toddler is typically engaged in exploring the environment while becoming increasing mobile. Safety issues are an important part of anticipatory guidance with parents of toddlers.8. Pancrelipase (Viokase), an enzyme replacement, has been prescribed for a client with chronicpanc

13、reatitis. The nurse evaluates the client's understanding of how to take this drug. Which ofthe following statements indicates the client has adequate knowledge?A. "The enzyme mixture should be taken after each meal. "B. "The enzyme mixture should be stored in the refrigerator to k

14、eep it fresh. "C. "I should be careful not to inhale the powder when mixing it with food. "D. "I should chew the capsule thoroughly. /A.B.C. D.解析： When mixing the enzyme (lipase, protease, amylase) powder into food, the client should be careful not to inhale it as the powder may

15、trigger an asthma attack.9. Which of the following serum electrolyte levels would the nurse expect to find in an infant with persistent vomiting?A. K +, 3.2 mEq/L; ClB. K +, 3.4 mEq/L; ClC. K +, 3.5 mEq/L; Cl +D. K +, 5.5 mEq/L; Cl A. , 92 mEq/L; Na +, 120 mEq/L., 120 mEq/L; Na +, 140 mEq/L.+, 90 mE

16、q/L; Na +, 145 mEq/L.+, 110 mEq/L; Na +, 130 mEq/L.B.C.D.解析： The serum electrolyte values in an infant with persistent vomiting reflect hypokalemia (K level of 3.2mEq/L), hypochloremia (Cl - level of 92mEq/L), and hyponatremia (Na+ level of 120mEq/L).Chloride and sodium function together to maintain

17、 fluid and electrolyte balance. With vomiting, sodium chloride and water are lost in gastric fluid. As dehydration occurs, potassium moves into the extracellular fluid.10. Which one of the following nursing interventions should be included in a plan of care for a client with a T tube?A. Maintain cli

18、ent in a supine position while T tube is in place.B. Keep T tube clamped except for during mealtimes.C. Inspect skin around the T tube daily for irritation.D. Irrigate the T tube every 4 hours to maintain patency.A.B.C. D.解析： Bile is erosive and extremely irritating to the skin. Therefore, it is ess

19、ential that skin around the T tube be kept clean and dry.11. When instructing the client with severe burns about proper nutrition, the nurse would encourage him to eat which of the following meals?A. Chicken breast, salad, iced tea.B. Roast beef sandwich, milkshake, cottage cheese.C. Hamburger, oran

20、ge, coffee.D. Pasta salad, carrots, iced tea.A.B. C.D.解析： A roast beef sandwich, milkshake, and cottage cheese would provide the burn victim with the extra protein and calories needed for healing.12. The nurse evaluates the client's understanding of myasthenia gravis. The nurse would judge that

21、the client has formed a realistic concept of her condition when she saysA. "By taking medication and pacing activities, I will live longer, but ultimately the disease will cause my death. "B. "By taking medication and pacing activities, my fatigue will berelieved, but I should expecto

22、ccasional periods of muscle weakness. "C. "By taking medication and pacing activities, my symptoms will be controlled and eventually the disease will be cured. "D. "By taking medication and pacing activities, I should be able to control the disease and enjoy a healthy lifestyle.

23、/A.B.C.D. 解析： With a well-managed regimen, a client with myasthenia gravis should be able to control symptoms, maintain a normal lifestyle, and achieve a normal life expectancy.13. The nurse has assisted a multigravida with a precipitous delivery of a viable neonate in a local grocery store. Because

24、 a precipitous delivery can lead to decreased uterine tone, which of the following nursing actions would help to prevent this complication?A. Place the neonate on the client's fundus.B. Place the mother in a supine position.C. Encourage the mother to breast-feed the infant.D. Massage the client&

25、#39;s fundus continuously.A.B.C. D.解析： The nurse should encourage the mother to breast-feed the infant. Neonatal sucking will induce the release of natural oxytocin which will help contract the uterus and control uterine bleeding.14. The nurse is caring for a client who has generalized anxiety disor

26、der. Which statement is true about this client?A. The client has regular obsessions.B. Relaxation techniques and psychotherapy are necessary for cure.C. Nightmares and flashbacks are common in individuals who suffer from generalized anxiety disorder.D. Generalized anxiety disorder is characterized b

27、y anxiety that lasts longer than 6 months.A.B.C.D. 解析： Constant patterns of anxiety that affect the client for more than 6 months and interfere with normal activities are characteristic of generalized anxiety disorder. Frequently, pharmaceutical therapy with benzodiazepines can help. Clients having

28、regular obsessions are probably suffering from obsessive-compulsive disorder. Nightmares and flashbacks are typical symptoms of posttraumatic stress disorder.15. The nurse is preparing a gastric lavage for a comatose victim of the car accident. Which of the following positions would be most appropri

29、ate for the client during this procedure?A. Trendelenburg's.B. Lithotomy.C. Lateral.D. Supine.A.B.C. D.解析： An unconscious client is best positioned in a lateral or semiprone position because thesepositions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent a

30、spiration.16. A pregnant client who is diabetic is at risk for having a large-for-gestational-age infant because of which of the following?A. Excess sugar causing reduced placental functioning.B. Insulin acting as a growth hormone on the fetus.C. Maternal dietary intake of high calories.D. Excess in

31、sulin reducing placental functioning.A.B. C.D.解析： Insulin acts as a growth hormone on the fetus. Therefore, pregnant diabetic clients mustmaintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean section. Neither excess sugar nor excess insulin r

32、educes placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size.17. Which of the following findings is suggestive of myocardial infarction (MI)?A. Below-normal erythrocyte sedimentation rate.B. Elevated white blood cell count.C. El

33、evated serum cholesterol value.D. Elevated creatine phosphokinase (CPK) value.A.B.C.D. 解析： Commonl aboratory findings in the client who has suffered a MI include elevated CPK level. CPK is also released during muscle injury and brain injury. The CPK isoenzyme CPK-MB elevates only in response to myoc

34、ardial damage.18. When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should use which of the following interventions to help him learn to dress himself?A. Encourage the client to wear clothing designed especially for people who have had a CVA.B. Dr

35、ess the client, explaining each step of the process as it is completed.C. Teach the client to put on clothing on the affected side first.D. Encourage the client to ask his wife for help when dressing.A.B.C. D.解析： When dressing, the client should put clothing on the affected side first.19.Susan is an

36、 adolescent client with pregnancy-induced hypertension (PIH). The physician orders 5% dextrose in Ringer's solution and magnesium sulfate intravenously for her. Before the magnesium sulfate is administered, which of the following assessments would be the priority?A. Maternal urinary output.B. Fe

37、tal position.C. Fetal heart rate variability.D. Maternal respiratory rate.A.B.C.D. 解析： Magnesium sulfate is a central nervous system depressant used as an anticonvulsant for severe PIH. It may depress respirations to a dangerously low and even life-threatening level. Therefore, the nurse must assess

38、 the client's respiratory rate before administering the drug. If the client's respiratory rate is below 12 to 14 breaths/ minute, the physician should be notified and the drug should be withheld.20. A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds ha

39、s the client lost?A. 1 pound.B. 3 pounds.C. 5 pounds.D. 7 pounds.A.B.C.D. 解析： 1kg=2.2 pounds; therefore, 3.2× 2.2=7.04 pounds.21. Which of the following health-promoting activities should the nurse teach the client with a new laryngectomy?A. Cleanse the mouth three times a day.B. Avoid taking t

40、ub baths.C. Develop an aggressive program of exercise to increase airway functioning.D. Dehumidify the air for comfort.A. B.C.D.解析： Oral hygiene is an important aspect of self-care for the laryngectomy client, who is lessable to detect mouth odor. Additionally, the mouth harbors bacteria. Good mouth

41、 care reduces the risk of infection.22. The community health nurse develops a health education program about preventing the transmission of hepatitis B. The nurse evaluates that the teaching has been effective when the community residents identify which of the following activities to be high risk fo

42、r acquiring hepatitis B?A. Sharing needles for drug use.B. Ingestion of contaminated seafood.C. Frequent use of marijuana.D. Ingestion of large amounts of acetaminophen (Tylenol).A. B.C.D.解析： Sharing needles is associated with increased incidence of blood-borne diseases such as hepatitis.23. Which o

43、f the following is an early sign of laryngeal cancer?A. Difficulty swallowing.B. Chronic foul breath.C. Persistent mild hoarseness.D. Nagging unproductive cough.A.B.C. D.解析： Hoarseness occurs early in the course of most laryngeal cancers because the tumor prevents accurate approximation of the vocal

44、 cords during phonation.24. Mrs. Cray, an African American, is admitted to the hospital after sustaining a hip fracture. She is 5 ft. , 4 inches tall and weighs 96 lbs. She has five children and has used estrogen replacement therapies for 10 years. She told the nurse that she "just stepped forw

45、ard and fell. " The results of her bone density tests indicate she has osteoporosis. Which of the following is the greatest risk factor for osteoporosis for this woman?A. Her long-term use of estrogen.B. Her weight.C. Her family.D. Her race.A.B. C.D.解析： Heavier body weights and some body fat st

46、ress bones and promote their maintenance.Osteoporosis is most often associated with being underweight. Womenw ho are thin throughout their lives are twice as likely to develop hip fractures.25. Which of the following would be an appropriate expected outcome of nursing care for the client with ulcera

47、tive colitis?A. The client experiences decreased frequency of constipation.B. The client accepts that an ileostomy will be necessary.C. The client maintains an ideal body weight.D. The client verbalizes the importance of restricting fluids.A.B.C. D.解析： An appropriate expected outcome for a client wi

48、th ulcerative colitis is maintaining an ideal body weight.26. Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?A. Monitoring intake and output.B. Allowing the infant to rest undisturbed.C. Providing age-appropr

49、iate diversionary activities.D. Initiating oral feedings.A. B.C.B. 解析： In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure.27. A pregnant client with premature rupture of the membranes has had contraction

50、s every 10 minutes. After 48 hours, the contractions stop and the client is to be discharged with home monitoring.The nurse discusses with the client about preterm labor symptoms. Which of the following statements made by the client indicates that she needs further instruction?A. "I should repo

51、rt contractions that occur every 10 minutes in 1 hour. "B. "I should lie in bed on my left side if contractions begin. "C. "I should call the doctor if my contractions occur every hour for 6 hours. "D. "If I start having contractions, I should empty my bladder. /A.B.C.

52、D.解析： It is not necessary for the client to call the health care provider if she experiences contractions every hour for 6 hours, but she should continue to monitor the contraction pattern to determine if the contractions are increasing in frequency.28. The nurse is assessing a client with an ileal

53、conduit. She notes that the client's urinary appliance contains pale yellow urine with large amounts of mucus. How would the nurse best interpret these data?A. These findings are normal for the client.B. There is irritation of the stoma.C. The client is developing an infection of the urinary tra

54、ct.D. The mucus is caused by elevated levels of glucose in the urine.A. B.C.D.解析： A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous

55、 membrane.29. A primigravida at 28 weeks' gestation is admitted with a diagnosis of preterm labor. The client's contractions are occurring every 15 to 20 minutes, lasting 25 seconds. The membranes are intact. What should the nurse do?A. Request assistance from the neonatal resuscitation team

56、.B. Place the client on bed rest on her left side.C. Obtain equipment for an amniotomy.D. Prepare terbutaline in an intravenous solution of normal saline.A.B. C.D.解析： This client is experiencing early signs of preterm labor. The nurse should plan to placethe client on bed rest on her left side which

57、 promotes uterine placentalperfusion and increasedoxygen supply to the fetus.30. The nurse notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse would suspect which of the following?A. The client is responding to the an

58、tipsychotic.B. The client may be experiencing increased energy and is at an increased risk for suicide.C. The client is ready to be discharged from treatment.D. The client is experiencing a split personality.A.B. C.D.解析： As antidepressants take effect, individuals suffering from depression may begin to feel energetic enough to mobilize a suicide plan. Option A is incorrect because Elavil is an antide