国际护士证试题及答案国际护士证

第第5页共5页国际护士证试题及答案国际护士证PracticeTestQuestions1.Whenassessingapatientforthepotentialdevelopmentofhypovolemicshock,whichofthefollowingmanifestationswouldthenursemostlikelyseefirst?A.nervousnessandapprehensionB.decreasedurinaryoutputC.systolicbloodpressurebelow90mmHgD.hypoventilationandtachycardia2.Apsychiatricpatientcontinuestodisrupttheunitmilieubypacingupanddownthehall.Thenurserespondsbyplacingthepatientintheseclusionroom.Asaresultorheractions,thenursemaybeheldresponsibleforwhichofthefollowinglegalimplications?A.falseimprisonmentB.batteryC.invasionofprivacyD.defamationofcharacterAneight-year-oldchildhascerebralpalsy,atracheostomy,andiso ygen(O2)dependent.Duringaninitialvisittothehome,thenursewouldwhichofthefollowingquestionsinanenvironmentalsafetyassessment?“Aretheredraftsorairleaksinthehome?”“Arethereotherchildreninthehome?”“Doesanyonesmokeinthehome?”“AretherepetsintheRationaleKey:AClientNeed:PhysiologicalAdaptationA.Earlyhypo icandhypocapnicchangesinrestlessness,confusion,an iousness,apprehension,agitation,lethargyandmentalcloudiness. B.Decreasedurinaryoutputisaclinicalmanifestationofhypovolemicshock,occurslaterthannervousnessandapprehension.C.Duringthepensatorystageofshock,thebloodpressureisadequatetoperfusethevitalorgans.Thesystolicbloodpressuredoesnotdroptobelow90mmHguntiltheprogressivestageofshock. D.Theheartrateisincreasedandthedepthofventilationisincreasedintheearlystagesofshocktopensateforthelacticacidproducedduetoanaerobicmetabolism. 2.Key:AClientNeed:PsychosocialAdaptationA.Thereisnoindicationfortheuseofseclusionwiththispatient.Theuseofseclusionorrestraintthatisnotdefensibleasbeingnecessaryandintheclient’sbestinterestmayresultinfalseimprisonmentoftheclientandliabilityforthenurse.B.Batteryisharmfuloroffensivetouchingofanotherperson.Thisisnotpresentinthescenario.C.Invasionofprivacywouldinvolvesharingofinformationordiscussionoftheclient’scasewithoutpermission.Thereisnoevidencethathisoccurred. D.Chargesofdefamationcanbebroughtinformationregardingtheclientisdivulgedandthatinformationultimatelyharmstheclient’sreputation.3.Key:CClientNeed:SafetyandInfectionControlC.Thechildisbeingdischargedtohomeandis ygendependent.O ygenmaybeadministeredinthehome.HomeO ygentherapyrequiresthataofsafetyfeaturesshouldbeinplace.Because ygenishighlyflammablegas,precautionsmusttakentoensurethesafetyofthepatientandfamily.Assessingthehomeforpotentialfirehazardsisnecessary.Thereshouldbenoopenflames,electricalsparksorflammablematerialspresent.Smokinginthehomebyanypersonwhen ygenisinuseiscontraindicated. A.Draftsairleaksinthehomemayaffecttheenvironmentaltemperaturebutwouldhavenodirectimpactonthecareorsafetyofthechildathomewhorequires ygentherapy. B.Otherchildreninthehomedonotposeanydirectthreattothechildwhoisathomeono ygen.Returningthechildtohomewillreducetheamountofdevelopmentaldelayorsocialhandicaprelatedtoprolongedhospitalization. D.Petsinhomecouldbeapotentialproblemiftheyshedfinehire.Smallparticles