国际护士模拟试题13
今天是【点名时间】与你第13次见面。
小编这里最近的天气都不好，时而大雨时而阴天。在这样的天气里，小编觉得，只有戴着耳机单曲循环陈奕迅的《阴天快乐》其他什么事也不干，才称得上是美好的生活，你说对吗？你那里的天气如何？
美好生活必须要努力的，我们就努力做题吧！
61. A patient with a terminal illness is rapidly deteriorating but remains alert, oriented and verbally responsive. He states, I am tired of being ill. I wish it could end today.The nurse should record this information using which of the following statements?
A. Patient states. "I am tired of being ill. I wish it could end today.”
B. Patient seems depressed about his illness.
C. Patient reports being sick all the time and wishes to die.
D. Patient seems worried about something and states he wants to end it all.
62.A patient is receiving radiation therapy to her right breast. The nurse's teaching plan related to skin care should include which of the following measures?
A. Completely clean the skin each day to remove ointments and markings.
B. Cover broken skin in the treatment area with a medicated ointment before each radiation treatment.
C. Wear a bra at all times to support the breasts.
D. Protect the breast area from direct sunlight.
63. When caring for a patient in restraints, on what area of the bed should the restraints be anchored?
A. The side rails.
B. The mattress hook.
C. The footboard.
D. The bed frame.
64. Which of the following nursing diagnoses shouh the nurse use to best address the suicidal patient's feelings of despair?
A. Ineffective coping.
B. Spiritual distress.
C. Anxiety.
D. Dysfunctional grieving.
65.An 80-year-old with right-sided weakness followIng a cerebrovascular accident (CVA) is to ambulate with the aid of a walker. What age-related changes in this individual will increase the risk of injury?
A. Improved muscle mass and strength.
B. Slowed response to sensory stimuli.
C. Increased cognitive functioning.
D. Development of arcus senilis.
56. Key: A
Client Need: Physiological Adaptation
A. Absence of a palpable thrill over the shunt. The patient should be taught to feel for the "thrill" of blood moving through the shunt when it is touched. This should be done daily. The increased pressure in the arterialized vein will create a "thrill".
B. A bruit is a blowing sound. This should be heard when an AV shunt is in use. The blood is flowing from the patient's artery through the shunt into the vein.
C. The arm with the shunt should be protected, and all healthcare personnel should be reminded that the involved arm with the shunt should not be used for blood pressure.
D. The arm with the shunt should be protected, and all healthcare personnel should be reminded that the involved arm should not be used for phlebotomy.
57. Key: C
Client Need: Reduction of Risk Potential
C. Tachycardia is listed as one of the primary side effects of Brethine. The mother may report feeling like"her heart is beating out of her chest. " The fetal and maternal heart rates should be monitored. Usually, the tachycardia is mild in nature.
A. The action of the Brethine is to relax smooth muscles. The uterine muscle is smooth in nature.
B. Epistaxis or nosebleeds are not associated with Brethine administration.
D. Dysuria or painful urination is associated with urinary tract infections and not with the use of Brethine.
58. Key: B
Client Need: Growth and Development
B. The response by the nurse. "Let's check your baby together to see what he needs. " is most appropriate because it is non-judgmental and directs the mother to recognize that she should respond to the infant's cue. Crying is the infant's first means of verbal communication. It conveys a message of urgency and signals displeasure such as hunger or being wet. Parents need to learn to respond to the infant's cry in order to provide physical care and emotional security for the infant.
A. "Your baby is crying and needs your attention now" sounds harsh and implies that the nurse is ordering the mother to pay attention to her baby.
C. "Why do you think your baby is crying at this time?" is not an appropriate response because the care-taker must determine what is causing the baby to cry. This is done by assessing the baby to determine if the baby is wet. hungry, cold or in pain. After considering physical needs. it may be sufficient to hold the infant to provide emotional support and cuddling.
D. The response by the nurse. "When did you last feed your baby?" assumes that the only reason the baby is crying is because the baby is hungry. The mother must learn to respond appropriately to her infant's crying and to determine what the baby needs.
59. Key: D
Client Need: Management of Care
D. If the nurse has difficulty assessing the pulse. a Doppler is a useful tool. A hand-held Doppler permits the assessment of arterial disease through the evaluation of audible arterial signals.
A. Sometimes, the pedal pulses may be difficult to palpate, but it does not necessarily mean that surgery is indicated.
B. Apical radial pulses are preformed to assess for pulse deficits. which may indicate an alteration in cardiac output.
C. Elevating the front of the bed will decrease blood flow and exacerbate claudication. Warm compresses may help to reduce edema and improve circulation.
60. Key: B
Client Need, Management of Care
B. Ask the supervisor to assign another nurse to the case. This is an ethical dilemma. The nurse has instituted the proper steps to process an ethical dilemma. The nurse has examined and identified her own values. verbalized the problem and then considered alternatives (i. e. , have another nurse assigned to the case).
A. There is no need for the patient to know the nurses' beliefs. The nurse should be non-judgmental and not attempt to place her beliefs on another.
C. The facility has already made a pro-choice decision and is performing abortions.
D. The nurse has already made an ethical decision that she is opposed to abortion based on moral principles.
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