【点名时间】——国际护士模拟试题4

　　今天是国际护士考试模拟题与你第4次见面。

　　为考试而做题，为做题而提问，为解惑而留言。“童鞋们”我们又要继续了。

　　16. When orienting a new nurse to the psychiatric unit, an experienced nurse should provide which of the following explanations regarding the use of patient restraints?

　　A.“PRN orders for restraints are unacceptable”.

　　B. "Documentation must be done every eight hours while a patient is restrained.”.

　　C. A restraint order, once written, is in effect for the entire hospitalization.”.

　　D. The vest restraint is the safest type of restraint to use.”.

　　17. Which of the following actions should be included in the teaching plan for the parents of pre-school aged child who has pediculosis capitis?

　　A. Administer topical anti-itch medication.

　　B. Apply calamine lotion Burow's solution.

　　C. Comb the child's hair each week.

　　D. Wash all of the family's clothing and linens.

　　18. Which of the following actions would be most appropriate for the charge nurse to take when caring for a patient who has schizophrenia and a history of violence?

　　A. Assign the same staff to care for the patient daily to provide consistency.

　　B. Assign a staff member of the same sex to care for the patient to provide more open communication.

　　C. Place the patient on unit restriction to provide disciplinary measures.

　　D. Place the patient in walking restraints to restrict activity.

　　19. Home safety for an elderly patient whose mobility is impaired should include which of the following measures?

　　A. Carpeting stairways.

　　B. Waxing kitchen floors.

　　C. Installing handrails next to the tub and toilet.

　　D. Placing throw rugs in hallways anti doorways.

　　20. Which of the following actions would be essential for the nurse to take when caring for a patient in restraints in the psychiatric unit?

　　A. Document the events leading to the use of restraints.

　　B. Check the patient every four hours while restrained.

　　C. Obtain a physician’s order within 24 hours of the restraints being applied.

　　D. Replace the restraints every 24 hours to ensure proper fit.

　　昨天答案解析

　　11. Key: B

　　Client Need: Physiological Adaptation

　　B. Impetigo is a bacterial infection of the skin characterized by reddish macules that become vesicular and can rupture easily, resulting in some drainage. The exudate dries and forms a thick honey-colored crust. The rash may be itchy. but there are minimal systemic affects. The major nursing functions related to bacterial skin infections are to prevent the spread of infection and to prevent complications.Hand-washing is mandatory before and after contact with an affected child. Hand-washing is also emphasized to the child and the family.

　　A. A diet high in protein is not required to treat this illness or promote healing.

　　C. There is no need to separate or isolate the child with impetigo. The child can continue normal,age appropriate play activities that may include outdoor play.

　　D. A sun lamp is not considered an appropriate treatment for impetigo. A sun lamp can emit harmful light waves that are not safe for a child's skin.

　　12. Key: C

　　Client Need: Pharmacological and Parenteral Therapies

　　C. For a confused patient with memory failure, supervision of medication administration is essential. In order for a patient to self-medicate, the patient needs to understand and comprehend drug information. The patient with cognitive changes has difficulty remembering. especially when multiple medications are given.

　　A. Not all medications are to be administered with meals. Some medications are better absorbed on an empty stomach.

　　B. A confused patient does not understand the implications of refusing medications. and therefore the nurse needs to instruct the family how to handle medications for the patient who refuses them.

　　D. Self-medication. even though it gives the patient control and independence, is not recommended in a confused patient for safety reasons.

　　13. Key: B

　　Client Need: Safety and Infection Control

　　B. Surgical repair of the cleft palate in a young child results in several important nursing considerations postoperatively, including the child's comfort,positioning, restraints and feeding. Children who have had a cleft palate repair are positioned on their abdomen to facilitate the drainage of secretions from their month. Pain medication is important to provide comfort and relief of pain at the surgical site.

　　Elbow restraints are required to prevent the child from touching the mouth. Elbow restraints must be worn at all times except for brief intervals when they can be removed one at a time to exercise arms,provide relief from restriction and observe the skin for signs of irritation. Parents are instructed on the use of restraints prior to the child's discharge.

　　A. Placing mittens on the child's hands would not prevent the child from touching the operative site. It is very important that the palate be protected in order to promote proper healing.

　　C. The restraints should not be removed for long periods of time. This would increase the risk of the child touching the mouth. Removal of the restraints for brief periods. at regular intervals, is sufficient to allow movement of the extremity and assessment of the skin for irritation.

　　D. Parents need to know the rationale for using elbow restraints as well as how to apply them properly.Children who are discharged to home after a cleft palate repair are required to wear elbow restraints until the surgical site is healed. A physician's order is required for elbow restraints, but a separate parental consent is not required.

　　14. Key: D

　　Client Need: Safety and Infection Control

　　D. Placing the bed in the low position is an important step in a falls prevention program. The bed should be as low to the floor as possible to decrease falls and prevent injury.

　　A. The resident has the right to be free from physical restraints. Physical restraints often increase agitation and restlessness.

　　B. Lorazepam (Ativan) is a chemical restraint. Residents should not be given psychotropic medications unless they are required to treat the patient's medical condition. Psychotropics may increase confusion and an unsteady gait.

　　C. Changing a confused patient's environment may increase confusion and the risk for injury.

　　15. Key: A

　　Client Need: Management of Care

　　A. Chest pula could be a sign of a myocardial infarction or life-threatening pulmonary embolus. The nurse should assess the patient for changes in the blood pressure. heart rate. rhythm. and electrocardiogram(EKG). Assessment of accompanying symptoms and precipitating factors to the chest pain should be performed.

　　B. The intravenous medication is not due for 30 minutes. The nurse has time to assess the other patients.

　　C. A temperature of 101' Fahrenheit should be assessed. However, it is not life threatening. Because chest pain has the potential to be life threatening. it should be assessed first.

　　D. Although the preoperative patient needs to be assessed, this situation does not require immediate asessment.

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