【点名时间】——国际护士模拟试题5

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　　21. A bone mineral analysis reveals that a patient who is postmenopausal has severe osteoporosis.Which of the following instructions should the nurse give to the patient's family to ensure a safe environment for the patient?

　　A. "Disinfect the bathroom weekly. "

　　B. "Carpet floor surfaces.”

　　C. "Install handrails on stairways.”

　　D. "Keep the lights dim.

　　22. Which of the following nursing measures should be included in the care plan of an elderly patient with bladder incontinence who is identified as a high risk for falls?

　　A. Monitor activities every two hours.

　　B. Toilet every one to two hours.

　　C. Sedate as needed.

　　D. Use a chest posey restraint.

　　23. Which of the following reasons,given by a mother who permits her preschool-aged child to sleep in the same bed (co-sleeping) as the parents，requires further investigation by the nurse?

　　A. "I am too tired to get up at night to check on the baby in the other room.”.

　　B. "This promotes bonding between us and our child.”.

　　C. "I slept with my parents when I was a small child.

　　D.“I can be certain my husband is not being inappropriate.

　　24. Which of the following questions would be essential in a cultural assessment of a patient?

　　A. How many times have you been married?

　　B. At what times do you take your medications?

　　C. Do you have any siblings?

　　D. Are there foods that you cannot eat together?

　　25. Which of the following explanations would the nurse give to a patient regarding the role of the case manager?

　　A. The case manager makes daily patient assignments for staff.

　　B. The case manager coordinates both inpatient hospitalization and home care.

　　C. The case manager negotiates insurance benefits with the hospital.

　　D. The case manager decides what treatments are essential

　　昨天答案解析

　　16. Key：A

　　Client Need:Safety and Infection Control

　　A. Physical restraints, usually leather straps, are used to immobilize a person who is clearly dangerous to self or others. In almost all cases. a specific physician's order is required for each episode. as is clearly documented evidence that the restraints were needed. A standing PRN order is not legally sufficient.

　　B. Documentation of the patient's status should be done at least every two hours or more often depending on hospital policy. A patient in restraints must be observed and cannot be left alone. All observations should be documented.

　　C. The physician must write a restraint order each time the patient is put into restraints. Restraint orders are generally written for 24-hour periods and rewritten as necessary after patient behavior is assessed.

　　D. Vest restraints may displace if the patient is agitated. and may cause choking.

　　17. Key: D

　　Client Need: Prevention and Early Detection of Disease

　　D. Pediculosis capilis (bead lice) is an infestation of the scalp caused by a common parasite. Lice infestation is not a major health threat but is highly communicable and may cause embarrassment to the child and family. Lice cause the child to have an itchy scalp. Lice eggs or nits attach to the hair shaft, and the organism lives by feeding on the child's scalp. A teaching plan for the parents should include measures for eliminating the infestation and preventing the spread and reoccurrence of Pediculosis. Machine wash all clothing, towels and bed linens in hot water and dry in a hot dryer for at least 20 minutes. Non-washable clothing should be dry-cleaned.

　　A. Administering a topical ant-itch medication is not recommended. Routine treatment consists of the application of pediculicides and manual removal of nit cases. Commonly used medicated shampoos include Nix or RID.

　　B. Calamine lotion is a topical application that is used as a protectant and an astringent. Burow's solution is used as an astringent and topical antiseptic. Neither is used in the treatment of head lice.

　　C. The child's hair must be combed with a nit comb (fine-toothed comb) to remove the nits from the hair shaft. Hair combing must be performed along with the medicated shampoo treatments. Specific directions for combing and shampooing are included in the product's package directions.

　　18. Key:A

　　Client Need: Psychosocial Adaptation

　　A. Patients with schizophrenia may become violent due to alterations in perceptions and suspiciousness.Assigning the same staff member to promote consistency will help the patient to establish trust.

　　B. Assigning a member of the same sex to care for a client with schizophrenia would be helpful for assisting the client with self-care activities but is not required to promote consistency of care.

　　C. Unit restriction is a measure taken when the patient is not ready or able to handle the stimuli away from the unit. It is not used as a disciplinary measure.

　　D. Placing a patient in walking restraints is unacceptable, both ethically and legally. Patients must be cared for in the least restrictive manner.

　　19. Key: C

　　Client Need, Safety and Infection Control

　　C. Installing handrails next to the tub and toilet assists in providing balance by giving the patient something to grab onto and reduces the risk of falling. They are used to prevent accidents in patients with mobility impairments.

　　A. Carpeting stairways increases the potential for sliding even though it may decrease the amount of injuries by providing padding.

　　B. Waxed or slippery surfaces can increase the risk of falling. Waxed floors can produce a glare, which can cause temporary visual impairment.

　　D. Throw rugs can be hazardous because of the potential for tripping over them and sliding on them.

　　20. Key: A

　　Client Need, Safety and Infection Control

　　A. It is critical to document the events leading up to the use of restraints. Specifically, what was happening immediately before the event and what other measures were attempted before restraints were used.Clear danger to self or others must be evident in the documentation.

　　B. The frequency of observation is determined by regulatory agencies and is often set at every 15 minutes. Four hours is too long an interval between observations.

　　C. A physician's order is required for the use of mechanical restraints and must be obtained as soon as possible if the client was placed in restraints in an emergency situation. The time required to obtain this order is determined by facility and regulatory agency guidelines.

　　D. Proper fit of restraints is checked frequently. Limbs are alternately released from restraints and range-of-motion exercises performed every two hours or according to facility guidelines.

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