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> 护士证书 > ISPN > ISPN备考 > ISPN课后练习 > 国际护士证ISPN考试课后练习题解析(1-5)

国际护士证ISPN考试课后练习题解析(1-5)

发表日期:2015-12-11 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
1)  The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likelyrelated to which problem?
 
    1. Anxiety related to the need to make lifestyle changes
    2. Boredom resulting from having already learned the material
    3. An attempt to ignore or deny the need to make lifestyle changes
    4.Lack of understanding of the material provided at the teaching session and embarrassment about asking questions
 
Correct Answer: 3

Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.
 
2)  Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated?
 
    1. Libel
    2. Slander
    3. Assault
    4. Negligence
 
 Correct Answer: 2

Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.
 
 3)  The nurse is preparing a plan of care for a client with a diagnosis of brain attack (stroke). On reviewing the client's record, the nurse notes an assessment finding of anosognosia. The nursing care plan should address which manifestation related to this finding?
 
    1. The client will be easily fatigued.
    2. The client will have difficulty speaking.
    3. The client will have difficulty swallowing.
    4. The client will exhibit neglect of the affected side.
 
 Correct Answer: 4

In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. Options 1, 2, and 3 are not associated with anosognosia.
 
4)  Epoetin alfa (Epogen, Procrit) by the subcutaneous route is prescribed for a client. Which is the correct action for the nurse to implement?
 
    1. Shake the vial before use.
    2. Freeze the medication before use.
    3. Refrigerate the medication until used.
    4. Obtain syringes with 1½-inch needles from the pharmacy.
 
 Correct Answer: 3

Epoetin alfa (Epogen, Procrit) should be refrigerated at all times. The bottle should not be shaken and the medication should not be frozen because this will affect the chemical composition. Syringes with a 5/6-inch needle are used for subcutaneous injection. A 1½-inch needle may be used for intramuscular injection.
 
5)  A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. What type of angina should the nurse determine that the client is experiencing?
 
    1. Stable
    2. Variant
    3. Unstable
    4. Intractable
 
 Correct Answer: 1

Stable angina is triggered by a predictable amount of effort or emotion. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early in the day and at rest. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Intractable angina is chronic and incapacitating and is refractory to medical therapy.

 

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