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ISPN考试模拟试题(四十五)

Questions

1.A nurse is caring for a client with chronic occlusive arterial disease. What precipitating cause is the nurse most likely to identify for the development of ulceration and gangrenous lesions?

A.Emotional stress, which is short-lived

B.Poor hygiene and limited protein intake

C.Stimulants such as coffee, tea, or cola drinks

D.Trauma from mechanical,chemical, or thermal sources


2.A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space?

A.Cerebral embolism

B.Pulmonary embolism

C.Dry gangrene of a limb

D.Coronary vessel occlusion


3.A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the health care provider?

A.Client pushes the airway out.

B.Client has snoring respirations.

C.Respirations of 16 breaths/min are shallow.

D.Systolic blood pressure drops from 130 to 90 mm Hg.


4.After abdominal surgery a client suddenly reports numbness in the right leg and a “funny feeling” in the toes. What should the nurse do first?

A.Elevate the legs and tell the client to drink more fluids.

B.Instruct the client to remain in bed and notify the health care provider.

C.Rub the client’s legs to stimulate circulation and cover the client with a blanket.

D.Tell the client about the dangers of prolonged bed rest and encourage ambulation.


5.After a bilateral lumbar sympathectomy a client has a sudden drop in blood pressure, but there is no evidence of bleeding. What should the nurse identify as the most likely cause of the change in blood pressure?

1.Inadequate fluid intake

2.Consequence of anesthesia

3.Increased level of epinephrine

4.Reallocation of the blood supply

Rationales

1.D 

Diminished sensation decreases awareness of injury. Injured tissue cannot heal properly because of cellular deprivation of oxygen and nutrients;ulceration and gangrene may result.

A,Emotional stress does not cause tissue injury; however, because of vasoconstriction, it may prolong healing.

B,Inadequate hygiene is only one stress that may cause tissue trauma; protein is not related to this disease.

C,Although caffeine stimulates the peripheral vessels to constrict, limiting oxygen to cells, it is not the major cause of ulceration.

Client Need:Physiological Adaptation;

Cognitive Level:Application;

Nursing Process:Assessment/Analysis;

Reference:Ch6,Vascular Disease, Data Base


2.B 

The pulmonary capillary beds are the first small vessels that the embolus encounters once it is released from the calf veins.

A, D,This will not occur because the embolus will enter the pulmonary system first.

C,Dry gangrene occurs when the arterial rather than the venous circulation iscompromised.

Client Need:Physiological Adaptation;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch6,Vascular Disease,Nursing Care


3.D 

A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death.

A,This is an expected response; the client will push out the airway as the effects of anesthesia subside.

B,C,This is a common response to depressant effects of anesthesia.

Client Need:Management of Care;

Cognitive Level:Application;

Integrated Process:Communication/Documentation;

Nursing Process:Planning/Implementation;

Reference:Ch6,Shock, Data Base


4.B

 Localized sensory changes may indicate nerve damage, impaired circulation,or thrombophlebitis. Activity should be limited and the health care provider notified.

A,Symptoms may indicate a serious problem, and the health care provider must be notified. While fluids may be helpful to prevent hemoconcentration and the resulting risk of thrombus formation, fluids should be held in case a surgical procedure or diagnostic test is performed that requires the client to refrain from oral intake.

C,Rubbing or massaging the legs is contraindicated because of possible dislodging of a thrombus if present.

D,Bed rest is indicated to prevent the possibility of further damage or creation of an embolus.

Client Need:Management of Care;

Cognitive Level:Application;

Integrated Process:Communication/Documentation;

Nursing Process:Planning/Implementation;

Reference:Ch6,Vascular Disease, Data Base


5.D 

A sympathectomy causes dilation of the blood vessels in the lower extremities; the resulting shift in the blood volume lowers the systemic blood pressure.

A,Fluid losses associated with surgery may gradually lower the blood pressure;this is compensated by endocrine and renal mechanisms.

B,Although anesthesia depresses vital signs, generally there is not a sudden drop in blood pressure postoperatively.

C,Epinephrine will increase the blood pressure by stimulating cardiac contractility.

Client Need:Physiological Adaptation;

Cognitive Level:Comprehension;

Nursing Process:Evaluation/Outcomes;

Reference:Ch6,Review of Anatomy and Physiology,Regulating Mechanisms Affecting Circulation

小编寄语:结果从来不会陪你演戏!Fighting!

时间:2019-07-10 15:44:17
 
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