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ISPN考试模拟试题(十五)

Questions

1.A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client’s outburst, what is the best indication that the nurse-client interaction has been therapeutic?

A. Increased physical activity

B. Absence of further outbursts

C. Relaxation of tensed muscles

D. Denial of the need for further discussion


2. A nursing supervisor sends a recently oriented nursing assistant to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to the nursing assistant? Select all that apply.

A. Taking routine vital signs

B. Applying a sterile dressing

C. Answering clients’ call lights

D. Administering saline infusions

E. Changing linens on an occupied bed

F.Documenting client responses to ambulation


3. A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention?

A. Sitting quietly with the client

B. Telling the client that crying is not helpful

C.Suggesting that the client play a board game

D. Recommending how the client can change this situation


4. A client has been told to stop smoking by the health care provider. The nurse discovers a pack of cigarettes in the client’s bathrobe. What is the nurse’s initial action?

A. Notify the health care provider.

B. Report this to the nurse manager.

C. Tell the client that the cigarettes were found.

D. Discard the cigarettes without commenting to the client.


5. A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure.What is the initial nursing action?

A.Perform an assessment of the client before resuming the change-of-shift report.

B.Continue the change-of-shift report and include the decrease in blood pressure.

C.Lower the diastolic pressure limits on the monitor during the change-of-shift report.

D.Turn off the alarm temporarily and alert the oncoming nurse to the decrease in blood pressure

Rationales

1.C 

Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled.

A,Increased activity may be an expression of anger or hostility.

B,Clients may suppress verbal outbursts despite feelings and become withdrawn.

D,Refusing to talk may be a sign that the client is just not ready to discuss feelings.

Client Need: Psychosocial Integrity;

Cognitive Level: Application;

Integrated Process: Communication/Documentation;

Nursing Process:Evaluation/Outcomes;

Reference: Ch 2, The Nurse-Client Relationship


2. Answer: A, C, E.

A,Taking routine vital signs is a universal activity that all nursing assistants (NAs) are taught to perform regardless of the setting; it is within the job description for NAs.

B, NAs do not have the expertise or credentials to apply sterile dressings.

C, Answering call lights is a universal activity that all NAs are taught to perform regardless of the setting; it is within the job description for NAs.

D, NAs do not have the expertise or credentials to administer intravenous solutions.

E, Making an occupied bed is a universal activity that all NAs are taught to perform regardless of the setting; it is within the job description for NAs.

F,NAs do not have the expertise or credentials to document clients’ responses.

Client Need: Management of Care;

Cognitive Level: Analysis;

Nursing Process:Planning/Implementation;

Reference: Ch 2, Leadership and Management,Principles of Leadership


3.A

Sitting quietly with the client conveys the message that the nurse cares and accepts the client’s feelings; this helps to establish trust.

B, This is negating feelings and the client’s right to cry when upset.

C,Distraction closes the door on further communication of feelings.

D,After a trusting relationship has been established, the nurse can help the client explore the problem in more depth.

Client Need: Psychosocial Integrity;

Cognitive Level: Application;

Integrated Process: Caring;

Nursing Process: Planning/Implementation,;

Reference: Ch 2, The Nurse-Client Relationship


4.C 

An honest nurse-client relationship should be maintained so that trust can develop.

A, B, Although other health care team members may need to be informed eventually, the initial action should involve only the nurse and client.

D,This does not promote trust or communication between the client and nurse.

Client Need: Psychosocial Integrity;

Cognitive Level: Application;

Integrated Process: Communication/Documentation;

Nursing Process:Planning/Implementation;

Reference: Ch 2, The Nurse-Client Relationship


5.A 

The cause of the alarm should be investigated and appropriate intervention instituted; after the client’s needs are met, then other tasks can be performed.

B,An alarm should never be ignored; the client’s status takes priority over the change-of-shift report.

C,The diastolic pressure limit has been ordered by the health care provider and should not be changed for the convenience of the nurse.

D,Alarms should always remain on; the alarm indicates that the client’s blood pressure has decreased and immediate assessment is required.

Client Need: Management of Care;

Cognitive Level: Application;

Nursing Process: Planning/Implementation;

Reference: Ch 2, Nursing Process

小编寄语:只要坚持向前,路途再远,也能和梦想相见。Fighting!

时间:2019/5/21 15:14:32
 
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