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ISPN考试模拟试题(二十)


Questions

1. A client with cancer of the lung says to the nurse, “If I could just be free of pain for a few days, I might be able to eat more and regain strength.” Which stage of grieving does the nurse conclude the client is in?

A. Bargaining

B. Frustration

C. Depression

D. Rationalization


2. A client who has reached the stage of acceptance in the grieving process appears peaceful, but demonstrates a lack of involvement with the environment.How should the nurse address this behavior?

A. Ignore the client’s behavior when possible.

B. Accept the behavior the client is exhibiting.

C. Explore the reality of the situation with the client.

D. Encourage participation within the client’s environment.


3. A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, “What happened to me? I don’t remember a thing.” What is the nurse’s initial response?

A. “Tell me what you think happened.”

B. “You will remember more as you get better.”

C. “You were in a work-related accident this morning.”

D. “It was necessary to amputate your leg after the accident.”


4. After being medicated for anxiety, a client says to a nurse, “I guess you are too busy to stay with me.” How should the nurse respond?

A. “I’m so sorry, but I have to see other clients.”

B. “I have to go now, but I will come back in ten minutes.”

C. “You’ll be able to rest after the medicine starts working.”

D. “You’ll feel better after I’ve made you more comfortable.”


5. A physically ill client is being verbally aggressive to the nursing staff. What is the most appropriate initial nursing response?

A. Accept the client’s behavior.

B. Explore the situation with the client.

C. Withdraw from contact with the client.

D. Tell the client the reason for the staff’s actions

Rationales

1.A 

Bargaining is one of the stages of grieving, in which the client promises some type of desirable behavior to postpone the inevitability of death.

B, Frustration is a subjective experience, a feeling of being thwarted, but it is not one of the stages of grieving.

C,Classified as the fourth stage of grieving,depression represents the grief experienced as the individual recognizes the inescapability of fate.

D,Rationalization is a defense mechanism in which attempts are made to justify or explain an unacceptable action or feeling; it is not a stage of the grieving process.

Client Need: Psychosocial Integrity;

Cognitive Level: Application;

Integrated Process: Caring;

Nursing Process: Assessment/Analysis;

Reference: Ch 1, Grieving Process


2.B

Detachment is a coping mechanism that the client needs, especially when faced with the inevitability of death; the nurse should accept this behavior.

A, Ignoring the behavior does not convey a willingness to listen and denies the client’s feelings.

C,The client is in acceptance. It is unnecessary to point out the reality of the situation.

D, It is counterproductive to encourage the client to become involved with the environment.

Client Need: Psychosocial Integrity;

Cognitive Level: Application;

Integrated Process: Caring;

Nursing Process: Planning/Implementation;

Reference: Ch 1,Grieving Process


3.C 

This is truthful and provides basic information that may prompt recollection of what occurred; it is a starting point.

A,This ignores the client’s question; avoidance may increase anxiety.

B,This ignores the client’s question; the frustration of trying to remember will increase anxiety.

D,This is too blunt for the initial response to the client’s question; the client may not be ready to hear this at this time.

Client Need: Psychosocial Integrity;

Cognitive Level:Application;

Integrated Process: Caring;

Communication/Documentation;

Nursing Process:Planning/Implementation;

Reference: Ch 2, The Nurse-Client Relationship


4.B 

This response demonstrates that the nurse cares about the client and will have time for the client’s special emotional needs. This approach allays anxiety and reduces emotional stress.

A,This indicates that the nurse’s other tasks are more important than the client’s needs.

C,This is false reassurance and not therapeutic.

D,This does not respond to the client’s need and cuts off communication.

Client Need: Psychosocial Integrity;

Cognitive Level:Application;

Integrated Process: Communication/Documentation;

Nursing Process:Planning/Implementation;

Reference:Ch 2, The Nurse-Client Relationship


5.A 

At this time the client is using this behavior as a defense mechanism.Acceptance can be an effective interpersonal technique, since it is nonjudgmental.

Eventually, limits may need to be set to address the behavior if it becomes more aggressive or hostile.

B, During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally.

C,Withdrawal signifies nonacceptance and rejection.

D,The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client’s feelings are not considered.

Client Need: Psychosocial Integrity;

Cognitive Level: Application;

Integrated Process: Caring;

Nursing Process: Planning/Implementation;

Reference: Ch 2, The Nurse-Client Relationship

小编寄语:宝剑锋从磨砺出,梅花香自苦寒来!Fighting!


时间:2019-05-31 14:40:53
 
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