2023年CGNS美國(guó)海外護(hù)士資格認(rèn)證歷年高頻考題帶答案難題附詳解

2023年CGNS美國(guó)海外護(hù)士資格認(rèn)證歷年高頻考題帶答案難題附詳解（圖片大小可自由調(diào)整）第1卷一.Comprehensivetestcenter(共50題)1.It'simportanttoassessthematurityofenzymesystems(kidneyandliver)inwhichpediatricpopulationbeforeadministeringmedications?A.Adolescents.B.Neonates.C.Prematureinfants.D.Toddlers.2.Apregnantclientistakingfolicacid.Duringprenatalteaching,whichofthefollowingfoodswouldthenurserecommendashighinfolicacid?A.Eggyolks.B.Fruit.C.Bread.D.Milk.3.Thenurseisabouttoadministeramedicationtoaclientwithwhomthenurseisunfamiliar.Toverifytheclient'sidentity,thenurseshouldA.asktheclienthisname.B.checkthenamepostedoutsidetheclient'sroom.C.askafamilymembertheidentityoftheclient.D.checktheclient'sidentificationbracelet.4.Ayoungmanisremandedbythecourtsforpsychiatrictreatment.Fromhispolicerecordthenursenoticesthattheclienthasrecordsofdelinquency,runningaway,autotheft,andvandalisminhisearlyteenageyears.Hedroppedoutofschoolatage16andhasbeenlivingonhisownsincethen.Hishistorysuggestsmaladaptivecoping.Whichofthefollowingproblemsismostassociatedwithmaladaptivecoping?A.Antisocialpersonalitydisorder.B.Borderlinepersonalitydisorder.C.Obsessive-compulsivepersonalitydisorder.D.Narcissisticpersonalitydisorder.5.Aclientdiagnosedwithgestationaldiabeteshasbeenadmittedforinductionoflaborat38weeks.Theclientasksthenurse,"Mypreviouslaborsstartedontheirown.Howwillthisinductionoflaborbedifferentfrommylastlabor?"Uponwhichtheorywouldthenursebaseherresponse?A.Aninductioncausesthecontractionstobemoreintenseduringthefirststageoflabor.B.Theriskofuterineruptureislessbecausetheoxytocin(Pitocin)iscontrolledwithaninfusionpump.C.Thegoalofinductionistoproduceacontractilepatternsimilartothatobservedinspontaneouslabor.D.Duringaninduction,fetalmonitoringbeginsassoonasoxytocinisstarted,whereasinaspontaneouslabor,monitoringbeginswhensignsofdistressoccur.6.Whichnursingmeasurewouldbemosteffectiveinhelpingtheclientcoughanddeepbreatheafteracholecystectomy?A.Havingtheclienttakerapid,shallowbreathstodecreasepain.B.Havingtheclientlayontheleftsidewhilecoughinganddeepbreathing.C.Teachingtheclienttouseafoldedblanketorpillowtosplinttheincision.D.Withholdingpainmedicationsotheclientcanbealertenoughtofollowthenurse'sinstructions.7.Immediatelyaftera1-year-oldclientreturnsfromacardiaccatheterization,thenursenotesthatthepulsedistaltothecatheterinsertionsiteisweak.Thenurseshouldtakewhichofthefollowingactions?A.Removethepressurebandagefromtheinsertionsite.B.Performpassiveexercisesontheaffectedextremity.C.Notifythephysicianoftheassessment.D.Recordthedataonthenursingnotesandcontinuetoevaluate.8.Whichofthefollowingwouldthenurseteachthemotherofachildwithleukemiawhohasanabsoluteneutrophilcountof900/mm3?A.Thechildshouldweargloveswhenincontactwithothers.B.Thechildshouldstayawayfromcrowdsofpeople.C.Thechildshouldeatrawfruitsandvegetables.D.Anyoneindirectcontactwiththechildmustwearagownandmask.9.Whichofthefollowingsignsandsymptomsisclassicforapatientwithrheumatoidarthritis?A.Jointswelling,jointstiffnessinthemorning,andbilateraljointinvolvement.B.Crepitus,developmentofHeberden'snodes,andanemia.C.Painonweight-bearing,rash,andlow-gradefever.D.Fatigue,leukopenia,andjointpain.10.Thenurseinterviewsayoungfemaleclientwithanorexianervosatoobtaininformationforthenursinghistory.TheclientshistoryislikelytorevealA.Astrongdesiretoimproveherself-imageB.Aclose,supportivemother-daughterrelationshipC.Lowachievementinschool,withlittleconcernforgradesD.satisfactionwithandadesiretomaintainherpresentweight11.Whilecaringfortheclientwithaburninjury,thenurseshouldobserveforsignsandsymptomsofwhichcomplicationbelievedtobedueprimarilytohypersecretionofgastricacid?A.Paralyticileus.B.Gastricdistention.C.Hiatalhernia.D.Gastrointestinalulceration.12.One-year-oldSusan,thesecondchildtohavesicklecelldiseaseinafamilyoffivechildren,isadmittedtothehospitalwithsicklecellcrisis.Whenpreparingtheplanofcareforher,whichofthefollowingtreatmentswouldthenursemostlikelyexpecttoincludeintheplan?A.Intravenousfluidtherapy.B.Fast-actinganticoagulanttherapy.C.Parenteralirontherapy.D.Exchangetransfusion.13.Whichofthefollowingpositionsismostappropriateforaneonatewithcongenitalhipdislocation?A.Semi-Fowler'swithbothlegsflexed.B.Legsadductedwithheadelevated.C.Swaddledinababycarrier.D.Pronepositionwithhipsabducted.14.Aclientisadmittedtotheemergencydepartmentwithasuspectedoverdoseofanunknowndrug.Theclient'sarterialbloodgasvaluesindicaterespiratoryacidosis.Whatshouldthenursedofirst?A.Preparetoassistwithventilation.B.Monitortheclient'sheartrhythm.C.Preparetobegingastriclavage.D.Obtainurinefordrugscreening.15.Positivesymptomsofschizophreniaincludewhichofthefollowing?A.Waxyflexibility,alogia,andapathy.B.Flataffect,avolition,andanhedonia.C.Hallucinations,delusions,anddisorganizedthinking.D.Somaticdelusions,echolalia,andaflataffect.16.Thenurseiscaringaclientinanacutecarementalhealthprogram.Theclientrefuseshismorningdoseofanoralantipsychoticmedicationandbelieveshe'sbeingpoisoned.Whatshouldthenursedo?A.Crushingthemedicationandputtingitinhisfood.B.Consultingwiththephysicianaboutaplanofcare.C.Administeringthemedicationbyinjection.D.Omittingthedoseandtryingagainthenextday.17.Duringapanicattack,aclientrunstothenurseandreportsbreathingdifficulty,chestpains,andpalpitations.Theclientalsoispaleandhasawideopenmouthandraisedeyebrows.Whatshouldthenursedofirst?A.Assistwithdeepbreathingintoapaperbag.B.Orienttheclienttoperson,place,andtime.C.Setlimitsforactingoutdelusionalbehaviors.D.AdministerananxiolyticagentIM.18.Hormonaleffectsoftheantipsychoticmedicationsincludewhichofthefollowing?A.Retrogradeejaculationandgynecomastia.B.Dysmenorrheaandincreasedvaginalbleeding.C.Polydipsiaanddysmenorrhea.D.Akinesiaanddysphasia.19.Thenurseisteachingtheclienthowtouseacane.Whichofthefollowingstatementsismostinaccurate?A.Theclientshouldholdthecaneontheinvolvedside.B.Theclientshouldholdthecaneclosetohisbody.C.Thestridelengthandthetimingofeachstepshouldbeequal.D.Thenurseshouldstandbehindtheclienttopreventfalls.20.A16-year-oldgirlcomestotheschoolnursecomplainingofcramps,backache,andnauseawithherperiods.Thenursemostlikelywouldinterpretthesesymptomsaswhichofthefollowing?A.Pathologic.B.Physiologic.C.Psychogenic.D.Psychosomatic.21.Whenaclientexperiencesalossofvibratorysenseonexamination,thisindicatesA.injurytothecranialnerves.B.injurytotheperipheralnerves.C.intactcranialnerves.D.intactperipheralnerves.22.Thenursehasbeenteachingtheclientstrategiestopreventarecurrenceofhemorrhoids.Onestrategyismaintainingahigh-fiberdiet.Whichofthefollowingbreakfastmenusisappropriatefortheclient?A.Danishpastry,prunejuice,coffee,andmilk.B.Oatmeal,milk,grapefruitwedges,andbranmuffin.C.Cornflakes,milk,whitetoast,andorangejuice.D.Scrambledeggs,bacon,Englishmuffin,andapplejuice.23.Thenurseiscaringforaclientinanacutemanicstate.What'sthemosteffectivenursingactionforthisclient?A.Assigninghimtogroupactivities.B.Reducinghisstimulation.C.Assistinghimwithself-care.D.Helpinghimexpresshisfeelings.24.Aclientisscheduledtohaveadescendingcolostomy.He'sveryanxiousandhasmanyquestionsconcerningthesurgicalprocedure,careofastoma,andlifestylechanges.Itwouldbemostappropriateforthenursetomakeareferraltowhichmemberofthehealthcareteam?A.Socialworker.B.Registereddietitian.C.Occupationaltherapist.D.Enterostomalnursetherapist.25.Achild,age3,isbroughttotheemergencydepartmentinrespiratorydistresscausedbyacuteepiglottiditis.Whichclinicalmanifestationsshouldthenurseexpecttoassess?A.Severesorethroat,drooling,leaningforwardtobreathe.B.Low-gradefever,stridor,barkingcough.C.Pulmonarycongestion,productivecough,fever.D.Sorethroat,fever,generalmalaise.26.Whichofthefollowinginterventionswillassisttheclientintakingphenytoinasprescribed?A.Callinghimdailyforthefirstweekafterhospitaldischarge.B.Havingafamilymembermonitorhimtoensurecompliance.C.Providinghimwithwrittenandverbalinstructionsaboutthemedicine.D.Emphasizingthatembarrassingseizuresmayoccuragainifhedoesnottakethemedicine.27.Whichofthefollowingshouldthenurseincludeinapostoperativeteachingplanforaclientwithalaryngectomy?A.Tellingtheclienttospeakbycoveringthestomawithasterilegauzepad.B.Reassuringtheclientthatnormaleatingwillbepossibleafterhealinghasoccurred.C.Instructingtheclienttoavoidcoughinguntilthesuturesareremoved.D.Instructingtheclienttocontroloralsecretionsbyswabbingthemwithtissuesorbyexpectoratingintoanemesisbasin.28.Thenurseteachestheclientwithpepticulcerdiseaseabouthowtoeffectivelyadjusthisresponsetowork-relatedstress.Whichofthefollowingstatementsbytheclientindicatesthattheeducationiseffective?A."Myjobistoostressful.Iwillhavetofindadifferentcareer."B."Idon'thaveanycontrolovermystressorsatwork.Mycoworkersaredifficulttoworkwith."C."Well,IguessthisulcermeansIwon'tbeabletoworktowardapromotion."D."Iwillhavetoimprovemyabilitytocopewithstress."29.Whatshouldthenurse'sreactionbetoamanicpatient'sloudjokesandcrudepranks?SheshouldA.ReactwithstudiedprudishnessB.ChastisethepatientC.PutrestraintsonthepatientD.Reactwithsilence,ignoringit30.Thenurseisteachingapsychiatricclientaboutherprescribeddrugs,chlorpromazineandbenztropine.Whyisbenztropineadministered?A.Toreducepsychoticsymptoms.B.Toreduceextrapyramidalsymptoms.C.Tocontrolnauseaandvomiting.D.Torelieveanxiety.31.Anelderlyclient'slithiumlevelis1.4mEq/L.Shecomplainsofdiarrhea,tremors,andnausea.Thenurse'sfirstactionistoA.holdthelithium(Lithobid)andnotifythephysician.B.reassuretheclientthatthesearenormaladverseeffects.C.administeranotherlithiumdose.D.discontinuethelithium.32.Thenurseisteachingbreastself-examination(BSE)toacollegestudent.Thenurseknowsthattheclientunderstandsthebesttimetoexamineherbreastswhenshesays:A."I'llexaminemybreasts1weekaftermyperiodstarts."B."I'llperformaBSEjustbeforemyperiodstarts."C."Imustexaminemybreaststhesametimeeachday."D."EverytimeIshowerI'lldoabreastexamination."33.Aclientcomplainsofasevere,throbbingheadachefollowingalumbarpuncture.TheprioritynursinginterventionforthisclientistoA.restrictfluidintake.B.increasefluidintake.C.raisetheheadofthebed.D.assessvitalsigns.34.Tocheckforarterialinsufficiencywhenaclientisinasupineposition,thenurseshouldelevatetheextremityata45-degreeangleandthenhavetheclientsitup.Thenursesuspectsarterialinsufficiencyiftheassessmentrevealswhichofthefollowing?A.Elevationalrubor.B.Noruborfor10secondsafterthemaneuver.C.Dependentpallor.D.A30-secondfillingtimefortheveins.35.Thenurseiscaringforaclientwithafracturedleftfemur.Whatsignsindicatepotentialfatemboli?A.Increasedpartialpressureofarterialoxygen(PaO2),reducedsensationinleftlegorfoot.B.Leftlegpain,dyspnea.C.Bradycardia,skinbruises.D.Cyanosis,decreasedPaO2.36.Whichofthefollowingwouldthenurseexpecttofindinaclientdiagnosedwithhyperparathyroidism?A.Hypocalcemia.B.Hypercalcemia.C.Hyperphosphatemia.D.Hypophosphaturia.37.Abreast-feedingneonatewillturnhisheadtowardthemother'sbreastinanaturalinstincttofindfood.Whatisthenameofthisreflex?A.Tonicneckreflex.B.Moro'sreflex.C.Graspreflex.D.Rootingreflex.38.Aclient'sbloodglucoselevelis45mg/dL.Thenurseshouldbealertforwhichsignsandsymptoms?A.Coma,anxiety,confusion,headache,andcool,moistskin.B.Kussmaul'srespirations,dryskin,hypotension,andbradycardia.C.Polyuria,polydipsia,hypotension,andhypernatremia.D.Polyuria,polydipsia,polyphagia,andweightloss.39.Thenurseiscaringforanelderlyclientwhoexhibitssignsofdementia.ThemostcommoncauseofdementiainanelderlyclientisA.delirium.B.depression.C.excessivedruguse.D.Alzheimer'sdisease.40.Mrs.SwithpretermlaborwillbeunderTerbutaline(Brethine)therapy.Beforebeginningthetherapy,whichofthefollowingassessmentswouldbemostimportant?A.Estimatedfetalsize.B.Maternalheartrate.C.Contractionintensity.D.Deeptendonreflexes.41.Theclientexperiencesawoundeviscerationonday2aftertheabdominalhysterectomy.Whatshouldthenurseimmediatelydo?A.Approximatethewoundedgesbyapplyingstripsofadhesiveoverthewound.B.Covertheexposedtissueswithsteriledressingsmoistenedwithnormalsalinesolution.C.Replacetheabdominalcontentsintothewoundcarefullywhilewearinggloves.D.Applyaloose-fittingsterileabdominalbinderoverthewound.42.Aclientreceivedburnstohisentirebackandleftarm.UsingtheRuleofNines,thenursecancalculatethathehassustainedburnsonwhatpercentageofhisbody?A.9%.B.18%.C.27%.D.36%.43.ThenurseisawarethatthemajorhealthcomplicationassociatedwithsevereanorexianervosaisA.ProteindepletionresultinginmusclewastingB.EndocrineimbalanceresultinginamenorrheaC.GlucoseintoleranceresultinginhypoglycemiaD.Cardiacdysrhythmiasresultingincardiacarrest44.Whileinspectingtheclient'schest,thenursenotesthatthechestwallcontractsoninspirationandbulgesonexpiration.Thenursesuspectswhichofthefollowingproblemfromthisassessment?A.Hemothorax.B.Flailchest.C.Pneumothorax.D.Tensionpneumothorax.45.Assertivebehaviorinvolveswhichofthefollowingelements?A.Expressinganairofsuperiority.B.Sayingwhatisonyourmindattheexpenseofothers.C.Avoidingunpleasantsituationsandcircumstances.D.Standingupforyourrightswhilerespectingtherightsofothers.46.AclientisadmittedtothehospitalfortreatmentofPrinzmetal'sangina.Whendevelopingtheclient'splanofcare,thenurseshouldrememberthatthistypeofanginaistriggeredbyA.coronaryarteryspasm.B.anunpredictableamountofactivity.C.activitiesthatincreaseoxygendemand.D.anunknownsource.47.Aclientwithaserumglucoselevelof618mg/dLisadmittedtothefacility.He'sawakeandoriented,hashotdryskin,andhasthefollowingvitalsigns,temperatureof100.6°F(38.1℃),heartrateof116beats/minute,andbloodpressureof108/70mmHg.Basedontheseassessmentfindings,whichnursingdiagnosistakeshighestpriority?A.Deficientfluidvolumerelatedtoosmoticdiuresis.B.Decreasedcardiacoutputrelatedtoelevatedheartrate.C.Imbalancednutrition.Lessthanbodyrequirementsrelatedtoinsulindeficiency.D.Ineffectivethermoregulationrelatedtodehydration.48.Thenurseobservesthattheclient'stotalparenteralnutrition(TPN)solutionisinfusingtooslowly.Thenursecalculatesthattheclienthasreceived300mLlessthanwasorderedfortheday.Whatshouldthenursedonext?A.Assesstheinfusionsystem,notetheclient'scondition,andnotifythephysician.B.Discontinuethesolutionandadministerdextrosein5%wateruntiltheinfusionproblemisresolved.C.Increasetheflowratetoinfuseanadditional300mLoverthenexthour.D.Maintaintheflowrateatthecurrentrateanddocumentanydiscrepancyinthechart.49.A30-year-oldprimigravidatellsthenursethatherhemorrhoidshavebecomeitchyandpainful.Thenurseinstructstheclientaboutreliefmeasures.Fromwhichofthefollowingstatementsbytheclientwouldthenursesuspectthattheclientneedsfurtherinstructions?A."Ishouldsitinawarmsitzbathdaily."B."Icanuseatopicalointmentforrelief."C."Ishouldapplyanicepackatnight."D."Ishoulddecreasemyfluidintake."50.AclienthasbeendiagnosedwithtypeAhepatitis.Whatspecialprecautionsshouldthenursetakewhencaringforthisclient?A.Putonamaskandgownbeforeenteringtheclient'sroom.B.Wearglovesandagownwhenremovingtheclient'sbedpan.C.Preventthedropletspreadoftheorganism.D.Usecautionwhenbringingfoodtotheclient.第1卷參考答案一.Comprehensivetestcenter1.參考答案：CFactorsrelatedtogrowthandmaturationsignificantlyalteranindividual'scapacitytometabolizeandexcretedrugs.Thus,theprematureinfantisatriskforproblemsbecauseofimmaturity.Deficienciesassociatedwithimmaturitybecomemoreimportantwithdecreasingage.Enzymesystemsdevelopquickly,withmostincreasingtoadultlevelswithinIto8weeksafterbirth.Withinthe1styearoflife,allareprobablyasactiveastheywilleverbe.2.參考答案：AEggyolks,nuts,seeds,andliverareallhighinfolicacid.Theotheroptionsaren'tgoodsourcesoffolicacid.3.參考答案：DToverifytheclient'sidentity,checktheidentificationbracelet.Ifconfused,theclientmaygiveaninaccurateanswer.Thenamepostedoutsidethedoormaybeinaccurateoranotherclientmayhavewanderedintothewrongroom.Afamilymemberwithwhomthenurseisunfamiliarisn'tareliablesource.4.參考答案：ATheclient'shistoryofdelinquency,runningawayfromhome,vandalism,anddroppingoutofschoolarecharacteristicofantisocialpersonalitydisorder.Thismaladaptivecopingpatternismanifestedbyadisregardforsocietalnormsofbehaviorandaninabilitytorelatemeaningfullytoothers.Inborderlinepersonalitydisorder,theclientexhibitsmoodinstability,poorself-image,identitydisturbance,andlabileaffect.Obsessive-compulsivepersonalitydisorderischaracterizedbyapreoccupationwithimpulsesandthoughtsthattheclientcan'tcontrol,eventhoughherealizesthey'resenseless.Narcissisticpersonalitydisorderismarkedbyapatternofself-involvement,grandiosity,anddemandforconstantattention.5.參考答案：CThegoalduringinductionoflaboristoproduceacontractilepatternsimilartothatobservedinspontaneouslabor.Theinfusionofoxytocinisincreaseduntilacontractilepatternisachievedinwhichthecontractionsoccurevery2to3minuteswithadurationof40to60secondsina10-minuteperiodandtheuterusrelaxesbetweencontractions.Oneofthecomplicationsofaninductionistheriskofuterinerupture.Theclientscheduledtoreceiveoxytocinismonitoredforatleast20minutesbeforeinitiationofthedrugtoestablishabaselinefetalheartrate.Thereafter,theclientismonitoredinthesamewayasaclientinspontaneouslabor,whichdependsonthematernalandfetalresponsestolabor.6.參考答案：CAfoldedbathblanketorpillowplacedovertheincisionwillbemosteffectiveinhelpingtheclientcoughanddeepbreatheafteracholecystectomy.7.參考答案：DThepulsedistaltotheinsertionsitemaybeweakforafewhoursbutshouldgraduallyincreaseinstrength.Thepressuredressingshouldn'tberemovedbecauseoftheriskofhemorrhage.Passiveexercisesontheaffectedextremitywouldn'tbeperformedafteracardiaccatheterization.Thephysiciandoesn'tneedtobenotifiedatthistimebutshouldbenotifiediftheweakpulsecontinuesforlongerthan2hours.8.參考答案：BThenormalneutrophilcountrangeis3,000to5,000cells/mm3.Anabsoluteneutrophilcountof900/mm3islow,placingthechildathighriskforinfection.Therefore,thenurseshouldinstructthemothertohavethechildavoidcrowdsbecauseoftheriskofexposuretoinfection.Additionally,siblingsandotherswhohaveanactiveinfectionshouldstayawayfromthechild.9.參考答案：AClassicsignsandsymptomsofrheumatoidarthritisincludejointpain,swelling,andwarmth.Symptomsaretypicallybilaterallysymmetric.Jointstiffnessinthemorninglastinglongerthan30minutesisanotherclassicsymptom.Rheumatoidarthritisisasystemicdisease.Othersymptomscanincludefatigue,low-gradefever,anemia,andweightloss.10.參考答案：A11.參考答案：DGastrointestinalulceration,alsoknownasCurling'sulcer,occursinabouthalfofclientssufferingfromsevereburns.Theincidenceofulcerationappearsproportionaltotheextentoftheburnsandisbelievedtobeduetohypersecretionofgastricacidandcompromisedgastrointestinalperfusion.12.參考答案：ADuringasicklecellcrisis,increasingthetransportandavailabilityofoxygentothebody'stissuesisparamount.Administeringahighvolumeofintravenousfluidandelectrolytestohelpcompensatefortheacidosisresultingfromhypoxemiaassociatedwithsicklecellcrisisisonewaytoaccomplishthis.Fluidadministrationalsohelpsovercomedehydration,apossiblepredisposingfactorcommoninclientswithsicklecellcrisis.13.參考答案：DAbductionplacesthefemoralheadintotheacetabulumforcorrectalignment.Placingtheclientinsemi-Fowler'spositionwithbothlegsflexedorwithhislegsadductedandhisheadelevatedwon'thelpcorrecttheproblem.Swaddlingtheclientinababycarrierwouldworsenthedislocation.14.參考答案：ARespiratoryacidosisisassociatedwithhypoventilation,whichinthisclientsuggestsintakeofadrugthatsuppressesthebrain'srespiratorycenter.Therefore,thenurseshouldassumetheclienthasrespiratorydepressionandshouldpreparetoassistwithventilation.Aftertheclient'srespiratoryfunctionhasbeenstabilized,thenursecansafelymonitortheheartrhythm,prepareforgastriclavage,andobtainaurinesamplefordrugscreening.15.參考答案：CThepositivesymptomsofschizophreniaaredistortionsofnormalfunctioning,includinghallucinations,delusions,disorganizedthinking,somaticdelusions,echolalia,andwaxyflexibility.Aflataffect,alogia,apathy,avolition,andanhedoniarefertothenegativesymptoms.Negativesymptomslistthediminutionorlossofnormalfunction.16.參考答案：BTodetermineplansofcareforclientswhoarenoneompliantwithmedications,thenurseshouldconsultwiththephysician.Unlesstheclientpresentsadangertohimselforothers,medicationscan'tbeforcedonaclient.Adoseshouldn'tbeomittedwithoutfirstcheckingwiththephysician.Intentionallydeceivingormisleadingaclientviolatesthetherapeuticrelationship.17.參考答案：APhysiologicneeds,particularlybreathing,arethefirstpriorityduringapanicattack.

Restoringnormalbreathingpatternsshouldrelievetheothersymptoms.Orientationusuallyisunnecessarybecausemostclientsrespondtoexternalcontrolandreducedstimulation.Duringapanicattack,theclientisn'tlikelytoactoutbutmaystrikeoutiffeelingthreatened.Ananxiolyticagentmaybeeffectivebutisn'tthefirstpriority.18.參考答案：ADecreasedlibido,retrogradeejaculation,andgynecomastiaareallhormonaleffectsthatcanoccurwithantipsychoticmedications.Reassuretheclientthattheeffectscanbereversedorthatchangingmedicationmaybepossible.Polydipsia,akinesia,anddysphasiaaren'thormonaleffects.19.參考答案：ATheclientisinstructedtoholdthecaneontheuninvolvedside,94"to26"(61to66era)fromthebaseofthelittletoe.Thisisdonetopromoteareciprocalgaitpattern.Thenurseshouldinstructtheclienttoholdthecaneclosetohisbodytopreventleaning.Thestridelengthandtimingofeachstepshouldbeequal.Topreventfails,thenursestandsbehindtheclientashe'slearningtousethecane.20.參考答案：BThebasisforthesesymptomsismostlikelyphysiologic.Therearetwotypesofdysmenorrhea,primaryandsecondary.Primary,themostcommontype,isbelievedtobecausedbyanincreasedlevelofprostaglandinsproducinguterinehyperactivityandcontractions.21.參考答案：BAppropriateperceptionofvibrationindicatesintactdorsalcolumntractsandperipheralnerves.Ifthere'salossofvibratorysense,aninjurytotheperipheralnervesisprobable.22.參考答案：BOatmeal,grapefruitwedges,andbranmuffinsareallhigh-fiberfoods.23.參考答案：BReducingstimulihelpstoreducehyperactivityduringamanicstate.Groupactivitieswouldprovidetoomuchstimulation.Tryingtoassisttheclientwithself-carecouldcauseincreasedagitation.Wheninamanicstate,theseclientscan'texpresstheirinnerfeelingsinaproductive,introspectivemanner.Thefocusoftreatmentforaclientinthemanicstateisbehaviorcontrol.24.參考答案：DAnenterostomalnursetherapistisaregisterednursewhohasreceivedadvancededucationinanaccreditedprogramtocareforclientswithstomas.Theenterostomalnursetherapistcanassistwithselectionofanappropriatestomasite,teachaboutstomacare,andprovideemotionalsupport.Socialworkersprovidecounselingandemotionalsupport,buttheycan'tprovidepreoperativeandpostoperativeteaching.Aregistereddietitiancanreviewanydietarychangesandhelptheclientwithmealplanning.Theoccupationaltherapistcanassistaclientwithregainingindependenceinactivitiesofdailyliving.25.參考答案：AAchildwithacuteepiglottiditisappearsacutelyill,andclinicalmanifestationsmayincludedrooling(becauseofdifficultyswallowing),severesorethroat,hoarseness,leaningforwardwiththeneckhyperextended,highfever,andsevereinspiratorystridor.Alow-gradefever,stridor,andbarkingcoughthatworsensatnightaresuggestiveofcroup.Pulmonarycongestion,productivecough,andfeveralongwithnasalflaring,retractions,chestpain,dyspnea,decreasedbreathsounds,andcracklesareindicativeofpneumococcalpneumonia.Asorethroat,fever,andgeneralmalaisepointtoviralpharyngitis.26.參考答案：CProvidingtheclientwithwrittenandverbalinstructionswillincreaseunderstandingofthemedicationregimen27.參考答案：BNormaleatingispossibleoncethesuturelinehashealed.28.參考答案：DAlthoughclientscannoteliminatestress,theycanimprovetheirabilitytocopewithit.29.參考答案：D30.參考答案：BBenztropineisananticholinergicmedication,administeredtoreducetheextrapyramidaladverseeffectsofchlorpromazineandotherantipsyehoticmedications.Benztropinedoesn'treducepsychoticsymptoms,relieveanxiety,orcontrolnauseaandvomiting.31.參考答案：ATheclienthassymptomsoflithiumto