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ISPN考试模拟试题(九)

Questions

1.During a newborn assessment the nurse identifies that the temperature, pulse,respirations, and other physical characteristics are within the expected range.The nurse records these findings on the clinical record. Legally, how should the nurse’s action be interpreted?

A. The nurse met the requirements set forth in the Nurse Practice Act.

B. This is a medical diagnosis and the nurse overstepped the legal boundary.

C. Nursing assessments are not equivalent to a health care provider’s assessments.

D. The initial assessment of the infant’s physical status is the responsibility of the client’s health care provider.


2.Which nursing action is protected from legal action?

A. Providing health teaching regarding family planning

B. Offering first aid at the scene of an automobile collision

C. Reporting incidents of suspected child abuse to the appropriate authorities

D. Administering resuscitative measures to an unconscious child pulled from a swimming pool

3.A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client’s plan of care include?

A. Foster self-activity whenever possible.

B. Plan care to be completed at one time followed by a long rest.

C. Teach family members how to assist with the client’s basic care.

D. Limit visiting to evening hours before the client goes to sleep.


4.A nurse is evaluating a client’s knowledge of ambulating with crutches. The nurse identifies the need for further teaching when the client states, “I must practice:

A. sitting down and standing up.”

B. ambulating several hours a day.”

C. standing and maintaining balance.”

D. doing active exercises on a regular schedule.”

Rationales

1.A 

The Nurse Practice Act requires nurses to diagnose human responses.

B,This is a physical assessment, not a medical diagnosis, and is within the nurse’s role.

C,Assessments should not differ when done by the nurse.

D,The nurse is capable of independently performing a physical assessment.

Client Need: Management of Care;

Cognitive Level: Application;

Integrated Process: Communication/Documentation;

Nursing Process:Evaluation/Outcomes;

Reference: Ch 2, The Nurse’s Rights and Responsibilities


2.C 

The reporting of possible child abuse is required by law, and the nurse’s identity can remain confidential.

A,The nurse is functioning in a professional capacity and therefore can be held

accountable.

B, D,Although the Good Samaritan Act protects

health professionals, the nurse is still responsible for acting as any reasonably prudent nurse would in a similar situation.

Client Need: Management of Care;

Cognitive Level: Comprehension;

Nursing Process: Planning/Implementation;

Reference: Ch 2, The Nurse’s Rights and Responsibilities

 

3.C 

Because family members are old enough to understand the client’s needs, they should be encouraged to participate in the care.

A,Self-care increases oxygen utilization, thereby increasing fatigue and dyspnea.

B,Overworking the client causes undue fatigue; there should be frequent rest periods between different aspects of care.

D,This deprives the client of a support system.

Client Need: Basic Care and Comfort;

Cognitive Level: Application;

Integrated Process: Caring;

Nursing Process: Planning/Implementation;

Reference: Ch 1,Type of Condition Affecting the Client


4.B 

Practicing ambulation several hours a day without adequate preparation is not helpful in the rehabilitation process and may exhaust the client; it is essential that the client master specific skills such as maintaining balance, sitting, standing,and stair climbing for safety.

A,Because different muscle groups are utilized, the client must be instructed about simple maneuvers; transfer from a sitting to a standing position must be accomplished before ambulation.

C,Balance is essential to prevent falls.

D,The muscles used for crutch walking are different from those used in

nonassisted ambulation;therefore,they must be strengthened by active exercises before ambulation.

Client Need: Basic Care and Comfort;

Cognitive Level: Application; Integrated

Process: Teaching/Learning;

Nursing Process: Evaluation/Outcomes;

Reference:Ch 2, Teaching-Learning

小编寄语:越努力,越幸运!Fighting!

时间:2019-05-13 15:18:24
 
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