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ISPN考试模拟试题(五十一)

Questions

1.A client admitted to the hospital has edematous ankles.What should the nurse do to best reduce edema of the lower extremities?

A.Restrict fluids.

B.Elevate the legs.

C.Apply elastic bandages.

D.Do range-of-motion exercises.


2.What clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply.

A.Edema

B.Vertigo

C.Polyuria

D.Dyspnea

E.Palpitations


3.What change in pressure does the nurse conclude is responsible for the lower extremity pitting edema of a client with right ventricular heart failure?

A.Increase in plasma hydrostatic pressure

B.Increase in tissue colloid osmotic pressure

C.Decrease in the tissue hydrostatic pressure

D.Decrease in the plasma colloid osmotic pressure


4.The family of a client with right ventricular heart failure expresses concern about the client’s increasing abdominal girth. What physiologic change should the nurse consider when explaining the client’s condition?

A.Loss of cellular constituents in blood

B.Rapid osmosis from tissue spaces to cells

C.Increased pressure within the circulatory system

D.Rapid diffusion of solutes and solvents into plasma


5.What dietary choices should the nurse instruct the client taking spironolactone (Aldactone) to avoid? Select all that apply.

A.Potatoes

B.Red meat

C.Cantaloupe

D.Wheat bread

E.Flavored yogurt

Rationales

1.B 

Elevation of extremities promotes venous and lymphatic drainage by gravity.

A,C,This is a dependent function of the nurse.

D,This procedure may have little effect on edema.

Client Need:Physiological Adaptation;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch6,Heart Failure,Nursing Care


2.Answer:A,D.

A,Heart failure is the failure of the heart to pump adequately to meet the needs of the body, resulting in a backward buildup of pressure in the venous system.Clinical manifestations include edema, ascites, hepatomegaly, tachycardia,dyspnea,and fatigue.

B,Vertigo generally is not related to right ventricular failure.

C,Because a diminished cardiac output decreases blood flow to the kidneys,there will be a decreased, not increased, urine output.

D,Dyspnea occurs because of pulmonary congestion and inadequate delivery of oxygen to all body cells.

E,Palpitations may indicate coronary insufficiency or infarction.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process:Assessment/Analysis;

Reference:Ch6,Heart Failure,Data Base


3.A 

In right ventricular heart failure, blood backs up in the systemic capillary beds; the increase in plasma hydrostatic pressure shifts fluid from the intravascular compartment to the interstitial spaces, causing edema.

B,This occurs with crushing injuries or if proteins pathologically shift from the intravascular compartment to the interstitial spaces.

C,Increased fluid pressure in the intravascular compartment causes fluid to shift to the tissues; the tissue hydrostatic pressure does not decrease.

D,Although a decrease in colloid osmotic(oncotic) pressure can cause edema,it results from lack of protein intake, not increased hydrostatic pressure associated with right ventricular heart failure.

Client Need:Physiological Adaptation;

Cognitive Level:Comprehension;

Nursing Process:Assessment/Analysis;

Reference:Ch6,Heart Failure,Data Base


4.C 

Failure of the right ventricle causes an increase in pressure in the systemic circulation. To equalize this pressure,fluid moves into the tissues,causing edema,and into the abdominal cavity,causing ascites;ascites leads to an increased abdominal girth.

A,There is no loss of the cellular constituents in blood with right ventricular heart failure.

B,Ascites is the accumulation of fluid in an extracellular space, not intracellular.

D,The opposite results when there is a pressure increase in the systemic circulation.

Client Need:Physiological Adaptation;

Cognitive Level:Comprehension;

Nursing Process:Assessment/Analysis;

Reference:Ch6,Heart Failure,Data Base


5.Answer: A,C.

A,Spironolactone (Aldactone) is potassium-sparing, and therefore beverages and foods containing potassium such as potatoes,bananas,avocados,oranges,dates, apricots, and raisins should be avoided to prevent hyperkalemia.

B,Red meat may need to be limited for other reasons not related to spironolactone.

C,Spironolactone is potassium-sparing,and therefore beverages and foods containing potassium such as cantaloupe should be avoided to prevent hyperkalemia.

D,Whole grains are associated with prevention of constipation and should not be avoided.

E,Dairy products are rich in sodium and calcium;spironolactone may cause hyponatremia.

Client Need:Pharmacological and Parenteral Therapies;

Cognitive Level:Analysis;

Integrated Process:Teaching/Learning;

Nursing Process:Planning/Implementation;

Reference:Ch6,Related Pharmacology,Diuretics

小编寄语:坚持一定是一件很酷的事情!Fighting!

时间:2019-07-22 16:34:10
 
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