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ISPN考试模拟试题(492)

Question:

A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes? 

1. Allow the client to grieve for body image changes. 

2. Restrict foods that are high in potassium. 

3. Restrict fluid intake to 1,000 mL/day. 

4. Assess the client’s mental status regularly.

 

Central nervous system changes include such symptoms as apathy, lethargy, and decreased concentration. Seizures and coma can also occur. The nurse should assess the client’s level of consciousness at regular intervals and maintain client safety. Allowing the client to express feelings related to body image changes and restricting foods high in potassium and fluid intake are all appropriate activities, but they are not related to the central nervous system changes. 

CN: Physiological adaptation; CL: Synthesize

Answer:4

翻译

 

问题:

慢性肾功能衰竭患者正在经历由尿毒症毒素引起的中枢神经系统改变。哪种护理干预最适合应对这些变化?

1.允许病人为身体形象的改变而悲伤。

2.限制高钾食物。

3.限制液体摄入量为1000毫升/天。

4.定期评估病人的精神状况。

 

答案:4

中枢神经系统的改变包括诸如冷漠、嗜睡和注意力下降等症状。癫痫和昏迷也会发生。护士应定期评估病人的意识水平,维护病人的安全。允许病人表达与身体形象改变有关的感受,限制高钾和高液体摄入的食物都是适当的干预活动,但与中枢神经系统的变化无关。

CN:生理适应;CL:合成

小编寄语:Eliminate the unhappy things regularly so that there is room for happiness.不开心的事情要定期清除,那样才有储存快乐的空间。

时间:2021/4/14 14:31:55
 
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