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ISPN考试模拟试题(三十九)

Questions

1.A nurse applies an ice pack to a client’s leg for 20 minutes. What clinical indicator helps the nurse determine the effectiveness of the treatment?

A.Local anesthesia

B.Peripheral vasodilation

C.Depression of vital signs

D.Decreased viscosity of blood


2. A homeless person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse anticipate? Select all that apply.

A.Stupor

B.Erythema

C.ncreased anxiety

D.Rapid respirations

E.Paresthesia in affected body parts


3.An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Select all that apply.

A.Massage extremities.

B.Obtain a rectal temperature.

C.Assess the fingers for areas of frostbite.

D.Determine client’s level of consciousness.

E.Ask for identification so that the family can be notified.


4.A client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of the pain?

A.Encourage rest.

B.Obtain the vital signs.

C.Administer the prn analgesic.

D.Document the client’s pain response.


5.A peripheral nerve or dorsal column stimulator is implanted to allay a client’s intractable pain. What discharge instructions should the nurse give the client after surgery?

A.Tub baths should be avoided.

B.Analgesics will no longer be necessary.

C.The transmitter must be worn externally.

D.The transmitter will interfere with electronic devices.

Rationales

1.A 

Cold reduces the sensitivity of pain receptors in the skin. In addition, local blood vessels constrict, limiting the amount of edema and its related pressure and discomfort.

B,Local blood vessels constrict.

C,Local cold applications do not depress vital signs.

D,Local cold applications do not directly affect blood viscosity. This is not a clinical indicator that a nurse can observe.

Client Need:Basic Care and Comfort;

Cognitive Level:Application;

Nursing Process:Evaluation/Outcomes;

Reference Ch3, Nonpharmacologic Pain Management Strategies


2.Answer:A, E.

A,Stupor may occur with hypothermia because of slowed cerebral metabolic processes.

B,Pallor, not erythema, is present as a result of peripheral vasoconstriction.

C,Drowsiness occurs; the client is unable to focus on anxiety-producing aspects of the situation.

D,Respirations are decreased.

E,Peripheral vasoconstriction and the effect of cold on the peripheral nervous system result in paresthesias in the affected body parts.

Client Need:Reduction of Risk Potential;

Cognitive Level:Analysis;

Nursing Process:Assessment/Analysis;

Reference:Ch3,Emergency Situations,Specific Emergencies


3.Answer: B, C, D, E.

A,Massage is contraindicated because it may injure tissues that have sustained frostbite.

B,A rectal temperature provides the most accurate temperature.

C,Older adults have less subcutaneous fat and inefficient temperature regulating mechanisms, which makes them vulnerable to extremes in environmental temperature. The extremities are more distal sites of circulation and are at increased risk for frostbite.

D,Hypothermia decreases cerebral perfusion, which will result in confusion and a decreased level of consciousness.

E,Significant others should be notified of the client’s admission to the emergency department, if condoned by the client. Significant others can provide additional client information and may be a support for the client.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process:Planning/Implementation;

Reference:Ch3,Emergency Situations, Specific Emergencies


4.B 

Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension,respirations ≤12 breaths/min).

A,Pain prevents both psychologic and physiologic rest.

C,Before administration of an analgesic, the nurse must check the health care provider’s prescription, the time of the last administration, and the client’s vital signs.

D,A complete assessment including vital signs should be done before documenting.

Client Need:Reduction of Risk Potential;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch3,General Nursing Care of Clients in Pain


5.C 

Electrodes are attached to sensory nerves or over the dorsal column; a transmitter is worn externally and, by electric stimulation, may be used to interfere with the transmission of painful stimuli as needed.

A,Clients may bathe when the transmitter is disconnected.

B,The client may need analgesics in conjunction with the transmitter.

D,The transmitter should not interfere with other electronic devices.

Client Need:Basic Care and Comfort;

Cognitive Level:Application;

Integrated Process:Teaching/Learning;

Nursing Process:Planning/Implementation;

Reference:Ch3,General Nursing Care of Clients in Pain

小编寄语:持之以恒方能成功!Fighting!


时间:2019-07-01 16:24:17
 
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