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《Kaplan NCLEX-RN Question Trainer Test-1》(995-997)

发表日期:2016-12-21 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
995. Which of the following should be the nursing priority for an infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis?

1. Encourage intake of oral fluids to prevent dehydration.
2. Restrain the child appropriately to maintain the integrity of the IV site.
3. Place the child on droplet precautions.
4. Encourage the parents to hold and rock the infant to promote comfort.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) fluid requirements are determined by child’s hydration status; fluids are usually limited to prevent cerebral edema
(2) not a priority
(3) correct—to prevent spread of infection, child is placed on droplet precautions for at least 24 hours after implementation of antibiotic therapy
(4) would cause discomfort to infant’s head 
NCLEX Question Trainer

 996. The nurse is caring for a client who has overdosed on a large quantity of diazepam (Valium). Which of the following nursing actions should take priority during the first several days of this client’s inpatient treatment?

1. Complete a full psychiatric assessment.
2. Get in touch with the client’s family to involve them in treatment.
3. Observe and record vital signs frequently, including neurological symptoms.
4. Determine whether this client may need long-term therapy after this hospitalization.

Strategy: Think Maslow.

(1) psychosocial, can be done after the client has been medically stabilized
(2) psychosocial, can be done after the client has been medically stabilized
(3) correct—physical, because of potentially life-threatening complications of depressant overdose such as respiratory failure, pulmonary edema, and seizures, nurse’s priority is observation and documentation of vital signs
(4) psychosocial, can be done after the client has been medically stabilized

997. During the second session of individual therapy, a client sits quietly with arms folded and eyes cast down. Which of the following statements by the nurse is BEST?

1. “What is the weather like outside?”
2. “Do you not want to talk with me today?”
3. “Are you cold sitting here?”
4. “You seem to be feeling sad today.”

Strategy: “BEST” indicates that this is a priority question. Remember therapeutic communication.

(1) is used to get client comfortable, but would not help to focus on what is important
(2) focusing on client’s difficulty speaking may make him defensive and block communication
(3) concrete questions will encourage client to give yes/no answers, factual answers may block communication of feelings
(4) correct—reflection allows client to verbalize feelings
  

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