2023年CGNS美國(guó)海外護(hù)士資格認(rèn)證歷年高頻考題帶答案難題附詳解

2023年CGNS美國(guó)海外護(hù)士資格認(rèn)證歷年高頻考題帶答案難題附詳解（圖片大小可自由調(diào)整）第1卷一.Comprehensivetestcenter(共50題)1.Drugstotreatacuteanxietyareprescribedtoaclienthospitalizedforanacutemyocardialinfarction.Theclientisreluctanttotakeanti-anxietydrugs.Thenursesuspectsthattheclientisholdingthedrugsunderhistongueanddisposingofthemaftershehaslefttheroom.Whatshouldthenursedofirst?A.Reporthersuspicionstotheclient'sphysician.B.Talktotheclientabouthisattitudetowardthemedications.C.Searchtheclient'sroomforevidenceofthemedications.D.Telltheclientthathisbehaviormuststopforhisownwell-being.2.AnurseinstructsaprenatalclassabouttheimportanceofdoingKegelexercisesfrequently.KegelexerciseshelptoA.promotebetterbreathingbystrengtheningthediaphragmmuscle.B.maintaingoodperinealmuscletonebytighteningthepubococcygeusmuscle.C.minimizelegcrampsbystrengtheningthecalfmuscles.D.preparethemotherforpushingbystrengtheningtheabdominalmuscles.3.Whichofthefollowingsignsorsymptomswouldthenurseexpecttoseeinaclientwithpancreatitis?A.Bradycardia.B.Hypertension.C.Decreasedwhitebloodcellcount.D.Leftupperquadrantabdominalpain.4.Thenurseisperformingwoundcare.Whichofthefollowingpracticesviolatessurgicalasepsis?A.Holdingsterileobjectsabovethewaist.B.Consideringa1"(2.5cm)edgearoundthesterilefieldasbeingcontaminated.C.Pouringsolutionontoasterilefieldcloth.D.Openingtheoutermostflapofasterilepackageawayfromthebody.5.AnurseinapsychiatricsettinghaspromotedatherapeuticrelationshipwithanAPDpatient.Onedaythenurseisoffdutyandisprepareforleaving,theclientssaysinapitytone,"Don'tletmealone,please,otherstaffdon'tlikemeandoftenpunishme."Whatthenursesayissuitableandcanassistthepatient?A."Don'tworry,Iwillbebacksoon."B."Iwillaskthestaffnottopunishyou."C."Youarelying,noneofstaffwillpunishyou."D."YouknowIleaveatthistimeeveryday.We'lltalkaboutthisinmynextdutytime."6.Thenurseisassessingaclientwithpossibleosteoarthritis.ThemostsignificantriskfactorforosteoarthritisisA.congenitaldeformity.B.age.C.trauma.D.obesity.7.Whichpregnancy-relatedphysiologicchangewouldplacetheclientwithahistoryofcardiacdiseaseatthegreatestriskfordevelopingseverecardiacproblems?A.Decreasedheartrate.B.Decreasedcardiacoutput.C.Increasedplasmavolume.D.Increasedbloodpressure.8.ThemostsignificantsignofacuterenalfailureisA.elevatedbodytemperature.B.increasedbloodpressure.C.decreasedurineoutput.D.increasedurinespecificgravity.9.Whenaclientbeingseeninafertilityclinicdoesn'trespondtotheclomiphenecitrate,thephysicianprescribesIMmenotropins(Pergonal).Thisdrugincreasesherriskofproducingmultiplefolliclesthatcouldmaturetoovulation.ToreducethehighriskofmultifetalpregnancyanditspossibleadverseeffectsthenurseshouldmonitorA.ultrasoundstudyresultsandserumestradiollevels.B.ultrasoundstudyresultsandserumprogesteronelevels.C.resultsofteststodetectluteinizinghormone(LH)inurine.D.serumlevelsofhumanchorionicgonadotropin(HCG).10.Thenursediscussesdischargeplanwiththeparentsofachildfollowingasicklecellcrisis.Whichofthefollowingwouldthenurseemphasizetheneedtoseekprompthealthcare?A.Headachesandnausea.B.Fatigueandlassitude.C.Skinrashanditching.D.Sorethroatandfever.11.Johnoftenfindsherselfdaydreamingaboutboy'sandwonderingwhatherlifewillbelikewhenshegetsmarried.AccordingtoPiaget,Johnislikelyinwhichstage?A.SensorimotorstageB.PreoperationalstageC.ConcreteoperationalstageD.Formaloperationalstage12.Whichofthefollowingwouldbethebestapproachwhentryingtotakeacryingtoddler'stemperature?A.Ignorethecryingandscreaming.B.Encouragethemothertoholdthechild.C.Talktothemotherfirstandthentothetoddler.D.Bringextrahelpsoitcanbedonequickly.13.Whichofthenursingactionsdescribedbelowwouldyoucorrectifyousawanursingassistantdoingthis?A.TalkingtoacomatosepatientB.SittingonthebedofadyingpatientholdingherhandandcryingC.AgreeingwiththedaughterofadyingresidentwithAlzheimer'sdiseasethattheburdensassociatedwithartificiallyfeedingherfathermayoutweighthebenefitsD.Tellingadyingpatienttositbackandrelaxandthatshewillwashhimbecauseit'seasierthatway14.Thenurseisspeakingtoagroupofwomenaboutearlydetectionofbreastcancer.Theaverageageofthewomeninthegroupis47.FollowingtheAmericanCancerSociety(ACS)guidelines,thenurseshouldrecommendthatthewomenA.performbreastself-examinationannually.B.haveamammogramannually.C.haveahormonalreceptorassayannually.D.haveaphysicianconductaclinicalexaminationevery2years.15.Whichofthefollowingisnormalneonatecalorieintake?A.90to100caloriesperkilogram.B.110to130caloriesperkilogram.C.30to40caloriesperlbofbodyweight.D.Atleast2mLperfeeding.16.Thenurseispreparingtobeginone-personcardiopulmonaryresuscitation.ThenurseshouldfirstA.establishunresponsiveness.B.callforhelp.C.opentheairway.D.assesstheclientforacarotidpulse.17.Aclientwithahistoryofpanicattacksseekstoincreasesocialinteraction.Eachtimetheclienttriestogotothedayroom,shebeginstoperspireandbecomesshortofbreath.Whichactionbythenursewillhelpeasetheclient'sfeelingsofpanic?A.Haveotherclientsvolunteertoaccompanytheclient.B.Telltheclientshehastoovercomeherfear.C.Allowtheclienttostayinherroom.D.Walkwiththeclientandstaywithherwhileshe'sinthedayroom.18.Thenurseiscaringforabulimicclientandananorecticclient.Whatcognitivecharacteristicswouldbesimilarforbothoftheseclients?A.Perfectionism,preoccupationwithfood.B.Relaxedpersonality,butpreoccupiedwithfood.C.Nosimilarities.D.Preoccupationwithexercise.19.Aclientwhowasfoundhuddledinherapartmentbythepoliceisadmittedtotheclinic.Theclientstarestowardonecorneroftheroomandseemstoberespondingtosomethingnotvisibletoothers.Sheappearshyperalertandscared.Whichofthefollowingconclusionbythenurseismostappropriateaccordingtothesituation?A.Nothingiswrongbecausetheclientisn'tathreattosociety.B.Theclientismalingering.C.Theclientmaybehallucinating.D.Theclientissuicidal.20.Positivesymptomsofschizophreniaincludewhichofthefollowing?A.Waxyflexibility,alogia,andapathy.B.Flataffect,avolition,andanhedonia.C.Hallucinations,delusions,anddisorganizedthinking.D.Somaticdelusions,echolalia,andaflataffect.21.Thenurse-managerofahospitalunitholdsmonthlystaffmeetings.Duringthesemeetings,shemaintainscontroloverthemeetingandagenda,resistsconsensusdecisionmaking,andusesdisciplineandcoerciontoelicitdesiredbehaviorfromstaff.Thismanageruseswhattypeofleadershipstyle?A.Autocratic.B.Democratic.C.Participative.D.Laissez-faire.22.Achildissenttotheschoolnursebecause,accordingtohisteacher,he'sconstantlyscratchinghishead.Whenthenurseassesseshishairandscalp,shefindsevidenceoflice.Whatdidsheprobablysee?A.Flakingofthescalpwithpink,irritatedskinexposed.B.Smallwhitespotsthatadheretothehairshaft,closetothescalp.C.Scaly,circumscribedpatchesonthescalp,withmildalopeciaintheseareas.D.Multipletinypustulesonthescalpwithnoabnormalfindingsonthehairshafts.23.Mr.Lambersrefusestopayincometaxesbecausehisconsciencewillnotallowhimtosupportagovernmentthatspendsbillionsofdollarsonmilitaryweapons.Mr.

Lambers'sreasoningbestillustratesKohlberg's______stage.A.EgocentricB.PreconventionalC.PostconventionalD.Conventional24.Thenurseinstructsthefemaleclientconcerninghormonereplacementtherapyformenopausalsymptoms.Whichofthefollowingpointsshouldthenurseincludeintheclient'steachingplan?A.Estrogentherapyeliminatestheneedforsupplementalcalciumintake.B.Estrogentherapycanreducetheriskofmenopausalboneloss.C.Theriskofuterinecancerisdecreasedaftermenopause.D.Smokingisassociatedwithalateronsetofmenopause.25.Whichassessmentfindingwouldleadthenursetosuspectdehydrationinapretermneonate?A.Bulgingfontanels.B.Excessiveweightgain.C.Urinespecificgravitybelow1.012.D.Urineoutputbelow1mL/hour.26.Amotherofanillchildtellsthenursethatherchild"isn'teatingwell."Whichofthefollowingstrategiesdevisedbythemothertohelpincreasethechild'sintakeisnotappropriate?A.Askingthechildtosaywhyheisnoteating.B.Tellingthechildhemusteatorelsehewillnotgetbetter.C.Allowingthechildtochoosehismealsfromanacceptablelistoffoods.D.Lettingthechildtosubstituteitemsonhistrayforothernutritiousfoods.27.Whichnursinginterventionwouldmostlikelyleadtoahyposmolarstate?A.Performingnasogastric(NG)tubeirrigationwithnormalsalinesolution.B.Weighingtheclientdaily.C.Administeringtapwaterenemauntilthereturnisclear.D.Encouragingtheclientwithexcessiveperspirationtodrinkbroth.28.Whichtoywouldbemostappropriatefora3-year-old?A.Abicycle.B.Apuzzlewithlargepieces.C.Apulltoy.D.Acomputergame.29.Whichofthefollowingnursingdiagnoseswouldbemostappropriatewhenteachingthemotherofatoddler?A.Activityintolerance.B.Riskforinjury.C.Delayedgrowthanddevelopment.D.Impairedmobility.30.Thenurseispreparingtoadministeraunitofbloodtoaclientwhoisanemic.Afteritsremovalfromtherefrigerator,thebloodshouldbeadministeredwithinA.1hour.B.2hours.C.4hours.D.6hours.31.Aclientwhoisagravida1para0hasbeenadmittedtotheperinataladmissionunitandisinearlylabor.Theclient'scervicalexaminationwouldrevealwhichofthefollowing?A.2cmdilated;100%effacedat0station.B.4to5cmdilated;80%effacedat-1station.C.2cmdilated;50%effacedat+1station.D.3cmdilated;50%effacedat0station.32.Afterabingewithcocaine,ayoungmaleisfoundunconsciousandisadmittedtothehospitalwithacutecocainetoxicity.InitialnursingactionshouldbedirectedtowardA.SettinglimitforthepatientB.GivingsupportandunderstandingforthepatientC.EstablishingatherapeuticrelationshipD.Providingthenecessaryphysicalcare33.Whencaringforaclientwhohasrecentlydelivered,thenurseassessestheclientforurinaryretentionwithoverflow.Whichofthefollowingprovidesthemostaccuratepictureofretentionwithoverflow?A.Frequenttripstothebathroomwithanaverageoutputof200to300mLpervoid.B.Intenseurgetourinatewithanaverageoutputof250mL.C.Avaryingurgetourinatewithanaverageoutputof100mL.D.Uterusdisplacedtotherightwithincreasedvaginalbleeding.34.Whilecaringfortheclientwithaburninjury,thenurseshouldobserveforsignsandsymptomsofwhichcomplicationbelievedtobedueprimarilytohypersecretionofgastricacid?A.Paralyticileus.B.Gastricdistention.C.Hiatalhernia.D.Gastrointestinalulceration.35.Thenurseisprovidingcareforapostoperativeclientwhohasundergoneasmallbowelresection.Thenursemayuseanepiduralcatheterforwhichofthefollowing?A.Antibiotictherapy.B.Painmanagement.C.Bloodtransfusion.D.Anticoagulation.36.A14-year-oldfemaleclientinskeletaltractionfortreatmentofafracturedfemurisexpectedtobehospitalizedforseveralweeks.Whenplanningcare,thenurseshouldtakeintoaccounttheclient'sneedtoachievewhatdevelopmentalmilestone?A.Autonomy.B.Initiative.C.Industry.D.Identity.37.A10-year-oldchildwithappendicitisisbeingpreparedforsurgery.Whichofthefollowingwouldbethenurse'sfirstaction?A.Administeranenema.B.Insertanasogastrictube.C.Obtainvitalsigns.D.Administerantibiotics.38.Anadolescentclientimmobilizedinaspicacastcomplainsofhavingtroublebreathingaftermeals.Whichofthefollowingactionswouldbebest?A.Encouragetheclienttodrinkmorebetweenmeals.B.Teachtheadolescentpurse&lipbreathing.C.Givetheclientalaxativeaftermeals.D.Offertheclientsmallfeedingsseveraltimesaday.39.TheclientistoreceiveanIVinfusionof3000mLofdextroseandnormalsalinesolutionover24hours.Thenurseobservesthattherateis150mL/hour.Ifthesolutionrunscontinuouslyatthisrate,theinfusionwillbecompletedinA.12hours.B.20hours.C.24hours.D.50hours.40.Thenurseiscaringforatoddlerinrespiratoryarrest.ThenursewillassistwithendotrachealintubationanduseanuncurledtubebecausetheA.vocalcordsprovideanaturalseal.B.tracheaisshorter.C.larynxisanteriorandcephalad.D.cricoidcartilageisthenarrowestpartofthelarynx.41.Thecorrectprocedureforauscultatingtheclient'sabdomenforbowelsoundswouldincludeA.palpatingtheabdomenfirsttodeterminecorrectstethoscopeplacement.B.encouragingtheclienttocoughtostimulatemovementoffluidandairthroughtheabdomen.C.placingtheclientontheleftsidetoaidauscultation.D.listeningfor5minutesinallfourquadrantstoconfirmabsenceofbowelsounds.42.AclientwhohasrecentlyhadsurgeryforprostatecancerexpressestothenursefeelingsofangertowardGod,hischurch,andtheclergy.Whichinterventionisn'tappropriateforthisclient?A.Acknowledgingtheclient'sspiritualdistress.B.Invitingtheclient'sclergymantovisithim.C.Encouragingtheclienttodiscussreligiousbeliefsandpractices.D.Encouragingtheclienttodiscussconcernswiththeclergy.43.Aclientinacuterenalfailureisadmittedtothenephrologyunit.Theperiodofoliguriaintheseclientsusuallylastsaboutt0days.Whichofthefollowingassessmentsofkidneyfunctionwouldthenursemakeduringtheoliguricphase?A.Nourineoutput;kidneysinastateofsuppression.B.Urineoutputof30to60mL/hr.C.Urineoutputoflessthan400to600mLin24hours.D.UrineoutputdirectlyrelatedtotheamountofIVfluidsinfused.44.Amultigravidainher34thweekofgestationpresentsintheemergencydepartmentcomplainingofvaginalbleeding.Whichofthefollowingshouldbethenurse'sfirstaction?A.EstablishIVaccess.B.Assessfetalheartrate(FHR)andmaternalbloodpressure.C.Preparetheclientforacesareandelivery.D.Assessmaternalheartrateandrespiratoryrate.45.ThenurseisteachingaclientandhisfamilyaboutdietarypracticesrelatedtoParkinson'sdisease.ApriorityforthenursetoaddressisriskofA.fluidoverloadanddrooling.B.aspirationandanorexia.C.chokinganddiarrhea.D.dysphagiaandconstipation.46.Thenurseisassessingapregnantwomanintheclinic.Inthecourseoftheassessment,thenurselearnsthatthiswomansmokesonepackofcigarettesperday.Whichofthefollowingisthefirststepthenurseshouldtaketohelpthewomanstopsmoking?A.Assesstheclient'sreadinesstostop.B.Suggestthattheclientreducethedailynumberofcigarettessmokedbyone-half.C.Providetheclientwiththetelephonenumberofaformalsmoking-cessationprogram.D.Helptheclientdevelopaplantostop.47.ThenurseshouldencourageaclientwithawoundtoconsumefoodshighinvitaminCbecausethisvitaminA.restorestheinflammatoryresponse.B.enhancesoxygentransporttotissues.C.reducesedema.D.enhancesproteinsynthesis.48.Aclienthashadatotalgastrectomyforgastriccancer.Whichoneofthefollowingisthemostappropriateexpectedoutcomesaboutnutrition?A.Theclientwilllearntoself-administerenteralfeedingsevery4hours.B.Theclientwillmaintainadequatenutritionthroughoralorparenteralfeedings.C.Theclientwillregainanyweightlostwithin4weeksofthesurgicalprocedure.D.Theclientwilleatthreefullmealsadaywithoutexperiencinggastriccomplications.49.Followingacystoscopythatconfirmedadiagnosisofbladdercancer,aclientisscheduledforchemotherapyandailealconduiturinarydiversion.Thenurseshouldincludewhichofthefollowingpointsintheclient'spreoperativeteaching?A.Theclient'sneedtoperformstomaself-careimmediatelyaftersurgery.B.Theclient'sneedtoremainonbedrestfor3daysfollowingsurgery.C.Theprocedurecreatesastomaandhemustwearapouchafterward.D.Theclientwillbeabletocontrolurinepassagethroughthestoma.50.Whenaclientexperiencesalossofvibratorysenseonexamination,thisindicatesA.injurytothecranialnerves.B.injurytotheperipheralnerves.C.intactcranialnerves.D.intactperipheralnerves.第1卷參考答案一.Comprehensivetestcenter1.參考答案：BBeforereportingtheseconcernstothephysician,thenurseshoulddiscusstheperceivedproblemaboutthemedicationswiththeclient.Thenursewillthenhavemoreinformationabouttheclient'sattitudetowardanti-anxietymedicationswhensheinformsthephysicianofhersuspicions.Searchingtheclient'sroomforthemedicationsisaviolationoftheclient'srighttoprivacy.Thenurseandthephysiciancantalktotheclientaboutthebenefitsoftakingthemedicationprescribed;however,theclienthastherighttorefusethemedication.2.參考答案：BKegelexercisesareperformedbyalternatelytighteningandreleasingperinealmusclestostrengthenthepubococcygeusmuscleandincreaseitselasticity.Thepubococcygeusmusclesupportsinternalorgans,suchastheuterusandbladder.Kegelexercisesdon'taffectbreathingormusclesofthediaphragm,leg,orabdomen.3.參考答案：DThemostcommonsymptomofpancreatitisisintenseabdominalpaininthemid-epigastricareaortheleftupperquadrant.Thepainmayradiatetotheback.4.參考答案：CPouringsolutionontoasterilefieldclothviolatessurgicalasepsisbecausemoisturepenetratingtheclothcancarrymicroorganismstothesterilefieldviacapillaryaction.Theotheroptionsarepracticesthathelpensuresurgicalasepsis.5.參考答案：D6.參考答案：BAgeisthemostsignificantriskfactorfordevelopingosteoarthritis.Developmentofprimaryosteoarthritisisinfluencedbygenetic,metabolic,mechanical,andchemicalfactors.Secondaryosteoarthritisusuallyhasidentifiableprecipitatingeventssuchastrauma.7.參考答案：CPregnancyincreasesplasmavolumeandexpandstheuterinevascularbed,possiblyincreasingtheheartrateandcardiacoutput.Thesechangesmaycausecardiacstress,especiallyduringthesecondtrimester.Bloodpressureduringearlypregnancymaydecrease,butitgraduallyreturnstoprepregnancylevels.8.參考答案：CAsuddenchangeinurineoutputistypicalofacuterenalfailure.Mostcommonly,theinitialchangeisgreatlydecreasedurineoutput.Laterinthecourseofacuterenalfailure,theclientmayhavemarkeddiuresis(nonoliguricfailure).9.參考答案：ATheobjectiveofmenotropinstherapyistoproduceoneortwohealthyfollicles;bycarefullymonitoringtheclient'sultrasoundstudyresultsandserumestradiollevels,thenursecandeterminethenumberofmaturingfollicles.Serumprogesteronelevelsindicatewhetherovulationhasoccurredandcorrelatewellwithbasalbodytemperaturechangesbutdon'tindicatethenumberoffollicles.ThetesttodetecturinarylevelsofLHisahormonalassessmentofovulatoryfunction--notanassessmentofthenumberofmaturingcells.SerumlevelsofHCGindicatewhetherthecorpusluteumisproducingenoughestrogenandprogesteronetomaintainthepregnancyuntiltheplacentadevelopsfurther.10.參考答案：DChildrenwithsicklecelldiseasearepronetodevelopinfectionsasaresultofthenecrosisofareaswithinthebodyandageneralizedless-than-optimalhealthstatus.Ifthechildwithsicklecellanemiadevelopssignsofinfection,suchassorethroatandfever,promptevaluationisnecessarybecauseaninfectioncanprecipitateacrisis.11.參考答案：D12.參考答案：CWhendealingwithacryingtoddler,thebestapproachistotalktothemotherandignorethetoddleratfirst.Thisapproachhelpsthetoddlergetusedtothenursebeforesheattemptsanyprocedures.Italsogivesthetoddleranopportunitytoseethatthemothertruststhenurse.Ignoringthecryingandscreamingmaybethesecondstep.Havingthemotherholdthetoddlerwillhelpifshecandothis.Thelastresortistobringinassistancesotheprocedurecanbecompletedquickly.13.參考答案：D14.參考答案：BAccordingtotheACSguidelines,"Womenolderthanage40shouldhaveamammogramannuallyandaclinicalexaminationatleastannually(notevery2years);allwomenshouldperformbreastself-examinationmonthly(notannually)."Thehormonalreceptorassayiscloneonaknownbreasttumortodeterminewhetherthetumorisestrogen-orprogesterone-dependent.15.參考答案：BCaloriesperkgistheacceptedwayofdeterminingappropriatenutritionalintakeforaneonate.Therecommendedcalorierequirementis110to130caloriesperkgofneonatebodyweight.Thislevelwillmaintainaconsistentbloodglucoselevelandprovideenoughcaloriesforcontinuedgrowthanddevelopment.16.參考答案：AThecorrectsequencebeginswithestablishingunresponsiveness.Thenurseshouldthencallforhelp,assesstheclientforbreathingwhileopeningtheairway,delivertwobreaths,andcheckforacarotidpulse.17.參考答案：DTheclientmayfindsecurityinthepresenceofatrustedperson.Herfearsareveryrealandshe'llneedtheemotionalsupportofcaringprofessionalstoovercomethem.Tellingtheclientshehastoovercomeherfearsminimizesherfeelings.Allowingtheclienttostayinherroomdoesn'thelptheclientovercomeherfeelingsofpanic.18.參考答案：ACognitivedistortionsaresimilarinbothdisorders.Rarelydopeoplewitheatingdisordershaverelaxedpersonalities.Theanorecticclientismorelikelythanthebulimicclienttooverexerciseforweightcontrol.19.參考答案：CThescenarioistypicalofaclientwhoishallucinating.Notenoughinformationisavailabletosuggestthatshe'sathreattoherselfortosociety.Malingeringreferstoamedicallyunprovensymptomthatisconsciouslymotivated.20.參考答案：CThepositivesymptomsofschizophreniaaredistortionsofnormalfunctioning,includinghallucinations,delusions,disorganizedthinking,somaticdelusions,echolalia,andwaxyflexibility.Aflataffect,alogia,apathy,avolition,andanhedoniarefertothenegativesymptoms.Negativesymptomslistthediminutionorlossofnormalfunction.21.參考答案：AAutocraticleadersobtainpowerwithagroupbymaintainingcontroloverthegroup.Democraticleaderssharepowerbyallowingconsensusdecisionmakinganddistributionofpower.Participativeleadershipisanothertermfordemocraticleadership.Laissez-faireleadersmaintainnocontroloverthegroup;decisionmakingisunstructuredandcommonlyperformedbyanunofficialleaderofthegroup.22.參考答案：BThesmallwhitespotsthatadheretothehairshaftsaretheeggs,ornits,oflice.Theseareeasytoseeandcan'tbebrushedofflikedandruff.Flakingofthescalpmayindicatedandrufforadryscalp.Scalypatchesandpustules,duetothescratching,mayaccompanyaliceinfestation,butnitswouldalsobefoundonthehairshafts.23.參考答案：C24.參考答案：BResearchstudieshavedemonstratedthatestrogenhasbeeneffectiveindecreasingboneloss.25.參考答案：DAurineoutputbelow1mL/hourisasignofdehydration.Othersignsofdehydrationincludedepressedfontanels,excessiveweightloss,decreasedskinturgor,drymucousmembranes,andurinespecificgravityabove1.012.26.參考答案：BAlthoughnutritionplaysalargepartinthehealingprocess,itisnotadvisabletotellachildthathewillnotgetbetterifhedoesordoesnotdoaparticularactivity.Notonlyisthisdishonest,italsomakesthechildbelievethathisownactionsarecausingtheillness.27.參考答案：CAdministeringatapwaterenemauntilreturnisclearwouldmostlikelycontributetoahyposmolarstate.Becausetapwaterishypotonic,itwouldbeabsorbedbythebody,dilutingthebodyfluidconcentrationandloweringosmolality.NGtubeirrigationwithnormalsalinesolutionwouldn'tcauseashiftinfluidbalance.Weighingtheclientistheeasiest,mostaccuratemethodtodeterminefluidchanges.Therefore,ithelpsidentifyratherthancontributetofluidimbalance.Drinkingbrothwouldn'tcontributetoahyposmolarstatebecauseitdoesn'treplacesodiumandwaterlostthroughexcessiveperspiration.28.參考答案：BAtage3,childrenliketocolor,draw,andputtogetherpuzzles.Abicycleisappropriatefora5-or6-year-oldchild;apulltoy,foratoddler;andacomputergame,foraschool-agechild.29.參考答案：BThemostappropriatenursingdiagnosiswouldbeRiskforinjurybecauseatoddleristypicallyengagedinexploringtheenvironmentwhilebecomingincreasingmobile.Safetyissuesareanimportantpartofanticipatoryguidancewithparentsoftoddlers.30.參考答案：CAfterthebloodisremovedfromtherefrigerator,itmustbeadministeredwithin4hours.Refrigerationdelaysthegrowthofbacteriaintheblood.OptionsAandBareincorrectbecausetheclientcouldexperiencefluidoverloadifthebloodisadministeredtoorapidly.OptionDisincorrectbecauseoftheextendedtimeoutofrefrigerationandriskofcontaminationandgrowthofbacteria.31.參考答案：AThenursemustdistinguishbetweentheprimigravidaandmultigravidacervicaldilationtomakeaplanofcareforthelaboringclient.Primigravidaswilleffaceandthendilate,whilemultigravidaswilleffaceanddilateatthesametime.32.參考答案：D33.參考答案：CRetentionwithoverflowisacommonlymissednursingassessment.Becausetheclientmaybevoidingandmaynothaveanurgetovoiddoesn'tmeanthatbladderfunctionhasbeenproperlyrestored.Avaryingurgetourinatewithanaverageurineoutputof100mLisaclassicpictureofaclientwhosebladderisdistendedandneedstobecatheterizedtorestorenormalfunction.34.參考答案：DGastrointestinalulceration,alsoknownasCurling'sulcer,occursinabouthalfofclientssufferingfromsevereburns.Theincidenceofulcerationappearsproportionaltotheextentoftheburnsandisbelievedtobeduetohypersecretionofgastricacidandcompromisedgastrointestinalperfusion.35.參考答案：BAdministrationofpainmedicationthroughanepiduralcatheterisrecommendedifseverepainisanticipatedorifthepaindoesn'trespondtolessinvasivemeasures.Epiduralcatheterscanalsobeusedfortheadministrationofregionalanesthesia.Epiduralcathetersmaynotbeusedforantibiotictherapy,bloodtransfusion,oranticoagulation.36.參考答案：DAccordingtoErickson'stheoryofpersonaldevelopment,theadolescentisinthestageofidentityversusrole