1、美国护士资格认证(CGFNS)-20 及答案解析(总分：53.00，做题时间：90 分钟)一、Part One(总题数：30，分数：30.00)1.While a client with hypertension is being assessed, he says to the nurse, “I really dont know why Im here. I feel fine and havent had any symptoms. “ Which of the following would be the nurses best response?A. “Symptoms of hyp
2、ertension are often not present. “B. “Symptoms of hypertension signify a high risk of stroke. “C. “Symptoms of hypertension occur only with malignant hypertension. “D. “Symptoms of hypertension appear after irreversible kidney damage has occurred. /（分数：1.00）A.B.C.D.2.Mrs. Cray, an African American,
3、is admitted to the hospital after sustaining a hip fracture. She is 5 ft. , 4 inches tall and weighs 96 lbs. She has five children and has used estrogen replacement therapies for 10 years. She told the nurse that she “just stepped forward and fell. “ The results of her bone density tests indicate sh
4、e has osteoporosis. Which of the following is the greatest risk factor for osteoporosis for this woman?A. Her long-term use of estrogen.B. Her weight.C. Her family.D. Her race.（分数：1.00）A.B.C.D.3.The client exhibits signs of sleep disturbance. Which intervention should the nurse try first?A. Administ
5、er sleeping medication before bedtime.B. Provide the client with normal sleep aids, such as pillows, back rubs, and snacks.C. Ask the client each morning to describe the quality of sleep during the previous night.D. Teach the client relaxation techniques, such as guided imagery, meditation, and prog
6、ressive muscle relaxation.（分数：1.00）A.B.C.D.4.A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is d
7、iscussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?A. Provide an unstructured environment for the client.B. Rotate the nurses who are assigned to the client.C. Ignore the clients behaviors.D. Bend unit rules to meet the
8、clients needs.（分数：1.00）A.B.C.D.5.The nurse is caring for several clients who have eating disorders. Based on appearance, how would the nurse distinguish bulimic clients from anorectic clients?A. By their teeth.B. By body size and weight.C. By looking for Mallory-Weiss tears.D. The clients are indist
9、inguishable upon physical examination.（分数：1.00）A.B.C.D.6.The nurse is instructing an unlicensed assistant on how to collect a urine specimen from an indwelling catheter. Which of the following statements indicates that the assistant understands the instructions?A. “I will empty the catheter drainage
10、 bag, have the client drink some water, and an hour later collect the urine that drains into the bag. “B. “I will get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container. “C. “I should collect urine from the catheter drainage bag at the
11、 end of the shift and place it in the specimen container. “D. “I will disconnect the drainage tube from the catheter and let urine run from the catheter into the specimen container. /（分数：1.00）A.B.C.D.7.The nurse plans to teach a client who is receiving radiation therapy how to care for his skin at h
12、ome. Which of the following should be included in the nurses instructions?A. “Apply a heating pad to the area to relieve pain. “B. “Keep the area covered when you go outdoors. “C. “You may use deodorant soap if you wish to cleanse the area. “D. “Put baby oil on the area after each treatment to keep
13、it from getting dry. /（分数：1.00）A.B.C.D.8.A client with diabetes is explaining to the nurse how he cares for his feet at home. The nurse could judge from which of the following statements that the client needs further instruction on how to care for his feet properly?A. “I inspect my feet once a week
14、for cuts and redness. “B. “I am not allowed to use a heating pad on my feet. “C. “It is important to dry my feet carefully after my bath. “D. “I should not go barefoot, even in my home. /（分数：1.00）A.B.C.D.9.Which of the following nursing interventions is most important postoperatively for an infant w
15、ho has received a ventriculoperitoneal shunt?A. Monitoring intake and output.B. Allowing the infant to rest undisturbed.C. Providing age-appropriate diversionary activities.D. Initiating oral feedings.（分数：1.00）A.B.C.D.10.The nurse noticed that an 8-month-old childs posterior fontanel is slightly ope
16、n. Which of the following should the nurse do next?A. Check the childs head circumference.B. Question the mother about the childs delivery.C. Schedule an X-ray of the childs head.D. Document this as a normal finding.（分数：1.00）A.B.C.D.11.When developing a teaching plan for the mother of a child diagno
17、sed with spastic cerebral palsy, which of the following descriptions would the nurse include?A. Wide-based gait and poor muscle coordination.B. Tremors and lack of active movement.C. Increased muscle tone and stretch reflexes.D. Slow, wormlike writhing movements.（分数：1.00）A.B.C.D.12.Which of the foll
18、owing findings is suggestive of myocardial infarction (MI)?A. Below-normal erythrocyte sedimentation rate.B. Elevated white blood cell count.C. Elevated serum cholesterol value.D. Elevated creatine phosphokinase (CPK) value.（分数：1.00）A.B.C.D.13.Mrs. Wilson, a primigravida, was admitted to the hospita
19、l at 12 weeks gestation. She is complaining of abdominal cramping, exhibits bright red vaginal spotting without cervical dilation. The nurse determines that the client is most likely experiencing which of the following types of abortion?A. Complete.B. Threatened.C. Inevitable.D. Missed.（分数：1.00）A.B.
20、C.D.14.A client with a seizure disorder has been prescribed phenytoin (Dilantin). Which of the following should the nurse include in the teaching plan?A. It will be necessary for the client to take potassium supplements to prevent hypokalemia.B. The client should use a soft toothbrush and floss teet
21、h daily.C. The use of phenytoin can lead to the development of diabetes.D. It is appropriate to substitute various brands of phenytoin as long as the dosage is the same.（分数：1.00）A.B.C.D.15.A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nu
22、rse would expect to administer which of the following medication?A. Ritodrine (Yutopar).B. Bromocriptine (Parlodel).C. Betamethasone (Celestone).D. Magnesium sulfate.（分数：1.00）A.B.C.D.16.The client experiences a wound evisceration on day 2 after the abdominal hysterectomy. What should the nurse immed
23、iately do?A. Approximate the wound edges by applying strips of adhesive over the wound.B. Cover the exposed tissues with sterile dressings moistened with normal saline solution.C. Replace the abdominal contents into the wound carefully while wearing gloves.D. Apply a loose-fitting sterile abdominal
24、binder over the wound.（分数：1.00）A.B.C.D.17.While caring for the client with a burn injury, the nurse should observe for signs and symptoms of which complication believed to be due primarily to hypersecretion of gastric acid?A. Paralytic ileus.B. Gastric distention.C. Hiatal hernia.D. Gastrointestinal
25、 ulceration.（分数：1.00）A.B.C.D.18.Which of the following serum electrolyte levels would the nurse expect to find in an infant with persistent vomiting?A. K+, 3.2 mEq/L; Cl-, 92 mEq/L; Na+, 120 mEq/L.B. K+, 3.4 mEq/L; Cl-, 120 mEq/L; Na+, 140 mEq/L.C. K+, 3.5 mEq/L; Cl-, 90 mEq/L; Na+, 145 mEq/L.D. K+,
26、 5.5 mEq/L; Cl-, 110 mEq/L; Na+, 130 mEq/L.（分数：1.00）A.B.C.D.19.A priority nursing diagnosis during the first 24 hours following an MI isA. Ineffective cardiac tissue perfusion.B. Risk for infection.C. Deficient fluid volume.D. Constipation.（分数：1.00）A.B.C.D.20.The physician prescribes clomiphene citr
27、ate (Clomid) for a woman who has been having difficulty getting pregnant. When preparing the teaching plan for the client about this drugs potential side effects, which of the following would the nurse include in the teaching plan?A. Increase in fibrocystic breast disease.B. Increase in congenital a
28、nomalies.C. Multiple pregnancies.D. Increase in spontaneous abortions.（分数：1.00）A.B.C.D.21.The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?A. Presence of menses.B. Uterine enlargement.C. Breast sensitivity.D. Fetal heart
29、 tones.（分数：1.00）A.B.C.D.22.A client is prescribed 1000 mL of an antibiotic solution to be given over 6 hours. What would be the flow rate? The infusion set administers 15 gtts/mL.A. 28 gtts/min.B. 35 gtts/min.C. 42 gtts/min.D. 45 gtts/min.（分数：1.00）A.B.C.D.23.During the assessment stage, a client wit
30、h schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. Which of the following explains his action?A. Somatic delusions.B. Waxy flexibility.C. Neologisms.D. Nihilistic delusions.（分数：1.00）A.B.C.D.24.A client is taking chlorpropamide (Diabenese). Which of the following
31、side effects should be nurse expect from the medication?A. Hypoglycemia.B. Oral candidiasis.C. Dumping syndrome.D. Extrapyramidal symptoms.（分数：1.00）A.B.C.D.25.An agitated client demands to see his chart so that he can read what has been written about him. Which of the following statements is the nur
32、ses best response in this situation?A. “Im sorry the chart is the property of the facility. We dont permit clients to read them. “B. “You have the right to see your chart. Please discuss this with your primary care provider. “C. “You may see your chart after youre discharged. “D. “Please discuss thi
33、s matter with your attorney. /（分数：1.00）A.B.C.D.26.The nurse notices that a depressed client taking amitriptyline (Elavil) for 2 weeks has become very outgoing, cheerful, and talkative. The nurse would suspect which of the following?A. The client is responding to the antipsychotic.B. The client may b
34、e experiencing increased energy and is at an increased risk for suicide.C. The client is ready to be discharged from treatment.D. The client is experiencing a split personality.（分数：1.00）A.B.C.D.27.When caring for an adolescent client diagnosed with depression, the nurse should remember that depressi
35、on manifests differently in adolescents and adults. In an adolescent, signs and symptoms of depression are likely to include which of the following?A. Helplessness, hopelessness, hypersomnolence, and anorexia.B. Truancy, a change of friends, social withdrawal, and oppositional behavior.C. Curfew bre
36、aking, stealing from family members, truancy, and oppositional behavior.D. Hypersomnolence, obsession with body image, and valuing of peers opinions.（分数：1.00）A.B.C.D.28.The nurse is assessing a client with an ileal conduit. She notes that the clients urinary appliance contains pale yellow urine with
37、 large amounts of mucus. How would the nurse best interpret these data?A. These findings are normal for the client.B. There is irritation of the stoma.C. The client is developing an infection of the urinary tract.D. The mucus is caused by elevated levels of glucose in the urine.（分数：1.00）A.B.C.D.29.T
38、he nurse is caring for a client who has generalized anxiety disorder. Which statement is true about this client?A. The client has regular obsessions.B. Relaxation techniques and psychotherapy are necessary for cure.C. Nightmares and flashbacks are common in individuals who suffer from generalized an
39、xiety disorder.D. Generalized anxiety disorder is characterized by anxiety that lasts longer than 6 months.（分数：1.00）A.B.C.D.30.Which of the following signs or symptoms would the nurse expect to see in a client with pancreatitis?A. Bradycardia.B. Hypertension.C. Decreased white blood cell count.D. Le
40、ft upper quadrant abdominal pain.（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23.00)31.Which of the following is an appropriate health promotion activity to reduce the incidence of osteoporosis?A. Teaching women to maintain adequate calcium intake.B. Teaching women how to administer pain medication safely.
41、C. Avoiding estrogen replacement therapy when postmenopausal.D. Teaching women to increase caffeine intake as a preventive measure.（分数：1.00）A.B.C.D.32.A client has just expelled a hydatidiform mole. Shes visibly upset over the loss and wants to know when she can try to become pregnant again. Which o
42、f the following would be the nurses best response?A. “I can see youre upset. Why dont we discuss this with you at a later time when youre feeling better. “B. “I can see that youre upset; however, you must wait at least 1 year before becoming pregnant again. “C. “Let me check with your physician and
43、get you something that will help you relax. “D. “Pregnancy should be avoided until all of your testing is normal. /（分数：1.00）A.B.C.D.33.Immediately after a spontaneous rupture of the membranes, the nurse observes a loop of umbilical cord protruding from the vagina. What should the nurse do first?A. A
44、dminister oxygen.B. Notify the physician.C. Document the deceleration.D. Elevate the hips on two pillows.（分数：1.00）A.B.C.D.34.A 30-year-old primigravida tells the nurse that her hemorrhoids have become itchy and painful. The nurse instructs the client about relief measures. From which of the followin
45、g statements by the client would the nurse suspect that the client needs further instructions?A. “I should sit in a warm sitz bath daily. “B. “I can use a topical ointment for relief. “C. “I should apply an ice pack at night. “D. “I should decrease my fluid intake. /（分数：1.00）A.B.C.D.35.During a conv
46、ersation with the client, the nurse observes the client shaking his leg and tapping his fingers on the table next to him. The nurses best statement is.A. “Ill get you something to help you feel less anxious. “B. “I know that you feel anxious. Lets discuss something more pleasant. “C. “I see that you
47、re anxious. Ill be back later when youre calmer. “D. “I noticed that your leg is shaking and youre tapping your fingers on the table. How are you feeling now?/（分数：1.00）A.B.C.D.36.Which of the following is the nurses goal in crisis intervention?A. To provide medication to sedate the client.B. To prov
48、ide nondirective techniques such as free association.C. To provide problem-solving techniques and structured activities.D. To provide an insight-oriented analytic approach.（分数：1.00）A.B.C.D.37.When caring for a client who has had a cesarean birth, which of the following nursing interventions is least
49、 appropriate?A. Removing the initial dressing for incision inspection.B. Monitoring pain status and providing necessary relief.C. Supporting self-esteem concerns about delivery.D. Assisting with parental neonate bonding.（分数：1.00）A.B.C.D.38.In developing a plan of care for a client with rheumatoid arthritis, the nurse should consider that clients with rheumatoid arthritis should be positioned so as toA. prevent flexion deformities of the joints.B. decrease edema around the joints.C. promote maximum comfort.D. prevent venous stasis.（分数：1.00）A.B.C.D.39.Which one o
