1、美国护士资格认证(CGFNS)-26 及答案解析(总分：49.00，做题时间：90 分钟)一、BPart One/B(总题数：29，分数：29.00)1.When an adolescent female client with the diagnosis of anorexia nervosa starts to discuss food and eating, the nurse should plan to A.Tell her gently but firmly to direct all discussion of food to the dietitian B.Use her cu
2、rrent interest in food to encourage her to increase her intake C.Listen closely to determine her favorite foods and secure these foods for her D.Let her talk about food as long as she wants, but limit discussion about her eating（分数：1.00）A.B.C.D.2.The nurse is providing care for a pregnant 16-year-ol
3、d client. The client says that shes concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying. A. “Now isnt a good time to begin dieting because you are eating for two. “ B. “Lets explore your feelings further. “ C. “ Nutrition is important because deprivi
4、ng your baby of nutrients can cause developmental and growth problems. “ D. “The prenatal vitamins should ensure the baby gets all the necessary nutrients. “（分数：1.00）A.B.C.D.3.A client with a seizure disorder has been prescribed phenytoin (Dilantin). Which of the following should the nurse include i
5、n 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 teeth daily. C. The use of phenytoin can lead to the development of diabetes. D. It is appropriate to substitute various brands of ph
6、enytoin as long as the dosage is the same.（分数：1.00）A.B.C.D.4.Positive symptoms of schizophrenia include which of the following? A. Waxy flexibility, alogia, and apathy. B. Flat affect, avolition, and anhedonia. C. Hallucinations, delusions, and disorganized thinking. D. Somatic delusions, echolalia,
7、 and a flat affect.（分数：1.00）A.B.C.D.5.One-year-old Susan, the second child to have sickle cell disease in a family of five children, is admitted to the hospital with sickle cell crisis. When preparing the plan of care for her, which of the following treatments would the nurse most likely expect to i
8、nclude in the plan? A. Intravenous fluid therapy. B. Fast-acting anticoagulant therapy. C. Parenteral iron therapy. D. Exchange transfusion.（分数：1.00）A.B.C.D.6.A client is prescribed Gentamycin (Garamycin) IV to treat infection. It is important to monitor the client for the development of which of th
9、e following side effects from the medication? A. Ascites. B. Confusion. C. Ototoxicity. D. Cardiac dysrhythmias.（分数：1.00）A.B.C.D.7.Which of the following is NOT a contributory factor to thermoregulation in the preterm neonate? A. Immature central nervous system (CNS). B. Large skin surface area. C.
10、Lack of subcutaneous (SC) and brown fat. D. Tendency toward capillary fragility.（分数：1.00）A.B.C.D.8.The nurse is providing care for an immobilized client. For this client, the most appropriate and most effective nursing intervention would be A. getting the client out of bed and into a chair for 30 mi
11、nutes, twice daily. B. avoiding repositioning the client if hes comfortable. C. repositioning the client on alternate sides at least every 2 hours. D. positioning the client with the greatest pressure at the bony prominence.（分数：1.00）A.B.C.D.9.The nurse is evaluating a client who is complaining of sh
12、ortness of breath. The clients respiratory rate is 26 breaths per minute so the nurse documents that he is tachypneic. The nurse understands that tachypnea means A. frequent bowel sounds. B. heart rate greater than 100 beats/minute C. hyperventilation. D. respiratory rate greater than 20 breaths/min
13、ute（分数：1.00）A.B.C.D.10.When a client experiences a loss of vibratory sense on examination, this indicates A. injury to the cranial nerves. B. injury to the peripheral nerves. C. intact cranial nerves. D. intact peripheral nerves.（分数：1.00）A.B.C.D.11.Mrs. Cray, an African American, is admitted to the
14、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 she has osteoporosis.
15、 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.12.Which client has the highest risk of ovarian cancer? A. 30-year-old woman taking oral contraceptive pills. B. 45-year-o
16、ld woman who has never been pregnant. C. 40-year-old woman with three children. D. 36-year-old woman who had her first child at age 22.（分数：1.00）A.B.C.D.13.A 6-year-old girl has been hospitalized with rheumatic fever for 4 weeks. Her symptoms have gradually subsided, and shes now ready for discharge.
17、 Which of the following plans for her health care is most important for her future well-being? A. Arrange for her to return to school as soon as possible to promote psychosocial development. B. Encourage her to engage in unrestricted physical activity to regain physical strength. C. Arrange for the
18、administration of prophylactic antibiotics to prevent a recurrence of rheumatic fever. D. Maintain seizure precautions, as central nervous system involvement may persist for several months.（分数：1.00）A.B.C.D.14.The nurse is administering magnesium sulfate to a client with preeclampsia. The nurse expla
19、ins to the client that this drug is given for which of the following reason? A. To prevent seizures. B. To reduce blood pressure. C. To slow the process of labor. D. To increase diuresis.（分数：1.00）A.B.C.D.15.At an outpatient clinic, a client asks the nurse how she can prepare for pregnancy. Which of
20、the following responses by the nurse would be best? A. “Begin an iron supplement of 100 mg daily. “ B. “Supplement your diet with 400 meg of folio acid. “ C. “Avoid raw eggs and cats until conception. “ D. “Receive immunization against toxoplasmosis. “（分数：1.00）A.B.C.D.16.The nurse is teaching a clie
21、nt recently diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by A. genetic dysfunction. B. upper and lower motor neuron lesions. C. decreased conduction of impulses in an upper motor neuron lesion. D. a lower motor neuron lesion.（分数：1.00）A.B.C.D.17
22、.A 15-year-old boy is admitted to the health care facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include which of the following? A. Violence on television. B. Passive parents. C. An internal locus of control. D. A single-pare
23、nt family.（分数：1.00）A.B.C.D.18.A client who has been admitted to the emergency room is restless and agitated, has dry mucous membranes, and is complaining of intense thirst. The nurse suspects which of the following electrolyte imbalances? A. Hypokalemia. B. Hypercalcemia. C. Hypomagnesemia. D. Hyper
24、natremia.（分数：1.00）A.B.C.D.19.Whats the most appropriate nursing diagnosis for a client exhibiting obsessive-compulsive behavior? A. Ineffective coping. B. Imbalanced nutrition: Less than body requirements. C. Imbalaneed nutrition: More than body requirements. D. Interrupted family processes.（分数：1.00
25、）A.B.C.D.20.A client with heart failure loses 3.2 kg while hospitalized. Approximately how many pounds has the client lost? A. 1 pound. B. 3 pounds. C. 5 pounds. D. 7 pounds.（分数：1.00）A.B.C.D.21.From an analysis of the data collected about the client who has had a gastric resection, the nurse formula
26、tes the nursing diagnosis Risk for ineffective airway clearance. Based on which of the following postoperative factors would the nurse make this diagnosis? A. Incisional pain. B. Nausea. C. Progressive ambulation. D. Maintenance of a semi-Fowlers position.（分数：1.00）A.B.C.D.22.A male client with a tot
27、al hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take? A. Assume hes anxious about discharge, and administer pain medication. B. Assess the surgical sit
28、e and affected extremity. C. Reassure the client that pain is a direct result of increased activity. D. Suspect a wound infection, and monitor the clients temperature and vital signs.（分数：1.00）A.B.C.D.23.Which of the following would not be an indication of placental detachment? A. An abrupt lengtheni
29、ng of the cord. B. An increase in the number of contractions. C. Relaxation of the uterus. D. Increased vaginal bleeding.（分数：1.00）A.B.C.D.24.Many clients on the eating disorders unit have been admitted for anorexia nervosa. The signs and symptoms that would be most specific for this diagnosis are A.
30、Slow pulse, 10% weight loss, and alopecia B.Compulsive behaviors, excessive fears, and nausea C.Excessive activity, memory lapses, and an increased pulse D.Excessive weight loss, amenorrhea, and abdominal distention（分数：1.00）A.B.C.D.25.An elderly client with Alzheimers disease begins supplemental tub
31、e feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for A. hypoglycemia. B. fluid volume excess. C. aspiration. D. constipation.（分数：1.00）A.B.C.D.26.The nurse plans to teach a client who is receiving radiation therapy how to
32、care for his skin at home. 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 aft
33、er each treatment to keep it from getting dry. “（分数：1.00）A.B.C.D.27.A client hospitalized with a pneumothorax has the following arterial blood gas (ABG) analysis: pH, 7.19; partial pressure of arterial carbon dioxide (PaCO2), 63 mmHg; and , 22 mEq/L. A chest tube was inserted and oxygen administered
34、 at 4 L/min by nasal cannula. One hour after the initiation of treatment, ABG analysis reveals: pH, 7.28; PaCO2, 52 mmHg; and （分数：1.00）A.B.C.D.28.A 20-year-old woman has just been diagnosed with Crohns disease. She has lost 10 lb (4.5kg) and has cramps and occasional diarrhea. The nurse should inclu
35、de which of the following when doing a nutritional assessment? A. Let the client eat as desired during hospitalization. B. Weigh the client daily. C. Ask the client to list what she eats during a typical day. D. Place the client on IO status and draw blood for electrolyte levels.（分数：1.00）A.B.C.D.29.
36、After teaching the mother about tests performed to monitor the success of the infants treatment for congenital hypothyroidism, the nurse would determine that the teaching was effective when the mother states that the child will need frequent blood tests and regular assessment of which of the followi
37、ng? A. Blood electrolyte levels. B. Metabolic rate. C. Muscular coordination. D. Bone age.（分数：1.00）A.B.C.D.二、BPart Two/B(总题数：20，分数：20.00)30.The nurse is assessing an 8-month-old during a wellness checkup. Which of the following is a normal developmental task for an infant this age? A. Sitting withou
38、t support. B. Saying two words. C. Feeding himself with a spoon. D. Playing patty-cake.（分数：1.00）A.B.C.D.31.In a group therapy setting, one member is very demanding, repeatedly interrupting others, and taking most of the group time. The nurses best response would be, A. “Will you briefly summarize yo
39、ur point because others need time also?“ B. “Your behavior is obnoxious and drains the group. “ C. To ignore the behavior and allow him to vent. D. “Im so frustrated with your behavior. “（分数：1.00）A.B.C.D.32.When assessing a client with chest pain, the nurse obtains a thorough history. Which statemen
40、t by the client is most suggestive of angina pectoris? A. “The pain lasted for about 45 minutes. “ B. “The pain resolved after I ate a sandwich. “ C. “The pain worsened when I took a deep breath. “ D. “The pain occurred while I was mowing the lawn. “（分数：1.00）A.B.C.D.33.For a client with bulimia, whi
41、ch assessment is least important in the care plan? A. Observe the client after eating for 1 hour. B. Note the clients intake. C. Note changes in appetite. D. Note changes in respiratory rate.（分数：1.00）A.B.C.D.34.A client received burns to his entire back and left arm. Using the Rule of Nines, the nur
42、se can calculate that he has sustained burns on what percentage of his body? A. 9%. B. 18%. C. 27%. D. 36%.（分数：1.00）A.B.C.D.35.For a client with a head injury whose neck has been stabilized, the preferred bed position is A. Trendelenburgs. B. 30-degree head elevation. C. flat. D. side-lying.（分数：1.00
43、）A.B.C.D.36.During afternoon rounds, the nurse finds a male client using a pencil to scratch inside his knee-to-toe cast. The client is complaining of severe itching in the ankle area. Which action should the nurse take? A. Allow him to continue to scratch inside the cast with a pencil. B. Give him
44、a sterile metal object to use for scratching instead of the pencil. C. Encourage him to avoid scratching, and obtain an order for diphenhydramine (Benadryl) if severe itching persists. D. Obtain an order for a sedative, such as diazepam (Valium), to prevent him from scratching.（分数：1.00）A.B.C.D.37.Co
45、nditions necessary for the development of a positive sense of self-esteem include A. consistent limits. B. critical environment. C. inconsistent boundaries. D. physical discipline.（分数：1.00）A.B.C.D.38.Which of the following is the most important aspect of nursing care in the postpartum period? A. Sup
46、porting the mothers ability to successfully feed and care for her neonate. B. Providing group discussions on infant care. C. Monitoring the normal progression of lochia. D. Involving the family in the teaching.（分数：1.00）A.B.C.D.39.To assess the clients dorsalis pedis pulse, the nurse should palpate t
47、he A. medial surface of the ankle. B. lateral surface of the ankle. C. ventral aspect of the top of the foot. D. medial aspect of the dorsum of the foot.（分数：1.00）A.B.C.D.40.A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. What should the nurse do first?
48、A. Auscultate for bowel sounds. B. Palpate the abdomen. C. Change the clients position. D. Insert a rectal tube.（分数：1.00）A.B.C.D.41.The child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary? A. To obtain a heart rate that isnt affected by medication. B. To eliminate interference from the jerky movements of chorea. C. To ensure that the child cant consciously raise or lower the heart rate. D. To compensate for the effects of activity on the heart rate.（分数：1.00）A.B.C.
