1、美国护士资格认证(CGFNS)-5 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.A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. The child doesnt enunciate words well and holds onto furniture when he walks. The nurse should ask the motherA. how long the child has been li
2、ke this.B. if the child can walk without holding onto furniture.C. how the childs condition today differs from his normal condition.D. if the child always drools.（分数：1.00）A.B.C.D.2.A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the foll
3、owing would the nurse instruct the client to report to her primary caregiver?A. Breast tenderness.B. Breakthrough bleeding within first 3 months of use.C. Decreased menstrual flow.D. Blurred vision and headache.（分数：1.00）A.B.C.D.3.The nurse is caring for a toddler in respiratory arrest. The nurse wil
4、l assist with endotracheal intubation and use an uncurled tube because theA. vocal cords provide a natural seal.B. trachea is shorter.C. larynx is anterior and cephalad.D. cricoid cartilage is the narrowest part of the larynx.（分数：1.00）A.B.C.D.4.A client tells the nurse that she has been working hard
5、 for the last 3 months to control her type 2 (non-insulin-dependent) diabetes mellitus with diet and exercise. To determine the effectiveness of the clients efforts, the nurse should checkA. urine glucose level.B. fasting blood glucose level.C. serum fructosamine level.D. glycosylated hemoglobin (Hb
6、) level.（分数：1.00）A.B.C.D.5.Which of the following statements summarizes the underlying principle for the development of a parenbchild relationship?A. The parents to-be had good role models in their childhood.B. The relationship is part of the adult maturational process.C. The development is directly
7、 related to the physical needs of the neonate.D. The relationship is based on the need for early and frequent parent-infant contact.（分数：1.00）A.B.C.D.6.After striking his head on a tree while falling from a ladder, a young man is admitted to the emergency department. Hes unconscious and his pupils ar
8、e nonreactive. Which intervention would be the most dangerous for the client?A. Give him a barbiturate.B. Place him on mechanical ventilation.C. Perform a lumbar puncture.D. Elevate the head of his bed.（分数：1.00）A.B.C.D.7.When assessing a preschooler who has sustained a head trauma, the nurse notes t
9、hat the child appears to be obtunded. Which of the following denotes the childs level of consciousness?A. No motor or verbal response to noxious (painful) stimuli.B. Remains in a deep sleep; responsive only to vigorous and repeated stimulation.C. Can be aroused with stimulation.D. Limited spontaneou
10、s movement; sluggish speech.（分数：1.00）A.B.C.D.8.A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms ofA. right-sided heart failure.B. acute pulmonary edema.
11、C. pneumonia.D. cardiogenic shock.（分数：1.00）A.B.C.D.9.The nurse brings a new mother her neonate for the first time approximately 1 hour after the neonates birth. After checking the identification, the nurse hands the neonate to the mother. Within a few minutes, the mother begins to undress her neonat
12、e. Which of the following should the nurse do?A. Call the pediatrician and report the behavior.B. Anticipate and support the behavior as a normal part of bonding.C. Encourage the mother to rewrap the neonate because the room is cold.D. Take the neonate back to the nursery and recheck the neonates te
13、mperature.（分数：1.00）A.B.C.D.10.During the assessment stage, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence ofA. somatic delusions.B. waxy flexibility.C. neologisms.D. nihilistic delusions.（分数：1.00）A.B.C.D.11.Which statemen
14、t about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) ?A. Administer 2 to 3 L of IV fluid rapidly.B. Administer 6 L of IV fluid over the first 24 hours.C. Administer a dextrose solution containing normal saline solution.D. Administer IV fluid s
15、lowly to prevent circulatory overload and collapse.（分数：1.00）A.B.C.D.12.During a late stage of acquired immunodeficiency syndrome (AIDS), a client demonstrates signs of AIDS-related dementia. The nurse should give the highest priority to which nursing diagnosis?A. Bathing or hygiene self-care deficit
16、.B. Ineffective cerebral tissue perfusion.C. Dysfunctional grieving.D. Risk for injury.（分数：1.00）A.B.C.D.13.The nurse is teaching a client recently diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused byA. genetic dysfunction.B. upper and lower motor ne
17、uron 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.14.A physician schedules an invasive procedure for a client with acquired immunodeficiency syndrome-related dementia. He lives with his male companion, who is present. His
18、 mother, who lives in another state, is also present. The nurse anticipates that the consent form should be signed byA. the companion.B. the mother.C. the client.D. two physicians.（分数：1.00）A.B.C.D.15.A 33-year-old male client is admitted with an exacerbation of ulcerative colitis. The nurse is perfo
19、rming an admission assessment and assessing the teaching needs regarding appropriate diet and lifestyle modifications for the client. To develop an effective teaching plan, the nurse must solicit which of the following input from the client?A. Details about his childhood phobias.B. His feelings, bel
20、iefs, and attitudes about his chronic illness.C. Information about his financial status.D. Information about his relationship with his wife.（分数：1.00）A.B.C.D.16.Following coronary artery bypass grafting, a client begins having chest “fullness“ and anxiety. The nurse suspects cardiac tamponade and pri
21、nts a lead electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion isA. narrowing complex.B. widening complex.C. amplitude increase.D. amplitude decrease.（分数：1.00）A.B.C.D.17.What is the most appropriate nursing d
22、iagnosis for the client with acute pancreatitis?A. Deficient fluid volume.B. Excess fluid volume.C. Decreased cardiac output.D. Ineffective gastrointestinal tissue perfusion.（分数：1.00）A.B.C.D.18.Following a fall from a horse during rodeo practice, an 18-year-old client is seen in the emergency depart
23、ment. He has a large, dirty laceration on his leg. The wound is vigorously cleaned, closed, and dressed. In the past, the client has received the full immunization regimen for tetanus toxoid. The nurse asks the client about his tetanus immunization history and he says, “I had my last shot when I was
24、 11 years old. “ The nurse shouldA. advise the client to get a tetanus vaccine within 3 years.B. request the physician to order a serum tetanus titer.C. plan on administering a dose of tetanus vaccine.D. teach the client that he has life-long immunity to tetanus.（分数：1.00）A.B.C.D.19.A female neonate
25、delivered by elective cesarean birth to a 25-year-old mother weighs 3,265g (7 lb, 3 oz). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which of the following?A. Temperature instability due to type of birth.B.
26、 Respiratory distress due to lack of contractions.C. Signs of acrocyanosis.D. Unstable blood sugars.（分数：1.00）A.B.C.D.20.Which of the following statements should be included when teaching clients about monoamine oxidase (MAO) inhibitor antidepressants?A. Dont take prescribed or over-the-counter medic
27、ations without consulting the physician.B. Avoid strenuous activity because of the cardiac effects of the drug.C. Have blood levels screened weekly for leukopenia.D. Dont take with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).（分数：1.00）A.B.C.D.21.When caring for a client with preeclampsia
28、, which action is a priority?A. Monitoring the clients labor carefully and preparing for a fast delivery.B. Continually assessing the fetal tracing for signs of fetal distress.C. Checking vital signs every 15 minutes to watch for increasing blood pressure.D. Reducing visual and auditory stimulation.
29、（分数：1.00）A.B.C.D.22.Which action should the nurse include in a plan of care for a client with a fiberglass cast on the right arm?A. Keep the casted arm warm with a light blanket.B. Avoid handling the cast for 24 hours or until dry.C. Assess pedal and posterior tibial pulses every 2 hours.D. Assess m
30、ovement and sensation in the fingers of the right hand.（分数：1.00）A.B.C.D.23.The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?A. Avoiding the use of illicit drugs and alcohol.B. Refraining from tel
31、ling anyone about the diagnosis.C. Following safer-sex practices.D. Telling potential sex partners about the diagnosis, as required by law.（分数：1.00）A.B.C.D.24.A 21-year-old client with a history of ulcerative colitis is hospitalized for an exacerbation. When planning dietary teaching, the nurse shou
32、ld recommend that the client consumeA. high-protein foods, such as eggs, meat, and cheese.B. whole milk and other dairy products.C. raw fruits and vegetables.D. products containing caffeine.（分数：1.00）A.B.C.D.25.A client with Hashimotos thyroiditis and a history of two myocardial infarctions and coron
33、ary artery disease is to receive levothyroxine (Synthroid). Because of the clients cardiac history, the nurse would expect that the clients initial dose for the thyroid replacement would be which of the following?A. 25 g/day, initially.B. 100 g/day, initially.C. Delayed until after thyroid surgery.D
34、. Initiated before thyroid surgery.（分数：1.00）A.B.C.D.26.The nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treatA. hypernatremia.B. hypokalemia.C. hyperkalemia.D. hypercalcemia.（分数：1.00）A.B.C.D.2
35、7.During the admission interview, a client reports that she frequently has nightmares and memories of a rape that occurred 3 years ago. She feels depressed and asks the nurse, “Do you think I will ever get better? I dont know what is wrong with me. “ The nurses most supportive response would beA. “I
36、t sounds like you have some unresolved pain about the trauma. Take time here to talk and allow yourself to heal. “B. “Im not sure what is wrong, but the medication will help you soon enough. “C. “Its important to talk to your physician about an issue such as this. “D. “Dont feel bad; the treatment w
37、ill help you. /（分数：1.00）A.B.C.D.28.Physical assessment findings in the eyes of elderly people may includeA. decreased lens thickness.B. decreased visual acuity.C. lightening of the skin around the orbits.D. unequal pupillary light reflex.（分数：1.00）A.B.C.D.29.The physician prescribes several drugs for
38、 a client with hemorrhagic stroke. Which drug order should the nurse question?A. Heparin sodium (Hep-Lock).B. Dexamethasone (Deeadron).C. Methyldopa (Aldomet).D. Phenytoin (Dilantin).（分数：1.00）A.B.C.D.30.A client, age 59, complains of leg pain brought on by walking several blocks-a symptom that first
39、 arose several weeks ago. The clients history includes diabetes mellitus and a two-pack-a-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and prescribes pentoxifylline (Trental), 400 mg three times daily with meals. The nurse should provide which instruct
40、ion concerning long-term care?A. “Practice meticulous foot care. “B. “Consider cutting down on your smoking. “C. “Reduce your level of exercise. “D. “See the physician if complications occur. /（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23.00)31.A 49-year-old client with acute respiratory distress watches
41、 everything the staff does and demands full explanations for all procedures and medications. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort?A. Making decreased eye contact.B. Asking to see family members.C. Joking about the
42、 present condition.D. Sleeping undisturbed for 3 hours.（分数：1.00）A.B.C.D.32.Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for which condition?A. Hypocortisolism.B. Hypoglycemia.C. Hyperglycemia.D. Hypercalcemia.（分数：1.00）A.B.C.D.33.Following a cystoscopy that
43、 confirmed a diagnosis of bladder cancer, a client is scheduled for chemotherapy and a ileal conduit urinary diversion. The nurse should include which of the following points in the clients preoperative teaching?A. The clients need to perform stoma self-care immediately after surgery.B. The clients
44、need to remain on bed rest for 3 days following surgery.C. The procedure creates a stoma and he must wear a pouch afterward.D. The client will be able to control urine passage through the stoma.（分数：1.00）A.B.C.D.34.A client has been diagnosed with type A hepatitis. What special precautions should the
45、 nurse take when caring for this client?A. Put on a mask and gown before entering the clients room.B. Wear gloves and a gown when removing the clients bedpan.C. Prevent the droplet spread of the organism.D. Use caution when bringing food to the client.（分数：1.00）A.B.C.D.35.An appropriate-for-gestation
46、al-age neonate should weighA. between the 10th and the 90th percentiles for age.B. at least 2,500 g (5 lb, 8 oz).C. between 2,000 and 4,000 g (4 lb, 6 oz and 8 lb, 12 oz).D. in the 50th percentile.（分数：1.00）A.B.C.D.36.A certified nursing assistant (CNA) is caring for a client with Clostridium diffici
47、le diarrhea and asks the charge nurse, “How can I keep from catching this from the client?“ The nurse reminds the CNA to wash her hands and to ensure the client is placedA. on protective isolation.B. on neutropenic precautions.C. in a negative-pressure room.D. on contact isolation.（分数：1.00）A.B.C.D.3
48、7.Which behavior would cause the nurse to suspect that a clients labor is moving quickly and that the physician should be notified?A. An increased sense of rectal pressure.B. A decrease in intensity of contractions.C. An increase in fetal heart rate variability.D. Episodes of nausea and vomiting.（分数
49、：1.00）A.B.C.D.38.A client complains of a severe, throbbing headache following a lumbar puncture. The priority nursing intervention for this client is toA. restrict fluid intake.B. increase fluid intake.C. raise the head of the bed.D. assess vital signs.（分数：1.00）A.B.C.D.39.The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitaminA. restores the inflammatory response.B. enhances oxygen transport to tissues.C. reduces edema.D. enhances protein synthesis.（分数：1.00）A.B.C.D.40.A clients chest X-ray reveals bilateral white-out
