1、美国护士资格认证(CGFNS)-7 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.The nurse assesses the client to determine the cause of autonomic dysreflexia. Which of the following is the most common stimulus for an autonomic dysreflexia episode?A. Rising intracranial pressure.B. Bowel distention.C. Bladd
2、er distention.D. Anxiety.（分数：1.00）A.B.C.D.2.The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?A. Make inhalation longer than exhalation.B. Exhale through an open mouth.C. Use diaphragmatic breathing.D. Us
3、e chest breathing.（分数：1.00）A.B.C.D.3.A 6-week-old female infant exhibits dry scaly skin and a protruding tongue after having trouble breast-feeding. A diagnosis of congenital hypothyroidism is made. The mother asks the nurse why the child was not diagnosed with this condition at birth. Which of the
4、following would be the nurses best response?A. “We had the results of the newborn screen, but you did not bring the baby in for the 2-week checkup. “B. “We could not reach you at home to give you the results of tests taken at birth. “C. “Your baby had little need for thyroid hormone until she was 1
5、month old. “D. “Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks. /（分数：1.00）A.B.C.D.4.Which of following would lead the nurse to suspect that a clients labor is moving quickly and that the physician should be notified?A. An increased sense of rectal pre
6、ssure.B. An increase in fetal heart rate variability.C. A decrease in intensity of contractions.D. Episodes of nausea and vomiting.（分数：1.00）A.B.C.D.5.The nurse is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan?A. Set up a strict eating
7、 plan for the client.B. Encourage the client to exercise, which will reduce her anxiety.C. Restrict visits with the family until the client begins to eat.D. Provide privacy during meals.（分数：1.00）A.B.C.D.6.Which of the following would be best to help prepare a preschool-aged child for an injection?A.
8、 Having an older child explain that shots do not hurt.B. Helping the child to imagine she is in a different place.C. Giving the child a play syringe and a bandage to give a doll injections.D. Giving the child a pounding board to encourage expressions of anger.（分数：1.00）A.B.C.D.7.The nurse assesses th
9、e clients urinary stoma regularly for edema. Which of the following signs and symptoms might indicate excessive stomal edema?A. Elevated temperature.B. Urine output below 30 mL/hour.C. Urine dribbling from the stoma.D. Complaints of discomfort around the stoma.（分数：1.00）A.B.C.D.8.Which of the followi
10、ng nursing diagnoses would be most appropriate for a client newly diagnosed with non-insulin-dependent diabetes mellitus?A. Risk for infection related to newly diagnosed diabetes.B. Altered nutrition, more than body requirements related to overproduction of insulin.C. Altered health maintenance rela
11、ted to lack of knowledge of proper foot care.D. Pain related to elevated blood glucose levels.（分数：1.00）A.B.C.D.9.When completing an assessment of a healthy adolescent client, which of the following would be most appropriate?A. Obtain a detailed account of the adolescents prenatal and early developme
12、ntal history.B. Discuss sexual preferences and behaviors with the parents present for legal reasons.C. Discuss the clients smoking with parents present in the room.D. Assess the adolescent in private; gather additional information from the parents.（分数：1.00）A.B.C.D.10.Which of the following case meet
13、s the criteria for involuntary commitment?A. A single parent who leaves her minor children unattended and stays out all night drinking.B. A person who lives alone and isnt able to care for himself and has schizophrenia with delusions of persecution.C. A man who threatens to kill his wife.D. A person
14、 with depression who says hes tired of living but doesnt have a suicide plan.（分数：1.00）A.B.C.D.11.A client diagnosed with a peptic ulcer undergoes an upper gastrointestinal endoscopy to help the physician visualize the ulcers location and severity. Immediately after the endoscopy, what would be a pri
15、ority for the nurse to assess?A. Return of the gag reflex.B. Bowel sounds.C. Peripheral pulses.D. Intake and output.（分数：1.00）A.B.C.D.12.The nurse is caring for a client with bipolar disorder in a manic state. Which of the following nursing interventions should be included in the plan of care?A. Allo
16、wing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.B. Listening attentively with a neutral attitude and avoiding power struggles.C. Offering high-calorie meals and strongly encouraging the client to finish all food.D. Insisting that the client remain acti
17、ve through the day so that hell sleep at night.（分数：1.00）A.B.C.D.13.Which of the following would the nurse expect to find in a client diagnosed with hyperparathyroidism?A. Hypocalcemia.B. Hypercalcemia.C. Hyperphosphatemia.D. Hypophosphaturia.（分数：1.00）A.B.C.D.14.The nurse would teach the client to im
18、plement which of the following nasal care measures after the nasal packing is removed?A. Irrigate the nares with normal saline solution daily.B. Remove old blood from inside the nares with cotton-tipped applicators.C. Avoid cleaning the nares for at least 2 days.D. For comfort lubricate the membrane
19、s with a water-soluble lubricant.（分数：1.00）A.B.C.D.15.A client with type 1 (insulin-dependent) diabetes mellitus who is a multigravida visits the clinic at 28 weeks gestation. Which of the following instruction by the nurse is appropriate for the client?A. Nonstress testing is performed weekly until
20、32 weeks gestation.B. Weekly fetal movement counts are made by the mother.C. Contraction stress testing is performed weekly.D. Induction of labor is begun at 34 weeks gestation.（分数：1.00）A.B.C.D.16.Labor is divided into how many stages?A. Two.B. Three.C. Four.D. Five.（分数：1.00）A.B.C.D.17.A respectable
21、 lawyer is admitted to an acute care facility with epigastric pain. Since admission, the client has called the nurse every 15 minutes with one request or another. Which of the following could explain this clients behavior?A. Repression.B. Somatization.C. Regression.D. Conversion.（分数：1.00）A.B.C.D.18.
22、A client with multiple sclerosis has been prescribed baclofen. The nurse teaches the client about the action of the drug. Which of the following is an accurate instruction regarding this drugs action?A. “Baclofen will decrease your fatigue and help increase your energy levels. “B. “Baclofen will hel
23、p relieve the muscle spasms that you have been experiencing. “C. “It is an antibiotic that will help treat your urinary tract infection. “D. “Taking this drug will help decrease the visual problems you have been having. /（分数：1.00）A.B.C.D.19.For the child experiencing excessive vomiting secondary to
24、pyloric stenosis, the nurse should assess the child for which of the following acid-base imbalances?A. Respiratory alkalosis.B. Respiratory acidosis.C. Metabolic alkalosis.D. Metabolic acidosis.（分数：1.00）A.B.C.D.20.The nurse is administering magnesium sulfate to a client with preeclampsia. The nurse
25、explains 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.21.Which of the following methods would the nurse use to feed an infant after surgical repair o
26、f cleft lip?A. Gastric gavage.B. Intravenous fluids.C. Rubber-tipped medicine dropper.D. Bottle with a lambs nipple.（分数：1.00）A.B.C.D.22.The nurse is teaching a client and his family about dietary practices related to Parkinsons disease. A priority for the nurse to address is risk ofA. fluid overload
27、 and drooling.B. aspiration and anorexia.C. choking and diarrhea.D. dysphagia and constipation.（分数：1.00）A.B.C.D.23.Which assessment finding would lead the nurse to suspect dehydration in a preterm neonate?A. Bulging fontanels.B. Excessive weight gain.C. Urine specific gravity below 1.012. D. Urine o
28、utput below 1 mL/hour.（分数：1.00）A.B.C.D.24.Which of the following would lead the nurse to suspect that a neonate with an infection is developing septic shock?A. Axillary temperature is 99.8F?(37.7).B. Blood pressure is 45/25 mmHg.C. Heart rate during sleep is 205 beats per minute.D. Respiratory rate
29、while awake is 32 breaths per minute.（分数：1.00）A.B.C.D.25.A client is being admitted to the labor unit. Because shes well advanced in labor, the nurse must prioritize the admission questions. Which information is most important to obtain when birth is imminent?A. Duration of previous labor.B. Frequen
30、cy of contractions.C. Presence of bloody show.D. Expected due date.（分数：1.00）A.B.C.D.26.The most effective health-promotion measure related to glaucoma that the nurse could teach clients is which of the following?A. Appropriate blood pressure control.B. Prompt treatment of all eye infections.C. Avoid
31、ance of extended-wear contact lenses by older people.D. Annual intraocular pressure measurements for people older than 40 years.（分数：1.00）A.B.C.D.27.Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous
32、 because the child has which of the following?A. Poor ability to concentrate urine.B. Little skin pigment to prevent sunburn.C. Poorly functioning temperature control center.D. Abnormally high salt loss through perspiration.（分数：1.00）A.B.C.D.28.A 2-year-old child is brought to the emergency room with
33、 a broken arm. Which of the following findings would lead the nurse to suspect child abuse?A. The child has bruises on the forearms.B. The childs clothes are dirty, torn, and obviously “hand-me-downs. “C. The childs father alters the story of the injury each time he tells it.D. The childs mother did
34、 not come to the hospital with the child.（分数：1.00）A.B.C.D.29.During the first 3 months, which hormone is responsible for maintaining pregnancy?A. Human chorionic gonadotropin (HCG).B. Progesterone.C. Estrogen.D. Relaxin.（分数：1.00）A.B.C.D.30.Which of the following concepts would the nurse incorporate
35、into the plan of care for a 4-year-old child to psychologically prepare the child for cardiac catheterization?A. Anxiety decreases when a preschooler is protected from learning about unpleasant events.B. Preschoolers are unable to understand the procedure.C. Little psychological preparation can be g
36、iven to preschoolers.D. Preparation is a joint responsibility of the physician, parents, and nurse.（分数：1.00）A.B.C.D.二、Part Two(总题数：18，分数：23.00)31.A client is fully dilated. Which of the following actions would be inappropriate during the second stage of labor?A. Positioning the mother for effective
37、pushing.B. Preparing for delivery of the baby.C. Assessing for rupture of membranes.D. Assessing vital signs every 15 minutes.（分数：1.00）A.B.C.D.32.To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the c
38、lient sit up. The nurse suspects arterial insufficiency if the assessment reveals which of the following?A. Elevational rubor.B. No rubor for 10 seconds after the maneuver.C. Dependent pallor.D. A 30-second filling time for the veins.（分数：1.00）A.B.C.D.33.A client who has been using crutches at home f
39、or t week reports that he is having trouble using the crutches because his armpits hurt and his fingers tingle. What would be the nurses most appropriate response?A. “You need to do more arm exercises. It sounds like your muscles need strengthening. “B. “Thats normal. As you adjust to the crutches,
40、the discomfort will diminish. “C. “Be sure to take your pain medication before ambulating. That will help your discomfort. “D. “Let me watch you ambulate. Your crutches or technique may need some adjustment. /（分数：1.00）A.B.C.D.34.A client diagnosed as having panic disorder with agoraphobia is admitte
41、d to the inpatient psychiatric unit. Until her admission, she had been a virtual prisoner in her home for 5 weeks, afraid to go outside even to buy food. Which of the following should be the nurses overall goal of care?A. To help the client perform self-care activities.B. To help the client function
42、 effectively in her environment.C. To help control the clients symptoms.D. To help the client participate in group therapy.（分数：1.00）A.B.C.D.35.The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, which of the following interventions is
43、appropriate?A. Administer oxygen.B. Have the client take deep breaths and cough.C. Place the client in high Fowlers position.D. Perform chest physiotherapy.（分数：1.00）A.B.C.D.36.A client is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). The nurse explains the procedure to
44、the client. Which of the following statements by the nurse is most appropriate?A. “PTCA involves opening a blocked artery with an inflatable balloon located on the end of a catheter. “B. “PTCA involves cutting away blockages with a special catheter. “C. “PTCA involves passing a catheter through the
45、coronary arteries to find blocked arteries. “D. “PTCA involves inserting grafts to divert blood from blocked coronary arteries. /（分数：1.00）A.B.C.D.37.Most antipsychotic medications exert which of the following effects on the central nervous system (CNS) ?A. Stimulate the CNS by blocking postsynaptic
46、dopamine, norepinephrine, and serotonin receptors.B. Sedate the CNS by stimulating serotonin at the synaptic cleft.C. Depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine.D. Depress the CNS by stimulating the release of acetylcholine.（分数：1.00）A.B.C.D.3
47、8.The nurse assesses the clients burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. What should be the nurses priority response?A. Document findings and recheck in 1 hour.B. Elevate extremity on one pillow.C. Implement passive range-of-mot
48、ion exercises.D. Notify the physician immediately.（分数：1.00）A.B.C.D.39.Which of the following would the nurse teach the mother of a child with leukemia who has an absolute neutrophil count of 900/mm3?A. The child should wear gloves when in contact with others.B. The child should stay away from crowds
49、 of people.C. The child should eat raw fruits and vegetables.D. Anyone in direct contact with the child must wear a gown and mask.（分数：1.00）A.B.C.D.40.A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, “Youre worried about your medication?“ The nurses communication isA. an example of presenting reality.B. reinforcing the clients delusions.C. focusing on emotional content.D. a nontherapeutic technique called mind reading.（分数：1.00）A.B.C.D.41.The client was admitted with s
