【医学类职业资格】美国护士资格认证(CGFNS)-2及答案解析.doc

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1、美国护士资格认证(CGFNS)-2 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.During the night, a 50-year-old Vietnam veteran with posttraumatic stress syndrome wakens shaking and tells you that someone is trying to smother him. What is the appropriate response for the nurse in this situation?A. “It was

2、a bad dream. You are safe. Ill stay here with you until you go back to sleep. “B. “We can talk about it tomorrow. Try to see if you can get back to sleep. “C. “It was only a dream. Theres nothing to be frightened about. “D. “Ill call the physician and see whether I can get you medication to help you

3、 go back to sleep. /（分数：1.00）A.B.C.D.2.A client is admitted to the hospital with an exacerbation of her chronic systemic lupus erythematosus (SLE). She gets angry when her call bell isnt answered immediately. The most appropriate response to her would be,A. “You seem angry. Would you like to talk ab

4、out it?“B. “Calm down. You know that stress will make your symptoms worse. “C. “Would you like to talk about the problem with the nursing supervisor?“D. “I can see youre angry. Ill come back when youve calmed down. /（分数：1.00）A.B.C.D.3.In an industrial accident, a client who weighs 155 lb (70.3 kg) s

5、ustained full-thickness burns over 40% of his body. Hes in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the client?A. A urine output consistently above 100 mL/hr.B. A weight gain of 4 lb (1.8 kg) in 24 hours.C. Body temperature readi

6、ngs all within normal limits.D. An electrocardiogram (ECG) showing no arrhythmias.（分数：1.00）A.B.C.D.4.A client with type 1 (insulin-dependent) diabetes mellitus has just learned shes pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse prov

7、ide?A. “Insulin requirements dont change during pregnancy. Continue your current regimen. “B. “Insulin requirements usually decrease during the last two trimesters. “C. “Insulin requirements usually decrease during the first trimester. “D. “Insulin requirements increase greatly during labor. /（分数：1.

8、00）A.B.C.D.5.Which pregnancy-related physiologic change would place the client with a history of cardiac disease at the greatest risk for developing severe cardiac problems?A. Decreased heart rate.B. Decreased cardiac output.C. Increased plasma volume.D. Increased blood pressure.（分数：1.00）A.B.C.D.6.A

9、 client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentions that she likes salty foods. The nurse should warn her to avoid foods containing sodium becauseA. reducing sodium promotes urea nitrogen excretion.B. reducing sodium decreases edema.C. reducing sodium improves

10、 her glomerular filtration rate.D. reducing sodium increases potassium absorption.（分数：1.00）A.B.C.D.7.One day after an appendectomy, a 9-year-old rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on

11、the childs chart?A. The child is in no apparent distress, and no pain medication is needed at this time.B. The child rates pain at 4 out of 5. Pain medication administered as prescribed.C. The child doesnt understand the pain scale. Performed teaching to help child match his pain rating to how he ap

12、pears to be feeling.D. The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when hes visibly showing signs of pain.（分数：1.00）A.B.C.D.8.The nurse is providing care to a 5-year-old client with a fractured femur whose nursing diagnosis is Imbalanced nutrition: less

13、than body requirements related to impaired physical mobility. Which of the following is most likely to occur with this condition?A. Decreased protein catabolism.B. Increased calorie intake.C. Increased digestive enzymes.D. Increased carbohydrate need.（分数：1.00）A.B.C.D.9.Before a transesophageal echoc

14、ardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse shouldA. insert an oral airway.B. withhold food and fluids.C. position the client on his side.D. introduce a nasogastric

15、(NG) tube.（分数：1.00）A.B.C.D.10.The nurse is caring for a primigravida who is scheduled for a fetal acoustic stimulation test (FAST). The nurse should explain to the client that the primary purpose of this test is toA. induce contractions.B. induce fetal heart rate accelerations.C. shorten the contrac

16、tion stress test.D. determine fluid volume.（分数：1.00）A.B.C.D.11.The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse shouldA. encourage verbalizations about fears and stressful life situations.B. agree wit

17、h the client because she feels a specific physical feature is awful.C. ignore the comment and talk about less threatening issues.D. compliment the client on her appearance.（分数：1.00）A.B.C.D.12.For the past few days, a client has been having calf pain and notices that the painful calf is larger than t

18、he other one. The right calf is red, warm, achy, and tender to touch. Which of the following questions about the pain should the nurse include in the assessment?A. “Does the pain worsen in the morning upon rising?“B. “Does the pain increase with activity and lessen with rest?“C. “Is the pain relieve

19、d by position changes?“D. “Is the pain worse with the toes pointed toward the knee?/（分数：1.00）A.B.C.D.13.A client seeks care for low back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk?A. Pain that radiates down the posterior thigh.B. Back pain when the kn

20、ees are flexed.C. Atrophy of the lower leg muscles.D. Positive Homans sign.（分数：1.00）A.B.C.D.14.As an adolescent is receiving care, hes inadvertently injured with a warm compress. The nurse completes an incident report based on the knowledge that identification of which of the following is not a goal

21、 of the report?A. Staff involved so theyre reprimanded for their actions.B. Learning needs of staff to prevent recurrence of incidents.C. Patterns of client care problems.D. Facts surrounding each incident.（分数：1.00）A.B.C.D.15.A client with intrauterine growth retardation is admitted to the labor and

22、 delivery unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her plan of care?A. Carefully titrating the oxytocin based on her pattern of labor.B. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes.

23、C. Allowing the client to ambulate as tolerated.D. Helping the client use breathing exercises to manage her contractions.（分数：1.00）A.B.C.D.16.The nurse is interviewing a client admitted to the facility with a diagnosis of schizophrenia. The client states, “I run apple, train, grass, window. “ This re

24、sponse by the client is known asA. echopraxia.B. a word salad.C. flight of ideas.D. neologisms.（分数：1.00）A.B.C.D.17.The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society (ACS) guidelines

25、, the nurse should recommend that the womenA. perform breast self-examination annually.B. have a mammogram annually.C. have a hormonal receptor assay annually.D. have a physician conduct a clinical examination every 2 years.（分数：1.00）A.B.C.D.18.A client who has cervical cancer is scheduled to undergo

26、 internal radiation. In teaching the client about the procedure, the nurse would be most accurate in telling the clientA. shell be in a private room with unrestricted activities.B. a bowel-cleansing procedure will precede radioactive implantation.C. shell be expected to use a bedpan for urination.D.

27、 the preferred positioning in bed will be semi-Fowlers.（分数：1.00）A.B.C.D.19.A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instructions?A. “Weigh yourself daily and report a loss of 1 lb in 1 day. “B. “Eat a

28、 high-sodium diet. “C. “Weigh yourself daily and report a gain of 2 lb in 1 day. “D. “Maintain bedrest. /（分数：1.00）A.B.C.D.20.A 28-year-old woman is scheduled for a glucose tolerance test (GTT). She asks the nurse what result indicates diabetes mellitus. The nurse should respond that the minimum para

29、meter for indication of diabetes mellitus is a 2-hour blood glucose level greater thanA. 120 mg/dLB. 150 mg/dLC. 200 mg/dLD. 250 mg/dL（分数：1.00）A.B.C.D.21.When a client experiences a loss of vibratory sense on examination, this indicatesA. injury to the cranial nerves.B. injury to the peripheral nerv

30、es.C. intact cranial nerves.D. intact peripheral nerves.（分数：1.00）A.B.C.D.22.The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client toA. restrict fluid intake to 1 qt (1,000 mL)/day.B. drink liquids only with meals.C. dont

31、 drink liquids 2 hours before meals.D. drink liquids only between meals.（分数：1.00）A.B.C.D.23.A 23-month-old child is brought to the emergency department with suspected croup. Which assessment finding reflects increasing respiratory distress?A. Intercostal retractions.B. Bradycardia.C. Decreased level

32、 of consciousness.D. Flushed skin.（分数：1.00）A.B.C.D.24.The nurse must apply an elastic bandage to a clients ankle and calf. She should apply the bandage beginning at the clientsA. foot.B. ankle.C. lower thigh.D. knee.（分数：1.00）A.B.C.D.25.A 35-year-old female client who complains of weight gain, facial

33、 hair, absent menstruation, frequent bruising, and acne is diagnosed with Cushings syndrome. Cushings syndrome is most likely caused by which of the following?A. An ectopic corticotropin-secreting tumor.B. Adrenal carcinoma.C. A corticotropin-secreting pituitary adenoma.D. An inborn error of metabol

34、isrn.（分数：1.00）A.B.C.D.26.The nurse is caring for a client undergoing a cystoscopy to diagnose bladder cancer. Following the test, the client returns to his room. Which signs should alert the nurse to a potential complication?A. Chills and tachycardia.B. Urinary frequency and burning on urination.C.

35、Dizziness and fainting.D. Pink-tinged urine and bladder spasms.（分数：1.00）A.B.C.D.27.Which of the following should be the nurses initial action immediately following the birth of the neonate?A. Aspirating mucus from the neonates nose and mouth.B. Drying the infant to stabilize the neonates temperature

36、.C. Promoting parental bonding.D. Identifying the neonate.（分数：1.00）A.B.C.D.28.When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately?A. Complaints of intense thirst.B. Moderate to severe pain.C. Urine output of 70 mL the

37、1st hour.D. Hoarseness of the voice.（分数：1.00）A.B.C.D.29.A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the child hasA. patent ductus arteriosus.B. coarctati

38、on of the aorta.C. a ventricular septal defect.D. truncus arteriosus.（分数：1.00）A.B.C.D.30.Acarbose (Precose), an alpha-glucosidase inhibitor, is prescribed for a client with type 2 diabetes mellitus. During discharge planning, the nurse would be aware that the client has understood teaching when the

39、client states,A. “If I have hypoglycemia, I should eat some sugar, not dextrose. “B. “The drug makes my pancreas release more insulin. “C. “I should never take insulin while Im taking this drug. “D. “Its best if I take the drug with the first bite of a meal. /（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23

40、.00)31.A boy, age （分数：1.00）A.B.C.D.32.A client undergoes a total hip replacement. Which statement made by the client would indicate to the nurse that the client requires further teaching?A. “Ill need to keep several pillows between my legs at night. “B. “I need to remember not to cross my legs. Its

41、such a habit. “C. “The occupational therapist is showing me how to use a sock puller to help me get dressed. “D. “I dont know if Ill be able to get off that low toilet seat at home by myself. /（分数：1.00）A.B.C.D.33.In a group therapy setting, one member is very demanding, repeatedly interrupting other

42、s, and taking most of the group time. The nurses best response would be,A. “Will you briefly summarize your 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.

43、B.C.D.34.A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?A. High volumes of fluid intake.B. Aerobic exercise programs.C. Caffeine-containing products.D. Foods rich in protein.（分数：1.00）A.B.C.D.35.A client is admitte

44、d to the emergency department with a suspected overdose of an unknown drug. The clients arterial blood gas values indicate respiratory acidosis. What should the nurse do first?A. Prepare to assist with ventilation.B. Monitor the clients heart rhythm.C. Prepare to begin gastric lavage.D. Obtain urine

45、 for drug screening.（分数：1.00）A.B.C.D.36.When teaching the mother of a 17-month-old about toilet training, which instruction would initially be most appropriate?A. Place the toddler on the potty chair every 2 hours for t0 minutes.B. Offer a reward every time the child has a bowel movement in the pott

46、y chair.C. Remove the diaper and use training pants to begin the process.D. Be sure the child is ready before starting to toilet train.（分数：1.00）A.B.C.D.37.A client is diagnosed with hyperthyroidism. The nurse should expect clinical manifestations similar toA. hypovolemic shock.B. adrenergic stimulat

47、ion.C. benzodiazepine overdose.D. Addisons disease.（分数：1.00）A.B.C.D.38.A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention isnt appropriate for this client?A. Acknowledging the clients spiritual

48、 distress.B. Inviting the clients clergyman to visit him.C. Encouraging the client to discuss religious beliefs and practices.D. Encouraging the client to discuss concerns with the clergy.（分数：1.00）A.B.C.D.39.The nurse reinforces the physicians description of a fasciotomy for a client. When a fasciot

49、omy is performed to alleviate compartment syndrome, the fascia is opened along the length of the muscle compartment andA. the skin is sutured loosely.B. a pressure dressing is applied.C. the skin is left open.D. a skin graft is placed.（分数：1.00）A.B.C.D.40.A client with a diagnosis of a bleeding gastric ulcer goes to the operating room for a partial gastrectomy. Postoperative nursing care would includeA. administering pain medications every 6 hours.B. withholding fluids by mouth until the return of peristalsis.C. positioning the client in high Fowler