1、美国护士资格认证(CGFNS)-22 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.An unconscious client has been admitted with a head injury. Which of the following nursing diagnoses would receive the greatest priority in the plan of care?A. Disturbed sensory perception related to decreased level of conscio
2、usness.B. Ineffective airway clearance related to inability to remove respiratory secretions.C. Impaired gas exchange related to shallow irregular breathing.D. Risk for injury related to disorientation and decreased level of consciousness.（分数：1.00）A.B.C.D.2.Linda is a 19-year-old primipara who deliv
3、ered a viable male neonate 2 hours ago. She has decided to breast-feed. Her 22-year-old husband supports her decision. She tells the nurse, “My mother breast-fed all of her children, but Im going to need lots of help with breastfeeding. Im worried that I wont be able to do this. “ Which of the follo
4、wing should the nurse include when assessing the client?A. Determine the clients level of motivation to breast-feed.B. Perform a complete physical examination to determine her need for help.C. Assess her body-to-fat ratio and nutritional status before beginning breast-feeding.D. Ask the client if sh
5、e has read any literature about breast-feeding.（分数：1.00）A.B.C.D.3.A pregnant client who is diabetic is at risk for having a large-for-gestational-age infant because of which of the following?A. Excess sugar causing reduced placental functioning.B. Insulin acting as a growth hormone on the fetus.C. M
6、aternal dietary intake of high calories.D. Excess insulin reducing placental functioning.（分数：1.00）A.B.C.D.4.A client with diverticulitis is treated as an outpatient with drug therapy. Which of the following medication would most probably be included in the drug therapy?A. Broad-spectrum antibiotics.
7、B. Opioid analgesics.C. Tranquilizers.D. Laxatives.（分数：1.00）A.B.C.D.5.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, echol
8、alia, and a flat affect.（分数：1.00）A.B.C.D.6.A pregnant client with premature rupture of the membranes has had contractions every 10 minutes. After 48 hours, the contractions stop and the client is to be discharged with home monitoring. The nurse discusses with the client about preterm labor symptoms.
9、 Which of the following statements made by the client indicates that she needs further instruction?A. “I should report contractions that occur every 10 minutes in 1 hour. “B. “I should lie in bed on my left side if contractions begin. “C. “I should call the doctor if my contractions occur every hour
10、 for 6 hours. “D. “If I start having contractions, I should empty my bladder. /（分数：1.00）A.B.C.D.7.The nurse is instructing a client with angina about sublingual nitroglycerin. Which of the following points should be included?A. The shelf life of nitroglycerin is long, it keeps for up to 2 years.B. S
11、tore the tablets in a tight, light-resistant container.C. Use the tablets only when the pain is severe.D. The drug will cause increased urine output.（分数：1.00）A.B.C.D.8.The physician has ordered Oxtriphyllin (Choledyl SA) 0.2 g. Available tablets of the medicine are 100 mg. How many tablets should be
12、 given?A. 0.5 tablets.B. 2.0 tablets.C. 2.5 tablets.D. 5.0 tablets.（分数：1.00）A.B.C.D.9.Mr. Smith has had a cast applied to his arm as an outpatient in the emergency room. Which of the following home care instructions should the nurse advice for his cast care?A. Use a ruler to reach inside and scratch
13、 under the cast.B. Apply a heating pad to the arm for 24 hours after the injury.C. Use powder on the skin around the cast.D. Smell the cast for foul odors.（分数：1.00）A.B.C.D.10.A client has been placed on levodopa to treat his Parkinsons disease. Which of the following is a common side effect of levod
14、opa that the nurse should include in the clients teaching plan?A. Pancytopenia.B. Peptic ulcer.C. Orthostatic hypotension.D. Weight loss.（分数：1.00）A.B.C.D.11.The mother of a new-born asks the nurse how often she should breastfeed her baby. Which of the following responses by the nurse would be best?A
15、. “Newborns should breastfed at least every 3 hours during the day. “B. “Newborns should be fed when they cry. “C. “As long as the baby feeds four times a day, he will get enough. “D. “Newborns may breastfeed continuously until they stabilize. /（分数：1.00）A.B.C.D.12.Mrs. S with preterm labor will be u
16、nder Terbutaline (Brethine) therapy. Before beginning the therapy, which of the following assessments would be most important?A. Estimated fetal size.B. Maternal heart rate.C. Contraction intensity.D. Deep tendon reflexes.（分数：1.00）A.B.C.D.13.Antipsyehotie medications may cause which of the following
17、 adverse effects?A. Increased production of insulin.B. Lower seizure threshold.C. Increased coagulation time.D. Increased risk of heart failure.（分数：1.00）A.B.C.D.14.The nurse is evaluating a clients lung sounds. Which of the following breath sounds indicate adequate ventilation when auscultated over
18、the lung fields?A. Vesicular.B. Bronchial.C. Bronchovesicular.D. Adventitious.（分数：1.00）A.B.C.D.15.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.16.When instructing the cli
19、ent with severe burns about proper nutrition, the nurse would encourage him to eat which of the following meals?A. Chicken breast, salad, iced tea.B. Roast beef sandwich, milkshake, cottage cheese.C. Hamburger, orange, coffee.D. Pasta salad, carrots, iced tea.（分数：1.00）A.B.C.D.17.Mrs. Brown, who is b
20、reast-feeding, asks the nurse if she should supplement breast- feeding with formula feeding. The nurse bases the response on which of the following?A. Formula feeding should be avoided to prevent interfering with the breast milk supply.B. Primarily, water supplements should be used to prevent jaundi
21、ce.C. Formula supplements can provide nutrients not found in breast milk.D. More vigorous sucking is needed for a bottle-feeding, so supplements should be avoided.（分数：1.00）A.B.C.D.18.The client with a lumbar laminectomy asks to be turned onto his side. What should the nurse do?A. Inform the client t
22、hat because of his laminectomy, he may only lie supine.B. Ask the client to help by using an overhead trapeze to turn himself.C. Turn the clients shoulders first, followed by his hips and legs.D. Get another nurse to help log roll the client into position.（分数：1.00）A.B.C.D.19.A client has had a total
23、 gastrectomy for gastric cancer. Which one of the following is the most appropriate expected outcomes about nutrition?A. The client will learn to self-administer enteral feedings every 4 hours.B. The client will maintain adequate nutrition through oral or parenteral feedings.C. The client will regai
24、n any weight lost within 4 weeks of the surgical procedure.D. The client will eat three full meals a day without experiencing gastric complications.（分数：1.00）A.B.C.D.20.A client with ulcerative colitis is chatting with the nurse. Which of the following statements indicates the client understands the
25、lifestyle modifications he needs to make?A. “I will have to stop smoking. “B. “I can eat popcorn for an evening snack. “C. “I may have coffee with my meals. “D. “I am allowed to have alcohol as long as I only drink wine. /（分数：1.00）A.B.C.D.21.The nurse has assisted a multigravida with a precipitous d
26、elivery of a viable neonate in a local grocery store. Because a precipitous delivery can lead to decreased uterine tone, which of the following nursing actions would help to prevent this complication?A. Place the neonate on the clients fundus.B. Place the mother in a supine position.C. Encourage the
27、 mother to breast-feed the infant.D. Massage the clients fundus continuously.（分数：1.00）A.B.C.D.22.A client has had a cerebrovascular accident (CVA). Because the CVA affected the left side of the clients brain, the nurse should anticipate that the client would most likely experienceA. dyslexia.B. apra
28、xia.C. agnosia.D. expressive aphasia.（分数：1.00）A.B.C.D.23.The client with a head injury receives mannitol (Osmitrol) during surgery to help decrease intracranial pressure. Which of the following nursing observations would most likely indicate that the drug is having the desired effect?A. Urine output
29、 increases.B. Pulse rate decreases.C. Blood pressure decreases.D. Muscular relaxation increases.（分数：1.00）A.B.C.D.24.While managing the separation anxiety during hospitalization for a two-year-old boy, which of the following suggestions would be most helpful to the parents?A. Tell the child the time
30、they are leaving and returning.B. Bring the childs favorite toys from home.C. Leave while the child is sleeping.D. Keep the visit time short.（分数：1.00）A.B.C.D.25.The nurse administers a preoperative intramuscular medication at the ventrogluteal site. The nurse will inject the medication into which mu
31、scle?A. Rectus femoris.B. Gluteus maximus.C. Gluteus minimus.D. Vastus lateralis.（分数：1.00）A.B.C.D.26.Nursing measures for the client who has had an MI include helping the client to avoid activity that results in Valsalvas maneuver. Valsalvas maneuver may cause cardiac dysrhythmias, increased venous
32、pressure, increased intrathoracic pressure, and thrombi dislodgment. Which of the following actions would help prevent Valsalvas maneuver?A. Have the client drink fluids through a straw.B. Have the client avoid holding her breath during activity.C. Have the client assume a side-lying position.D. Hav
33、e the client clench her teeth while moving in bed.（分数：1.00）A.B.C.D.27.A mother of an ill child tells the nurse that her child “isnt eating well. “ Which of the following strategies devised by the mother to help increase the childs intake is not appropriate?A. Asking the child to say why he is not ea
34、ting.B. Telling the child he must eat or else he will not get better.C. Allowing the child to choose his meals from an acceptable list of foods.D. Letting the child to substitute items on his tray for other nutritious foods.（分数：1.00）A.B.C.D.28.A primigravida at 28 weeks gestation is admitted with a
35、diagnosis of preterm labor. The clients contractions are occurring every 15 to 20 minutes, lasting 25 seconds. The membranes are intact. What should the nurse do?A. Request assistance from the neonatal resuscitation team.B. Place the client on bed rest on her left side.C. Obtain equipment for an amn
36、iotomy.D. Prepare terbutaline in an intravenous solution of normal saline.（分数：1.00）A.B.C.D.29.The client delivers a viable male neonate who is given a score of 9 at 5 minutes on the Apgar rating system. The client asks the nurse what it means. The nurse interprets this finding as indicating that the
37、 neonates physical condition is which of the following?A. Good.B. Fair.C. Poor.D. Critical.（分数：1.00）A.B.C.D.30.An adolescent is admitted to the hospital for headaches. She approaches the nurse and confides that she is being sexually abused by a family friend. Which of the following would be the nurs
38、es best initial response?A. “Can you tell me what happened?“B. “I believe you; you were right to tell me. “C. “Have you told your mother and father about this?“D. “Who else have you told about this?/（分数：1.00）A.B.C.D.二、Part Two(总题数：23，分数：23.00)31.A patient who is admitted for treatment of an eating d
39、isorder displays controlling behaviors, takes responsibility for others actions, and has difficulty identifying feelings. These manifestations suggestA. dependency.B. manipulation.C. learned helplessness.D. codependency.（分数：1.00）A.B.C.D.32.In caring for the client with hepatitis B, which of the foll
40、owing situations would most likely expose the nurse to the virus?A. Contact with fecal material.B. A blood splash into the nurses eyes.C. Disposing of syringes and needles without recapping.D. Touching the clients arm with ungloved hands while taking blood pressure.（分数：1.00）A.B.C.D.33.Mr. Smith is a
41、dmitted to the psychiatric hospital for evaluation after numerous incidents of threatening, angry outbursts and two episodes of hitting a coworker at the grocery store where he works. He is very anxious and tells the nurse, “I didnt mean to hit him. He made me so mad that I just couldnt help it. I h
42、ope I dont hit anyone here. “ Which of the following is the nurses best response?A. “It sounds like you were angry. When you feel angry here, talk to the staff about it instead of hitting. “B. “Im sure you didnt mean to hit him and that it wont happen here. “C. “Youd better not hit anyone here, even
43、 if you do get mad. “D. “Tell me more about what happened. /（分数：1.00）A.B.C.D.34.Which of the following measures would the nurse take into consider to help minimize joint pain in a child with rheumatic fever?A. Massaging the affected joints.B. Applying ice to the affected joints.C. Limiting movement
44、of the affected joints.D. Encouraging progressive weight bearing.（分数：1.00）A.B.C.D.35.Which of the following functions would the nurse expect to be unrelated to the placenta?A. Production of estrogen and progesterone.B. Detoxification of some drugs and chemicals.C. Exchange site for food, gases, and
45、waste.D. Production of maternal antibodies.（分数：1.00）A.B.C.D.36.The immobile adolescent with a recent fractured femur suddenly complains chest pain, dyspnea, diaphoresis, and tachycardia. Which of the following would the nurse suspect?A. Atelectasis.B. Pneumonia.C. Pulmonary edema.D. Pulmonary emboli
46、.（分数：1.00）A.B.C.D.37.A parent group is discussing different types of punishment. The parents ask the nurse to discuss corporeal punishment. What would be the nurses response?A. “Corporeal punishment does not physically harm the child. “B. “Corporeal punishment can result in children becoming accusto
47、med to spanking. “C. “Corporeal punishment can be beneficial in teaching children what they should do. “D. “Corporeal punishment reinforces the idea that violence is not acceptable. /（分数：1.00）A.B.C.D.38.Which of the following is not a contributory factor to thermoregulation in the preterm neonate?A.
48、 Immature central nervous system (CNS).B. Large skin surface area.C. Lack of subcutaneous (S. . ) and brown fat.D. Tendency toward capillary fragility.（分数：1.00）A.B.C.D.39.The nurse is preparing an elderly client to get out of bed on the first postoperative day after a total hip replacement. Which of
49、 the following activities would be most helpful to the client?A. Demonstrate the use of a walker with partial weight bearing.B. Explain to the client that she will be lifted out of bed to a chair.C. Reassure the client that she will be assisted to walk to the hall.D. Demonstrate the swing-through crutch-walking gait with limited weight hearing.（分数：1.00）A.B.C.D.40.The nurse is teaching a new mental health aide. For which of the following clients is setting limits most important?A. A depressed client.B. A manic client.C. A suicidal client.D. An anxious client.（分
