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[填空题]Discovery Channel’s weekly series" Unsolved History" is one of the best among similar TV programs.
[单项选择]During a client’s chemotherapy regimen for breast cancer, which is important for the nurse to include in her plan of care（）
A. Instruct the client to consume plenty of raw fruits and vegetables.
B. Take rectal temperatures for greater accuracy.
C. Tell the client to avoid crowds and infected individuals.
D. Ask friends and relatives not to visit during the course of chemotherapy.
[单项选择]To deal with a client’s hallucinations therapeutically, the nurse plans to（ ）
A. Reinforce the perceptual distortions until the client develops new defenses
B. Provide an unstructured environment and assign the client to a private room
C. Avoid helping the client make connections between anxiety-producing situations and hallucinations
D. Distract the client’s attention by providing a competing stimulus that is stronger than the hallucinations
[单项选择]The nurse observes that the client’s total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. What should the nurse do next（）
A. Assess the infusion system, note the client’s condition, and notify the physician.
B. Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved.
C. Increase the flow rate to infuse an additional 300 mL over the next hour.
D. Maintain the flow rate at the current rate and document any discrepancy in the chart.
[单项选择]Which of these signs suggests that a client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion has developed complications（）
A. Tetanic contractions.
B. Neck vein distention.
C. Weight loss.
D. Polyuria.
[单项选择]The nurse notices that a client’s abdominal wound has eviscerated. Which of the following would the nurse do first（）
A. Notify the client’s physician immediately.
B. Reinsert the protruding viscera into the abdominal cavity.
C. Place the client in reverse Trendelenburg’s position.
D. Cover the wound with sterile saline-moistened dressings.
[单项选择]A male client’s statement about a microcomputer implanted in his ear by a foreign agent would help the nurse recognize that the client is experiencing（ ）
A. Illusions
B. Hallucinations
C. Neologistic thinking
D. Delusional thoughts
[单项选择]The nurse is irrigating a client’s colostomy when the client complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse do first
A. Stop the flow of solution temporarily.
B. Reposition the client on to her right side.
C. Remove the irrigation tube.
D. Massage the abdomen gently.
[单项选择]The nurse assesses the client’s 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.
[单项选择]The nurse notices that the client’s pupils are fixed and dilated. What does this finding indicate（）
A. The client is permanently paralyzed.
B. The client is going to be blind as a result of an injury.
C. The client probably has meningitis.
D. The client has received a significant brain injury.
[单项选择]When prioritizing a client’s care plan based on Maslow’s hierarchy of needs, the nurse’s first priority would be
A. allowing the family to see a newly admitted client.
B. ambulating the client in the hallway.
C. administering pain medication.
D. placing wrist restraints on the client.
[单项选择]When bandaging the burned client’s hand, the nurse should pay more attention about which of the following（）
A. The bandage is free of elastic.
B. The bandage material is moistened with sterile normal saline solution.
C. The hand and finger surfaces do not touch.
D. The hand and fingers are not elevated above heart level.
[单项选择]While inspecting the client’s chest, the nurse notes that the chest wall contracts on inspiration and bulges on expiration. The nurse suspects which of the following problem from this assessment（）
A. Hemothorax.
B. Flail chest.
C. Pneumothorax.
D. Tension pneumothorax.
[单项选择]An elderly client’s family tells the nurse that the client has suffered some memory loss in the last few years. They say that the client is sensitive about not being able to remember and tries to cover up this loss to avoid embarrassment. When attempting to increase the client’s self-esteem, the nurse should try to avoid discussing events that require memory of the client’s（ ）
A. Married
B. Work years
C. Recent days
D. Young adulthood
[单项选择]The nurse is delivering the client’s 10 AM medications. The client is away from his room for a diagnostic study. Which action is the most appropriate for the nurse to take（）
A. Leave the medications on the client’s bedside table.
B. Ask the client’s roommate to keep the medications for the client until he returns.
C. Lock the medications in the medicine preparation area until the client returns.
D. Have the client skip that dose of medication.
[单项选择]The nurse assesses the client’s burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. What should be the nurse’s priority response（）
A. Document findings and recheck in 1 hour.
B. Elevate extremity on one pillow.
C. Implement passive range-of-motion exercises.
D. Notify the physician immediately.
[单项选择]The nurse evaluates the client’s understanding of myasthenia gravis. The nurse would judge that the client has formed a realistic concept of her condition when she says（ ）
A. "By taking medication and pacing activities, I will live longer, but ultimately the disease will cause my death. "
B. "By taking medication and pacing activities, my fatigue will be relieved, but I should expect occasional periods of muscle weakness. "
C. "By taking medication and pacing activities, my symptoms will be controlled and eventually the disease will be cured. "
D. "By taking medication and pacing activities, I should be able to control the disease and enjoy a healthy lifestyle. /
[单项选择]To assess a client’s cranial nerve function, the nurse should（）
A. assess hand grip.
B. assess orientation to person, time, and place.
C. assess arm drifting.
D. assess gag reflex.
[单项选择]To assess the client’s dorsalis pedis pulse, the nurse should palpate the（ ）
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.
