1、23. A young boy, who is receiving chemotherapy, develops alopecia and says to the nurse, “Im so ugly Ive lost all my hair“Which of the following responses would be appropriate for the nurse to make to the case?A. “Did you know that because your hair fellout, we know that the medicine is working to m
2、ake you better?“B. “Would you like to see some pictures offamous men who are bald?“C. “its hard to look different from the wayyou used to look.“D. “You can wear a baseball cap until yourhair grows back.“接受化疗的年轻男孩发展为秃发，他对护士说：“我很丑，我已经掉光了我所有的头发。 ”对于处理这个案例的护士来说，下列哪项回答是合适的？A. “你知道吗，正是因为你头发的脱落，我们才能知道药物是否使
3、你的病情改善了?“B. “你想看一些秃发名人的照片吗?“C. “用不同于你以前的方式来看问题是很难的.“D. “你可以戴一顶棒球帽，直到你的头发重新长出来.“23. Key: C Client Need :Coping and AdaptationC. This response encourages the teenager to elaborate about his body image.A. Hair Loss is a side effect of chemotherapy and not an indicator of the effectiveness of treatment.
4、B. This response may help the teenager to identify with someone else who does not have hair, butit should not be the nurses initial response.D. The nurse can offer suggestions for how to handle the hair loss, but the nurses initial response should be directed toward getting the patient to talk about
5、 his feelings.答案：C 患者的需要：应对与适应C.这个回答鼓励这名青少年关注自己的身体情况A.脱发是化疗的一个副作用，而不是治疗效果的提示.B. 这个回答可以帮助这名青少年向其他没有头发的人学习，但是这不应该是护士的最初回答.D.护士可以对如何应对脱发提出建议，但是其最初的回答应该是直接针对如何让患者表达出自己的感觉.24. A community health nurse teaches a mother comfort measures for her six-year-old child who has varicella zosterFor Which of the fo
6、llowing actions, if taken by the mother, requires further intervention?A. Applying a cortisone-based cream to the Childs lesionsB. Patting the childs lesions with calaminelotionC. Bathing the child in a tepid oatmeal bathD. Trimming the childs fingernails very short社区卫生机构的护士在教一位母亲如何使其患带状疱疹的六岁孩子更加舒服的
7、方法时，其下列行为提示她需要进一步的指导？A.在孩子皮肤受损处涂抹考的松乳膏B. 在孩子皮肤受损拍打炉甘石洗剂C. 用温的燕麦水给孩子洗浴D. 把孩子的指甲修剪的特别短24. Key: A Client Need: Basic Care and ComfortA. Medications that affect wound healing, such as corticosteroids, impair phagocytosis, inhibit fibroblast proliferation, depress formation of granulation tissue and inhi
8、bit wound closure. They should not be used by patients with varicella.B. Calamine lotion provides supportive therapy for patients with varicella.C. Oatmeal baths are helpful and soothing.D. Children are prone to scratching the lesions. Keeping the fingernails short may prevent scarring.答案：A 患者的需要：基本
9、的照顾与舒适A. 影响伤口愈合的药物，像糖皮质激素，会损伤嗜菌作用，抑制纤维原细胞的增殖，肉芽组织生成的受阻，以及抑制伤口的闭合。它们不应该被用于带状疱疹的患者。B. 炉甘石洗剂能够给带状疱疹的患者提供支持性的治疗.C. 燕麦澡是有用的，并且可以缓解症状的。.D. 孩子是容易抓伤伤口的.保持短指甲可以预防抓伤。42. The parent of a 14-year-old girl calls a rape crisis center and says, “My daughter says she has just been rape. What should Ido? ” Which of
10、the following responses by the nurse counselor is most appropriate? A. “Without allowing your daughter to bathe or change her clothes, take her immediately to the nearest emergency department. B. “Make an appointment for your daughter to have a physical examination by your family doctor as soon as p
11、ossible.“C. “Take your daughter immediately to the nearest police station and file a criminal report.”D. “Your daughter needs to go to the nearest health department to be tested for pregnancy and sexually transmitted diseases.“ 14 岁女孩的父母给妇女性暴力危机中心打电话说：“我女儿说她被强奸了，我应该怎么做？”护理咨询者的下列哪项回答是最合适的？A. “ 不要让你女儿
12、洗澡或换衣服，立刻带她去最近的急诊室.”B. “尽快和你的家庭医生约定为你的女儿做体格检查“C. “立刻带你的女儿去最近的警察局做一份犯罪记录.”D. “你女儿需要去最近的卫生结构检查怀孕和性传播疾病.“ 42. Key: A Client Need: Psychosocial AdaptationA. Evidence of rape can be altered if the victim has bathed, urinated, defecated, douched or changed clothing; therefore, these activities are recorde
13、d. The physical exam is carried out as soon as possible after the rape, since physical evidence deteriorates rapidly.B. Adolescents who have been raped arrive at the emergency room or practitioners office under a variety of circumstances. They are usually brought in by parents, friends or the police
14、, but some may seek medical help on their own. They should be seen as soon as possible and should not wait for an appointment.C. The physical exam and collection of evidence is carried out as soon as possible. Practitioners specially trained for rape examination should be used when possible. Nurses
15、are often members of this group, known as sexual assault nurse examiners (SANE).D. Most care providers prescribe prophylactic administration of antibiotics at the initial exam. Pregnancy prophylaxis with high-dose estrogen is offered to the victim who is not already pregnant or not using a contracep
16、tive method.答案：A 患者的需要：心理社会适应A. 如果受害者洗澡，排尿，排便，冲洗或换衣服，强奸的证据可能会被改变，因此这些行为应该被记录。体格检查应该在强奸后被尽快实施，因为身体方面的证据会很快毁坏掉。B. 被强奸的青少年在多种情况下来到急诊室或开业者的办公室。她们通常会被父母，朋友或是警察带来，但是有些人会自己寻求医疗帮助，而这些都应该被尽快进行，而不是等待预约。C. 体格检查和证据的收集应该被尽快进行，并且在可能的情况下应该是接受过强奸检查特殊培训的开业者进行实施。护士通常是这个检查团队的一员，并且应该是作为性攻击护理检查者。D. 大多数照顾者在最初检查阶段会预防给予抗生素
17、，伴随大剂量雌激素使用的避孕药可以提供给不打算怀孕或不使用其他避孕措施的受害者。46. A young child has experienced a minor superficial burn to the forearm. As an immediate first aid measure, a nurse wouldadvise the parent to apply which of the following substances to the affected area?A. Cool waterB. Antibiotic ointmentC. Hydrogen peroxide
18、D. iodine solution患儿发生前臂的小面积表面烧伤,作为立即的急救措施，护士应该建议其父母在患儿的患处敷下列哪种物质？A. 凉水B. 抗生素药膏C. 过氧化氢D. 碘酒46 Key: A Client Need: Psychosocial AdaptationA. The aims of immediate treatment of thermal injury are to stop the burning process, begin emergency procedures, cover the wound, transport the child to medical a
19、id and provide reassurance. spontaneous cooling of burns by immersion in cool water helps relive the pain. Tins is medically acceptable for a minor burn if the period of immersion is no longer than 30 seconds at a the.B, C and D. Emergency treatment of minor burns includes applying cool water to the
20、 burn or holding the burned area under cool running water The burn should be covered with a clean cloth if there is a risk of damage or contamination. None of these substances should be applied to the burned area.答案：A 患者的需要：心理社会适应A. 烧伤采取即刻治疗的目的是停止燃烧过程，在伤口上实行急救措施，转送孩子去医疗机构，提供安全的保障。烧伤处通过浸入凉水中产生的自发冷却可以
21、帮助减轻疼痛。如果浸入的时间不超过 30 秒，对于小面积的烧伤，这种方法在医学上是可以接受的。B, C and D. 小面积烧伤的急救治疗包括在烧伤处施以冷水或是将烧伤处放于自来水下。如果有污染的危险，伤处应该盖有清洁的布类。上述提到的物品都不应该敷以患处。64. Which of the following statements, if made by the parent of an eight-year-old child undergoing treatment for impetigo, indicates an accurate understanding of the treat
22、ment plan?A. “I have been draining the lesions as they develop.“B. “I wash the lesions every day using a freshly laundered cloth.“C. “I keep the lesions covered with a gauze dressing.”D. “I remind my child several times each day not to touch the lesions.“进行脓疱病治疗的 8 岁患儿，在其父母的陈述中，下列哪一项提示他们对治疗计划有了正确的理解
23、？A. “在脓疱恶化时，我已经对其皮肤破损处进行了引流.“B. “我每天会使用洗涤布清洗伤处.“C. “我用纱布敷料覆盖伤处 .”D. “我会一天提醒几次孩子不要碰触伤处.“64. Key: D Client Need: Psychosocial AdaptationD. Impetigo is easily spread by self-inoculation ;therefore, the child must be cautioned against touching the involved area.A. Children and parents are often tempted
24、to squeeze follicular Lesions. They must be warned that squeezing will not hasten the resolution of the infection and that there is a risk of making theLesion worse or spreading the infection. No attempt should be made to puncture the surface of the pustule with a needle or sharp instrument.B. Using
25、 a cloth to wash the Lesions everyday may be too abrasive and could rupture the lesions, leading to spread of the lesions.C. Topical application of bactericidal ointment may be indicated. There is no documentation to support covering the lesions with a gauze dressing. Burows solution compresses may
26、help to soften crusts and debris. 答案：D 患者的需要：心理社会适应D. 脓疱 contagiosia 是通过自身* 很容易被传播的，因此，孩子必须被提醒不要碰触损伤的部位。A. 孩子和父母通常会去尝试挤压脓泡处，他们必须被警告挤压并不能加速感染问题的解决，并且还存在使受损皮肤恶化或感染扩散的危险。使用针或尖锐的小物件来刺破脓疱表皮的这种尝试是不应该的。B. 每天使用布类来清洗伤处可能对表皮太有磨损力了，可能会擦破伤处，导致脓疱的传播。C. 表面使用抗菌药膏可能是可以的，但是没有任何的资料支持表皮需要使用纱布敷料覆盖。Burows 溶液敷料可能对软化表皮和残皮
27、有帮助。66. A parent calls the emergency department and tells a nurse, “My two-year-old child ate about half a bottle of chewable vitamin, but seems to be feeling fine.“ Which of the following questions would the nurse ask the parent first?A. “Were the vitamins in a locked cabinet?“B. “Have you notified
28、 your family doctor yet?“C. “Did you make your child vomit?“D. “Are the vitamins fortified with iron?“一位家长打电话给急诊室告诉护士：“我两岁的孩子吃了大约半瓶可咀嚼的维生素，但是看上去挺好的。 ”护士应该首先询问家长下列哪个问题？A. “维生素是放在上锁的柜子里吗?“B. “你已经通知你的家庭医生了吗?“C. “你试着使孩子呕吐了吗 ?“D. “这些维生素富含铁吗?“66. Key: D Client Need: Safety and Infection ControlD. Iron poi
29、sonings occurs in stages. The initial stage occurs within 30 minutes to six hours of ingestion and is characterized by vomiting, hematemesis, diarrhea, bloody stools and gastric pain. The latency stage occurs in two to 12 hours and is characterized by improvement in the patient. The system toxicity
30、stage occurs four to 24 hours later and is character-ised by metabolic acidosis, fever hyperglycemia, bleeding, shock and, often, death.A. The nurse should not admonish the parents for negligence, lack of appropriate supervision or failure to saf6-proof the home in the emergency department. lf the n
31、urse prematurely attemptsto discuss ways of preventing such a poisoning from recurring, the parents anxiety will block out any suggestions or offered guidance.B. A poisoning may or may not require emergency intervention, but in every instance medical evaluation is necessary to initiate appropriate a
32、ction. Parents are advised to call the Poison ControlCenter before initializing treatment. Expert advice is essential to minimize side effects.C. In general, the immediate treatment is to remove the ingested poison by inducing vomiting and absorbing the toxin with activated charcoal, performing gast
33、ric lavage or increasing bowel mobility. However, the nurse needs to know the content of the ingested substance before initiating treatment.答案：D 患者的需要：安全和感染控制D.铁中毒是分阶段发生的，最初的阶段发生在摄入后 30 分钟到六小时内，是以呕吐，咯血，腹泻，血便以及胃痛为特征的，潜伏期发生在 2 到 12 小时内，是以患者病情的改善为特征的，机体中毒阶段发生在 4到 24 小时内，是以代谢性酸中毒，发热，高血糖，出血，休克以及通常致死。A. 护
34、士不应该在急诊室内训诫家长的疏忽大意，缺乏恰当的监护或家庭安全防护的失败，如果护士过早尝试讨论如何预防像这样的中毒的再次发生，家长的焦虑将会阻碍任何建议或提供的指导的听取。B. 中毒可能需要急救措施，但是在任何情况下，药物的评价对于最初适当的行为来说都是必需的，家长应该被建议在进行最初的治疗之前致电给毒物控制中心，专家的建议对于减少副作用来说是必需的。C. 一般来说，祛除摄入毒物的最先的治疗方法是通过催吐和使用活性炭来吸收毒物，实施胃部清洗或增加肠部运动，然而护士在实施治疗之前需要了解摄入物质的内容。69. A three-Year-old child has an upper respira
35、tory infection. During a physical examination, a nurse observes bruises tothe lower back and buttocks of the child. The nurse would first assess the child for manifestations ofA. child maltreatment syndrome.B. blood dyscrasias.C. neuromuscu1ar dysfunction.D. acquired immune deficiency syndrome.3 岁的孩
36、子发生上呼吸道感染，在体格检查过程中，护士观察到在孩子的下背部和臀部有瘀斑，那么她应该首先评估孩子的下列哪个表现？A. 虐童症状.B. 恶液质 .C. 神经肌肉功能紊乱.D. 获得性免疫缺陷症状.69. Key A Client Need: Psychosocial AdaptationA. The deliberate infliction of physical injury on a child, usually by the childs caregiver, is termed physical abuse. Warning signs of physical abuse inclu
37、de bruises and welts on the lower back, buttocks and thighs. these bruises may be in various stages of healing.B. A sudden tendency to bruise is a cardinal symptom of cancer in children. Clinical symptoms of idiopathic thrombocytopenia purpura include petechiae, bruising, bleeding from mucous membra
38、nes and prolonged bleeding from abrasions. The pattern of bruising is not indicative of a blood dyscrasia. Assessment for abuse should be performed first.C. Neuromuscular dysfunction generally results in weakness or abnormal performance of muscles rather than in bruising.D. The most common AIDS-defi
39、ning illnesses in children include recurrent bacterial infections, parotitis, interstitial pneumonitis, wasting syndrome and progressive neurologic deterioration. Bruising over the buttocks and lower back is not characteristic.答案：A 患者的需要：心理社会适应A. 通常是孩子的监护人，对孩子进行有意的身体伤害，被命名为身体虐待，身体虐待*包括低背部，臀部和大腿部的瘀斑和
40、鞭痕，这些瘀斑可能存在于康复的各个阶段。B. 瘀斑的突然发生对孩子来说是癌症的一个重要症状。1的临床症状包括瘀斑，瘀伤，黏膜的出血和破损处长时间的流血，瘀伤的类型不是恶液质的提示，对虐待的评估应该是最先进行的。C. 神经肌肉功能紊乱通常导致肌肉的虚弱或不正常表现，而不是瘀伤。D. 孩子最常见的 AIDS 病包括循环发生的细菌感染，腮腺炎，间质性肺炎，消耗性症状和进展性神经恶化，臀部和低背部的瘀伤不是它的特征。1O7. A seven-year-old child who was in a house fire is being evaluated in the emergency depart
41、ment. The child has no visible burn injuries but vomits undigested food with black particles. Which of the following goals would be given priority in thechilds care plan?A. Minimize discomfortB. Conserve urinary outputC. Maintain a patent airwayD. Preserve gastrointestinal function遭遇房子失火的 7 岁孩子在急诊室接
42、受评估，孩子没有明显的烧伤但是呕吐出伴有黑色物质的未消化食物，在孩子的照顾计划中下列哪一项目标应该是优先实现的？A. 减低不适B. 保存尿排出量C. 保持气道通畅D. 保护胃肠道功能107. Key :C Client Need: Management of Care C. Possible inhalation injury is suspected when there is a history of exposed to flames in a closed space whether or not burns are present. Sooty martial around the
43、nose or in the sputum, singed nasal hairs, mucosal burns of the nose, lips, mouth or throat, hoarse voice and cough and stridor indicate that the affected person requires observation for possible pulmonary injury. Therapeutic management of smoke inhalation is Symptomatic; however, administering humi
44、dified 100% oxygen as soon as possible and monitoring for signs of respiratory distress is a priority.A. Respiratory distress is the primary symptom rather than pain.B. Fluid requirements are carefully managed to avoid pulmonary edema while maintaining adequate hydration.D. lf the child experiences
45、vomiting and/or respiratory distress, the child may be NPO to reduce the risk of aspiration. The priority goal, however, is the patients airway.答案：C 患者的需要：照顾的管理C. 不论烧伤是否存在，只要在密闭的空间里暴露于火焰之中，可能存在的吸入性伤就应被疑为存在。在鼻子周围或痰液中有乌黑的物质，烧焦的鼻毛，鼻腔，嘴唇，嘴巴或喉黏膜的损伤，嘶哑的声音，咳嗽和尖锐的声音提示受伤的患者需要对潜在的吸入性烧伤进行观察。烟尘吸入的治疗性 Therapeutic management of smoke inhalation is Symptomatic;但是尽可能给予湿化的 100%的氧气和监测呼吸窘迫的症状是应该优先实施的。A.呼吸窘迫是最首要的问题，而不是疼痛。B. 保持足够的水分时，液体的需要应该被谨慎的给予，以避免发生肺水肿D. 如果发生了呕吐和/或呼吸窘迫，孩子应该经口禁食以减少误吸的危险，但是，最首要的目标，应该是患者的气道。
