Medical Tests CCNS 問題集

質問 1：
During a family therapy, the nurse notes that the patient's mother is sitting with the patient's father with
her arms and legs crossed and her body turned away from her husband. This non-verbal behavior is an
example of:
A. Distancing
B. Blocking
C. Incongruence
D. Cultural posturing
正解：A
解説: (Topexam メンバーにのみ表示されます)

質問 2：
A nurse is assigned in caring for newborn patients admitted at the neonatal intensive care unit. The nurse
should immediately refer a patient who has:
A. Body temperature of 97.8oF
B. Respiratory rate of 25 beats per minute with sternal retractions
C. Cardiac rate that drops to 110 beats per minute
D. Immature kidneys with evidence of rust-colored stain in the diaper
正解：B
解説: (Topexam メンバーにのみ表示されます)

質問 3：
You were assigned to all of the following patients. Which patient should you assess first?
A. A patient who is on maximal medical therapy for 24 hours with persistent chest pain
B. A patient with body temperature of 101.2oF
C. A 10-year-old patient who is scheduled for cholecystectomy in an hour
D. A patient with tramadol drip, which is due in 30 minutes
正解：A
解説: (Topexam メンバーにのみ表示されます)

質問 4：
A nurse is caring for a child who has terminal cancer. The nurse is aware that the parents are in desperate
need of support from the medical staff. The nurse should not include which care plan before the death of a
child?
A. Assist them to make final arrangement like contacting a funeral home
B. Avoid judgmental reactions to what family members say or do
C. Provide referrals to support groups if available
D. Show caring by touching the child and encourage parents to do it as well
正解：A
解説: (Topexam メンバーにのみ表示されます)

質問 5：
A nurse teaches a patient with exopthalmos how to reduce discomfort and prevent corneal ulceration. The
nurse recognizes that the teaching is understood when the patient says "I should..."
A. ...elevate the head of my bed at night."
B. ...avoid using a sleeping mask at night."
C. ...eliminate excessive blinking."
D. ...not move my extraocular muscles."
正解：B
解説: (Topexam メンバーにのみ表示されます)

質問 6：
A nurse is caring for an adult patient who she thinks is at high risk for developing a pressure ulcer. As a
clinical nurse specialist, one of her responsibilities is to implement clinical changes and research-based
practices developed by others. Which of the following steps should the clinical nurse specialist avoid?
A. Look for a systematic research review about the issue. Limit the keywords to be able to come up to
information about pressure ulcer prevention and management
B. Work with administrative and medical leadership; determine which practices to incorporate into site
policy and procedure for pressure ulcer prevention and care
C. Identify populations that are developing pressure ulcers in her setting
D. Look first for evidence-based clinical practice guidelines produced by respected organizations
正解：A
解説: (Topexam メンバーにのみ表示されます)

質問 7：
An adult patient who smokes 3 packs of cigarettes a day was admitted to the hospital with a diagnosis of
pulmonary emphysema. When the nurse assessed the patient, she noticed shortness of breath and that
the patient used his accessory muscles during respirations. The nurse is aware that the patient's dyspnea
is due to:
A. Spastic bronchi which traps the air
B. Increased vital capacity of the lungs
C. Difficulty in expelling the air trapped in the alveoli
D. Rapid expulsion of air from the alveoli
正解：C
解説: (Topexam メンバーにのみ表示されます)