NCLEX Certification NCLEX-PNリアル試験問題と無料最新回答2022年11月24日
NCLEX-PN究極な学習ガイド
質問 377
The school nurse is conducting health screenings on schoolchildren. During the screening, she identifies a child with the behavioral characteristics of attention deficit disorder. Which of the following behaviors is consistent with this disorder?
- A. inability to carry on a conversation
- B. overreaction to stimuli from the surroundings
- C. slow speech development
- D. concrete thinking
正解: B
解説:
Children with attention deficit disorder are easily distracted but are able to carry on a conversation. Concrete thinking is more indicative of age, and slow speech development has more to do with other learning disabilities.Health Promotion and Maintenance
質問 378
Which sign might the nurse see in a client with a high ammonia level?
- A. edema
- B. coma
- C. polyuria
- D. hypoxia
正解: B
解説:
Explanation/Reference:
Explanation:
Coma might be seen in a client with a high ammonia level. Reduction of Risk Potential
質問 379
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
- A. hydramnios
- B. meconium
- C. blood
- D. caput
正解: B
解説:
Explanation/Reference:
Explanation:
Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract.
Physiological Adaptation
質問 380
When making an occupied bed, it is important for the nurse to ___________.
- A. use a bath blanket or top sheet for warmth and privacy
- B. constantly keep side rails raised on both sides
- C. move back and forth from one side to the other when adjusting the linens
- D. keep the bed in the low position
正解: A
解説:
Section: Physiological Integrity
Explanation:
Using a bath blanket or top sheet keeps the client warm and provides privacy.
Keeping the bed in the low position and working above raised side rails might strain the nurse's back.
Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.
質問 381
Which of the following is true concerning human immunodeficiency virus (HIV)?
- A. HIV infection involves CD4 receptor protein on the surface of helper T-cells.
- B. The presence of circulating antibodies that neutralize HIV is evidence that the individual has immunity-HIV.
- C. DNA replication
- D. HIV replication occurs extracellularly.
正解: A
解説:
Section: Physiological Integrity
Explanation:
The virus makes a DNA copy of its own RNA using the reverse transcriptase enzyme, and the DNA copy is inserted into the genetic material of the infected cell.
質問 382
A client with urinary tract calculi needs to avoid which of the following foods?
- A. broccoli
- B. lettuce
- C. cheese
- D. apples
正解: C
解説:
The client with urinary tract calculi needs to avoid cheese, which has high calcium content. The other foods do not.Physiological Adaptation
質問 383
A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Anasaid
- B. Colace
- C. Advil
- D. Clinocil
正解: B
解説:
Explanation/Reference:
Explanation:
Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate. Basic Care and Comfort
質問 384
Acyclovir is the drug of choice for __________.
- A. HSV 1 and 2 and VZV
- B. CMV
- C. HIV
- D. influenza A viruses
正解: A
解説:
Section: Physiological Integrity
Explanation:
Acyclovir (Zovirax) is specific for treatment of herpes virus infections. There is no cure for herpes.
Acyclovir is excreted unchanged in the urine and therefore must be used cautiously in the presence of renal impairment.
Drugs that treat herpes inhibit viral DNA replication by competing with viral substrates to form shorter, ineffective DNA chains.
質問 385
Nurses should understand the chain of infection because it refers to:
- A. the sequence required for transmission of disease.
- B. increasing virulence patterns among species of microorganisms.
- C. the linkages between various forms of microorganisms.
- D. the clustering of bacteria in a specific pattern.
正解: A
解説:
Explanation/Reference:
Explanation:
Infection occurs in a predictable sequence requiring virulence, movement from a reservoir, and entry into a susceptible host. Physiological Adaptation
質問 386
The chemotherapeutic DNA alkylating agents such as nitrogen mustards are effective because they:
- A. have few, if any, side effects.
- B. are cell-cycle-specific agents.
- C. cross-link DNA strands with covalent bonds between alkyl groups on the drug and guanine bases on DNA.
- D. are used to treat multiple types of cancer.
正解: C
解説:
Explanation/Reference:
Explanation:
Alkylating agents are highly reactive chemicals that introduce alkyl radicals into biologically active molecules and thereby prevent their proper functioning, replication, and transcription. Choice 2 is incorrect because alkylating agents have numerous side effects including alopecia, nausea, vomiting, and myelosuppression. Choice 3 is incorrect because nitrogen mustards have a broad spectrum of activity against chronic lymphocytic leukemia, non-Hodgkin's lymphoma, and breast and ovarian cancer, but they are effective chemotherapeutic agents because of DNA crosslinkage. Choice 4 is incorrect because alkylating agents are non-cell-cycle-specific agents. Pharmacological Therapies
質問 387
A standard walker is used when clients:
- A. have poor balance, have cardiac problems, or cannot use crutches or a cane.
- B. have poor balance, cannot stand up, have weak arms, and have good hand strength.
- C. have poor balance, have a broken leg, or have experienced amputation.
- D. have poor balance, have an autoimmune disease, or have weak arms.
正解: A
解説:
Explanation/Reference:
Explanation:
A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a cane. The client needs to bear partial weight and have strength in her wrists and arms. The client uses her upper body to propel the walker forward. Basic Care and Comfort
質問 388
All of the following factors, when identified in the history of a family, are correlated with poverty except:
- A. consultation with folk healers.
- B. high infant mortality rate.
- C. low incidence of dental problems.
- D. frequent use of Emergency Departments.
正解: C
解説:
Dental problems are prevalent because of the lack of preventive care and access to care. High infant mortality is one of the most significant problems correlated with poverty. Pregnant women who do not have access to care might come to the Emergency Department when in labor. Those in poverty are likely to use Emergency Departments because they may not be turned away. Those in poverty might also turn to folk healers or other persons in their community for care who might be easier to access and might not demand payment.Health Promotion and Maintenance
質問 389
A newborn has been delivered. An Apgar score is given. What does this scoring system indicate?
- A. heart rate, bleeding, cyanosis, edema
- B. bleeding, reflex, edema
- C. respiratory effort, heart rate, seizures
- D. heart rate, respiratory effort, color, muscle tone, reflex irritability
正解: D
解説:
Explanation/Reference:
Explanation:
The Apgar scoring system was put into place by Virginia Apgar, an anesthesiologist in New York, for the purpose of assessing newborns in the areas of heart rate, respiratory effort, color, muscle tone, and reflex irritability at 1, 5, and sometimes 10 minutes after birth. Safety and Infection Control
質問 390
When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
- A. when started, therapy must not be interrupted to prevent opportunistic infection.
- B. therapy should be interrupted for one day each month to prevent toxicity.
- C. when started, therapy must not be interrupted to prevent viral resistance.
- D. therapy should be interrupted for one week every three months to prevent toxicity.
正解: C
解説:
Explanation/Reference:
Explanation:
HIV mutates very rapidly, and any interruption of therapy can allow viral resistance to emerge - even taking a dose late. Choice 2 is incorrect because, when the virus is kept in check with anti-retrovirals, the client's own immune system is able to keep opportunistic infections at bay. Choices 3 and 4 are incorrect because therapy should not be interrupted for any reason. If the client develops toxicity, another anti- retroviral drug might be prescribed. Physiological Adaptation
質問 391
A complication of total parenteral nutrition (TPN) is the development of cholestasis.
What is this condition?
- A. the formation of gallstones
- B. an arrest of the normal flow of bile
- C. an inflammation of the gallbladder
- D. an inflammatory process of the extrahepatic bile ducts
正解: B
解説:
Section: Physiological Integrity
Explanation:
Cholestasis due to TPN administration is an intrahepatic process that interrupts the normal flow of bile.
Extrahepatic bile duct inflammation is cholangitis.
Inflammation of the gallbladder is cholecystitis.
Gallstones are formed by bile components.
質問 392
During which week does the fetal heart begin pumping its own blood?
- A. 6th week
- B. 5th week
- C. 9th week
- D. 3rd week
正解: D
解説:
Section: Health Promotion and Maintenance
Explanation:
The embryonic heart begins pumping its own blood, often a different blood type than the mother's, during week
3.
Week 5 includes the development of eyes, legs, and hands.
Brain waves become detectable during week 6 and teeth begin to develop during week 9 of gestation.
質問 393
A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client?
- A. Her pregnancy must be followed carefully by a genetic specialist.
- B. Her pregnancy is threatened, and the fetus is at risk for teratogenesis.
- C. Accutane is a Category D drug, which means it is unsafe in pregnancy.
- D. She has a reportable condition, and the pregnancy must be terminated.
正解: B
解説:
Explanation/Reference:
Explanation:
Accutane is a Category X drug, which means pregnancy is contraindicated due to teratogenesis associated with the medication. The pharmaceutical manufacturer should be notified of any pregnancy occurring while taking the drug, but reporting is voluntary. Choosing to terminate the pregnancy is a personal decision that requires full information. Consultation with a genetic specialist or OB physician is indicated. Safety and Infection Control
質問 394
Which of the following medications might cause upper-gastrointestinal (UGI) bleeding?
- A. Elavil (amitryptiline)
- B. Naprosyn (naproxen)
- C. Corgard (nadolol)
- D. Cardizem (diltiazem)
正解: B
解説:
Section: Physiological Integrity
Explanation:
Naprosyn might cause upper-gastrointestinal (UGI) bleeding.
質問 395
Who should receive the hepatitis A vaccine?
- A. individuals who might come into contact with blood
- B. infants, who should receive the vaccination at birth
- C. people who travel to other countries
- D. children who are 18 months of age
正解: C
解説:
Hepatitis A is for individuals who travel or persons with chronic liver disease. Infants receive the hepatitis B vaccine at birth. DTaP is administered at 18 months of age. Individuals who come into contact with blood should be immunized against hepatitis B.
Health Promotion and Maintenance
質問 396
A laboring patient is experiencing late decelerations.
Which position should she be placed in?
- A. right lateral
- B. semi-Fowler's
- C. lithotomy
- D. left lateral
正解: D
解説:
Section: Health Promotion and Maintenance
質問 397
A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:
- A. neostigmine (Prostigmin).
- B. labetalol (Normodyne).
- C. thiothixene (Navane).
- D. naloxone (Narcan).
正解: B
解説:
Tolerance is the capacity to ingest an increasing amount of a substance without effect and the experience of decreased sensitivity to the substance. Tolerance can develop with long-term use of many drugs. Choice 1 is the dose required to produce a defined magnitude of drug effect. Choice 3 binds to a receptor and causes an action. Choice 4 is the maximal response produced by a drug.Pharmacological Therapies
質問 398
A nurse is caring for a client with an elevated cortisol level.
The nurse can expect the client to exhibit symptoms of __________.
- A. hyperpituitarism
- B. urinary excess
- C. hyperthyroidism
- D. urinary deficit
正解: D
解説:
Section: Physiological Integrity
Explanation:
High levels of cortisol can produce sodium and fluid retention and potassium deficit, thus creating urinary deficit.
質問 399
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of:
- A. introjection.
- B. conversion.
- C. rationalization.
- D. regression.
正解: D
解説:
Crying is a regressive behavior. The ego returned to an earlier, comforting, and less-mature way of behaving in the face of disappointment. Conversion involves the transformation of anxiety into a physical symptom. Introjection involves intense unconscious identification with another person. Rationalization involves the unconscious process of developing acceptable explanations to justify unacceptable ideas, actions, or feelings.Psychosocial Integrity
質問 400
When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?
- A. 8 liters/minute
- B. 2 liters/minute
- C. 4 liters/minute
- D. 6 liters/minute
正解: D
解説:
Explanation/Reference:
Explanation:
The highest flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Higher flow rates must be delivered by mask. Reduction of Risk Potential
質問 401
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