【最新ISPN测试题】ISPN测试题(192)
2016/6/17 河南安琪职业培训学校

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     Exercise:

     1、A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure?

     1.Side-lying with a pillow under the hip

     2.Prone with a pillow under the abdomen

     3.Prone in slight Trendelenburg's position

     4.Side-lying with the legs pulled up and the head bent down onto the chest

     Correct Answer:4

     A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.

     2、A nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. What should the nurse instruct the client to do?

     1.Avoid the use of commercially prepared ice bags.

     2.Keep the ice pack on the eye continuously for 24 hours.

     3.Place the ice pack directly on the eye and cover with gauze.

     4.Cover the ice pack with a pillowcase and place it on the eye.

     Correct Answer:4

     If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle. To prevent tissue damage from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes and may be reapplied after a short time. An ice pack should never be placed directly against the skin but should be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as an ice pack.

     3、A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which is the therapeutic response by the nurse?

     1. "This is not a good time to make that decision."

     2. "What would your spouse think about your decision?"

     3."What aspects of this situation are the most difficult for you?"

     4."You seem to have a good grip on this situation. You probably should get out."

     Correct Answer:3

     The most helpful response is one that encourages the client to explore the problem and problem-solve. Option 2 disregards the client's concern and focuses instead on the reaction of the alcoholic spouse. The nurse should neither disagree nor agree with the client as in options 1 and 4. Giving advice implies that the nurse knows what is best and can also foster dependency.

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