看護留学しながらアメリカで看護資格NCLEX-RNをとるぞ

A client is complaining of difficulty concentrating

having outbursts of anger, and feeling "keyed up"

all the time. The nurse obtaining the client's

history discovers that the symptoms started about

6 month ago.

The client reveals that a best friend was killed in a

drive-by shooting while they were sitting on the

porch talking.

The nurse suspects that the client is experiencing :

1 Obsessive-compulsive disorder ( OCD )

2 Panic disorder

3 Post-traumatic stress disorder ( PTSD )

4 Social phobia

続きを読む "目前で親友が銃殺されたら・・・。" »

投稿者: Maru 日時: 23:08 | パーマリンク | コメント (0) | トラックバック (0)

A client being mechanically ventilated after

experiencing a fat embolus is visibly anxious.

The nurse takes which appropriate action ?

1 Encourages the client to sleep until arterial
blood gas results improve

2 Asks a family member to stay with the client
at all time

3 Asks the physician to obtain an order for an
antianxiety medication

4 Remains with the client and provides
reassurance

続きを読む "不安がある患者の看護" »

投稿者: Maru 日時: 16:17 | パーマリンク | コメント (0) | トラックバック (0)

A female client who is in manic state emerges

from her room.

She is topless and is making sexual remarks and

gestures toward staff and peers.

The best initial nursing action is to :

1 Quietly approach the client, escort her to her
room, and assist her in getting dressed

2 Approach the client in the hallway and insist
that she go to her room

3 Confront the client on the inappropriateness
of her behavior and offer her a time-out

4 Ask the other clients to ignore her behavior;
eventually she will return to her room

続きを読む "躁状態にある患者への適切な対応って？" »

投稿者: Maru 日時: 15:56 | パーマリンク | コメント (0) | トラックバック (0)

A nurse is planning the discharge instructions

from the emergency department for an adult

client who is a victim of family violence.

The nurse understands that the discharge plans

must include:

1 Instructions to call the police the next time
the abuse occurs

2 Exploration of the pros and cons of remaining
with the abusive family member

3 Specific information regarding "safe havens" or
shelters in the client's neighborhood

4 Specific information about selfdefense classes

続きを読む "虐待を受ける患者の退院プランに必要な事って？" »

投稿者: Maru 日時: 15:39 | パーマリンク | コメント (0) | トラックバック (0)

A client tells the nurse,"My doctor says i can

have the surgery and go home the same day

but i'm afraid. My husband's dead and my son is

3,000 miles away. i'm alone and what happens if

something goes wrong ? I'm not supposed to be

up walking unless absolutely necessary."

The nurse makes which therapeutic response to

the client ?

1 "I know, I know. They say, Maneged Care is no
Care! Have you got an alarm system so if you
fall, it will alert someone to come?
If worse comes to worse, call me and I'll come
immediately."

2 "Don't worry. This procedure is done all the time
without anyproblems. You'll be fine."

3 "Your concern is well voiced. i advise you to call
your son and insist he come home immediately !
You can't be too careful."

4 "You seem very concerned about going home
without help. Have you discussed your concerns
with your doctor ?"

続きを読む "混乱・困惑している患者への声かけ" »

投稿者: Maru 日時: 13:47 | パーマリンク | コメント (0) | トラックバック (0)

A nurse is assessing a client who has nursing

diagnosis of risk for self-directed violence.

The client says, "You won't have to worry

about me much longer."

The nurse interprets this statement as :

1 An expression of hopelessness

2 An expression of depression

3 The intention for self-mutilation

4 The intention of suicide

続きを読む "自傷行為のリスクのある患者" »

投稿者: Maru 日時: 12:55 | パーマリンク | コメント (0) | トラックバック (0)

A female victim of sexual assault is being seen in

the crisis center for a third visit.

She states that although the rape occurred nearly

2 months ago, she still feels "as though the rape

just happened yesturday."

The nurse would respond by standing :

1 "What can you do to alleviate some of your fear
about being assaulted again ?"

2 "Tell me more about those aspects of the rape
that cause you to feel like the rape just occurred."

3 "In time, our goal will be to help you move on from
these strong feelings about your rape."

4 "In reality,the rape did not just occur.
It has been over 2 month ago."

続きを読む "レイプ被害者に対するナースのありかたって？" »

投稿者: Maru 日時: 10:31 | パーマリンク | コメント (0) | トラックバック (0)

A nurse is performing an admission assessment on

a child and notes the presence of old and new bruises

on child's back and legs.

The nurse suspects physical abuse and would :

1 File charge against the mother and father of the child

2 Report the case to legal authorities

3 Ask the mother to identify the individual who is
physically abusing the child

4 Tell the child that she will need to go to a foster
home until the situation is straightened out

続きを読む "幼児虐待を発見したらナースはどうする？" »

投稿者: Maru 日時: 09:50 | パーマリンク | コメント (0) | トラックバック (0)

A nurse is monitoring a client for signs of

alcohol withdrawal.

which assessment deta indicates early signs

of withdrawal ?

1 Anxiety,tremor,irritability

2 Disorientation,and sleepiness

3 Dizziness,vomiting,headache

4 Clouding of consciousness,tirednedd, fatigue

続きを読む "アルコール離脱症状はどれ？" »

投稿者: Maru 日時: 22:26 | パーマリンク | コメント (0) | トラックバック (0)

A nurse is obtaining a health history on an

adolescent. Which statement by the adolecent

indicate a need for follow-up assessmet and

intervention.

1 "I find myself very moody-happy one minute
and crying the next."

2 "I can't seem to wake up in the morning.
I would sleep until noon if i could."

3 "I don't eat anything with fat in it and I 've
lost 8 pounds in 2 weeks"

4 "When i get stressed out about school,
I just like to be alone."

続きを読む "思春期の精神的特徴を考える" »

投稿者: Maru 日時: 16:59 | パーマリンク | コメント (0) | トラックバック (0)

A nurse receives a telephone call from a

male client who state that he wants to kill

himself and has a loaded gun on the table.

The best nursing intervention is to:

1 Insist that the client give you his name and
address so that you can get the police there
immediately

2 Keep the client talking and allow the client
to vetilate feeling

3 Use therapeutic communication techniques,
especially the reflection of feeling

4 Keep the client talking and signal to another
staff member to trace the cell so that
appropriate help can be sent

続きを読む "危機的状況下にあるナースの介入はどれ？" »

投稿者: Maru 日時: 10:47 | パーマリンク | コメント (0) | トラックバック (0)

A physician has written an order for a vest restraint

to be applied on a client from 10:00pm to 7:00am

because the client becomes disoriented during the

night and is at risk for falls.

At 11:00pm, the charge nurse makes rounds on all

of the clients in the unit.

When assessing the client with the vest restraint,

which observation by the charge nurse would indicate

that the nurse who cared for this client performed an

unsafe action in the use of the restraint?

1 A hitch knot was usd to secure the restrant.

2 The client's record indicate that the restrant will be
released every 2 hours.

3 The restrant was applied tightly.

4 The call light was placed within reach of the client.

続きを読む "抑制時の注意点は？" »

投稿者: Maru 日時: 18:17 | パーマリンク | コメント (0) | トラックバック (0)

A nurse is caring for a client with depression

who has not responded to antidepressant medication.

The nurse anticipates that what treatment modality

may be prescribed ?

1 Electroconvulsive therapy

2 Psychosurgery

3 Short term seclusion

4 Neuroleptic medication

続きを読む "鬱病患者の効果的な治療法とは？" »

投稿者: Maru 日時: 22:27 | パーマリンク | コメント (0) | トラックバック (0)

While the nurse is providing preoperative teaching, the client says, "I hate the idea of being
an invalid after they cut off my leg." The nurse's most therapeutic response would be

1. "You'll still have one good leg to use."

2. "Tell me more about how you're feeling."

3. "Let's finish the preoperative teaching."

4. "You're fortunate to have a wife who can take care of you."

続きを読む "治療的コミュニュケーション" »

投稿者: Maru 日時: 03:27 | パーマリンク | コメント (0) | トラックバック (0)

A psychotic client is pacing, agitated. and presenting with aggressive gestures. 'File client's speech pattern is rapid, and the client's affect is belligerent. Based on this objective data,
the immediate priority of care is to:

1 Provide safety for the client and other clients on the unit
2 Bring the client to a less stimulated area to calm down and gain control
3 Provide the clients on tile unit with a sense of comfort and safety
4 Assist the staff in caring for the client in a controlled environment

続きを読む "攻撃的状態にある患者の看護" »

投稿者: Maru 日時: 23:13 | パーマリンク | コメント (0) | トラックバック (0)

　The client exhibits a flat affect, psychomotor retardation, and depressed mood.
The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which of the following responses by the nurse would be most appropriate?

1. "I'll sit here with you for 15 minutes."
2. "I'll come back a little bit later to talk."
3. "I'll find someone else for you to talk with."
　4. "I'll get you something to read."

<引用>
Lippincott's Review for NCLEX-RN by Diane M. Billings
Jan 15, 2002

続きを読む "鬱" »

投稿者: Maru 日時: 05:21 | パーマリンク | コメント (0) | トラックバック (0)