2015 ISPN 考试 – 题解
Test Preperation for the CGFNS International Standards for Professional Nurses (ISPN) Program® in China
Practice test questions and rationales
Practice test rationales
1. Key: D Client Need: Health Promotion and Maintenance
D. Women who had their first child after age 30 have a slightly higher breast cancer risk.
A. Early menstruation (before age 12) is a risk factor.
B. Trauma is not a risk factor for breast cancer.
C. Breast-feeding lowers the risk of breast cancer.
2. Key: C Client Need: Management of Care
C. Informed consent is required prior to a surgical procedure. If a patient still does not understand, the primary care provider should respond to the patient’s questions and concerns.
A. The patient’s concerns may be valid but the patient’s understanding of the procedure should be the main concern.
B. The patient’s lack of understanding should be addressed first.
D. Informing the patient about the surgery, the procedure, and the possible complications is the role of the primary care provider.
3. Key: D Client Need: Safety and Infection Control
D. The nurse should observe the progression and length of the seizure and note the information in the patient’s chart.
A. The nurse should not attempt oral airway insertion during a seizure – this may result in injury to the patient.
B. This is not a necessary action. The patient’s vital signs can be taken after the seizure subsides.
C. The patient should not be restrained during a seizure. This may cause injury to the patient.
4. Key: D Client Need: Psychosocial Integrity
D. Conversion reactions are related to unresolved conflicts.
A. The patient will have physical limitations until the conflict is resolved.
B. The patient with a conversion reaction usually does not have difficulty accepting help (secondary gain).
C. Patients with conversion reactions are usually unconcerned about the loss of physical abilities.
5. Key: D Client Need: Basic Care and Comfort
D. Low-fat cheese may be eaten but regular cheese should be avoided because of the high-fat content.
A, B & C. Indicates correct understanding of the nurse’s teaching.
6. Key: D Client Need: Pharmacological and Parenteral Therapies
D. Low WBC, RBC, and platelet counts are side effects of therapy. The CBC should be monitored daily.
A. Measuring urine specific gravity is not required.
B. Auscultating lung sounds should be part of shift assessment but is not required protocol for 5-FU administration.
C. Serum potassium is not affected by 5-FU administration.
7. Key: B Client Need: Reduction of Risk Potential
B. Irritation/trauma from the bronchoscope may cause laryngeal edema and compromise respiratory status.
A. Bronchoscope biopsy is done under local anesthesia.
C. The patient’s gag reflex is suppressed. This action could cause aspiration.
D. The patient should be positioned with his head elevated.
8. Key: D Client Need: Physiological Adaptation
D. The patient will be in surgically induced menopause and will require an increase in calcium to prevent osteoporosis.
A. Fluid intake should be maintained.
B. Helpful but not a necessary instruction.
C. The patient should get an adequate amount of sleep. Generally 8 hours is the norm.
9. Key: C Client Need: Management of Care
C. The nurse should first ensure that the client is performing the procedure correctly.
A. The pacemaker is preset to fire below 72 beats per minute and should be doing so.
B. The client’s pulse-taking ability should be evaluated first.
D. An assessment of the client’s ability to take his own pulse is the best indicator that he is performing the procedure correctly.
10. Key: B Client Need: Safety and Infection Control
B. Ipecac syrup induces vomiting, which is not appropriate in all poisonings. The mother needs additional information.
A. Correct understanding. Toddlers are very inquisitive and should not have access to cabinets that contain cleaning materials.
C. Correct understanding. Medications that are not being used or that have expired should be removed from the home.
D. Correct understanding. Toddlers often imitate parent behaviors.
11. Key: B Client Need: Health Promotion and Maintenance
B. The mother’s behavior is the best indicator of acceptance/rejection of infant.
A. May provide insight into her preferences, but the mother’s behavior with the infant provides best indicator of acceptance.
C. Support systems are important but not an indicator of how a mother will treat her child.
D. Good to know but not as important as the mother’s behavior with her infant.
12. Key: A Client Need: Psychosocial Integrity
A. Limit setting prevents power struggles and lets the patient know what is expected of him/her.
B. Defending the patient when in trouble is not an appropriate nursing action.
C. The nurse should not support a patient’s actions if they are inappropriate.
D. These nursing actions will not decrease manipulation of others.
13. Key: C Client Need: Basic Care and Comfort
C. A patient with advanced cirrhosis and encephalopathy should have a low-protein diet.
A. Meat and dairy products have significant protein levels.
B. Eggs and beans are significant sources of protein.
D. Fish and dairy are significant sources of protein in the diet.
14. Key: C Client Need: Pharmacological and Parenteral Therapies
C. Sodium and fluid intake should remain constant during lithium therapy.
A. Decreased sodium can lead to the increased binding of lithium at receptor sites, which increases the chance of lithium toxicity.
B. Nausea and vomiting may indicate lithium toxicity and should be reported to the primary care provider.
D. Diarrhea rather than constipation is a side effect of lithium administration.
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