公式集、全トピックの解法の要点、6 問の演習問題。完全な解答は巻末にあります。
A patient with delirium is at risk of falls and of pulling out lines. Which option is less restrictive than restraints?
A patient on contact precautions for MRSA has become withdrawn and says, “Everyone avoids me.” What is the best nursing action?
A goal states: "The patient will report pain of 3/10 or less within one hour of analgesia." After one hour the patient reports 6/10. What should the nurse do?
A patient opens their eyes only to pain, makes incomprehensible sounds and withdraws from a painful stimulus. What is the Glasgow Coma Scale score?
進行した HIV 感染者に起こる Pneumocystis jirovecii 肺炎は何の例ですか？
咽頭痛、発熱、リンパ節腫脹のある若い成人にアモキシシリンを投与したところ、広範な発疹が出ました。最も可能性が高い感染症はどれですか？
答え: C · A trained sitter or video monitoring with staff nearby
Close observation by a sitter or video monitoring allows staff to step in quickly, without restricting the patient. It is often combined with reorientation and family presence.
答え: B · Explain why the precautions are needed and plan regular, unhurried time in the room
Isolation can cause loneliness, anxiety and depression, and patients in isolation may get less contact with staff. The nurse explains the reason for the precautions, spends planned time with the patient and supports visits from people who follow the precautions.
答え: C · Record the goal as not met and review the plan
Evaluation compares the outcome with the goal. The goal was not met, so the nurse reassesses, reports and revises the plan, for example with a different analgesic.
答え: C · 8
Eyes to pain score 2, incomprehensible sounds score 2 and withdrawal from pain scores 4, giving 8. A GCS of 8 or less suggests the patient may not be able to protect their airway.
答え: A · 日和見感染症
日和見感染症は弱った免疫系につけ込みます。HIV では CD4 数が低い水準に下がると多くなります。
答え: A · EB ウイルスによる伝染性単核球症
伝染性単核球症は EBV が原因です。病気の間にアモキシシリンを投与された患者の多くに発疹が出ます。原因はウイルスなので、抗生物質は役に立ちません。
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