公式集、全トピックの解法の要点、14 問の演習問題。完全な解答は巻末にあります。
A child with fever and headache develops a purple rash that does not fade when pressed with a glass. What should the nurse do?
A visitor on the ward becomes threatening and shows a knife. What is the nurse’s priority?
A visitor with a cold wants to see a patient who has severe neutropenia. What should the nurse advise?
A nurse has weeping dermatitis on both hands. What is the most appropriate action?
A patient is starting atorvastatin. Which laboratory test is usually checked at baseline?
新たに深部静脈血栓症を発症した患者がヘパリンを点滴中で、ワルファリンを開始したばかりです。ヘパリンを数日間続けるのはなぜですか？
Which finding with a groin hernia needs urgent surgical review?
重症喘息の患者が静かになり、「サイレントチェスト」、疲労困憊、呼吸数の低下がみられます。これは何を示していますか？
降圧薬を飲み始めたばかりの患者が、ベッドから出るときにめまいを感じます。正しい助言はどれですか？
A patient with life-threatening asthma has not responded to repeated nebulised salbutamol (albuterol), ipratropium and steroids. Which drug is commonly given intravenously next?
A patient with untreated hyperthyroidism is losing weight. Which diet is most appropriate until the condition is controlled?
A patient with a head injury now has a blood pressure of 190/70 mmHg, a pulse of 48/min and irregular breathing. How should the nurse interpret this?
Why is IV albumin often given after a large-volume paracentesis?
A nurse teaches a patient with a new ileostomy. Which statement shows a need for further teaching?
答え: A · Treat it as an emergency and escalate at once
A non-blanching rash with fever can be a sign of meningococcal septicemia, which can progress within hours. Urgent escalation for antibiotics and supportive care is needed.
答え: D · Move away to safety, keep others away and call security or the police
In a threat involving a weapon, staff keep a safe distance, protect patients where possible and call security or the police. Trying to disarm the person puts staff at serious risk.
答え: B · Postpone the visit until the visitor is well
Patients with severe neutropenia cannot fight infections well. People with respiratory or other infections should not visit until they are well; other visitors perform hand hygiene.
答え: D · Avoid direct patient care and handling of equipment until it heals, and see occupational health
Weeping skin lesions increase the risk of passing organisms to patients and of the nurse picking up bloodborne pathogens. The nurse should avoid direct patient contact and handling of patient equipment until the condition is assessed and resolved.
答え: A · Liver enzymes
Statins can raise liver enzymes, so a baseline ALT is usually checked, with a lipid panel to judge response. Routine repeat liver tests are not always needed, but symptoms of liver injury or muscle pain should be reported.確認に用いた資料: Statins · MedlinePlus (NIH) (2025)
答え: C · ワルファリンが十分な抗凝固作用に達するまでに、数日かかるため
ワルファリンは、ビタミン K 依存性の新しい凝固因子の産生を阻害しますが、既存の因子は数日間残ります。そのため、INR が目標範囲に入るまで（通常は少なくとも 24 時間、最低約 5 日間のあと）、ヘパリンを重ねて投与します。
答え: B · The lump has become painful and tender and cannot be pushed back
An irreducible, painful, tender hernia, especially with vomiting, suggests incarceration or strangulation. This is a surgical emergency because the trapped bowel can become ischaemic.
答え: D · 呼吸停止が迫った、命に関わる喘息
サイレントチェスト、疲労困憊、チアノーゼ、混乱は命に関わるサインです。患者にはただちに上級医と集中治療の関与が必要です。
答え: A · 立つ前に、しばらくベッドの端に座る
起立性低血圧は、降圧薬を開始するときによくみられます。ゆっくり体位を変えると転倒のリスクが減ります。症状が続く場合は報告し、臥位と立位の血圧を測定して、用量を見直します。
答え: C · Magnesium sulfate
A single dose of IV magnesium sulfate is recommended in acute severe or life-threatening asthma that does not respond to initial treatment. Senior and critical care help is called early. Sedatives and beta-blockers are dangerous in acute asthma.
答え: B · A high-calorie diet with enough protein
Excess thyroid hormone raises metabolism, so patients need more calories and protein to prevent weight loss. Caffeine is limited because it worsens palpitations, tremor and anxiety.
答え: C · Cushing's triad, a late sign of raised intracranial pressure
Cushing's triad is hypertension with a widening pulse pressure, bradycardia and irregular respiration. It shows that the brainstem is being compressed and herniation may be imminent, so it is an emergency.
答え: D · To prevent low blood pressure and kidney injury from fluid shifts
Removing large volumes of ascites can lead to hypotension and kidney injury as fluid moves from the blood into the abdomen. Albumin keeps fluid in the circulation; BP and urine output are monitored.
答え: C · "I'll drink less so my bag fills more slowly."
Restricting fluids increases dehydration risk with an ileostomy. Patients drink enough, add salt as advised, chew well and report high output or signs of dehydration.
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