解答つき内科外科看護：循環器と呼吸器ワークシート

Which three signs make up Beck's triad in cardiac tamponade?

1. ALow blood pressure, distended neck veins and muffled heart sounds
2. BFever, a new heart murmur and splinter haemorrhages under the nails
3. CChest pain, ST elevation and raised troponin
4. DHigh blood pressure, a slow pulse and irregular breathing

Which colour change is typical of Raynaud's phenomenon?

1. AFingers turn yellow, then green, then brown
2. BFingers stay red and hot for several days
3. CThe whole arm turns pale and then black
4. DFingers turn white, then blue, then red

What is Cheyne–Stokes breathing?

1. ABreathing only through pursed lips
2. BCycles of deeper then shallower breaths followed by a pause
3. CA harsh, high-pitched sound on breathing in through the throat
4. DConstant deep, fast breathing that never changes in depth

A patient taking isosorbide mononitrate asks about sildenafil for erectile dysfunction. What is the main danger?

1. ABleeding from the gums
2. BSevere hypertension
3. CA very high potassium level
4. DSevere hypotension

After coronary artery bypass surgery through a median sternotomy, which instruction is usually given for the first several weeks?

1. ALift the arms above the head often to stretch the chest
2. BSleep only on the stomach to protect the wound
3. CAvoid walking until the stitches are removed
4. DAvoid heavy lifting and pushing up with the arms

A patient with an implantable cardioverter-defibrillator asks what to do if it fires. Which teaching is correct?

1. ADrive straight to hospital alone after any shock so the device can be checked by the team
2. BOne shock and well: contact the device clinic; repeated shocks or unwell: call emergency services
3. CRemove the device battery at home if it fires more than once
4. DIgnore any shock at all, because the device is designed to fire every day and needs no follow-up

A nurse teaches a patient how to measure blood pressure at home. Which statement shows a need for further teaching?

1. A"I will sit with my back supported and my arm at heart level."
2. B"I will rest quietly for five minutes before measuring."
3. C"I will take two readings and write them both down."
4. D"I will measure it straight after my morning jog."

1日1.5 Lの水分制限を受けている心不全の患者が、強い口渇を訴えています。最も適切な対応はどれですか？

1. A渇きは常に満たすべきなので、水を無制限に
2. B翌朝の体重測定まで、一切の水分を与えない
3. C唾液を促して乾燥を和らげるための、塩気のある軽食
4. D口腔ケア、数を数えた氷片、1日を通して分けた水分