解答つき精神看護ワークシート

入院中の 6 歳の男児が、指しゃぶりをして、またおねしょをするようになりました。これはどの防衛機制ですか？

1. A投影
2. B知性化
3. C昇華
4. D退行

A patient's arm stays in an odd raised position for a long time after the nurse moves it. What is this called?

1. AEchopraxia
2. BWaxy flexibility
3. CAkathisia
4. DTardive dyskinesia

Which sequence shows the five stages of grief described by Kübler-Ross?

1. ADenial, anger, bargaining, depression, acceptance
2. BAnger, denial, acceptance, bargaining, depression
3. CShock, guilt, hope, sadness, recovery
4. DAcceptance, bargaining, anger, depression, denial

An 86-year-old nursing home resident becomes acutely confused over two days. Which cause should be considered first?

1. AThe normal ageing process
2. BA first episode of schizophrenia caused by moving into the home
3. CAn infection such as a urinary tract infection, or a medicine side effect
4. DA sudden onset of Alzheimer's disease

Which measurement should be monitored regularly in a patient taking venlafaxine?

1. AVisual acuity
2. BSerum lithium level
3. CPeak expiratory flow
4. DBlood pressure

A patient at high risk of suicide is placed on constant (one-to-one) observation. What does this mean?

1. AA staff member stays with the patient at all times, at the distance set by policy, including in the bathroom
2. BThe patient is seen once a shift by the nurse in charge, and otherwise checked by camera from the office when staff are free
3. CThe patient can be left alone while asleep
4. DThe patient is checked every hour during the day only

患者が反応がない状態で見つかり、呼吸数は 6 回/分、縮瞳があります。看護師が最初にすべきことは何ですか？

1. Aフルマゼニルを投与する
2. B回復体位にし、誰にも連絡せずに自然に目が覚めるのを待つ
3. C大きなコップ 1 杯の水を与える
4. D応援を呼び、気道を確保して呼吸を補助し、処方またはプロトコルに従ってナロキソンを投与する

患者が、自殺を計画していることを誰にも話さないと約束してほしいと看護師に頼みます。最もよい返答はどれですか？

1. A彼女の安全が大切なので、この秘密は守れず、チームと共有する必要があると優しく説明する
2. B話題を変える
3. C話を続けて信頼してもらうために秘密を守ると約束し、記録にも書かず、チームにも伝えない
4. D考えておくと伝える