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ISPN考试模拟试题(362)

Question:

Forty-eight hours after a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. The assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with the recommendation for: 

1. A dose of morphine (Astramorph). 

2. A fluid bolus of normal saline. 

3. A computerized tomography scan. 

4. A dose of furosemide (Lasix).
 


The infant is exhibiting signs and symptoms of increased intracranial pressure (ICP) caused by a shunt malfunction. A CT scan, shunt series x-ray, and tapping the shunt are performed to diagnose a shunt malfunction. The irritability is caused by the increased ICP, not postoperative pain. The infant has increased intracranial pressure: a fluid bolus will further increase her ICP. The increased ICP is caused by a shunt malfunction and will not be relieved byLasix. Surgical intervention is necessary to correct a shunt malfunction. 

CN: Physiological adaptation; CL: Apply

Answer:3

 

翻译

问题:

在脑室-腹腔分流术后48小时,婴儿烦躁,呕吐量大。评估显示有一个鼓胀的fontanel。使用SBAR(情况-背景-评估-建议)技术进行沟通,护士打电话给初级卫生保健提供者,建议:

1.一剂吗啡(Astramorph)。

2.一袋生理盐水。

3.电脑断层扫描。

4.一剂速尿(Lasix)。

 

答案:3

婴儿表现出分流器故障引起的颅内压升高(ICP)的症状和体征。通过CT扫描、分流器系列x光和分流器攻击来诊断分流器故障。刺激是由颅内压增加引起的,而不是术后疼痛。婴儿颅内压升高:液体注射会进一步增加颅内压。颅内压升高是由分流器故障引起的,并不会因Lasix而缓解。手术干预是纠正分流功能障碍的必要手段。

CN:生理适应;CL:应用

小编寄语Not picked, just a flower in spring, the whole spring is still yours.没有摘到的,只是春天里的一朵花,整个春天还是你的。

时间:2020/10/2 21:23:47
 
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