Aug 월 9 일통합최신기출강의 1. spinal shock 환자 first action? 1) V/S check 2) skin wound 확인 3) fecal impaction 있는지확인 2. Symptom of Neurogenic shock 1)

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1 8 월 9 일통합최신기출강의 1. spinal shock 환자 first action? 1) V/S check 2) skin wound 확인 3) fecal impaction 있는지확인 2. Symptom of Neurogenic shock 1) Hypertension 2) dry and warm skin 91. A client with massive trauma and possible spinal cord injury. confirm of neurogenic shock? 1) Apical heart rate 48/min 2) Blood pressure 186/92 mm Hg 3) Cool, clammy skin 4) Temperature 100 F (37.7 C) tympanic 3. spinal shock시소변양상은? 1) 1시간에한번소량씩. 2) 계속소량씩흐른다. 3) 4시간에한번씩다량. 5. spinal shock의증상 (multi) 1) bradycardia 2) diaphoresis 3) cool clammy skin 4) headache 5) flush of face 6) paralytic ileus 7. spinal cord injury 받았을때 neurologic shock의증상은? (multi) 1) pulse 55 2) BP 90/60 3) facial flushing 1

2 2. AD 증상? 1) headache 2) hypotension 3) paralytic ileus 4) no sweating 21. T3 다친후갑자기봐야할증상? (multi) 1) Nasal congestion 2) BP 갑자기오름 3) Headache 32. 우선순위 1) T5 손상환자, nausea 있고, anxiety 2) Rt. CVA환자, 여기가어딘지모르는것같다고, 보호자가호소함. 3) COPD 환자목욕후숨차다고호소함. 4) 당뇨환자 HbA1c 상승함 14. T5 손상. AD 증상나열 ~ (bradycardia, flaccid~)" 머리가터질것같다 " 라고함. first action? 1) sitting 2) BP 측정 3) urine cath 준비 4) rectal 손으로검사한다는의미 8. autonomic dysreflexia 증상이나오고, 이환자에게가장먼저해줘야할것은? 1) sitting position 2) enema 3) foley 4) 옷풀어주기 92. A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. priority? 1) Administer an analgesic as needed 2) Determine if there is bladder distention 3) Measure the client's blood pressure 4) Place the client in the Sims' position 5) Remove constrictive clothing 2

3 16. T6 손상된환자 Autonomic dysreflexia 발생했다. 유발요인은? sata 1) UTI 2) urine retention 3) constipation 4) dehydration 5) 아닌답 4. (exhibition) 다음환자에게가장먼저사정해야할부분은? BT : 100.3F (38도는넘지않았음.. ) BP : 200/ 120 P : 42 R : 24.etc Hx : SCI C6 1) 대변언제보았는지 (last time bowel movement) 2) infection 있는지 blood culture order 3) dr. notify 4) 기억안남 4. spinal cord injury 시 piloerection, severe headache 시사정해야할것은? 1) urine retention & rectal impaction 9. C5 손상된환자가 diaphoresis,?,? 를호소하고있다. nsg? 단답. 1) foley cath insert. 2) gentle 하게 enema. 19. exhibition EKG: bradycardia 40 회머리가아프고혈압이높고 T4 가손상된 history 가있다. 이때중재해야되는것 (sata) 1) sitting position 2) fecal impaction 이있는지확인한다 3) seizure precaution 6. CVA risk? 1) DM -use to cocaine severe time to week 2) 담배한갑 4) pancreatitis-wine 2 to 3 glass daily 3

4 22. Stroke risk 설명으로옳은것 1) Non Caucasian이 Caucasian보다 risk 높다. 2) 임신하면 risk 줄일수있어 3) 남자보다여자가 risk 높다 16. Stroke risk factor sata 1) Cirrhosis 2) Hypercholesterolemia 3) Heavy smoking 4) pulmonary edema 19. Stroke 위험요인골라라 (sata, 보기정확 ) 1) a-fib 2) atherosclerosis 3) 고혈압 4) smoking 5) pulmonary edema 6) cirrhosis 44. stroke 환자가 175/85? 간호사는무슨오더를먼저처리해야하나 1) BP 약을준다 180/105 이하의 BP를유지해야되기때문에 2) 3) CT를찍는다 4) EKG 모니터시작한다 5. Stroke pt should have which lab test? 1) lipid 2) urine specific gravity 3) ketones 4) blood 3. Stroke prevention 1) If I decrease my number of cigarettes I smoke daily, it will reduce the risk of stroke. 2) I will excercise 30 minutes twice a week. 3) I should take prescribed HTN medication everyday. 4) I should limit alcohol to a glass of wine per day. 4

5 94. A client is brought to the emergency department by emergency medical services with a flaccid right arm and leg and lack of verbal response. The nurse takes which priority action? 1) Determine onset of symptoms 2) Ensure that the client has 2 large-bore intravenous (IV) lines 3) Maintain patent airway 4) Prepare for head CT scan 59. ER nurse, Rt.arm numbness and difficulty gaiting한환자가왔다. first question? 1) 2) 최근처방받은약 take? 3) rest or worsen onset sign 있니? 4) 증상이언제부터있었니? 10. CVA 환자가 thrombolytic 치료를받고자합니다. 옳은것을고르세요. ( 단답 ) 1) CVA 발생후 6 시간이내로 thrombolytic 치료를해야합니다. 2) 18 세미만아이한테는안됩니다. 11. 혈액용해제유로키나아제사용할수없는자 1) stroke 진단받은 12 시간이후환자 나머지는다맞는사람 14. CVA 환자, TCAc?? ( 혈전용해제 ) 사용가능한경우는? 1) 최근 3 개월간 head injury 받음 2) 최근 6 개월간 major surgery 받음 3) 기억 X ( 답이아니라고생각했어요 ) 4) CVA 환자 8h 안에혈전용해제사용한다. 13. ishcemic stroke pt 24 시간지남. concern 해야하는처방 1) 모르는약 2) b blocker 3) aspirin 4) clopidogrel 5

6 1. ischemic cva intervention 틀린것 1) 5dw iv 100cc/hr 2) lol iv 2min동안 3) 아스피린 81mg( 정확 )po once a day 4) clopidogrel 30mg( 정확x)po once a day 23. hemorrhagic CVA s/s all selection? 1) N & V 2) headache 3) hematuria 4) blurred vision 22. Hemorrhagic cva 증상 (m) 1) headache 2) n/v 3) seizure 20. CVA 합병증 (multi) 1) sz 2) contracture 3) aspiration pneumonia 4) nuchal rigidity 5) iicp 시간전에 hemorrhage stroke 환자에게할간호? 1) seizure precaution 2) 서포트그룹에참여하라고격려한다 3) 머리를낮춘자세를해준다 4) 상하지운동을가르쳐준다 21. Patient has CVA attack and nurse is checking MAP (mean arterial pressure). What is correct? 1) When MAP increase, this means to Improve Cerebral Perfusion in Patient. 2) MAP is average of patient's Systolic Blood Pressure and Diastolic Blood Pressure. 6

7 92. A client with ischemic stroke symptoms started 7 hours ago blood pressure is 202/108 mm Hg. What priority? 1) Assess the National Institutes of Health stroke scale 2) Document the current findings 3) Request a prescription for IV blood pressure medication 4) Request a prescription for IV antiseizure medication 93. an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The health care provider prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action? 1) Give the antihypertensive medication 2) Monitor the blood pressure 3) Notify the health care provider 4) Question the prescription 20. Rt. hemiplegic가있는 CVA환자에게퇴원교육예정이다. 퇴원교육을받아들일준비 (readiness) 가된말은? 1) 내병은더이상나빠지지않을것이다. 2) 내병은나에게 shock가같았다. 3) 내친구가매일나를도와주러올것이다. 4) 나는나스스로어느정도 self care를할수있는지궁금하다. 9. CVA 환자가널스에게 "I don't get enough meal but I don't want to eat in wheels on meal!" 이라고한다. 간호사의 best action은? 1) 남아있는환자의신체기능을사정한다. 2) 냉장고안에무엇이있나살펴본다. 3) Dietitian을연결해준다. 4) 지역사회간호사에게알려식단을점검한다? 같은내용이었던것같아요 ; 4. 1day 전에 stroke 와서입원한환자 referral 할 part? Sata 딱이렇게만나왔어요 1) social worker 2) speech therapist 3) occupational 4) physical therapists 5) 7

Jan 월 21 일통합최신기출강의 6. 태어난지 2 시간된아기비정상사인은무엇인가? 1) continuous moving 2) R 50/min 3) strawberry hemangioma 4) lanugo on the back 1. 신생아몽고반점 (

Jan 월 21 일통합최신기출강의 6. 태어난지 2 시간된아기비정상사인은무엇인가? 1) continuous moving 2) R 50/min 3) strawberry hemangioma 4) lanugo on the back 1. 신생아몽고반점 ( 1 월 21 일통합최신기출강의 6. 태어난지 2 시간된아기비정상사인은무엇인가? 1) continuous moving 2) R 50/min 3) strawberry hemangioma 4) lanugo on the back 1. 신생아몽고반점 ( 사진 )) 기출 2. 신생아출산후피부사정후정상소견 ( 멀티 ) 1) 엉덩이몽고반점 2) 콧등 3) inguinal