问题 问答题

男性,42岁。患胃溃疡8年余,近几个月来自觉症状加重。6小时前病人进食后突感上腹部刀割样剧痛,很快延及全腹,伴恶心、呕吐。体检:T37.1℃,P106次/分钟,R20次/分钟,Bp110/80mmHg。腹式呼吸消失,板状腹,全腹压痛和反跳痛,肠鸣音明显减弱,肝浊音界消失,移动性浊音阳性。
请分析:

目前的主要护理诊断/问题及护理措施

答案

参考答案:主要的护理诊断/问题及护理措施
1)疼痛:与胃十二指肠溃疡穿孔后消化液对腹膜的刺激有关。缓解疼痛的护理措施:①禁饮食、持续胃肠减压:以减少胃肠内容物继续流入腹腔。②体位:伴有休克者取平卧位,无休克或休克改善后取半卧位。
2)体液不足:与溃疡急性穿孔后大量液体渗入腹腔内有关。护理措施:①维持体液和酸碱平衡:根据出入水量,予以静脉输液和电解质。②观察病情变化。
3)潜在并发症:腹腔内残余脓肿。预防腹腔内残余脓肿的护理措施:①体位:无休克者或休克改善者取半卧位,以利漏出的消化液积聚于盆腔最低位和引流,并可减少毒素的吸收。②按医嘱应用抗生素控制感染。③保持腹腔内引流通畅。

选择题
单项选择题

Although there are many skillful Braille readers, thousands of other blind people find it difficult to learn that system. They are thereby shut (1) from the world of books and newspapers, having to (2) on friends to read aloud to them.

A young scientist named Raymond Kurzweil has now designed a computer which is a major (3) in providing aid to the (4) .His machine, Cyclops, has a camera that (5) any page, interprets the print into sounds, and then delivers them orally in a robot-like (6) through a speaker. By pressing the appropriate buttons (7) Cyclops’s keyboard, a blind person can "read" any (8) document in the English language.

This remarkable invention represents a tremendous (9) forward in the education of the handicapped. At present, Cyclops costs $ 50,000. (10) , Mr. Kurzweil and his associates are preparing a smaller (11) improved version that will sell (12) less than half that price. Within a few years, Kurzweil (13) the price range will be low enough for every school and library to (14) one. Michael Hingson, Director of the National Federation for the Blind, hopes that (15) will be able to buy home (16) of Cyclops for the price of a good television set.

Mr. Hingson’s organization purchased five machines and is now testing them in Maryland, Colorado, Iowa, California, and New York. Blind people have been (17) in those tests, making lots of (18) suggestions to the engineers who helped to produce Cyclops.

"This is the first time that blind people have ever done individual studies (19) a product was put on the market," Hingson said. "Most manufacturers believed that having the blind help the blind was like telling disabled people to teach other disabled people. In that (20) , the manufacturers have been the blind ones.

6()

A.behavior

B.expression

C.movement

D.voice