NURSING BOARD EXAM PRACTICE IV – Care of Clients with Physiologic and Psychosocial Alterations

NURSING BOARD EXAM PRACTICE IV – Care of Clients with Physiologic and Psychosocial Alterations

June 2008 Nursing Licensure Examination (NLE)
June 2008 NP5 Nursing Board Exam Answer Key
Nursing Board Exams Questions 56 - 70

Situation – One of the realities that we are confronted with is our mortality. It is important for us nurses to be aware of how we view suffering, pain, illness, and even our death as well as its meaning. That way we can help our patients cope with death and dying.

56. Irma is terminally ill, she speaks to you in confidence. You now feel that Irma’s family could be helpful if they knew what Irma has told to you. What should you do first?

A. Tell the physician who in turn could tell the family

B. Obtain Irma’s permission to share the information in the family

C. Tell Irma that she has to tell her family what she told you

D. Make an appointment to discuss the situation with the family

57. Ruby who has been told she has terminal cancer, turns away and refuses to respond to you. You can best help her by:

A. Coming back periodically and indicating your availability if she

would like you to sit with her

B. Insisting that Ruby should talk with you because it is not good to keep

everything inside

C. Leaving her alone because she is uncooperative and unpleasant to be

with

D. Encouraging her to be physically active as possible

58. Leo, who is terminally ill and recognizes that he is in the process of losing everything and everybody he loves, is depressed. Which of the following would best help him during his depression?

A. Arrange for visitors who might cheer him

B. Sit down and talk with him for a while

C. Encourage him to look at the brighter side of things

D. Sit silently with him

59. Which of the following statements would best indicate that Ruffy, who is dying, has accepted his impending death?

A. “I’m ready to go.”

B. “I have resigned myself to dying.”

C. “What’s the use?”

D. “I’m giving up”

60. Marla, 90 years old has planned ahead for her death-philosophically, socially, financially and emotionally. This is recognized as:

A. Acceptance that death is inevitable

B. Avoidance of the true situation

C. Denial with planning for continued life

D. Awareness that death will soon occur

Situation – Andrea is admitted to the ER following an assault where she was hit on the face and head. She was brought to the ER by a police woman. Emergency measures were stated.

61. As Andrea’s nurse, what will be your priority interventions?

A. Insert and intravenous catheter

B. Insert an oral or nasopharyngeal airway

C. Obtain arterial blood gases

D. Give 100% oxygen

62. Andrea’s arterial blood gases respiratory acidosis. This most likely related to:

A. Partially obstructed airway

B. Ineffective breathing pattern

C. Head injury

D. Pain

63. Andrea loses consciousness. You should prepare for which of the following FIRST?

A. Placement of nasogastric tube

B. Placement of a second IV line

C. Endotracheal intubation or surgical airway placement

D. CT scan of head

64. Andrea’s physician gives an order of Mannitol 0.25 g/kg IV bolus for increased ICP. This is given to:

A. Promote cerebral-tissue fluid movement

B. Promote renal perfusion

C. Correct acid-base imbalances

D. Enhance renal-excretion of drugs

65. As Andrea’s nurse your goal is to prevent increased Intracranial Pressure (ICP). Which of the following independent nursing interventions is NOT suited for her?

A. Do oropharyngeal suction every 15 minutes to prevent pulmonary aspiration?

B. Keep ahead of bed 30-35 degrees elevated

C. Maintain Andrea’s head in straight alignment and prevent hip flexion

D. Prevent constipation and increases in intra-abdominal pressure

66. Andrea’s respiration is described as waxing and waning. You know that this rhythm of respiration is defined as:

A. Biot’s

B. Kussmaul’s

C. Cheyne Stokes

D. Eupnca

67. What do you call the triad of sign and symptoms seen in a client with increasing ICP?

A. Virchow’s Triad

B. The Chinese triad

C. Cusching’s Triad

D. Charcot’s Triad

68. Which of the following is true with the Cushing’s Triad seen in head injuries?

A. Narrowing of Pulse Pressure, Cheyne strokes respiration, Tachycardia

B. Widening Pulse pressure, Irregular respiration, Bradycardia

C. Hypertension, Kussmaul’s respiration, Tachycardia

D. Hypotension, Irregular respiration, Bradycardia

69. In a client with a Cheyne stokes respiration, which of the following is the most appropriate nursing diagnosis?

A. Ineffective airway clearance

B. Ineffective breathing pattern

C. Impaired gas exchange

D. Activity Intolerance

70. You know the apnea is seen in client’s with cheyne stoke respiration, APNEA is defined as:

A. Inability to breath in a supine position so the patient sits up in bed to breathe.

B. The patient is dead, the breathing stops

C. There is an absence of breathing for a period of time usually 15 seconds or more

D. A period of hypercapnea and hypoxia due to cessation of respiratory effort inspite of normal respiratory functioning