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

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

June 2008 Nursing Licensure Examination (NLE)
June 2008 NP4 Nursing Board Exam Answer Key
Nursing Board Exams Questions 91 - 100

Situation – Brain tumor, whether malignant or benign, has serious

management implications. As a nurse, you should be able to understand the consequences of the disease and the treatment.

91. You are caring for Conrad who has a brained tumor and increased Intracranial Pressure (ICP). Which intervention should you include in your plan to reduce ICP?

A. Administer bowel softener

B. Position Conrad with his head turned toward the side of the tumor

C. Provide sensory stimulation

D. Encourage coughing and deep breathing

92. Keeping Conrad’s head and neck alignment results in:

A. increased inthrathoracic pressure

B. increased venous outflow

C. decreased venous outflow

D. increased intrabdominal pressure

93. Which of the following activities may increase intracranial pressure (ICP)?

A. Raising the head of the bed

B. Manual hyperventilation

C. Use of osmotic diuretics

D. Valsalva’s maneuver

94. After you asses Conrad, you suspected increased ICP. Your most appropriate respiratory goal is to:

A. maintain partial pressure of arterial O2 (PaO2) above 80 mmHg

B. lower arterial pH

C. prevent respiratory alkalosis

D. promote CO2 elimination

95. Conrad underwent craniotomy. As his nurse, you know that drainage on a craniotomy dressing must be measured and marked. Which findings should you report immediately to the surgeon?

A. Foul-smelling drainage

B. Yellowish drainage

C. Greenish drainage

D. Bloody drainage

Situation – As a nurse you are expected to be competent in utilizing the nursing process in the care of your clients.

96. Getty is receiving chemotherapy for cancer. You review Getty’s laboratory report and note that he has anemia. To which nursing diagnosis should you give the highest priority?

A. Activity intolerance

B. Impaired oral mucous membrane

C. Impaired tissue perfusion, cerebral, cardiovascular, gastrointestinal

D. Impaired tissue integrity

97. An immediate objective for nursing care of an overweight mildly hypertensive client with ureteral colic and hematuria is to decrease:

A. Hypertension

B. Pain

C. Hematuria

D. Weight

98. A difficult problem to deal with when caring for a patient with a partial thickness burns sustained 3 days ago is:

A. Alteration in body image

B. Maintenance of sterility

C. Frequent dressing change

D. Severe pain

99. Which outcome criterion would be appropriate for a client with a nursing diagnosis of effective airway clearance?

A. Continued use of oxygen when necessary

B. Breath sound clear on auscultation

C. Respiratory rate of 24/min

D. Presence of congestion

100. Which assessment would be most supportive of the nursing diagnosis, impaired skin integrity related to purulent drainage?

A. Heart rate of 88 beats/min

B. Dry and intact wound dressing

C. Oral temperature

D. Wound healing by first intention