EXAM COMPLETE 430 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES|ALREADY
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The RN on the day shift receive report about a client with depression who was
in bed most of the weekend. The RN walks into the client's room in the morning
and finds the client in bed. What intervention is best for the RN to implement?
A. Monitor the client's appetite and pattern of sleep.
B. Assess the client's feelings about the hospital stay.
C. Assist the client to get out of bed and involved in an activity.
D. Explain that staff will check on the client every 30 minutes.
C
Which client information indicates the need for the RN to use CAGE
questionnaire during the admission interview?
A. Client's medication history includes the frequent use of antidepressants.
B. Describe self as a social drinker who drinks alcoholic beverages daily.
C. Reports difficulties with short term memory since traumatic brain injury.
D. Medical history includes that the client was recently sexually assaulted.
B
A female client admitted to the mental health unit starts to shout and scream at
the RN. What is the best approach for the RN to take?
A. Stay quietly with the patient
B. Tell her that she is out of control.
C. Distractherbyofferingherfingerfoods.
D. Ignore the client's acting out behavior.
A
A woman is brought to the psychiatric clinic by her husband. He reports that his
wife is reluctant to leave home because of what she describes as a fear of open
,places and crowds. Which nursing problem applies to this client's behavior?
A. Ineffective protection to guard self from internal or external threats.
B. Risk for injury related to inability to communicate.
C. Risk prone health behavior related to self-esteem assault.
D. Anxiety related to real or perceived threat to physical integrity.
D
A client is receiving benztropine mesylate (Cogentin) for drug-induced
extrapyramidal syndrome (EPS). Which finding indicates that the RN should
further evaluate the client?
A. Decreased bowel movements.
B. Presence of a dry mouth.
C. Decreasinghandtremors.
D. Increased mouth movements.
B
A male client in the mental health unit is guarded and vaguely answers the
nurse's questions. He isolates in his room and sometimes opens the door to
peek into the hall. Which problem can the RN anticipate?
A. Visual hallucinations.
B. Auditory hallucinations.
C. Excessive motor activity.
D. Delusions of persecution.
D
A female client with obsessive compulsive personality disorder is admitted to
the hospital for a cardiac catheterization. The afternoon before the procedure,
the client begins to keep detailed notes of the nursing care she is receiving, and
reports her findings to the RN at bedtime. What action should the nurse
implement?
A. Explain to the client that her behavior invades the rights of the nursing staff.
B. Ask the client to explain why she is keeping a detailed record of her nursing
care.
C. Teach the client strategies to control her obsessive compulsive behavior.
,D. Encourage the client to express her feelings regarding the upcoming
procedure.
D
During admission to the psychiatric unit, a female client is extremely anxious
and states that she is worried about the sun coming up the next day. What
intervention is most important for the RN to implement during the admission
process?
A. Assist the client in developing alternative coping skills.
B. Remain calm and use a matter of fact approach.
C. Ask the client why she is so anxious
D. Administer a PRN sedative to help relieve her anxiety.
A
A female client is brought to the emergency department after police officers
found her disoriented, disorganized, and confused. The RN also determines that
the client is homeless and is exhibiting suspiciousness. The client's plan of care
should include what priority problem?
A. Acute confusion.
B. Ineffective community coping
C. Disturbed sensory perception.
D. Self-care deficit.
A
The occupational health nurse is working with a female employee who was just
notified that her child was involved in a MVA and taken to the hospital. The
employee states, "I can't believe this. What should I do?" Which response is
best for the RN to provide in this crisis?
A. Tell me what you think should happen.
B. How serious was the collision?
C. Whatdoyouthinkyoushoulddo?
D. Call for transportation to the hospital.
D
, A client tells the RN that he has an IQ of 400+ and is a genius and an inventor.
He also reports that he is married to a female movie star and thinks that his
brother wants a sexual relationship with her. What is the priority nursing
problem for admission to the psychiatric unit?
A. Ineffective sexual patterns.
B. Impaired environmental interpretation.
C. Disturbed sensory perception.
D. Compromised family coping.
A
The RN is providing care for a client diagnosed with borderline personality
disorder who has self-inflicted lacerations on the abdomen. Which approach
should the RN use when changing this client's dressing?
A. Provide detailed thorough explanations when cleansing wound.
B. Perform the dressing change in a non-judgmental manner.
C. Ask in a non-threatening manner why the client cut own abdomen.
D. Request another staff member assist with the dressing change.
B
While sitting in the day room of the mental health unit, a male adolescent
avoids eye contact, looks at the floor, and talks softly when interacting verbally
with the RN. The two trade places, and the RN demonstrates the client's
behaviors. What is the main goal of this therapeutic technique?
A. Initiate a non-threatening conversation with the client.
B. Dialog about the ineffectiveness of his interactions.
C. Allow the client to identify the way he interacts.
D. Discuss the client's feelings when he responds.
C
An antidepressant medication is prescribed for a client who reports sleeping
only 4 hours in the past 2 days and weight loss of 9 lbs within the last month.
Which client goal is most important to achieve within the first three days of
treatment?
A. Meet scheduled appointment with dietitian.
B. Sleep at least 6 hours a night.