Question

A nurse is caring for a client diagnosed with bipolar disorder in the manic phase. The client rapidly switches the topics mid-sentence. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Gently redirect the client to focus on one topic.

Rationale :

💠 Rapidly changing from one subject to another during a manic episode is characteristic of flight of ideas, in which thoughts move quickly from one topic to another.

💠 The nurse should use calm, brief, and focused communication because the client may have difficulty maintaining attention.

💠 Gently redirecting the client toward one topic at a time helps organize the conversation without confronting or embarrassing the client.

💠 Redirection provides external structure when the client's thought processes are accelerated and poorly organized.

💠 The nurse should avoid lengthy explanations because the client's distractibility and limited attention span can make complex communication difficult.

💠 Focusing on one topic can help the client communicate important needs despite the presence of racing thoughts.

💠 The nurse should remain patient and nonjudgmental, recognizing that the behavior is a manifestation of mania rather than intentional disruption.

💠 Therefore, gentle redirection is the most therapeutic intervention because it promotes organized communication while maintaining the therapeutic relationship.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers

Sleep Apnea [ Contraindication ]
Alcohol Withdrawal [ Therapeutic Use ]
Anxiety [ Therapeutic Use ]
COPD [ Contraindication ]

Rationale :

✅ Alcohol Withdrawal — Therapeutic Use

💠 Benzodiazepines such as diazepam are commonly used to treat alcohol withdrawal because they reduce CNS hyperexcitability.

💠 They help control anxiety, agitation, tremors, and autonomic hyperactivity associated with withdrawal.

💠 Benzodiazepines also decrease the risk of withdrawal seizures, which can be life-threatening.

💠 Diazepam has a relatively long duration of action, which can provide smoother control of withdrawal symptoms.

💠 It enhances the action of GABA, producing inhibitory effects in the central nervous system.

💠 Benzodiazepines can reduce progression to severe withdrawal manifestations such as hallucinations and delirium tremens.

💠 Clients receiving these medications still require monitoring for sedation, hypotension, and respiratory depression.

💠 Therefore, alcohol withdrawal is an important therapeutic indication for benzodiazepines.

✅ Anxiety — Therapeutic Use

💠 Benzodiazepines can provide relatively rapid relief of severe anxiety and panic symptoms.

💠 They decrease excessive neuronal activity by enhancing the inhibitory neurotransmitter GABA.

💠 This can reduce manifestations such as restlessness, tachycardia, muscle tension, and acute fear.

💠 Diazepam may be useful for short-term management when anxiety is severe and immediate symptom control is needed.

💠 Benzodiazepines are generally not preferred for indefinite long-term use because of the risk for tolerance and dependence.

💠 Clients should be monitored for drowsiness, impaired coordination, and cognitive slowing.

💠 Alcohol and other CNS depressants should generally be avoided because they can intensify sedation and respiratory suppression.

💠 Therefore, anxiety is an appropriate therapeutic use of benzodiazepines.

❌ Sleep Apnea — Contraindication

💠 Benzodiazepines can cause CNS and respiratory depression, which can worsen abnormal breathing during sleep.

💠 In sleep apnea, upper-airway obstruction or impaired respiratory drive already causes periods of reduced ventilation.

💠 Benzodiazepines may decrease muscle tone in the upper airway, potentially worsening airway collapse.

💠 Sedation can also decrease the client's ability to awaken in response to low oxygen levels.

💠 This can increase the frequency or severity of apneic episodes.

💠 Clients with sleep apnea are therefore at increased risk for hypoxemia and respiratory complications when sedatives are used.

💠 If a benzodiazepine is considered, the risks must be carefully evaluated and respiratory status closely monitored.

💠 Therefore, sleep apnea is considered a major contraindication or strong precaution for benzodiazepine therapy.

❌ COPD — Contraindication

💠 Benzodiazepines can suppress the respiratory drive, which is especially concerning in clients with compromised pulmonary function.

💠 Clients with COPD may already have difficulty maintaining effective ventilation and gas exchange.

💠 Sedation can reduce respiratory effort and make breathing more shallow.

💠 Benzodiazepines may also impair the client's ability to clear secretions effectively because of decreased alertness.

💠 Respiratory depression can lead to carbon dioxide retention, particularly in clients with advanced COPD.

💠 The risk increases when benzodiazepines are combined with opioids, alcohol, or other CNS depressants.

💠 If use is necessary, the nurse should closely monitor respiratory rate, level of consciousness, and oxygenation.

💠 Therefore, COPD is considered a contraindication or significant precaution because of the risk for respiratory depression.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Depersonalization disorder

Rationale :

💠 Depersonalization is the sensation of being detached from one’s own body, thoughts, or feelings, as though observing oneself from outside.

💠 Derealization is the feeling that the surrounding environment is unreal, dreamlike, distant, or distorted.

💠 The client describes both depersonalization and derealization, which strongly supports this diagnosis.

💠 Clients typically remain aware that these experiences are not actually reality, meaning reality testing is preserved.

💠 This helps distinguish the disorder from psychotic conditions in which the client may firmly believe altered perceptions are real.

💠 The absence of substance use or a medical condition is important because similar symptoms can occur with drug intoxication, neurologic disorders, or other medical causes.

💠 The current diagnostic term is generally depersonalization/derealization disorder, though some questions may shorten it to depersonalization disorder.

💠 Therefore, the client’s feeling of being outside their body combined with an unreal environment is most consistent with depersonalization disorder.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

This must be a very difficult time for you."

Rationale :

💠 This response demonstrates empathy by recognizing the client’s emotional pain.

💠 It encourages the client to continue expressing feelings about the loss.

💠 The nurse does not try to fix the grief or rush the client through it.

💠 Acknowledging the client’s sadness helps validate that grief is a real and significant emotional experience.

💠 The statement is open enough to allow the client to talk more about their husband and what the loss means to them.

💠 It avoids making assumptions about how long the grieving process should last.

💠 Therapeutic responses focus on presence, listening, and emotional support rather than advice.

💠 Therefore, this statement is the most therapeutic because it communicates understanding and acceptance.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Notify the provider immediately

Rationale :

💠 Phenelzine is a monoamine oxidase inhibitor (MAOI), and clients taking it must avoid foods high in tyramine, such as aged cheese.

💠 Tyramine is normally broken down by monoamine oxidase, but MAOIs block this process, allowing tyramine levels to rise.

💠 Excess tyramine can cause a sudden release of norepinephrine, resulting in severe vasoconstriction and a potentially dangerous rise in blood pressure.

💠 A severe headache after eating aged cheese is a classic warning sign of an MAOI-induced hypertensive crisis.

💠 Other possible manifestations include palpitations, neck stiffness, nausea, vomiting, sweating, chest pain, and markedly elevated blood pressure.

💠 This reaction can lead to serious complications such as stroke, intracranial hemorrhage, cardiac dysrhythmias, or myocardial ischemia.

💠 The nurse should immediately assess vital signs, especially blood pressure, and urgently notify the provider for further treatment.

💠 Therefore, this finding requires immediate medical evaluation, not routine symptom management.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Somatic symptom disorder

Rationale :

💠 Somatic symptom disorder involves one or more physical symptoms that cause significant distress or interfere with daily functioning.

💠 Common complaints can include pain, fatigue, gastrointestinal symptoms, and chest discomfort, similar to this client's presentation.

💠 The client continues to experience physical symptoms even though diagnostic testing has not identified a medical cause.

💠 The key feature is not simply that tests are normal, but that the client has persistent symptoms accompanied by excessive concern, anxiety, or preoccupation about their health.

💠 Clients may frequently seek medical evaluation because the symptoms feel real and distressing, even when objective findings are limited.

💠 The nurse should take the client's symptoms seriously and avoid suggesting that the symptoms are “imagined.”

💠 Treatment often focuses on consistent healthcare follow-up, coping strategies, and reducing excessive health-related anxiety or behaviors.

💠 Among the options provided, the pattern of ongoing physical complaints with a normal workup is most consistent with somatic symptom disorder.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

"I will avoid foods like aged cheese and smoked meats."

Rationale :

💠 MAOIs can interact dangerously with tyramine, a substance found in aged, fermented, cured, and smoked foods.

💠 Foods such as aged cheese, smoked or cured meats, some fermented products, and certain alcoholic beverages can contain high tyramine levels.

💠 When monoamine oxidase is inhibited, tyramine is not broken down normally and can accumulate.

💠 Excess tyramine can trigger a large release of norepinephrine, causing a rapid and severe rise in blood pressure.

💠 This reaction can result in a hypertensive crisis, which may cause severe headache, palpitations, chest pain, or neurologic complications.

💠 The client should carefully follow dietary restrictions for the entire time they are taking the MAOI.

💠 The client should also continue avoiding tyramine-rich foods for a period after stopping the medication, according to the specific drug and provider instructions.

💠 Therefore, avoiding aged cheese and smoked meats demonstrates correct understanding of MAOI safety teaching.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Ataxia
Sedation
Persistent nausea and diarrhea
Mental confusion

Rationale :

✅ Ataxia — Indicates lithium toxicity

💠 Ataxia, or impaired balance and coordination, is an important neurologic manifestation of lithium toxicity.

💠 Toxic lithium levels interfere with normal central nervous system function.

💠 The client may appear unsteady, have difficulty walking, or demonstrate poor coordination.

💠 Ataxia is more concerning than a mild fine tremor because it indicates more significant neurologic impairment.

💠 As lithium levels continue to rise, neurologic manifestations can become progressively more severe.

💠 Other serious findings can include coarse tremors, slurred speech, confusion, seizures, and decreased consciousness.

💠 The nurse should hold further lithium doses and promptly notify the provider when toxicity is suspected.

💠 Therefore, ataxia is a significant finding consistent with lithium toxicity.

✅ Sedation — Indicates lithium toxicity

💠 Excessive drowsiness, lethargy, or sedation can occur as lithium levels become toxic.

💠 This reflects increasing depression or dysfunction of the central nervous system.

💠 The client may become unusually sleepy, sluggish, or difficult to keep alert.

💠 Increasing sedation is particularly concerning when accompanied by other neurologic findings such as ataxia or confusion.

💠 Mental status should be monitored closely because toxicity can progress to stupor or coma in severe cases.

💠 The nurse should assess the client's recent lithium intake, hydration status, and possible drug interactions.

💠 A serum lithium level and other laboratory studies may be required to evaluate suspected toxicity.

💠 Therefore, new or excessive sedation can be an important manifestation of lithium toxicity.

✅ Persistent nausea and diarrhea — Indicates lithium toxicity

💠 Gastrointestinal manifestations are often among the early signs of increasing lithium levels.

💠 Persistent nausea and diarrhea are more concerning than mild, transient GI discomfort when beginning therapy.

💠 Ongoing diarrhea can also cause dehydration, which further increases lithium concentrations.

💠 Lithium is primarily eliminated by the kidneys, and fluid depletion can reduce its clearance.

💠 Sodium depletion can likewise increase renal lithium reabsorption and raise the risk of toxicity.

💠 Persistent GI symptoms may therefore both signal toxicity and contribute to its worsening.

💠 The nurse should assess hydration, sodium status, renal function, and lithium levels when significant GI symptoms occur.

💠 Therefore, persistent nausea and diarrhea are important warning signs of lithium toxicity.

✅ Mental confusion — Indicates lithium toxicity

💠 Confusion reflects neurologic involvement and is a significant warning sign of lithium toxicity.

💠 The client may become disoriented, inattentive, or unable to think clearly.

💠 Increasing confusion can indicate that lithium is significantly affecting the central nervous system.

💠 This finding is especially concerning when combined with ataxia, sedation, or severe GI symptoms.

💠 Neurologic toxicity can progress to seizures, severe altered consciousness, or coma if not treated.

💠 The nurse should promptly assess safety because confusion can increase the risk of falls and injury.

💠 Lithium should generally be withheld while suspected toxicity is evaluated and the provider is notified.

💠 Therefore, mental confusion is a clear manifestation consistent with lithium toxicity.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

3

Rationale :

💠 Formula:

Desired dose ÷ Dose on hand × Volume

💠 Calculation:

15 mg ÷ 5 mg × 1 mL = 3 mL

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Allow the client as much personal space as possible

Rationale :

💠 An agitated client may interpret close physical proximity as threatening or confrontational.

💠 Giving the client adequate personal space can reduce feelings of being cornered, pressured, or trapped.

💠 Maintaining distance also helps protect both the client and the nurse if the agitation suddenly escalates.

💠 The nurse should use a calm, low, nonthreatening voice while keeping communication brief and clear.

💠 A relaxed posture and avoidance of sudden movements further decrease the chance of escalating the client's anxiety or anger.

💠 The nurse should avoid blocking the client's exit or standing in a way that may appear physically intimidating.

💠 Providing personal space supports a sense of control, which is often helpful in reducing agitation.

💠 Therefore, allowing as much personal space as safely possible is an appropriate de-escalation technique.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

conditions	Therapeutic Use	Contraindication
Sleep Apnea
Alcohol Withdrawal
Anxiety
COPD

Ati Custom ASN Mental Health NSG 2510 Exam 2

No.

1 :
A nurse is caring for a client diagnosed with bipolar disorder in the manic phase. The client rapidly switches the topics mid-sentence. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client in the psychiatric unit.

Correct Answers

4 :
A nurse is caring for a grieving client. The client begins crying and states, "I don't know how to go on without my husband." Which response by the nurse is the most therapeutic?

5 :
A nurse is caring for a client taking phenelzine for depression. The client reports a severe headache after consuming aged cheese. What is the nurse's priority action?

6 :
A nurse is assessing a newly admitted client. The client reports ongoing fatigue, stomach pain, and chest discomfort, but all diagnostic tests have returned normal. Which mental health disorder does the nurse suspect?

7 :
A nurse is providing teaching to a client newly prescribe a Monoamine Oxidase Inhibitor (MAOI). Which statement made by the client indicates teaching was effective?

8 :
A nurse is caring for a client diagnosed with bipolar disorder. The client is prescribed lithium carbonate. Which manifestations indicate lithium toxicity?(Select All that Apply.)

9 :
The nurse is preparing to administer olanzapine 15 mg IM. The nurse has on hand 5mg/mL. How many mL should the nurse administer? (round to the nearest whole number).

10 :
A nurse is engaging with an agitated client. Which de-escalation technique should the nurse utilize?

Connect With Us

Ati Custom ASN Mental Health NSG 2510 Exam 2

No.

1 : A nurse is caring for a client diagnosed with bipolar disorder in the manic phase. The client rapidly switches the topics mid-sentence. Which of the following actions should the nurse take?

2 : A nurse is caring for a client in the psychiatric unit.

Correct Answers

4 : A nurse is caring for a grieving client. The client begins crying and states, "I don't know how to go on without my husband." Which response by the nurse is the most therapeutic?

5 : A nurse is caring for a client taking phenelzine for depression. The client reports a severe headache after consuming aged cheese. What is the nurse's priority action?

6 : A nurse is assessing a newly admitted client. The client reports ongoing fatigue, stomach pain, and chest discomfort, but all diagnostic tests have returned normal. Which mental health disorder does the nurse suspect?

7 : A nurse is providing teaching to a client newly prescribe a Monoamine Oxidase Inhibitor (MAOI). Which statement made by the client indicates teaching was effective?

8 : A nurse is caring for a client diagnosed with bipolar disorder. The client is prescribed lithium carbonate. Which manifestations indicate lithium toxicity?(Select All that Apply.)

9 : The nurse is preparing to administer olanzapine 15 mg IM. The nurse has on hand 5mg/mL. How many mL should the nurse administer? (round to the nearest whole number).

10 : A nurse is engaging with an agitated client. Which de-escalation technique should the nurse utilize?

1 :
A nurse is caring for a client diagnosed with bipolar disorder in the manic phase. The client rapidly switches the topics mid-sentence. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client in the psychiatric unit.

4 :
A nurse is caring for a grieving client. The client begins crying and states, "I don't know how to go on without my husband." Which response by the nurse is the most therapeutic?

5 :
A nurse is caring for a client taking phenelzine for depression. The client reports a severe headache after consuming aged cheese. What is the nurse's priority action?

6 :
A nurse is assessing a newly admitted client. The client reports ongoing fatigue, stomach pain, and chest discomfort, but all diagnostic tests have returned normal. Which mental health disorder does the nurse suspect?

7 :
A nurse is providing teaching to a client newly prescribe a Monoamine Oxidase Inhibitor (MAOI). Which statement made by the client indicates teaching was effective?

8 :
A nurse is caring for a client diagnosed with bipolar disorder. The client is prescribed lithium carbonate. Which manifestations indicate lithium toxicity?(Select All that Apply.)

9 :
The nurse is preparing to administer olanzapine 15 mg IM. The nurse has on hand 5mg/mL. How many mL should the nurse administer? (round to the nearest whole number).

10 :
A nurse is engaging with an agitated client. Which de-escalation technique should the nurse utilize?