a nurse is caring for a client who has been diagnosed with bipolar disorder and is experiencing a manic episode which of the following actions should
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Nursing Elites

ATI RN

ATI Mental Health Practice B

1. A client diagnosed with bipolar disorder is experiencing a manic episode. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may be easily overstimulated. Placing the client in a private room to decrease environmental stimuli is the priority intervention. This action can help reduce the risk of exacerbating manic symptoms and promote a calmer environment for the client. Choice A is not the priority as group therapy may be overwhelming during a manic episode. Choice C could potentially increase stimulation rather than decrease it. Choice D should not be the first action as sedatives are generally not the initial intervention for managing manic episodes.

2. A nurse is caring for a client who has been diagnosed with schizoaffective disorder. The client states, 'I am the president of the United States.' Which of the following responses should the nurse make?

Correct answer: C

Rationale: The nurse should avoid challenging the client's delusions directly. Asking for more information can help the nurse understand the client's experience and build rapport.

3. A client has been prescribed diazepam (Valium) for the treatment of anxiety. Which of the following instructions should the nurse include in the discharge teaching?

Correct answer: A

Rationale: The correct instruction is to avoid drinking alcohol while taking diazepam (Valium) as it can potentiate the sedative effects and increase the risk of side effects such as drowsiness and dizziness. Taking the medication with food may help reduce stomach upset, but avoiding alcohol is crucial to ensure safe and effective use of diazepam. Choice B is partially correct, as taking the medication with food can indeed help with stomach upset, but it is not as crucial as avoiding alcohol. Choice C is incorrect because abruptly stopping diazepam can lead to withdrawal symptoms and should only be done under medical supervision. Choice D is incorrect as doubling the dose is dangerous and should never be done without healthcare provider approval.

4. A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement first?

Correct answer: A

Rationale: The initial intervention for a client experiencing auditory hallucinations, especially in schizophrenia, is to assess the content of the hallucinations. By asking the client to describe the hallucinations, the nurse can determine if they are command hallucinations that might pose a risk. This assessment is crucial in guiding further appropriate interventions to ensure the client's safety and well-being. Instructing the client to ignore the hallucinations (Choice B) may not be effective, as the hallucinations are real to the client. Administering antipsychotic medication (Choice C) may be necessary but should come after assessing the situation. Engaging the client in reality-based activities (Choice D) is important but not the first priority when dealing with auditory hallucinations.

5. During cognitive-behavioral therapy, a 12-year-old patient reports to the nurse practitioner:

Correct answer: B

Rationale: In cognitive-behavioral therapy, recognizing and challenging negative thoughts is crucial for progress. Choice B demonstrates the patient's ability to identify and correct distorted thoughts, indicating positive advancement in therapy. This cognitive restructuring is a key component of cognitive-behavioral therapy, helping individuals develop healthier thinking patterns and coping strategies.

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