NSG 2700 EXAM 2 SOUTH COLLEGE
QUESTIONS AND CORRECT VERIFIED ANSWERS WITH
RATIONALES || 100% GUARANTEED PASS!!
<LATEST VERSION>
1. The nurse is caring for four clients on a psychiatric unit. Which client should the
nurse assess first?
A. A client with bipolar disorder who has slept 3 hours during the past 48 hours
and is pacing continuously
B. A client with major depressive disorder who reports having little interest in
attending group therapy
C. A client with borderline personality disorder who states, “Nobody here
understands me.”
D. A client with generalized anxiety disorder who requests medication for a
headache
Answer: A
Rationale: The client demonstrating severe sleep deprivation, continuous pacing,
and markedly increased activity may be experiencing escalating mania and is at
immediate risk for exhaustion, injury, dehydration, or behavioral dysregulation.
Safety and physiologic needs take priority over less acute psychiatric concerns.
2. A client experiencing acute mania is speaking rapidly, repeatedly interrupting
other clients, and attempting to participate in several activities simultaneously.
Which nursing intervention is most appropriate?
A. Encourage the client to participate in a large group activity to expend energy
B. Provide a quiet environment with clear, concise directions and consistent limits
C. Ask the client to identify the reasons for the current manic behavior
D. Allow the client unrestricted activity as long as no physical aggression occurs
Answer: B
,Rationale: A low-stimulation environment and simple, consistent communication
help decrease escalating stimulation. Firm but nonpunitive limits promote safety.
Insight-oriented questioning and large-group activities can increase stimulation
during acute mania.
3. A client taking lithium reports vomiting twice and experiencing coarse hand
tremors. The serum lithium level is 1.9 mEq/L. Which action should the nurse
take?
A. Administer the next lithium dose with food
B. Encourage the client to increase sodium restriction
C. Hold lithium and notify the healthcare provider
D. Reassure the client that the findings are expected during treatment
Answer: C
Rationale: A lithium level of 1.9 mEq/L is above the usual therapeutic range and,
combined with vomiting and coarse tremors, indicates toxicity. Lithium should be
withheld and the provider notified. Severe toxicity can progress to neurologic
impairment, dysrhythmias, seizures, and renal complications.
4. A client prescribed lithium has developed diarrhea after several days of
gastroenteritis and reports drinking very little because of nausea. Which
explanation by the nurse is most appropriate?
A. “Fluid loss can increase the risk of lithium accumulation and toxicity.”
B. “Diarrhea causes lithium to become ineffective, so the dose may need to
increase.”
C. “Lithium protects against dehydration by increasing renal water retention.”
D. “You should temporarily eliminate sodium from your diet.”
Answer: A
Rationale: Dehydration and sodium depletion reduce renal clearance of lithium
and can cause serum lithium levels to rise. Clients taking lithium should maintain
consistent fluid and sodium intake and promptly report significant vomiting,
diarrhea, or dehydration.
,5. A client prescribed phenelzine asks which meal would be safest. Which
selection should the nurse identify as appropriate?
A. Aged cheddar cheese, salami, and red wine
B. Smoked sausage, sauerkraut, and beer
C. Grilled chicken, fresh vegetables, and rice
D. Pepperoni pizza and fermented vegetables
Answer: C
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Tyramine-rich
foods, including aged cheeses and cured or fermented meats, can precipitate a
dangerous hypertensive reaction. Fresh chicken, vegetables, and rice are generally
appropriate choices.
6. A client taking an MAOI develops a severe occipital headache, palpitations,
neck stiffness, and blood pressure of 214/118 mm Hg. Which complication should
the nurse suspect?
A. Neuroleptic malignant syndrome
B. Hypertensive crisis
C. Lithium toxicity
D. Anticholinergic toxicity
Answer: B
Rationale: Severe hypertension accompanied by headache and cardiovascular
symptoms in a client taking an MAOI suggests a hypertensive crisis, potentially
caused by interaction with tyramine-containing foods or medications. This is an
emergency requiring immediate intervention.
7. A client taking sertraline is started on another serotonergic medication. Several
hours later, the client develops agitation, diaphoresis, temperature of 40°C (104°F),
hyperreflexia, and muscle rigidity. What is the nurse's priority action?
A. Administer the scheduled sertraline
B. Place the client in a high-stimulation environment
C. Recognize possible serotonin syndrome and notify the provider immediately
D. Encourage the client to ambulate to decrease muscle rigidity
, Answer: C
Rationale: Hyperthermia, autonomic instability, altered mental status,
hyperreflexia, and neuromuscular abnormalities strongly suggest serotonin
syndrome. The causative serotonergic medications should be stopped as directed,
and urgent medical treatment is required because severe cases can result in
seizures, rhabdomyolysis, metabolic abnormalities, and death.
8. The nurse is caring for a client with borderline personality disorder who
alternates between praising one nurse and criticizing another. The client tells the
nurse, “You're the only nurse who actually cares about me. The other nurse is
terrible.” Which response is best?
A. “You're correct; that nurse does not understand you.”
B. “You should discuss your concerns directly with the other nurse.”
C. “All members of the healthcare team are following the same treatment plan.”
D. “Why do you think you dislike the other nurse?”
Answer: C
Rationale: Splitting is common in borderline personality disorder. Consistent
boundaries, communication, and adherence to a unified treatment plan reduce
opportunities for manipulation and promote therapeutic consistency. The nurse
should avoid taking sides.
9. A client experiencing mania has been awake nearly continuously for two days
and repeatedly refuses meals because “eating wastes time.” Which intervention is
most appropriate?
A. Require the client to sit in the dining room for every meal
B. Offer high-calorie, nutritious finger foods that can be eaten while moving
C. Withhold snacks until the client agrees to participate in therapy
D. Encourage the client to prepare a three-course meal independently
Answer: B
Rationale: Clients experiencing mania often have excessive energy expenditure
and may be unable to remain seated for meals. Portable, high-calorie foods provide
nutrition without requiring prolonged concentration or inactivity.
QUESTIONS AND CORRECT VERIFIED ANSWERS WITH
RATIONALES || 100% GUARANTEED PASS!!
<LATEST VERSION>
1. The nurse is caring for four clients on a psychiatric unit. Which client should the
nurse assess first?
A. A client with bipolar disorder who has slept 3 hours during the past 48 hours
and is pacing continuously
B. A client with major depressive disorder who reports having little interest in
attending group therapy
C. A client with borderline personality disorder who states, “Nobody here
understands me.”
D. A client with generalized anxiety disorder who requests medication for a
headache
Answer: A
Rationale: The client demonstrating severe sleep deprivation, continuous pacing,
and markedly increased activity may be experiencing escalating mania and is at
immediate risk for exhaustion, injury, dehydration, or behavioral dysregulation.
Safety and physiologic needs take priority over less acute psychiatric concerns.
2. A client experiencing acute mania is speaking rapidly, repeatedly interrupting
other clients, and attempting to participate in several activities simultaneously.
Which nursing intervention is most appropriate?
A. Encourage the client to participate in a large group activity to expend energy
B. Provide a quiet environment with clear, concise directions and consistent limits
C. Ask the client to identify the reasons for the current manic behavior
D. Allow the client unrestricted activity as long as no physical aggression occurs
Answer: B
,Rationale: A low-stimulation environment and simple, consistent communication
help decrease escalating stimulation. Firm but nonpunitive limits promote safety.
Insight-oriented questioning and large-group activities can increase stimulation
during acute mania.
3. A client taking lithium reports vomiting twice and experiencing coarse hand
tremors. The serum lithium level is 1.9 mEq/L. Which action should the nurse
take?
A. Administer the next lithium dose with food
B. Encourage the client to increase sodium restriction
C. Hold lithium and notify the healthcare provider
D. Reassure the client that the findings are expected during treatment
Answer: C
Rationale: A lithium level of 1.9 mEq/L is above the usual therapeutic range and,
combined with vomiting and coarse tremors, indicates toxicity. Lithium should be
withheld and the provider notified. Severe toxicity can progress to neurologic
impairment, dysrhythmias, seizures, and renal complications.
4. A client prescribed lithium has developed diarrhea after several days of
gastroenteritis and reports drinking very little because of nausea. Which
explanation by the nurse is most appropriate?
A. “Fluid loss can increase the risk of lithium accumulation and toxicity.”
B. “Diarrhea causes lithium to become ineffective, so the dose may need to
increase.”
C. “Lithium protects against dehydration by increasing renal water retention.”
D. “You should temporarily eliminate sodium from your diet.”
Answer: A
Rationale: Dehydration and sodium depletion reduce renal clearance of lithium
and can cause serum lithium levels to rise. Clients taking lithium should maintain
consistent fluid and sodium intake and promptly report significant vomiting,
diarrhea, or dehydration.
,5. A client prescribed phenelzine asks which meal would be safest. Which
selection should the nurse identify as appropriate?
A. Aged cheddar cheese, salami, and red wine
B. Smoked sausage, sauerkraut, and beer
C. Grilled chicken, fresh vegetables, and rice
D. Pepperoni pizza and fermented vegetables
Answer: C
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI). Tyramine-rich
foods, including aged cheeses and cured or fermented meats, can precipitate a
dangerous hypertensive reaction. Fresh chicken, vegetables, and rice are generally
appropriate choices.
6. A client taking an MAOI develops a severe occipital headache, palpitations,
neck stiffness, and blood pressure of 214/118 mm Hg. Which complication should
the nurse suspect?
A. Neuroleptic malignant syndrome
B. Hypertensive crisis
C. Lithium toxicity
D. Anticholinergic toxicity
Answer: B
Rationale: Severe hypertension accompanied by headache and cardiovascular
symptoms in a client taking an MAOI suggests a hypertensive crisis, potentially
caused by interaction with tyramine-containing foods or medications. This is an
emergency requiring immediate intervention.
7. A client taking sertraline is started on another serotonergic medication. Several
hours later, the client develops agitation, diaphoresis, temperature of 40°C (104°F),
hyperreflexia, and muscle rigidity. What is the nurse's priority action?
A. Administer the scheduled sertraline
B. Place the client in a high-stimulation environment
C. Recognize possible serotonin syndrome and notify the provider immediately
D. Encourage the client to ambulate to decrease muscle rigidity
, Answer: C
Rationale: Hyperthermia, autonomic instability, altered mental status,
hyperreflexia, and neuromuscular abnormalities strongly suggest serotonin
syndrome. The causative serotonergic medications should be stopped as directed,
and urgent medical treatment is required because severe cases can result in
seizures, rhabdomyolysis, metabolic abnormalities, and death.
8. The nurse is caring for a client with borderline personality disorder who
alternates between praising one nurse and criticizing another. The client tells the
nurse, “You're the only nurse who actually cares about me. The other nurse is
terrible.” Which response is best?
A. “You're correct; that nurse does not understand you.”
B. “You should discuss your concerns directly with the other nurse.”
C. “All members of the healthcare team are following the same treatment plan.”
D. “Why do you think you dislike the other nurse?”
Answer: C
Rationale: Splitting is common in borderline personality disorder. Consistent
boundaries, communication, and adherence to a unified treatment plan reduce
opportunities for manipulation and promote therapeutic consistency. The nurse
should avoid taking sides.
9. A client experiencing mania has been awake nearly continuously for two days
and repeatedly refuses meals because “eating wastes time.” Which intervention is
most appropriate?
A. Require the client to sit in the dining room for every meal
B. Offer high-calorie, nutritious finger foods that can be eaten while moving
C. Withhold snacks until the client agrees to participate in therapy
D. Encourage the client to prepare a three-course meal independently
Answer: B
Rationale: Clients experiencing mania often have excessive energy expenditure
and may be unable to remain seated for meals. Portable, high-calorie foods provide
nutrition without requiring prolonged concentration or inactivity.
