Bipolar and Related Disorders
Which patient statement supports the diagnosis of mania? "I really don't need much sleep; two hours a night is enough." "I really enjoy cooking and eating all sorts of expensive foods." "My mother says this outfit is way too sexy but I like it and wear it all the time." "I've telephoned everyone I know and talked for hours; my husband will be mad." "My family is really upset with me but it's just because they're jealous of all I do."
"I really don't need much sleep; two hours a night is enough." "My mother says this outfit is way too sexy but I like it and wear it all the time." "I've telephoned everyone I know and talked for hours; my husband will be mad." "My family is really upset with me but it's just because they're jealous of all I do." When in full-blown mania, a person constantly goes from one activity, place, or project to another with little or no regard for sleep or food. Inactivity is impossible, even for the shortest period of time. Flowery and lengthy letters are written, and excessive phone calls are made. The behaviors often alienate family, friends, employers, health care providers, and others. Modes of dress often reflect the person's grandiose yet tenuous grasp of reality. Dress may be described as outlandish, bizarre, colorful, and noticeably inappropriate. The statement regarding cooking and eating is not supportive of manic behavior. pp. 223-224
A manic patient tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." The best approach for the nurse to use would be to say, "I don't have sex with patients." "It's time to work on your art project." "What an offensive thing to suggest!" "Let's walk down to the seclusion room."
"It's time to work on your art project." Distractibility works as the nurse's friend. Rather than discuss the invitation, the nurse may be more effective by redirecting the patient. p. 231, Table 13.3
What is the usual age of onset for cyclothymic disorders? Childhood Adolescence Middle adulthood Late adulthood
Adolescence Cyclothymic disorders usually begin in adolescence or early adulthood. They typically begin later than childhood but earlier than middle or late adulthood. p. 225
A patient is prescribed 300 mg lithium carbonate twice a day. The patient shows symptoms of exhaustion. Which category of drug would help to prevent exhaustion in the patient? Benzodiazepines Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors Serotonin-norepinephrine reuptake inhibitors
Benzodiazepines Patients with mania have a risk of exhaustion, coronary collapse, and death with lithium carbonate, as lithium reaches its therapeutic level in the blood after 7 to 14 days of treatment. Benzodiazepines can be used to prevent coronary collapse in patients. Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and monoamine oxidase inhibitors are antidepressants. Antidepressants must not be prescribed to the patients with mania because they enhance the symptoms of mania. p. 233
The nurse can expect a patient demonstrating typical manic behavior to be attired in clothing that is Ill-fitted and ragged Colorful and outlandish Dark-colored and modest Compulsively neat and clean
Colorful and outlandish Manic patients often manage to dress and apply makeup in ways that create a colorful, even bizarre, appearance. p. 228
Which symptom may be seen in patients with bipolar II disorder (hypomania)? Hallucinations Disturbed thoughts Impaired social functioning Hyperactivity and high energy
Hyperactivity and high energy The patients with bipolar II disorder (hypomania) are hyperactive and have high energy. These patients do not have impaired social functioning. Psychosis symptoms such as hallucinations are seen in patients with bipolar I disorder. Disturbed thoughts are seen in patients with bipolar disorder I but not in bipolar disorder II (hypomania). pp. 223-224
The first-line drug used to treat mania is Lamotrigine Clonazepam Carbamazepine Lithium carbonate
Lithium carbonate Lithium, a mood stabilizer, is the first-line drug for use in treating bipolar disorder. pp. 233-234
When a patient experiences four or more mood episodes in a 12-month period, the patient is said to be Incongruent Cyclothymic Rapid cycling Dyssynchronous
Rapid cycling Rapid cycling implies four or more mood episodes in a 12-month period, as well as more severe symptomology. p. 236
The priority nursing diagnosis for a hyperactive manic patient during the acute phase is Risk for injury Ineffective role performance Risk for other-directed violence Impaired verbal communication
Risk for injury Risk for injury is high, related to the patient's hyperactivity and poor judgment. p. 230
Which is an advanced sign of lithium toxicity? Sedation Polyuria Mild thirst Blurred vision
Sedation Sedation is sign of advanced lithium toxicity that is seen when the blood plasma level of lithium is 1.5 to 2.0 mEq/L. Polyuria is an early sign of lithium toxicity that is seen when the blood plasma level of lithium is 1.5 mEq/L. Mild thirst is an expected side effect of lithium that is seen when the blood plasma level of lithium is 0.4 1.0 mEq/L. Mental confusion, hyperirritability, and gastrointestinal upset are signs seen in patients when blood levels of lithium are 1.5 to 2.0 mEq/L. Blurred vision usually occurs when lithium toxicity is severe and blood levels are 2.0 to 2.5 mEq/L. p. 234, Table 13.4
The nurse assesses laboratory results for an adult patient who takes lithium 600 mg twice a day. The patient has taken this dose of lithium for 3 years. Which laboratory value should alert the nurse to confer promptly with the health care provider? Hemoglobin 15 g/dL Serum sodium 142 mEq/L Fasting glucose 99 mg/dL Serum creatinine 1.95 mg/dL
Serum creatinine 1.95 mg/dL The serum creatinine in this scenario is elevated, which indicates problems with renal function; the normal value is 0.5 to 1.2 mg/dL. A major long-term risk of lithium therapy is impairment of the kidney's ability to concentrate urine. The hemoglobin, fasting glucose, and serum sodium levels show normal laboratory findings. p. 234, Table 13.4
A nurse prepares the plan of care for a person having a manic episode. Which nursing diagnoses are most likely to apply? Social isolation Sleep deprivation Disturbed thought processes Risk for deficient fluid volume Altered nutrition; more than body requirements
Sleep deprivation Disturbed thought processes Risk for deficient fluid volume A person experiencing mania sleeps poorly, does not take time to eat or drink, and talks rapidly and insistently with others. Psychosis may be present. Impaired social interaction would be an appropriate diagnosis rather than social isolation. p. 230, Table 13.2
A nurse in a pediatric clinic observes that a child has defensive and ineffective coping. Which action done by the child supports the nurse's assumption? . The child sleeps for long hours. The child has reduced concentration. The child consumes larger quantities of food. The child doesn't allow others to touch his belongings. The child presumes to possess supreme powers.
The child has reduced concentration. The child presumes to possess supreme powers. Defensive and ineffective coping can be seen in bipolar disorder. It is characterized by symptoms of grandiosity and reduced levels of concentration. Patients believe themselves to be superior and possess supreme powers. Other symptoms of mania include reduced food intake and sleep deprivation as a result of anxiety. Patients often give away their valuables and allow others to touch and use their belongings. Patients may not care much about their belongings. p. 230, Table 13.2
To plan care for a manic patient the nurse must consider that lithium cannot be started until The physical examination and laboratory tests are analyzed The initial doses of antipsychotic medication have brought behavior under control Seclusion has proven ineffective as a means of controlling assaultive behavior Electroconvulsive therapy can be scheduled to coincide with lithium administration
The physical examination and laboratory tests are analyzed Lithium should not be given to patients with impaired renal or thyroid function. A thorough physical examination and various laboratory tests are necessary to rule out other organic causes for the behavior and to ensure that the lithium can be excreted normally. p. 234
Which principle should the nurse use when communicating with a patient experiencing an elated mood and euphoria? Use abstract concepts. Give detailed explanations. Use a calm, firm approach. Encourage frequent self-disclosure.
Use a calm, firm approach. A patient experiencing an elated mood and euphoria is distracted easily and can become irritable. A calm, firm approach sets limits while communicating caring. Consistency of all staff is needed to maintain controls and minimize manipulation by patient. Distractibility reduces the patient's ability to understand abstract concepts or pay attention to detailed explanations. The patient is likely to be hyperverbal, so it is not necessary to encourage the patient to talk. p. 231, Table 13.3
A patient who is treated with lithium carbonate shows no improvement and often gets agitated and depressed. Which drug would the nurse expect the primary health care provider to prescribe to the patient? Valproate Phenytoin Gabapentin Phenobarbital
Valproate Valproate, carbamazepine, and lamotrigine are the three anticonvulsants that can be used in treating bipolar disorders. Anticonvulsants are used when the patient is not responding to lithium therapy. They are also used in dysphoric mania characterized by mixed state, or when the patient often gets agitated and depressed. The other anticonvulsants such as phenobarbital, gabapentin, and phenytoin are not effective in bipolar disorders because they may worsen the patient's condition. pp. 235-236, Table 13.5
When a patient reports that lithium causes an upset stomach, the nurse suggests taking the medication With meals With an antacid 30 minutes before meals 2 hours after meals
With meals Many patients find that taking lithium with or shortly after meals minimizes gastric distress. p. 235, Box 13.1
What action should the nurse take on learning that a manic patient's serum lithium level is 1.8 mEq/L? Advise the patient to limit fluids for 12 hours. Continue to administer medication as prescribed. Advise the patient to curtail salt intake for 24 hours. Withhold medication and notify the health care provider.
Withhold medication and notify the health care provider. The patient's lithium level has exceeded desirable limits. Additional doses of the medication should be withheld and the health care provider notified. p. 234, Table 13.4
A patient states, "I am possessed by my dead father." What is this kind of thought content called? Hallucination Loose association Tangential speech Grandiose delusion
Grandiose delusion The patient is displaying grandiose delusions, which are manifested by a highly inflated self-regard. In this case, the patient is expressing a supernatural grandiose delusion. Tangential speech is when a patient loses the point he or she is trying to make and never finds it again. Loose associations represent the disordered way a person is processing information and thoughts that are only loosely connected to each other in the person's conversation. Hallucinations are things that may seem real but do not exist. p. 229
The nurse is writing a plan of care for a patient in the manic phase of bipolar I disorder. What is the most important outcome for the patient? Decreasing food intake Increasing physical activity Sleeping for 8 to 10 hours a night Maintaining a stable cardiac status
Maintaining a stable cardiac status During the manic phase of bipolar I disorder, the most important outcome for the patient is to maintain a stable cardiac status because cardiac problems can be life threatening. Other important outcomes include ensuring at least 4 to 6 hours of sleep a night, increasing food and fluid intake, and decreasing physical activity. p. 230
The nurse is teaching a patient and the patient's family about lithium therapy. Which instructions will the nurse include? "Restrict the sodium in your diet." "Take lithium on an empty stomach." "Take lithium with meals to avoid an upset stomach." "Lithium is a mood stabilizer that helps prevent relapse." "Maintain a consistent fluid intake of 1,500-3,000 mL/day." "You should stop taking lithium if you have excessive diarrhea, vomiting, or sweating."
"Take lithium with meals to avoid an upset stomach." "Lithium is a mood stabilizer that helps prevent relapse." "Maintain a consistent fluid intake of 1,500-3,000 mL/day." "You should stop taking lithium if you have excessive diarrhea, vomiting, or sweating." Lithium is a Food and Drug Administration-approved drug to treat acute mania and maintenance treatment. The patient should be taught the purpose of lithium as a mood stabilizer and significance in preventing relapse. Patients receiving lithium therapy should be taught the importance of maintaining a consistent fluid intake of 1,500 to 3,000 mL per day to avoid toxicity. The patient should take lithium with meals to avoid an upset stomach. The patient should be taught to stop taking lithium and notify prescriber if diarrhea, vomiting, or excessive sweating occur as these symptoms can lead to dehydration and lithium toxicity. Taking lithium on an empty stomach should be avoided due to possible gastrointestinal upset. Sodium in the diet should be consistent, not restricted. pp. 234-235
Which symptom related to communication is likely to be present in a patient experiencing mania? Mutism Poverty of ideas Clang associations Psychomotor retardation
Clang associations Clang associations are the stringing together of words because of their rhyming sounds, without regard to their meaning. This communication style occurs commonly in persons experiencing mania. Mutism, poverty of ideas, and psychomotor retardation are assessment findings usually associated with depression. p 229
Which antianxiety medication should be prescribed to patients with acute mania? Citalopram (Celexa) Propranolol (Inderal) Labetalol (Normodyne) Clonazepam (Klonopin)
Clonazepam (Klonopin) Antianxiety medications are prescribed to patients with acute mania who are resistant to lithium therapy. They are prescribed to reduce the psychomotor agitation in the patients. Clonazepam is a benzodiazepine class of drug and usually is prescribed to patients with mania because of its efficacy and fewer side effects. Citalopram belongs to the class of medications known as selective serotonin reuptake inhibitor. These medications are not prescribed because they produce side effects like nervousness and agitation. Labetalol is a beta blocker medication that is usually prescribed to reduce the blood pressure. Propranolol (Inderal) is a beta blocker used for the treatment of hypertension in the patients with anxiety. It is not prescribed for patients with acute mania. p. 233
The nurse is assessing a patient receiving chronic lithium therapy. Which assessment finding is an expected side effect of the therapy? Ataxia Goiter Incoordination Blurred vision
Goiter Expected side effects of chronic lithium therapy include goiter, renal toxicity, and hypothyroidism. Therefore, patients receiving lithium therapy should have renal function and thyroid levels check before therapy begins and then on an annual basis. Incoordination, ataxia, and blurred vision are unsafe signs of toxicity that must be reported to the physician immediately. p. 234
A bipolar patient tells the nurse, "I have the finest tenor voice in the world. The three tenors who do all those television concerts are going to retire because they can't compete with me." The nurse would make the assessment that the patient is displaying Grandiosity Limit testing Distractibility Flight of ideas
Grandiosity Exaggerated belief in one's own importance, identity, or capabilities is seen with grandiosity. p. 229
A manic patient under hospital supervision became aggressive and injured another patient. The primary health care provider advises that the patient be put in seclusion. What measures should the nurse take while secluding the patient? Keep any instructions to the patient brief. Document the patient's behavior every hour. Assure the patient that the seclusion is temporary. Ensure that no one is with the patient during seclusion. Give detailed explanation for the seclusion to the patient.
Keep any instructions to the patient brief. Assure the patient that the seclusion is temporary. During seclusion, the nurse should communicate by giving brief instructions because the patient has low concentration and memory. The nurse should reassure the patient that the seclusion is a temporary measure and the patient will be returned back to the unit if the patient shows controlled behavior. If the patient is aggressive and can cause self-harm, it is better to have one nurse with the patient on a continuous basis. The nurse should not give long explanations to the patient but can give brief instructions. The nurse should document the patient's behavior every 15 minutes of seclusion, not every hour. p. 237
What should the nurse monitor in bipolar disorder patients who have been administered divalproex sodium? Skin rashes Liver function Platelet count Blood pressure Pancreatic function
Liver function Platelet count The nurse should monitor platelet count and liver function in the patients who are prescribed divalproex sodium. It may cause thrombocytopenia by decreasing the platelet count, and it may cause liver dysfunction by altering the levels of liver enzymes. Blood pressure need not be monitored in the patients because it does not affect the blood pressure. Skin rashes are not caused by divalproex sodium but can be seen in patients who are prescribed lamotrigine. The drug does not cause impairment of pancreatic function, nor does it affect the levels of insulin and glucagon; thus the pancreatic function need not be monitored. p. 235
Which patient situation supports the use of seclusion and restraints? Patient is nonverbal Patient is displaying euphoric mood Patient fears staff is "out to get" him or her Patient is unable to control his or her actions
Patient is unable to control his or her actions A patient unable to control his or her actions requires seclusion or restraints. A nonverbal patient is posing no harm to his or her self or others and does not require seclusion or restraint. A patient displaying euphoria requires safety precautions such as adequate calories, frequent rest periods, and low stimulation. The patient fearing staff is "out to get" him or her is displaying paranoid features with no indication of the potential for harm of self or others. p. 237
When the wife of a manic patient asks about genetic transmission of bipolar disorder, the nurse's answer should be predicated on the knowledge that No research exists to suggest genetic transmission Much depends on the socioeconomic class of the individuals Highly creative people tend toward development of the disorder The rate of bipolar disorder is higher in relatives of people with bipolar disorder
The rate of bipolar disorder is higher in relatives of people with bipolar disorder This understanding will allow the nurse to directly address the question. Responses based on the other statements would be tangential or untrue. p. 225
With a lithium level of 0.8, which assessment data would be expected? Thirst Polyuria Diarrhea Muscle weakness Fine hand tremors
Thirst Polyuria Fine hand tremors Expected side effects for a 0.4 to 1.0 mEq/L lithium level (therapeutic level) include fine hand tremor, polyuria, and mild thirst. Muscle weakness and diarrhea are associated with early toxicity. page 234, Table 13.4
A patient diagnosed with bipolar disorder has taken lamotrigine (Lamictal) for 3 months with good results. Today, the patient phones the nurse with these complaints. Which complaint should receive the nurse's priority attention? "Last night I slept for only 7½ hours." "I have not had a bowel movement in 2 days." "I have a new rash on my chest and abdomen." "I bumped into a table yesterday and got a bruise on my elbow."
"I have a new rash on my chest and abdomen." Lamotrigine is a first-line treatment for bipolar depression and is approved for acute and maintenance therapy. Lamotrigine generally is tolerated well, but there is one serious but rare dermatological reaction: a potentially life-threatening rash. Patients should be instructed to seek immediate medical attention if a rash appears, although most rashes are likely benign. Sleeping for 7½ hours is healthy. Two days without a bowel movement does not necessarily represent constipation. A bruise is a normal result from a minor trauma. p. 235
A patient diagnosed with bipolar disorder has taken lithium for 1 year with good results. Today, the patient phones the nurse with these complaints. Which complaint should receive the nurse's priority attention? "I've had very bad diarrhea for 3 days." "I notice my hand trembling occasionally." "In the past 6 months, I have gained 8 pounds." "I have been putting a little extra salt on my food."
"I've had very bad diarrhea for 3 days." Diarrhea makes this patient vulnerable to dehydration, which can result in increased concentration of lithium in the blood. This increased drug concentration can lead to lithium toxicity. Fine tremors and weight gain are expected side effects associated with lithium therapy. The nurse should be sensitive to these concerns, but they are not a priority. Salt is important for patients who take lithium. pp. 234, 235, Box 13.1
Which room placement would be best for a patient experiencing a manic episode? A single room near the nurses' station A single room near the unit activities area A shared room with a patient with dementia A shared room away from the unit entrance
A single room near the nurses' station The room placement that provides a nonstimulating environment is best. Nearness to the nurses' station means close supervision can be provided. p. 231, Table 13.3
Which body system is most at risk for decompensation during the acute phase of a severe manic episode? Renal Cardiac Endocrine Pulmonary
Cardiac A primary consideration for a patient in acute mania is the prevention of exhaustion and death from cardiac collapse. In this instance, a careful cardiac assessment takes priority over renal, endocrine, and pulmonary systems. p. 230
A person who has numerous hypomanic and dysthymic episodes can be assessed as demonstrating characteristics of Cyclothymia Bipolar I disorder Bipolar II disorder Seasonal affective disorder
Cyclothymia Cyclothymia refers to mood swings involving hypomania and dysthymia of 2 years' duration. The mood swings are not severe enough to prompt hospitalization. p. 224
Which behavior would be most characteristic of a patient during a manic episode? Watching others intently and talking little Going rapidly from one activity to another Taking frequent rest periods and naps during the day Being unwilling to leave home to see other people
Going rapidly from one activity to another Hyperactivity and distractibility are basic to manic episodes. p. 223
Which behaviors describe the symptoms of the manic phase of bipolar disorder? Distractibility Low self-esteem Racing thoughts Excessive energy Pressured speech Purposeless movement Fatigue and increased sleep Withdrawal from environment
Distractibility Racing thoughts Excessive energy Pressured speech Purposeless movement Excessive energy, pressured speech, purposeless movement, racing thoughts, and distractibility describe mania. Fatigue and increased sleep, low self-esteem, and withdrawal from environment more aptly describe the opposite of what happens in mania. p. 223
A pregnant patient is diagnosed with bipolar disorder. Which treatment strategy would be included in the treatment plan? Lithium therapy Antianxiety therapy Anticonvulsant therapy Electroconvulsive therapy
Electroconvulsive therapy Electroconvulsive therapy can be used to treat the patient with manic episodes during pregnancy. Lithium, anticonvulsants, and antianxiety drugs have teratogenic effects and can cause congenital malformation in the developing fetus. They cannot be used for pregnant and breastfeeding patients. p. 236
A male patient admitted with acute mania tells the staff and the other patients that he is on a secret mission given to him by the President of the United States to monitor citizens for terrorist activity. He states, "I am the only one he trusts, because I am the best!" For documentation purposes what is this behavior referred to as? Grandiosity Rapid cycling Flight of ideas Unpredictability
Grandiosity Grandiosity is inflated self-regard. People with mania may exaggerate their achievements or importance, state that they know famous people, or believe they have great powers. Although patients with mania are unpredictable, the scenario does not describe unpredictability. Rapid cycling is switching between mania and depression in a given time period. The scenario does not describe flight of ideas, which means a continuous flow of speech with abrupt topic changes. p. 229
A patient with bipolar disorder takes lithium. After playing soccer on a hot summer day, the patient complains of nausea, vomiting, diarrhea, and thirst. The patient's hands begin to tremble and the gait becomes unsteady. What is the priority nursing intervention? Administer an antiemetic medication to the patient. Collaborate with the health care provider regarding increasing the daily lithium dose. Instruct the patient not to take any more lithium until directed by the health care provider. Collaborate with the health care provider about drawing a serum lithium level immediately. Complete an abnormal involuntary movement scale (AIMS) evaluation on this patient immediately.
Instruct the patient not to take any more lithium until directed by the health care provider. Collaborate with the health care provider about drawing a serum lithium level immediately. The patient likely became dehydrated by the high activity in the summer heat. Lithium toxicity probably has developed. The lithium must be held, and a serum lithium level needs to be drawn. It is the nurse's responsibility to discuss possible toxicity with the health care provider. p. 235, Box 13.1
The nurse is reviewing the medical records of several patients receiving therapy for manic disorders. Which medication has a rare, potentially life-threatening rash? Lithium Valproate Lamotrigine Carbamazepine
Lamotrigine Lamotrigine is an FDA-approved maintenance drug that patients usually tolerate well; however, a potentially life-threatening dermatologic reaction can occur, though rarely. Patients should be instructed to seek immediate medical attention if a rash develops during therapy. Liver function and platelet counts should be monitored periodically with valproate therapy. Liver enzymes and complete blood counts should be closely monitored in patients receiving carbamazepine. Lithium has many life-threatening side effects including convulsions, oliguria, and death, but life-threatening dermatological conditions are not associated with this therapy. pp. 234-235
The plan of care for a patient who takes lithium should include Dietary teaching to restrict daily sodium intake Periodic laboratory monitoring of renal and thyroid function The requirement for laboratory tests to monitor serum potassium level Tthe importance of discontinuing the medication if fine hand tremors occur
Periodic laboratory monitoring of renal and thyroid function Two major long-term risks of lithium therapy are hypothyroidism and impairment of the kidney's ability to concentrate urine; therefore, a person receiving lithium therapy must have periodic follow-ups to assess thyroid and renal function. Weight gain and fine tremors are common side effects associated with this medication, but the patient should continue taking the medication. Sodium intake for patients who take lithium is not restricted. p. 235, Box 13.1
A nurse is assisting a manic patient in dressing and maintaining basic hygiene tasks. Which nursing interventions are appropriate for the patient in a manic state? Provide step-by-step instructions for dressing. Allow the patient to wear whatever he or she chooses. Provide simple clothes and hygiene tasks to the patient. Warn the patient that seclusion can be used to control behavior. Provide repeated reminders to finish tasks if necessary.
Provide step-by-step instructions for dressing. Provide simple clothes and hygiene tasks to the patient. Provide repeated reminders to finish tasks if necessary. The nurse should supervise the clothes and hygiene of the patient who is in a manic state. The patient should be provided simple clothing and can be instructed in a step-by step manner so that the patient can understand and follow the instructions. The patient may need to be given frequent reminders to maintain hygiene because manic patients can be easily distracted and have poor concentration. Manic patients may choose overly flamboyant or bizarre fashion and should be provided with clothes that help to maintain their dignity while in a manic state. Frequent warning of seclusion to the patient can cause depression and withdrawal of the patient. p. 232, Table 13.3
A patient experiencing mania has not slept for three days and states, "I am not tired. I have so much energy!" What is the best way for the nurse to assure the patient is getting adequate rest? Keep patient stimulated during daylight hours. Recommend frequent rest periods during the day. Suggest the patient remain awake during the day. Encourage hot tea at bedtime to promote relaxation.
Recommend frequent rest periods during the day Adequate rest, sleep, and nutrition are essential during mania. The nurse should encourage the manic patient who hasn't slept to take frequent rest periods during the day. Hot tea at bedtime would not be appropriate since tea contains caffeine, which should be avoided. The patient should be encouraged to rest during the day, not remain awake. The patient's environment should be one with low stimulation. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be helpful, because it may mean that one of these look-alike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur. p. 232
Which behavior of the nurse is appropriate while caring for a patient experiencing acute mania? Judging the values of the patient as incorrect Giving long, detailed explanations to the patient Using a polite and gentle approach with the patient Redirecting the patient's energy into alternate channels
Redirecting the patient's energy into alternate channels The best way for the nurse to manage a patient in acute mania is to firmly redirect the patient's energy into more constructive channels. This intervention helps the patient to use the elevated energy levels associated with acute mania for useful activities. The nurse should avoid judging the patient's values because this could give the patient an excuse to argue and may exaggerate the mania. In acute mania, the patient has a short attention span and therefore the nurse should give short and precise explanations. The nurse should use a firm and calm approach to handle the patient in acute mania. p. 231, Table 13.3
Which action should the nurse take when managing a hospitalized patient experiencing acute mania? Encouraging frequent naps Advising the patient to avoid frequent toilet visits Giving the patient well-cooked three-course meals Allowing the patient to dress and groom unassisted
Encouraging frequent naps The patient experiencing acute mania is at risk for inadequate rest. The nurse should encourage the patient to take frequent naps and sleep during the day. To protect the patient's dignity while in a manic state, the nurse may need to encourage good grooming habits and conservative dress. Without assistance, the patient may be too distracted to finish grooming and his or her appearance may attract unwanted attention or ridicule. The nurse should encourage the patient to frequently visit the toilet to reduce the risk of fecal impaction. Patients experiencing acute mania find it difficult to sit and eat an entire meal. The nurse should provide high-calorie, high-protein finger foods that the patient can consume easily. p. 230
Which side effects of lithium can be expected at therapeutic levels? Nausea and thirst Ataxia and hypotension Fine hand tremor and polyuria Coarse hand tremor and gastrointestinal upset
Fine hand tremor and polyuria The fact that fine hand tremor and polyuria are present at therapeutic levels is quite annoying to some patients. These and other side effects are factors in noncompliance. p. 234, Table 13.4
Which closed-ended assessment question focuses on identifying a classic comorbid condition of bipolar disorder? Have you ever experienced a panic attack? Are you comfortable when you are among strangers? Have you ever been arrested by the police for fighting? Do you rely on alcohol to help cope with your problems? Have you ever been told you have obsessive-compulsive disorder?
Have you ever experienced a panic attack? Are you comfortable when you are among strangers? Have you ever been arrested by the police for fighting? Do you rely on alcohol to help cope with your problems? Within a lifetime, the most commonly co-occurring disorders for all bipolar disorders are panic attacks (62%), alcohol abuse (39%), social phobia (38%), oppositional defiant disorder (37%), specific phobia (35%), and seasonal affective disorder (35%). Obsessive-compulsive disorder generally is not associated with bipolar disorder. p. 225
The nurse cares for a patient in the acute phase of bipolar disorder who has mania. This patient annoys other patients, loudly engages in power struggles with staff, and gives orders to the housekeeping employees about how to clean. Which nursing diagnosis is most applicable? Defensive coping Ineffective coping Impaired social interaction Impaired verbal communication
Impaired social interaction This patient's behavior relates to interactions with others; therefore, impaired social interaction is the most appropriate diagnosis. Poor reality testing, grandiosity, denial of problems, difficulty organizing and attending to information, poor concentration, and inability to meet basic needs are aspects of coping problems. Impaired verbal communication is a diagnosis that applies to pressured speech, clang associations, and flight of ideas. Defensive coping also relates to denial of problems and grandiosity, but incorporates projection of blame to others and rationalization of own failures; therefore, impaired social interaction is a better diagnosis because of the additional behaviors presented in the scenario. p. 230, Table 13.2
A desirable short-term goal for the nursing diagnosis of defensive coping, related to biochemical changes as evidenced by aggressive verbal and physical behaviors, would be Sleeping soundly for 12 of the next 24 hours Making no attempts at self-harm within 12 hours of admission Willingly taking prescribed medication as offered by staff within 24 hours of admission Demonstrating psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission
Making no attempts at self-harm within 12 hours of admission Whenever aggressive verbal or physical behaviors are demonstrated, a desirable goal is cessation of those behaviors. Verbal and physical aggression are most apt to occur when staff are trying to structure the patient's behavior for his or her own safety or the safety of others. p. 230
What notation in the patient's medical record supports the diagnosis of mania? Patient demonstrates ritual behaviors. Patient reports, "God talks directly to me." Patient is disheveled and in need of a bath. Patient reports, "I haven't slept in 4 days; don't need to." Patient presents with a happy, near euphoric demeanor.
Patient reports, "God talks directly to me." Patient reports, "I haven't slept in 4 days; don't need to." Patient presents with a happy, near euphoric demeanor. People with mania are the happiest, most excited, and most optimistic people one could meet. They feel euphoric and energized; they don't sleep or eat and talk constantly. Because they feel so important and powerful, they take horrific chances and do foolish things. As the disorder intensifies, psychosis ensues and people with mania begin to hear voices, sometimes the voice of God. Being disheveled or demonstrating ritualistic behavior are not classic characteristics of mania. p. 223
When a hyperactive manic patient expresses the intent to strike another patient, the initial nursing intervention would be to Set verbal limits Initiate physical confrontation Question the patient's motive Prepare the patient for seclusion
Set verbal limits Verbal limit setting should always precede more restrictive measures. p. 231
A nurse is planning a diet chart for a manic patient who is on lithium therapy. Which instruction should be included in the diet chart? Reduce sodium intake. Take lithium with meals. Take lithium before breakfast. Avoid taking lithium before going to bed.
Take lithium with meals. Lithium should be given with meals because lithium causes irritation of the stomach lining. Patients on lithium therapy should ensure they have adequate salt in their diets because lithium decreases sodium reabsorption, leading to a possible deficiency of sodium. Lithium should not be taken on an empty stomach before breakfast because it causes irritation of the stomach lining. Lithium intake should not affect the patient's sleep patterns. p. 235, Box 13.1
A nurse caring for a manic patient observes that the patient has persistent gastrointestinal upset. The nurse assumes that the patient is showing advanced signs of lithium toxicity and tests the serum levels of lithium in the patient. What concentration of lithium does the nurse expect to find in the patient's blood serum? 0.5 mEq/L 1.8 mEq/L 2.5 mEq/L 3.4 mEq/L
1.8 mEq/L Serum levels of more than 1.8 mEq/L can cause advanced signs of toxicity such as gastrointestinal upset, mental confusion, incoordination, and sedation. Serum level of 0.5 mEq/L indicates the therapeutic level of lithium. Serum levels of 2.5 and 3.4 mEq/L indicate severe toxicity. The symptoms of severe toxicity include oliguria, convulsions, severe hypotension, and death. p. 234, Table 13.4
A manic patient with rapid-cycling manic symptoms is treated with carbamazepine. Which adverse effect should the nurse report on chronic administration of the drug? Convulsions Severe hypotension Bone marrow suppression Changes in the electroencephalograph
Bone marrow suppression Carbamazepine is an anticonvulsive drug. On chronic administration, it can cause bone marrow suppression and liver inflammation because of an increase in liver enzymes. Convulsions, changes in electroencephalograph, and severe hypotension are caused by increased levels of lithium in the blood, or more than or equal to 1.5 mEq/L.
The patient treated with lithium carbonate repeatedly requests water to drink and has slurred speech. What is the priority nursing action in this case? Provide food to the patient. Administer mannitol to the patient. Check the patient's blood lithium level. Report to the primary health care provider.
Check the patient's blood lithium level. Excessive thirst, slurred speech, and polyuria are early signs of lithium toxicity. The nurse should check the lithium level of the patient frequently. The nurse can report to the primary health care provider but after checking the lithium levels in the blood. Mannitol can be administered to eliminate the drug in case of severe toxicity. Food does not help prevent lithium toxicity. p. 234, Table 13.4
Which food should be incorporated in the diet of patients with bipolar disorder that would also help in mood regulation? Cereals Chocolates Cod liver oil Milk products
Cod liver oil Integrative therapy for bipolar disorder may involve the use of foods rich in omega-3 fatty acids because those help with mood regulation and improve attention. Cod liver oil is a rich source of omega-3 fatty acids; hence it can be included in a patient's diet. Milk products can be included, but they do not help in mood regulation but rather as a source of protein. Chocolate must be avoided for patients with bipolar disorder because chocolate contains cocoa, which has caffeine. Caffeine causes central nervous system stimulation and can cause anxiety. Cereals are a source of carbohydrates. They do not contain high amounts of omega-3 fatty acids, so they do not cause mood regulation. p. 236
A patient diagnosed with bipolar disorder was hospitalized 15 days ago and has been receiving lithium. Current assessment findings include increased restlessness, pressured speech, and flight of ideas. The patient sleeps 2 hours per night. What is the nurse's best intervention? Continue to monitor the patient's symptoms until the lithium begins to take effect. Discourage the patient from attending groups because of the likelihood of disruptive behavior. Offer the patient opportunities to practice concentration and ways to increase attention span. Consider the need to obtain a lithium level. The patient may not be swallowing the medication.
Consider the need to obtain a lithium level. The patient may not be swallowing the medication. Lithium must reach therapeutic levels in the blood to be effective, which usually takes 7 to 14 days. In this scenario, the assessment findings indicate continued mania, so the nurse should question whether the patient actually has been taking the medication. Only a serum lithium level can give definitive results. The patient has taken lithium long enough to begin to see therapeutic effects; continuing to monitor the patient's symptoms is an inadequate response by the nurse. The patient needs therapeutic intervention; excluding group therapies denies the patient's right to treatment. This patient will be unable to practice concentration because of continuing flight of ideas. p. 234
Which behavior is important to include for the patient and the family to recognize possible signs of impending mania? Decreased sleep Increased appetite Decreased social interaction Increased attention to body functions
Decreased sleep Changes in sleep patterns are especially important because they usually precede mania. Even a single night of unexplainable sleep loss can be taken as an early warning of impending mania. Increased appetite, decreased social interaction, and increased attention to bodily functions do not indicate impending mania. p. 237
A patient with mania reports inability to sleep. What appropriate action does the nurse take to help the patient sleep better? Provide a low-protein diet. Provide tea or coffee before sleep. Instruct the patient to perform slow exercises. Help the patient perform intense physical activity.
Instruct the patient to perform slow exercises. Manic patients suffer from sleep deprivation due to hyperactivity. The nurse directs the energy into productive and calming activities by providing slow exercise, writing, or playing soft music. The manic patient must be given frequent rest periods during a physical activity. Lack of rest can cause exhaustion and death. The patient must be given decaffeinated coffee, cola, and tea, as caffeine can interfere with sleep. Manic patients are usually overactive, so they must be provided high-calorie and high-protein foods. p. 232, Table 13.3
An outcome for a manic patient during the acute phase that would indicate that the treatment plan was successful would be that the patient Is free of injury Is highly distractible Ignores food and fluid Reports racing thoughts
Is free of injury Risk for injury is a diagnosis of high priority for manic patients because of their hyperactivity. Lack of injury is a highly desirable outcome. p. 230
What information regarding lithium carbonate is true? It is effective for patients with a history of rapid cycling. It demonstrates effectiveness in the treatment of bipolar I. Indefinite maintenance dosing is required for many patients. Manic behaviors generally show improvement in 10 to 21 days. Associated hypersexual behavior is well managed with the medication.
It demonstrates effectiveness in the treatment of bipolar I. Indefinite maintenance dosing is required for many patients. Manic behaviors generally show improvement in 10 to 21 days. Lithium is effective in the treatment of bipolar I acute and recurrent manic and depressive episodes. Lithium inhibits about 80% of acute manic and hypomanic episodes within 10 to 21 days. It can help reduce hypersexuality but to a lesser degree than for other symptomology. Lithium is less effective in those with rapid cycling. Many patients receive lithium for maintenance indefinitely and experience manic and depressive episodes if the drug is discontinued. p. 234
What information concerning electroconvulsive therapy (ECT) treatment and its effectiveness for patients diagnosed with bipolar disorder is true? It is appropriate for all cases of manic behavior. It is promising for patients with a history of rapid cycling. Treatment is appropriate for pregnant patients experiencing mania. Treatment is contraindicated for patients during depressive episodes. Treatment shows little effectiveness for patients experiencing paranoid tendencies.
It is promising for patients with a history of rapid cycling. Treatment is appropriate for pregnant patients experiencing mania. ECT is used to subdue severe manic behavior, especially in patients with treatment-resistant mania and patients with rapid cycling. Depressive episodes, particularly those with severe, catatonic, or treatment-resistant depression, are an indication for this treatment and may be helpful for mania during pregnancy. ECT is effective for patients with bipolar disorder who have rapid cycling, and for those with paranoid-destructive features. p. 236
A patient displays a period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extremely goal-directed activity. What is the term for the patient's behavior? Mania Hypomania Flight of ideas Loose associations
Mania Mania is a period of intense mood disturbance with persistent elevation, expansiveness, irritability, and extremely goal-directed activity or energy. Mania commonly occurs with bipolar I disorder. Flight of ideas is a continuous flow of accelerated speech with abrupt changes from topic to topic. Hypomania refers to a low-level and less-dramatic mania. Loose associations represent the disordered way that a person is processing information and thoughts that are only loosely connected to each other in the person's conversation. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 223
The nurse is managing the care of an older adult diagnosed with bipolar disorder who is in a manic phase. The nurse closely monitors the patient for risks to his or her safety. What factor makes this intervention especially appropriate for this patient? Such a patient is abused easily by other aggressive patients. Mania can result in irresponsible and physically risky behaviors. The manic phase will be followed by a phase of severe depression. Older adults experience physical conditions that greatly increase the potential for injury.
Mania can result in irresponsible and physically risky behaviors. Patients in the manic phase of bipolar disorder may have misperceptions about their power and importance and involve themselves in senseless, irresponsible, and risky activities that can result in physical harm. Although it is true that older adults are at risk for injury related to both acute and chronic illness, that depression generally follows mania, and that manic individuals are at risk for injury caused by those who are affected by or who misunderstand the behavior, the primary risk to this patient comes from the manic behavior itself. p. 230, Table 13.2
Which statement concerning seclusion should be included in the patient's medical record? Patient placed in seclusion at 1330. Patient was threatening to "kill anyone who comes near me." Attempts to deescalate patient's agitation were unsuccessful. Patient's vital signs are monitored and recorded every 15 minutes. Staff discussed future interventions to help minimize patient's potential for aggression.
Patient placed in seclusion at 1330. Patient was threatening to "kill anyone who comes near me." Patient's vital signs are monitored and recorded every 15 minutes. Careful and precise documentation is a legal necessity. The nurse documents the behavior leading up to the seclusion or restraint; actions taken to provide the least restrictive alternative (in this case the statement is too vague to be appropriate); time the patient was placed in seclusion; checking the patient's behavior, needs, nursing care, and vital signs every 15 minutes; and time and type of medications given and their effects on the patient. Staff discussions regarding future interventions are not considered relevant to this documentation. p. 237
Which patient is the best candidate for electroconvulsive therapy (ECT)? Patient with mania controlled on lithium therapy Patient with schizophrenia refusing medications Patient with bipolar depression displaying catatonia Patient with an altered level of consciousness (LOC)
Patient with bipolar depression displaying catatonia ECT is used to subdue severe bipolar disorder, especially in patients with treatment-resistant mania, rapid cycling, or depressive episodes with severe catatonia. Patients with schizophrenia refusing medications may require involuntary treatment such as an assistive medication program or involuntary admission to stabilize symptoms. A patient with altered LOC should have a physical examination to determine the cause. A patient on controlled lithium therapy does not require ECT unless he or she develops catatonia or treatment-resistant symptoms. p. 236
Which patients can be safely prescribed lithium therapy to treat bipolar disorder? Patients with renal diseases Patients with thyroid disorder Patients with myasthenia gravis Patients with erectile dysfunction
Patients with erectile dysfunction Patients with erectile dysfunction can be prescribed lithium therapy because lithium does not interfere with sexual function. Lithium therapy must be avoided in patients with myasthenia gravis because it causes ataxia and severe muscle weakness. Lithium causes hypothyroidism by reducing the levels of thyroxine hormone. It should not be prescribed to patients with thyroid disorder. Lithium causes impairment in kidney functioning. It should not be prescribed to patients with renal diseases. p. 235
A manic patient showed progressive improvement with continued lithium therapy. After successful treatment, the patient is discharged from the hospital. What appropriate suggestions should the nurse make to the patient and his or her family during discharge? Water pills or diuretics will help with lithium side effects. You can reduce the lithium dose if there is an excessive weight gain. Over-the-counter medications are safe if taken as instructed on the box. Schedule regular checkups to test the function of your thyroid and kidney. Contact the primary health care provider if there is any excessive vomiting.
Schedule regular checkups to test the function of your thyroid and kidney. Contact the primary health care provider if there is any excessive vomiting. Lithium affects thyroid and kidney functioning so the patient should be advised to have regular assessment of functioning after being discharged. Lithium may cause diarrhea, vomiting, or sweating as a result of dehydration, so the patient should be advised to consult the primary health care provider if these symptoms occur. Patients on lithium should be advised not to take over-the-counter medicine without consulting the primary health care provider. Patients should not be advised to reduce the medication if there is a weight gain; dosage should only be adjusted by the health care provider. Lithium causes dehydration in the patients, so water pills or other diuretics should not be taken by the patient. p. 235, Box 13.1
What intervention will help minimize staff-splitting by a manic patient? Set reasonable limits on patient behavior. Regularly self-reflect for possible countertransference. Consistently reenforce consequences for inappropriate behavior. Schedule frequent staff meetings to discuss problematic behavior. Identify one staff member who will work exclusively with the patient.
Set reasonable limits on patient behavior. Regularly self-reflect for possible countertransference. Consistently reenforce consequences for inappropriate behavior. Schedule frequent staff meetings to discuss problematic behavior. People with mania have the ability to staff-split using humor, manipulation, power struggles, or demanding behavior to prevent or minimize the staff's ability to set limits on and control dangerous behavior, or divide the staff into the good guys or the bad guys. This divisive tactic may pit one staff member or group against another, undermining a unified and consistent plan of care. Frequent staff meetings to deal with the behaviors of the patient and the nurses' responses to these behaviors can help minimize staff-splitting. Consistency among staff is imperative if the limit-setting is to be carried out effectively. If one is working with a patient experiencing mania, one may feel helplessness, confusion, or even anger. Understanding, acknowledging, and sharing these responses and countertransference reactions will enhance professional ability to care for the patient and perhaps promote personal development as well. Identifying one staff member to consistently work with the patient would eliminate the environment necessary for splitting. p. 237
Which statement is true of the relationship between bipolar disorder and suicide? Patients need to be monitored only in the depressed phase because this is when suicides occur. Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide. Patients with bipolar disorder are not considered high risk for suicide. As long as patients with bipolar disorder adhere to their medication regimen, there is little risk for suicide.
Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide. Mortality rates for bipolar disorder are severe because 25% to 60% of individuals with bipolar disorder will make a suicide attempt at least once in their lifetime, and nearly 20% of all deaths among this population are from suicide. Suicides occur in both the depressed and the manic phase. Bipolar patients are always considered high risk for suicide because of impulsivity while in the manic phase and hopelessness when in the depressed phase. Although staying on medications may decrease risk, there is no evidence to suggest that only patients who stop medications commit suicide. p. 223
Which statement regarding bipolar I is true? The median age for onset is 18 years. The disorder tends to begin with a depressive episode. The disorder is more common among women than men. Severe postpartum depression increases the risk for developing the disorder. The episodes tend to increase in number and severity during the course of the illness.
The median age for onset is 18 years. The disorder tends to begin with a depressive episode. Severe postpartum depression increases the risk for developing the disorder. The episodes tend to increase in number and severity during the course of the illness. The median age of onset for bipolar I is 18 years. Bipolar I tends to begin with a depressive episode in both women and men. The episodes tend to increase in number and severity during the course of the illness. Women who experience a severe postpartum psychosis within 2 weeks of giving birth have a four times greater chance of subsequent conversion to bipolar disorder. Bipolar I disorder seems to be somewhat more common among men. p. 225, Table 13.1
A patient with mania says to a nurse, "I will not talk with you, the nurse in the night shift advised me to stay away from you." What appropriate action does the nurse take? The nurse secludes the patient. The nurse asks the reason for avoiding. The nurse stops interacting with the patient. The nurse reports the patient's behavior in the staff meeting.
The nurse reports the patient's behavior in the staff meeting. Patients with mania often try to split the staff into groups by creating misunderstandings. The patient with mania may blame one nurse in front of another and cause a rift between the staff members. Frequent staff meetings must be conducted to avoid staff-splitting. The patient's behavior must be discussed in the staff meeting to provide effective care to the patient. It is not a professional approach to stop interacting with the patient, secluding the patient, or asking the reason for avoiding. The patient's manipulative behavior is due to his or her mental condition. p. 237
