Townsend Ch. 26 Bipolar Disorder

40. A client newly diagnosed in a manic episode of bipolar disorder tells the nurse, "Now that I'm only sleeping 4 hours a night, I can get so much more work accomplished." Which ego defense mechanism is this client using? 1) Denial 2) Intellectualization 3) Rationalization 4) Suppression

2) Intellectualization Intellectualization occurs when an individual attempts to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis. The individual in the question is using reasoning to avoid dealing with feelings about the new diagnosis of bipolar disorder.

52. A client who is prescribed lithium carbonate is being discharged from inpatient care. Which medication information should the nurse teach this client? 1) "Do not alter your dietary sodium intake." 2) "Have serum lithium levels checked every 6 months." 3) "Limit fluid intake to 1,000 mL per day." 4) "Adjust the dose if you feel out of control."

1) "Do not alter your dietary sodium intake." Clients taking lithium should consume a diet adequate in sodium and drink 2,500 to 3,000 mL of fluid per day. Lithium is a salt and competes in the body with sodium. If sodium is lost, the body will retain lithium, resulting in toxicity. Conversely, if sodium levels are significantly increased, it will reduce the level of lithium, resulting in decreased efficacy. Maintaining normal sodium and fluid levels is critical to maintaining therapeutic levels of lithium.

46. The physician has ordered lithium carbonate (Eskalith) for a client diagnosed with bipolar disorder. What is the most likely rationale for prescribing this drug? 1) Decrease hyperactivity 2) Control anger 3) Elevate the mood 4) Diminish anxiety

1) Decrease hyperactivity Lithium carbonate's primary therapeutic effect is to prevent or decrease the incidence of acute manic episodes and associated hyperactivity.

44. Sophie is admitted to an inpatient psychiatric unit in an acute manic episode. She is morbidly obese and believes she is a famous ballerina. She repeatedly runs from one end of the unit to the other and attempts to twirl around while standing on chairs in the patient lounge. She is prescribed temazepam (Restoril) for sleep, and since her admission she has generally slept for five to six hours each night. What should the nurse consider to be the priority nursing diagnosis? 1) Risk for Injury related to excessive hyperactivity. 2) Disturbed Sleep Pattern related to manic hyperactivity. 3) Imbalanced Nutrition, Less than Body Requirements, related to inadequate intake. 4) Situational Low Self-esteem related to embarrassment secondary to high-risk behaviors.

1) Risk for Injury related to excessive hyperactivity. According to Maslow's hierarchy of needs and this client's presentation, safety is a priority. The impulsiveness and hyperactivity seen in clients diagnosed with acute mania puts them at risk for injury.

8. A client diagnosed with bipolar II disorder has a nursing diagnosis of impaired social interactions R/T egocentrism. Which short-term outcome is an appropriate expectation for this client problem? 1. The client will have an appropriate one-on-one interaction with a peer by day 4. 2. The client will exchange personal information with peers at lunchtime. 3. The client will verbalize the desire to interact with peers by day 2. 4. The client will initiate an appropriate social relationship with a peer.

1. A client's having an appropriate one-on-one interaction with a peer is a successful outcome for the nursing diagnosis of impaired social interactions. The test taker should note that this outcome is specific, client centered, positive, realistic, and measurable and includes a time frame.

10. A client experiencing mania states, "Everything I do is great." Using a cognitive approach, which nursing response would be most appropriate? 1. "Is there a time in your life when things didn't go as planned?" 2. "Everything you do is great." 3. "What are some other things you do well?" 4."Let's talk about the feelings you have about your childhood."

1. By asking, "Is there a time in your life when things didn't go as planned?" the nurse is using a cognitive approach to challenge the thought processes of the client.

11. A newly admitted client is experiencing a manic episode. The client's nursing diagnosis is imbalanced nutrition, less than body requirements. Which meal is most appropriate for this client? 1. Chicken fingers and French fries. 2. Grilled chicken and a baked potato. 3. Spaghetti and meatballs. 4. Chili and crackers.

1. Chicken fingers and French fries are finger foods, which the client would be able to eat during increased psychomotor activity, such as pacing. Because these foods are high in caloric value, they also meet the client's increased nutritional needs.

23. A client prescribed lithium carbonate (Lithium) 300 mg qam and 600 mg qhs presents in the ED with impaired consciousness, nystagmus, arrhythmias, and a history of recent seizure. Which serum lithium level would the nurse expect to assess? 1. 3.7 mEq/L. 2. 3.0 mEq/L. 3. 2.5 mEq/L. 4. 1.9 mEq/L.

1. Clients with a serum lithium level greater than 3.5 mEq/L may show signs such as impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, or cardiovascular collapse.

15. A client diagnosed with bipolar I disorder, most recent episode manic, is now ready for discharge. Which of the following resource services should be included in discharge teaching? Select all that apply. 1. Financial and legal assistance. 2. Crisis hotline. 3. Individual psychotherapy. 4. Support groups. 5. Family education groups.

1. During a manic episode, clients are likely to experience impulse control problems, which may lead to excessive spending. 2. Clients diagnosed with bipolar disorder can experience hyperactivity or depression, which may lead to ambivalence regarding his or her desire to live. Having access to a crisis hotline may help the client to de-escalate and make the difference between life and death decisions. 3. During a manic episode, a client most likely would have had difficulties in various aspects of interpersonal relationships, such as with family, friends, and coworkers. Individuals experiencing mania may be difficult candidates for psychotherapy because of their inability to focus. When the acute phase of the illness has passed, the client may decide to access an available resource to deal with interpersonal problems. Psychotherapy, in conjunction with medication maintenance treatment, and counseling may be useful in helping these individuals. 4. During a manic episode, a client would not be a willing candidate for any type of group therapy. However, when the acute phase of the illness has passed, this individual may want to access support groups to benefit therapeutically from peer support. 5. During a manic episode, a client may have jeopardized marriage or family functioning. Having access to a resource that would help this client restore adaptive family functioning may improve not only relationships but also noncompliance issues and dysfunctional behavioral patterns, and ultimately may reduce relapse rates. Family therapy is most effective with the combination of psychotherapeutic and pharmacotherapeutic treatment.

50. A client diagnosed with bipolar disorder is experiencing hyperactive behavior and weight loss. Which nutritional intervention would be most therapeutic for this client? 1) Allow the client full kitchen privileges to eat anything as needed (prn). 2) Initiate tube feedings with nutritional supplements. 3) Provide small, frequent feedings of finger foods. 4) Provide a quiet place where the client can sit down to eat meals.

3) Provide small, frequent feedings of finger foods. The client experiencing mania is unable to sit still long enough to eat an adequate nutritious meal. Small, frequent feedings with finger foods allow the client to eat during periods of hyperactivity.

18. A nurse working with a client diagnosed with bipolar I disorder attempts to recognize the motivation behind the client's use of grandiosity. Which is the rationale for this nurse's action? 1. Understanding the reason behind a behavior would assist the nurse in accepting and relating to the client, not the behavior. 2. Change in behavior cannot occur until the client can accept responsibility for his or her own actions. 3. As self-esteem is increased, the client will meet individual needs without the use of manipulation. 4. Positive reinforcement would enhance self-esteem and promote desirable behaviors.

1. Grandiosity, which is defined as an exaggerated sense of self-importance, power, or status, is used by clients diagnosed with bipolar affective disorder to help reduce feelings of insecurity by increasing feelings of power and control. When the nurse understands the origin of this behavior, the nurse can better work with, and relate to, the client.

24. A client is newly prescribed lithium carbonate (Lithium). Which teaching point by the nurse takes priority? 1."Make sure your salt intake is consistent." 2. "Limit your fluid intake to 2000 mL/day." 3. "Monitor your caloric intake because of potential weight gain." 4."Get yourself in a daily routine to assist in avoiding relapse."

1. Lithium is similar in chemical structure to sodium, behaving in the body in much the same manner and competing with sodium at various sites in the body. If sodium intake is reduced, or the body is depleted of its normal sodium, lithium is reabsorbed by the kidneys, and this increases the potential for toxicity.

28. A client diagnosed with bipolar affective disorder is prescribed divalproex sodium (Depakote). Which of the following lab tests would the nurse need to monitor throughout drug therapy? Select all that apply. 1. Platelet count. 2. Aspartate aminotransferase (AST). 3. Fasting blood sugar (FBS). 4. Alanine aminotransferase (ALT). 5. Serum depakote level.

1. Platelet counts need to be monitored before and during therapy with Depakote because of the potential side effect of blood dyscrasias. 2. Aspartate aminotransferase is a liver enzyme test that needs to be monitored before and during therapy with Depakote because of the potential side effect of liver toxicity. 4. Alanine aminotransferase is a liver enzyme test that needs to be monitored before and during therapy with Depakote because of the potential side effect of liver toxicity. 5. Depakote levels need to be monitored to determine therapeutic levels and assess potential toxicity.

5. A newly admitted client diagnosed with bipolar I disorder is experiencing a manic episode. Which nursing diagnosis is a priority at this time? 1. Risk for violence: other-directed R/T poor impulse control. 2. Altered thought process R/T hallucinations. 3. Social isolation R/T manic excitement. 4. Low self-esteem R/T guilt about promiscuity.

1. Risk for violence: other-directed is defined as behaviors in which an individual demonstrates that he or she can be physically, emotionally, or sexually harmful to others. Because of poor impulse control, irritability, and hyperactive psychomotor behaviors experienced during a manic episode, this client is at risk for violence directed toward others. Keeping everyone in the milieu safe is always a nursing priority.

13. A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority? 1. Calmly redirect and remove the client from the milieu. 2. Administer prescribed prn intramuscular injection for agitation. 3. Ask the client to lower his or her voice while in the common area. 4. Obtain an order for seclusion to help decrease external stimuli.

1. When a client experiencing mania is yelling at other peers, it is the nurse's priority to address this situation immediately. Behaviors of this type can escalate into violence toward clients and staff members. By using a calm manner, the nurse avoids generating any further hostile behaviors, and by removing the client from the milieu, the nurse protects other clients on the unit.

27. A client on an in-patient psychiatric unit is prescribed lamotrigine (Lamictal) 50 mg qd. After client teaching, which client statement reflects understanding of important information related to lamotrigine? 1. "I will call the doctor if I miss more than 5 days before restarting the medication." 2. "I will schedule an appointment for my blood to be drawn at the lab next week." 3. "I will call the doctor immediately if my temperature rises above 100°F." 4."I will stop my medication if I start having muscle rigidity of my face or neck."

1. When the medication is titrated incorrectly, the risk for Stevens Johnson syndrome increases. Clients need to be taught the importance of taking the medication as prescribed and accurately reporting adherence.

41. A client diagnosed with bipolar disorder has been hospitalized for 2 weeks. The client asks the nurse, "Do you think that the doctor is ever going to discharge me?" Which is the appropriate nursing response? 1) "Ask your doctor when you can be discharged." 2) "Tell me more about your feelings about being hospitalized." 3) "You are not ready to go yet." 4) "Let the doctor know your feelings."

2) "Tell me more about your feelings about being hospitalized."

39. Tori has been diagnosed with bipolar I disorder and presents at her clinic appointment with complaints of feeling depressed and hopeless. What is the most important assessment for the nurse to make at this point? 1) If Tori has been taking her medication 2) If Tori is having thoughts of suicide 3) If Tori has had any new stressors in her life 4) If Tori is using alcohol

2) If Tori is having thoughts of suicide

55. The wife of a patient being treated with lithium for bipolar disorder states to the nurse, "My husband has been on lithium for 3 days and he's still as manic as ever." Which of the following is important for the nurse to include in patient/family education about lithium? 1) Lithium prevents relapse into depression but has no direct effects on manic episodes. 2) Lithium takes up to 3 weeks to reach peak effectiveness. 3) Lithium is a neurotransmitter that can trigger mania in some individuals. 4) Lithium can be rendered ineffective if the patient restricts sodium intake.

2) Lithium takes up to 3 weeks to reach peak effectiveness. This statement is true and is important for families and patients to understand so they don't prematurely interpret the medication to be ineffective.

33. A suicidal client with a history of manic behavior is admitted to the ED. The client's diagnosis is documented as "bipolar I disorder: depressed." What is the rationale for this diagnosis versus a diagnosis of major depressive disorder? 1) The physician does not believe the client is suffering from major depression. 2) The client has experienced a manic episode in the past. 3) The client does not exhibit psychotic symptoms. 4) There is no history of major depression in the client's family.

2) The client has experienced a manic episode in the past. According to the DSM-5 criteria, a manic episode rules out the diagnosis of major depressive disorder.

3. A nurse on an in-patient psychiatric unit receives report at 1500 hours. Which client would need to be assessed first? 1. A client on one-to-one status because of active suicidal ideations. 2. A client pacing the hall and experiencing irritability and flight of ideas. 3. A client diagnosed with hypomania monopolizing time in the milieu. 4. A client with a history of mania who is to be discharged in the morning.

2. A client's behavior of pacing the halls and experiencing irritability should be considered emergent and warrant immediate attention. Most assaultive behavior that occurs on an in-patient unit is preceded by a period of increasing hyperactivity. Because of these symptoms, this client would need to be assessed first.

14. A client newly admitted with bipolar I disorder has a nursing diagnosis of risk for injury R/T extreme hyperactivity. Which nursing intervention is appropriate? 1. Place the client in a room with another client experiencing similar symptoms. 2. Use prn antipsychotic medications as ordered by the physician. 3. Discuss consequences of the client's behaviors with the client daily. 4. Reinforce previously learned coping skills to decrease agitation.

2. A newly admitted client experiencing an extremely hyperactive episode as the result of bipolar I disorder would benefit from an antipsychotic medication to sedate the client quickly. A mood stabilizer may be given concurrently for maintenance therapy and to prevent or diminish the intensity of subsequent manic episodes.

1. Which statement about the development of bipolar disorder is from a biochemical perspective? 1. Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is about 28%. 2. In bipolar disorder, there may be possible alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium. 3. Magnetic resonance imaging reveals enlarged third ventricles, subcortical white matter, and periventricular hyperintensity in those diagnosed with bipolar disorder. 4. Twin studies have indicated a concordance rate among monozygotic twins of 60% to 80%.

2. Alterations in normal electrolyte transfer across cell membranes, resulting in elevated levels of intracellular calcium and sodium, is an example of a biochemical perspective in the development of bipolar disorder.

53. Cameron, who has been treated with lithium for several months, was recently placed on sodium-depleting diuretics by his family physician. He now presents in the ER with tremors, psychomotor retardation, confusion, and giddiness. What is the most likely reason for his symptoms? 1) Cameron's lithium level has dropped R/T sodium depletion and he is experiencing a return of manic symptoms. 2) Cameron is experiencing extrapyramidal symptoms R/T a drug:drug interaction. 3) Cameron is experiencing lithium toxicity R/T sodium depletion. 4) Cameron is experiencing psychosis R/T lithium toxicity.

3) Cameron is experiencing lithium toxicity R/T sodium depletion. Sodium depletion increases the risk for lithium toxicity, and Cameron's symptoms are consistent with lithium toxicity.

36. A client is diagnosed with bipolar disorder. The family describes the client as being "on the move." The client sleeps 3 to 4 hours nightly, spends excessively, and has recently lost 10 pounds. During the initial client assessment, which client response would the nurse expect? 1) Short, polite responses to interview questions. 2) Introspection related to present situation. 3) Inability to remain seated and racing thoughts. 4) Feelings of helplessness and hopelessness.

3) Inability to remain seated and racing thoughts. In the manic phase of bipolar disorder the client experiences hyperactivity, restlessness, and flight of ideas. This would cause the client to have difficulty remaining seated and have problems organizing thoughts.

51. A client demonstrating manic behavior has become demanding and hyperactive. Which is the most appropriate nursing intervention to address these client behaviors? 1) Help lessen the client's feelings of guilt and rejection. 2) Warn the client that restraints may be necessary if behavior does not improve. 3) Maintain a supportive, structured environment, setting firm limits in a nonthreatening manner. 4) Introduce the client to peers in order to increase interpersonal contacts.

3) Maintain a supportive, structured environment, setting firm limits in a nonthreatening manner. The client is having difficulty controlling behavior and maintaining impulse control. The nurse must help the client to do so in an objective, nonjudgmental way, focusing on the behavior and not the client.

12. A provocatively dressed client diagnosed with bipolar I disorder is observed laughing loudly with peers in the milieu. Which nursing action is a priority in this situation? 1. Join the milieu to assess the appropriateness of the laughter. 2. Redirect clients in the milieu to structured social activities, such as cards. 3. Privately discuss with the client the inappropriate provocative dress. 4. Administer prn antianxiety medication to calm the client.

3. Because dressing provocatively can precipitate sexual overtures that can be dangerous to the client, it is the priority of the nurse to discuss with the client the inappropriateness of this clothing choice.

4. A client diagnosed with cyclothymia is newly admitted to an in-patient psychiatric unit. The client has a history of irritability and grandiosity and is currently sleeping 2 hours a night. Which nursing diagnoses takes priority? 1. Altered thought processes R/T biochemical alterations. 2. Social isolation R/T grandiosity. 3. Disturbed sleep patterns R/T agitation. 4. Risk for violence: self-directed R/T depressive symptoms.

3. Disturbed sleep patterns is defined as a time-limited disruption of sleep amount and quality. Because the client is sleeping only 2 hours a night, the client is meeting the defining characteristics of the nursing diagnosis of disturbed sleep patterns. This sleep problem is usually due to excessive hyperactivity and agitation.

25. Which list contains medications that the nurse may see prescribed to treat clients diagnosed with bipolar affective disorder? 1. Lithium carbonate (Lithium), loxapine (Loxitane), and carbamazepine (Tegretol). 2. Gabapentin (Neurontin), thiothixene (Navane), and clonazepam (Klonopin). 3. Divalproex sodium (Depakote), verapamil (Calan), and olanzapine (Zyprexa). 4. Lamotrigine (Lamictal), risperidone (Risperdal), and benztropine (Cogentin).

3. Divalproex sodium (Depakote), an anticonvulsant, and verapamil (Calan), a calcium channel blocker, are used in the long-term treatment of BPAD. Olanzapine (Zyprexa), an antipsychotic, has been approved by the FDA for the treatment of acute manic episodes.

21. A client prescribed lithium carbonate (Eskalith) is experiencing an excessive output of dilute urine, tremors, and muscular irritability. These symptoms would lead the nurse to expect that the client's serum lithium level would be which of the following? 1. 0.6 mEq/L. 2. 1.5 mEq/L. 3. 2.6 mEq/L. 4. 3.5 mEq/L.

3. The client's symptoms described in the question support a serum lithium level of 2.6 mEq/L.

9. A client seen in the emergency department is experiencing irritability, pressured speech, and increased levels of anxiety. Which would be the nurse's priority intervention? 1. Place the client on a one-to-one observation to prevent injury. 2. Ask the physician for a psychiatric consultation. 3. Assess vital signs, and complete a physical assessment. 4. Reinforce relaxation techniques to decrease anxiety.

3. The nurse first should assess vital signs and complete a physical assessment to rule out a physical cause for the symptoms presented. Many physical problems manifest in symptoms that seem to be caused by psychological problems.

29. A client diagnosed with bipolar affective disorder is prescribed carbamazepine (Tegretol). The client exhibits nausea, vomiting, and anorexia. Which is an appropriate nursing intervention at this time? 1. Stop the medication, and notify the physician. 2. Hold the next dose until symptoms subside. 3. Administer the next dose with food. 4. Ask the physician for a stat carbamazepine (Tegretol) level.

3. When clients prescribed carbamazepine experience nausea, vomiting, and anorexia, it is important for the nurse to administer the medication with food to decrease these uncomfortable, but acceptable, side effects. If these side effects do not abate, other interventions may be necessary.

2. Which nursing charting entry is documentation of a behavioral symptom of mania? 1. "Thoughts fragmented, flight of ideas noted." 2. "Mood euphoric and expansive. Rates mood a 10/10." 3. "Pacing halls throughout the day. Exhibits poor impulse control." 4."Easily distracted, unable to focus on goals."

3. When the nurse documents, "Pacing halls throughout the day. Exhibits poor impulse control," the nurse is charting a behavioral symptom of mania. Psychomotor activities and uninhibited social and sexual behaviors are classified as behavioral symptoms.

16. A nursing instructor is teaching about the etiology of mood disorders. Which statement by a nursing student best indicates an understanding of the etiology of mood disorders? 1. "When clients experience loss, they learn that it is inevitable and become hopeless and helpless." 2. "There are alterations in the neurochemicals, such as serotonin, that cause the client's symptoms." 3. "Evidence continues to support multiple causations related to an individual's susceptibility to mood symptoms." 4. "Current research suggests that a genetic component affects the development of mood disorders."

3. When the student states that there is support for multiple causations related to an individual's susceptibility to mood symptoms, the student understands the content presented about the etiology of mood disorders.

54. A client is diagnosed with bipolar disorder. Which medication is the drug of choice for this diagnosis? 1) Risperidone (Risperdal) 2) Clozapine (Clozaril) 3) Lorazepam (Ativan) 4) Lithium carbonate (Eskalith)

4) Lithium carbonate (Eskalith) Lithium carbonate is the classic treatment and drug of choice for maintenance therapy for bipolar disorder. It stabilizes the mood lability that is characteristic of the disorder.

47. The activity therapist is planning an individualized program for a client diagnosed with bipolar I disorder: manic episode who is exhibiting hostility and excessive energy. Which activity would be most appropriate? 1) Writing memoirs 2) Team sports 3) Ping-pong 4) Walking

4) Walking Walking is the best activity choice because it is not considered competitive and provides an opportunity for the release of energy.

6. A client diagnosed with bipolar I disorder has a nursing diagnosis of disturbed thought process R/T biochemical alterations. Based on this diagnosis, which outcome would be appropriate? 1. The client will not experience injury throughout the shift. 2. The client will interact appropriately with others by day 3. 3. The client will be compliant with prescribed medications. 4. The client will distinguish reality from delusions by day 6.

4. Distinguishing reality from delusions by day 6 is an appropriate outcome for the nursing diagnosis of disturbed thought process R/T biochemical alterations. Altered thought processes have improved when the client can distinguish reality from delusions.

19. A nursing instructor is teaching about the criteria for the diagnosis of bipolar II disorder. Which student statement indicates that learning has occurred? 1. "Clients diagnosed with bipolar II disorder experience a full syndrome of mania and have a history of symptoms of depression." 2. "Clients diagnosed with bipolar II disorder experience numerous episodes of hypomania and dysthymia for at least 2 years." 3. "Clients diagnosed with bipolar II disorder have mood disturbances that are directly associated with the physiological effects of a substance." 4."Clients diagnosed with bipolar II disorder experience recurrent bouts of depression with episodic occurrences of hypomania."

4. Recurrent bouts of depression and episodic occurrences of hypomania are diagnostic criteria for bipolar II disorder. Experiencing a full manic episode would indicate a diagnosis of bipolar I disorder and rule out a diagnosis of bipolar II disorder.

20. A client diagnosed with bipolar I disorder is experiencing auditory hallucinations and flight of ideas. Which medication combination would the nurse expect to be prescribed to treat these symptoms? 1. Amitriptyline (Elavil) and divalproex sodium (Depakote). 2. Verapamil (Calan) and topiramate (Topamax). 3. Lithium carbonate (Eskalith) and clonazepam (Klonopin). 4. Risperidone (Risperdal) and lamotrigine (Lamictal).

4. Risperidone (Risperdal), an anti-psychotic, directly addresses the auditory hallucinations experienced by the client. Lamotrigine (Lamictal), a mood stabilizer, would address the classic symptoms of bipolar I disorder.

17. A nursing instructor is teaching about the psychosocial theory related to the development of bipolar disorder. Which student statement indicates that learning has occurred? 1. "The credibility of psychosocial theories in the etiology of bipolar disorder has strengthened in recent years." 2. "Individuals are genetically predisposed to being diagnosed with bipolar disorder if a parent is mentally ill." 3. "Following steroid, antidepressant, or amphetamine use, individuals can experience manic episodes." 4."The etiology of bipolar disorder is unclear, but it is possible that biological and psychosocial factors are influential."

4. The etiology of bipolar disorder is unclear; however, research evidence shows that biological and psychosocial factors are influential in the development of the disorder.

26. The nurse is evaluating lab test results for a client prescribed lithium carbonate (Lithium). The client's lithium level is 1.9 mEq/L. Which nursing intervention takes priority? 1. Give next dose because the lithium level is normal for acute mania. 2. Hold the next dose, and continue the medication as prescribed the following day. 3. Give the next dose after assessing for signs and symptoms of lithium toxicity. 4. Immediately notify the physician, and hold the dose until instructed further.

4. The nurse needs to notify the physician immediately of the serum lithium level, which is outside the therapeutic range, to avoid any risk for further toxicity.

45. Harold is admitted to the psychiatric unit with bipolar I disorder: manic episode in a highly agitated state. His speech is rapid and incoherent, he is pacing and in constant motion, and he is loudly proclaiming that his "lawyers are on the way and every one of you is going to be sued for malpractice." Which of the following nursing interventions are appropriate in this situation? Select all that apply. 1) Provide an environment with low levels of stimulation. 2) Set limits on Harold's threats by instructing him that he is not permitted to sue the staff. 3) Convey a calm attitude and voice when communicating with Harold. 4) Put Harold in seclusion with restraints for the protection of himself and others. 5) Offer activities that will provide safe outlets for Harold's agitation and excessive energy.

Correct 1: Even little amounts of stimulation can increase symptoms and agitation in an acutely manic patient. Providing an environment with low levels of stimulation is a priority to reduce the risk of further escalation. Feedback 2: Although setting limits on unacceptable behavior may be necessary with this client, this example of communication is not limit setting but rather is a defensive response by the nurse and would likely promote increased, not decreased, agitation. Correct 3: Even little amounts of stimulation can increase symptoms and agitation in an acutely manic patient. Conveying a calm attitude and voice contributes to a lower level of stimulation when communicating with this patient. Feedback 4: Seclusion and restraint would not be appropriate at this point. These interventions are appropriate only when all other efforts to help the patient remain in control have failed and there is imminent risk of harm to self and/or others. However, it would be prudent to have plans in place to manage aggressive behavior if it continues to escalate. Correct 5: Offering activities that provide safe outlets for the excessive energy and hyperactivity that occur in manic episodes can be an effective distraction and a tool to reduce agitation.

35. Kelly has come to the mental health clinic for an assessment at the request of her husband. Kelly refuses to talk to the nurse until her personal assistant arrives. She states, "Apparently you don't know that I'm a famous person, and when my fans get here, you'll be glad my personal assistant is here to manage the crowd." The nurse meets with the husband to begin the assessment process. Which of the following observations by the husband are consistent with symptoms of a manic episode? Select all that apply. 1) "She has concocted this story about having a personal assistant and being a famous person; none of it is true." 2) "She has over-extended our credit cards, buying huge quantities of unnecessary items." 3) "Ever since we married, she has had periods where she makes superficial cuts on her wrists and becomes convinced I'm going to divorce her." 4) "I've noticed her behaving in a very provocative manner around other men." 5) "When we go to a party she drinks more alcohol than anyone there and inevitably becomes loud and obnoxious."

Correct 1: Kelly's false belief that she is a famous person is evidence of a delusion of grandeur, which is a symptom of a manic episode. Correct 2: Excessive spending is a common symptom in manic episodes. Feedback 3: Although borderline personality disorder is often comorbid with bipolar disorder, this behavior is more characteristic of the former. Correct 4: In acute manic episodes, one of the symptoms is increased sex drive, which could manifest in provocative and/or high-risk behavior. Feedback 5: Although there is a high incidence of substance use disorder in this population, this behavior is more symptomatic of the substance use than a manic episode.

43. The psychiatrist has asked the nurse to make an assessment of how well Aaron is responding to the lithium he is being prescribed. Which of the following observations by the nurse suggest that Aaron's manic episode is subsiding? Select all that apply. 1) Aaron is able to finish his meals seated at a table. 2) Aaron is sleeping an average of six hours per night. 3) Aaron demonstrates an ability to listen and respond appropriately to questions. 4) Aaron complains of feeling less energetic and creative. 5) Aaron states he doesn't want to keep taking lithium.

Correct 1: One of the symptoms of a manic episode is hyperactivity. Aaron's ability to sit still long enough to finish a meal suggests that he is not excessively hyperactive. Correct 2: A hallmark symptom of a manic episode is lack of sleep, sometimes for days at a time. Aaron's ability to sleep for 6 hours a night is evidence that the manic episode is subsiding. Correct 3: Distractibility is a symptom in manic episodes that interferes with a person's ability to listen and respond appropriately. Aaron's ability to do this suggests the manic episode is subsiding. Correct 4: Lithium's desired effect is to reduce the excessive energy and hyperactivity associated with manic episodes, so Aaron's report of less energy suggests that the medication is having a therapeutic effect. It is not uncommon, though, for patients to be less satisfied with this change because the high energy and creativity that occur in manic episodes is pleasurable. Feedback 5: Although adherence to medication is an issue that needs to be discussed, refusal or lack of desire to take medication is not necessarily symptomatic of illness.

38. Barbara asks to speak to the nurse about her husband, who has been diagnosed with bipolar I disorder. She tells the nurse she is thinking of divorcing her husband because his agitation "comes out of nowhere" and is "impossible to manage." She also admits to being "fed up with his extramarital affairs" and says "I just don't know what to say anymore." The nurse recognizes that family psychoeducational treatment is important in improving adjustment and preventing relapses. Which of the following are components of family psychoeducational treatment that will be beneficial to Barbara on the basis of her expressed concerns? Select all that apply. 1) Problem-solving skills training 2) Communication training 3) Education about the illness 4) Codependency education 5) Divorce training

Correct 1: Teaching Barbara some problem-solving skills addresses her concern that she is having difficulty managing her husband's outbursts. One option for Barbara might be to strategize with her husband how they can problem-solve about what to do when he has difficulty managing his agitation. Correct 2: Teaching Barbara communication skills responds to her concern that "I don't know what to say." One option might be assertive communication skills training so that Barbara develops confidence in her ability to communicate concerns directly to her husband. Correct 3: Teaching Barbara about symptoms of the illness may help her to better understand the dynamics of her husband's engaging in high-risk activities such as extramarital affairs. Feedback 4: Codependency education may be a component in family psychoeducational treatment, but there is no evidence that this is an issue for Barbara. Feedback 5: Divorce training is not typically a component of family psychoeducation and may imply that problem solving is a hopeless venture. There are many avenues that families can access for support and education to facilitate adjustment and reduce or prevent relapses.

49. Donald's wife asks the nurse why her husband has been ordered an anticonvulsant when he's never had a seizure and his real problem is bipolar disorder. Which of these teaching points by the nurse are accurate? Select all that apply. 1) The mechanism of action for anticonvulsants in bipolar disorder is unclear. 2) Anticonvulsants are used to prevent seizures that may be an undesired effect of other medications the patient is taking. 3) Anticonvulsants have demonstrated mood stabilizing effects in patients with bipolar disorder. 4) The FDA does require that antiepileptic medications carry a warning label indicating an increased risk for suicidal thoughts and behavior. 5) Anticonvulsants are prescribed to prevent alcohol withdrawal, which is common in patients with bipolar disorder.

Correct 1: This is a true statement. Although anticonvulsants have demonstrated benefits in mood stabilization, the mechanism of action is unclear. Feedback 2: Anticonvulsants are used in this population for their mood-stabilizing benefits, not to manage side effects of other medications. Correct 3: The mood-stabilizing effect of anticonvulsants is the primary reason for their use in patients with bipolar disorder. Correct 4: Although anticonvulsant medication has positive effects on the mood, it may increase the risk for suicide ideation and attempts, and the FDA does require a warning label to that effect, so this teaching point is accurate. Feedback 5: Although there is a high incidence of substance abuse, including alcohol abuse in this population, the primary use for anticonvulsants in patients with bipolar disorder is for its mood-stabilizing effects.

37. The parents of a teenage son who was recently diagnosed with bipolar disorder ask the nurse to provide them with information about this illness, since they had previously been told their son had ADHD. Which of the following is evidence-based information that can be shared with the family? Select all that apply. 1) ADHD is the most common comorbid condition in children and adolescents with bipolar disorder. 2) Bipolar disorder in children and adolescents is an acute condition that they usually outgrow. 3) There is evidence to support that psychosocial therapy enhances the effectiveness of pharmacological therapy in treatment of bipolar disorder in children and adolescents. 4) Stimulants used in the treatment of ADHD can exacerbate mania in children and adolescents with bipolar disorder. 5) Medication discontinuation can be considered after the patient has been in remission for two months.

Correct 1: This statement is an accurate, evidence-based piece of information. Feedback 2: Evidence supports that bipolar disorder in children and adolescents is a chronic illness with a high risk of relapse. Sensitivity and caution are warranted in deciding if and when this is appropriate information to share with the family, since it can be devastating news to the family that their child has a chronic illness with a high risk for relapse. Correct 3: This is an evidence-based statement and informs the parents of important information for considering treatment options. Correct 4: This is an evidence-based statement and informs the parents of important information for considering treatment options. Feedback 5: This is an inaccurate statement. Some evidence suggests that tapering or discontinuation of medication should be considered only after 12 to 24 consecutive months of remission, and some clients may require long-term or life-long pharmacotherapy.

34. To assist the psychiatrist in determining appropriate medication needs, the nurse has been asked to assess whether a patient is in a hypomanic or an acute manic state. Which of the following symptoms are consistent with hypomania? Select all that apply. 1) Cheerful mood, but underlying irritability surfaces rapidly when needs are not fulfilled 2) Fragmented cognition and perception; often psychotic 3) Delusions of grandeur 4) Easily distracted, which sometimes interferes with completing goal-directed activity 5) Extroverted and sociable

Correct 1: This symptom is consistent with hypomania. In contrast, the individual in an acute manic state presents as euphoric, as if on a continuous "high." Feedback 2: This symptom is more consistent with acute mania. The individual with hypomania more often presents with flighty and rapid flow of ideas but not overt fragmentation. Feedback 3: The individual with hypomania may present with an exalted sense of self, but delusions of grandeur are manifesting of an acute manic episode. Correct 4: This symptom is consistent with hypomania. In contrast, the person in an acute manic episode manifests with inexhaustible energy, poor impulse control, and marked interference with completing tasks. Correct 5: The person in a hypomanic episode typically presents as extroverted and sociable. In contrast, the individual in an acute manic episode typically presents as uninhibited and manipulative. Dress and behavior may appear disorganized and bizarre.

48. Haley is a 35-year-old woman being assessed for complaints of racing thoughts, impulsive agitation, and distractibility. She denies having ever been diagnosed with a mental disorder. Which of the following items are important for the nurse to include in Haley's initial assessment to assist in identifying the correct diagnosis? Select all that apply. 1) Family history of thyroid disorders 2) Family history of depression or bipolar disorders 3) Medications and other substances currently being taken 4) Birth order 5) Interest in attending group therapy

Correct 1: Thyroid disorders, particularly hyperthyroidism, could manifest as the symptoms Haley is describing, and since these disorders show a familial tendency it is beneficial to assess for family history of these disorders. Correct 2: The symptoms Haley is experiencing could be evidence of a bipolar disorder. Bipolar disorders and depression show familial tendencies, so it is beneficial to assess for history of these. Correct 3: Several medications and other substances can produce the symptoms Haley is describing, so a thorough history of substance and medication use is essential. Feedback 4: Haley's birth order in the family is irrelevant in identifying the correct diagnosis. Feedback 5: Identifying interest in treatment options should follow thorough assessment and diagnosis. Exploring Haley's interest in group therapy at the initial assessment will not contribute to identifying the correct diagnosis.

32. Elizabeth has been taking lithium for 4 weeks and complains that she thinks she might have lithium toxicity. Which of these findings by the nurse are consistent with lithium toxicity? Select all that apply. 1) Elizabeth has had very little urine output in the last 24 hours. 2) Elizabeth has had several bouts of diarrhea in the last 24 hours. 3) Elizabeth's lithium level is 1.2 mEq/L. 4) Elizabeth's temperature is 99.6°F. 5) Elizabeth complains of less energy since she started taking lithium.

Feedback 1: Excessive output of dilute urine, not inadequate output, is evidence of lithium toxicity. Correct 2: Severe diarrhea can be a symptom of lithium toxicity, but when assessed in combination with her temperature and the lithium level, it does not appear that lithium toxicity is the cause of the diarrhea. Feedback 3: This level is within the therapeutic range, and toxicity symptoms don't begin to appear until the lithium level exceeds 1.5 mEq/L. Feedback 4: The elevated temperature is not a symptom of lithium toxicity and suggests there may be an infection or other issue that is contributing to the patient's complaint of diarrhea. Feedback 5: People often report feeling less energy when they are on lithium because it is in contrast to the high energy associated with manic episodes. Symptoms of lithium toxicity include drowsiness, mental confusion, impaired consciousness, or coma. There is no evidence of those CNS symptoms in this scenario.

42. A patient being treated with lamotrigine (Lamictal) develops a purplish skin rash that is blistering. This is a rare but potentially life-threatening reaction to the medication known as___________ syndrome.

Stevens-Johnson Although Stevens-Johnson syndrome is rare, it is a life-threatening condition that has been associated with Lamictal (as well as some other medications). It is one reason that nurses should educate patients taking the drug to immediately report skin rash to their prescribing physician.

30. A client thought to be cheeking medications is prescribed Lithium syrup 900 mg bid. The syrup contains 300 mg of lithium per 5 mL. At 0800, how many milliliters would the nurse administer? _____ mL.

The nurse would administer 15 mL.

7. The nurse is reviewing expected outcomes for a client diagnosed with bipolar I disorder. Number the outcomes presented in the order in which the nurse would address them. 1. _____ The client exhibits no evidence of physical injury. 2. _____ The client eats 70% of all finger foods offered. 3. _____ The client is able to access available out-patient resources. 4. _____ The client accepts responsibility for own behaviors.

The outcomes should be numbered as follows: 1, 2, 4, 3.

31. A patient arrives in the emergency department with impaired consciousness, nystagmus, and seizures. It is determined that he is suffering from lithium toxicity. With these symptoms, his lithium level would be expected to be above___________mEq/L.

These symptoms are manifestations of severe lithium toxicity and could include coma and cardiovascular collapse. They occur when the lithium level exceeds 3.5 mEq/L.