Varcarolis: Chapter 13 - Bipolar and Related Disorders

Which symptom may be seen in patients with bipolar II disorder (hypomania)?

Hyperactivity and high energy Rationale: The patients with bipolar II disorder (hypomania) are hyperactive and have high energy.

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?

Impaired Social Interaction Rationale: This patient's behavior relates to interactions with others; therefore, impaired social interaction is the most appropriate diagnosis.

A nurse prepares the plan of care for a person having a manic episode. Which nursing diagnoses are most likely to apply?

Sleep deprivation Disturbed thought processes Risk for deficient fluid volume Rationale: 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.

Which statement is true of the relationship between bipolar disorder and suicide?

Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide.

Serum levels of more than 1.8 mEq/L can cause advanced signs of toxicity such as:

gastrointestinal upset, mental confusion, incoordination, and sedation.

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?

"I have a new rash on my chest and abdomen." Rationale: 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.

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." Rationale: 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. The nurse should be sensitive to these concerns, but they are not a priority. Salt is important for patients who take lithium.

Which body system is most at risk for decompensation during the acute phase of a severe manic episode?

- Cardiac Rationale: 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.

Which behaviors describe the symptoms of the manic phase of bipolar disorder?

- Distractibility - Racing thoughts - Excessive energy - Pressured speech - Purposeless movement Rationale: Excessive energy, pressured speech, purposeless movement, racing thoughts, and distractability describe mania. Fatigue and increased sleep, low self-esteem, and withdrawal from environment more aptly describe the opposite of what happens in mania.

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 - Provide simple clothes and hygiene tasks to the patient - Provide repeated reminders to finish tasks if necessary. Rationale: 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.

The plan of care for a patient who takes lithium should include

-Periodic laboratory monitoring of renal and thyroid function Rationale: 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.

Which behavior is important to include for the patient and the family to recognize possible signs of impending mania? 1. Decreased sleep 2. Increased appetite 3. Decreased social interaction 4. Increased attention to body functions

1. Decreased sleep

A person who has numerous hypomanic and dysthymic episodes can be assessed as demonstrating characteristics of 1. Cyclothymia 2. Bipolar I disorder 3. Bipolar II disorder 4. Seasonal affective disorder

1. Cyclothymia

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 1. Grandiosity 2. Limit testing 3. Distractibility 4. Flight of ideas

1. Grandiosity

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? 1. Mania 2. Hypomania 3. Flight of ideas 4. Loose associations

1. Mania

The priority nursing diagnosis for a hyperactive manic patient during the acute phase is 1. Risk for injury 2. Ineffective role performance 3. Risk for other-directed violence 4. Impaired verbal communication

1. Risk for injury

To plan care for a manic patient the nurse must consider that lithium cannot be started until 1. The physical examination and laboratory tests are analyzed 2. The initial doses of antipsychotic medication have brought behavior under control 3. Seclusion has proven ineffective as a means of controlling assaultive behavior 4. Electroconvulsive therapy can be scheduled to coincide with lithium administration

1. The physical examination and laboratory tests are analyzed

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?

1.8 mEq/L Rationale: 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.

Which antianxiety medication should be prescribed to patients with acute mania? 1. Citalopram (Celexa) 2. Propranolol (Inderal) 3. Labetalol (Normodyne) 4. Clonazepam (Klonopin)

4. Clonazepam (Klonopin)

The nurse can expect a patient demonstrating typical manic behavior to be attired in clothing that is 1. Ill-fitted and ragged 2. Colorful and outlandish 3. Dark-colored and modest 4. Compulsively neat and clean

2. Colorful and outlandish

The nurse is assessing a patient receiving chronic lithium therapy. Which assessment finding is an expected side effect of the therapy? 1. Ataxia 2. Goiter 3. Incoordination 4. Blurred vision

2. Goiter

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 1. Sleeping soundly for 12 of the next 24 hours 2. Making no attempts at self-harm within 12 hours of admission 3. Willingly taking prescribed medication as offered by staff within 24 hours of admission 4. Demonstrating psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission

2. Making no attempts at self-harm within 12 hours of admission

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? 1. Such a patient is abused easily by other aggressive patients. 2. Mania can result in irresponsible and physically risky behaviors. 3. The manic phase will be followed by a phase of severe depression. 4. Older adults experience physical conditions that greatly increase the potential for injury.

2. Mania can result in irresponsible and physically risky behaviors.

The plan of care for a patient who takes lithium should include 1. Dietary teaching to restrict daily sodium intake 2. Periodic laboratory monitoring of renal and thyroid function 3. The requirement for laboratory tests to monitor serum potassium level 4. The importance of discontinuing the medication if fine hand tremors occur

2. Periodic laboratory monitoring of renal and thyroid function

The plan of care for a patient who takes lithium should include 1. Dietary teaching to restrict daily sodium intake 2. Periodic laboratory monitoring of renal and thyroid function 3. The requirement for laboratory tests to monitor serum potassium level 4. Tthe importance of discontinuing the medication if fine hand tremors occur

2. Periodic laboratory monitoring of renal and thyroid function

Which statement is true of the relationship between bipolar disorder and suicide? 1. Patients need to be monitored only in the depressed phase because this is when suicides occur. 2. Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide. 3. Patients with bipolar disorder are not considered high risk for suicide. 4. As long as patients with bipolar disorder adhere to their medication regimen, there is little risk for suicide.

2. Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide.

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? 1. Convulsions 2. Severe hypotension 3. Bone marrow suppression 4. Changes in the electroencephalograph

3. Bone marrow suppression

Which symptom related to communication is likely to be present in a patient experiencing mania? 1. Mutism 2. Poverty of ideas 3. Clang associations 4. Psychomotor retardation

3. Clang associations

Which side effects of lithium can be expected at therapeutic levels? 1. Nausea and thirst 2. Ataxia and hypotension 3. Fine hand tremor and polyuria 4. Coarse hand tremor and gastrointestinal upset

3. Fine hand tremor and polyuria

When a patient experiences four or more mood episodes in a 12-month period, the patient is said to be 1. Incongruent 2. Cyclothymic 3. Rapid cycling 4. Dyssynchronous

3. Rapid cycling

Which principle should the nurse use when communicating with a patient experiencing an elated mood and euphoria? 1. Use abstract concepts. 2. Give detailed explanations. 3. Use a calm, firm approach. 4. Encourage frequent self-disclosure.

3. Use a calm, firm approach.

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? 1. "Last night I slept for only 7½ hours." 2. "I have not had a bowel movement in 2 days." 3. "I have a new rash on my chest and abdomen." 4. "I bumped into a table yesterday and got a bruise on my elbow."

4. "I bumped into a table yesterday and got a bruise on my elbow."

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? 1. Continue to monitor the patient's symptoms until the lithium begins to take effect. 2. Discourage the patient from attending groups because of the likelihood of disruptive behavior. 3. Offer the patient opportunities to practice concentration and ways to increase attention span. 4. Consider the need to obtain a lithium level. The patient may not be swallowing the medication.

4. Consider the need to obtain a lithium level. The patient may not be swallowing the medication.

A patient states, "I am possessed by my dead father." What is this kind of thought content called? 1. Hallucination 2. Loose association 3. Tangential speech 4. Grandiose delusion

4. Grandiose delusion

Which symptom may be seen in patients with bipolar II disorder (hypomania)? 1. Hallucinations 2. Disturbed thoughts 3. Impaired social functioning 4. Hyperactivity and high energy

4. Hyperactivity and high energy

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? 1. Decreasing food intake 2. Increasing physical activity 3. Sleeping for 8 to 10 hours a night 4. Maintaining a stable cardiac status

4. Maintaining a stable cardiac status

Which patient situation supports the use of seclusion and restraints? 1. Patient is nonverbal 2. Patient is displaying euphoric mood 3. Patient fears staff is "out to get" him or her 4. Patient is unable to control his or her actions

4. Patient is unable to control his or her actions

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 1. No research exists to suggest genetic transmission 2. Much depends on the socioeconomic class of the individuals 3. Highly creative people tend toward development of the disorder 4. The rate of bipolar disorder is higher in relatives of people with bipolar disorder

4. The rate of bipolar disorder is higher in relatives of people with bipolar disorder

What action should the nurse take on learning that a manic patient's serum lithium level is 1.8 mEq/L? 1. Advise the patient to limit fluids for 12 hours. 2. Continue to administer medication as prescribed. 3. Advise the patient to curtail salt intake for 24 hours. 4. Withhold medication and notify the health care provider.

4. Withhold medication and notify the health care provider.

Which room placement would be best for a patient experiencing a manic episode?

A single room near the nurses' station Rationale: The room placement that provides a non-stimulating environment is best. Nearness to the nurses' station means close supervision can be provided.

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiological safety. Hyperactivity and poor judgment put the patient at risk for injury.

Four new patients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. Which patient will need the most watchful supervision? A patient diagnosed with: a. bipolar I disorder b. bipolar II disorder. c. dysthymic disorder d. cyclothymic disorder

ANS: A Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

ANS: C Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient's family during this phase of treatment? a. Attending psychoeducation sessions b. Decreasing physical activity c. Increasing food and fluids d. Meeting self-care needs

ANS: A During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

The nurse receives a laboratory report indicating a patient's serum level is 1 mEq/L. The patient's last dose of lithium was 8 hours ago. This result is: a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. invalid because of the time lapse since the last dose.

ANS: A Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of flu-id. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

ANS: A Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with: a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

ANS: A Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

The exact cause of bipolar disorder has not been determined; however, for most patients: a. several factors, including genetics, are implicated. b. brain structures were altered by stress early in life. c. excess sensitivity in dopamine receptors may trigger episodes. d. inadequate norepinephrine reuptake disturbs circadian rhythms.

ANS: A The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective? a. "Converses with few interruptions; clothing matches; participates in activities." b. "Irritable, suggestible, distractible; napped for 10 minutes in afternoon." c. "Attention span short; writing copious notes; intrudes in conversations." d. "Heavy makeup; seductive toward staff; pressured speech."

ANS: A The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

A patient diagnosed with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Which initial approach should the nurse select? a. Distraction: "Let's go to the dining room for a snack." b. Humor: "How much are you paying servants these days?" c. Limit setting: "You must stop ordering other patients around." d. Honest feedback: "Your controlling behavior is annoying others."

ANS: A The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feed-back may seem heavy-handed and may incite anger.

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they are my gift to you." How should the nurse document the patient's mood? a. Euphoric b. Irritable c. Suspicious d. Confident

ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient's mood. Suspiciousness is not evident.

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply. a. Limit credit card access. b. Provide a structured environment. c. Encourage group social interaction. d. Suggest limiting work to half-days. e. Monitor the patient's sleep patterns.

ANS: A, B, E A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure would help the patient maintain appropriate behavior. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work will be necessary to limit stimuli and prevent problems associated with poor judgment and inappropriate decision making that accompany hypomania.

A patient tells the nurse, "I'm ashamed of being bipolar. When I'm manic, my behavior embarrasses everyone. Even if I take my medication, there are no guarantees. I'm a burden to my family." These statements support which nursing diagnoses? Select all that apply. a. Powerlessness b. Defensive coping c. Chronic low self-esteem d. Impaired social interaction e. Risk-prone health behavior

ANS: A, C Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiological functioning. b. Provide a subdued environment. c. Supervise personal hygiene. d. Observe for mood changes.

ANS: B All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide? a. "A high proportion of patients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among patients with bi-polar disorder." c. "Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stress." d. "More individuals with bipolar disorder come from high socioeconomic and educational backgrounds."

ANS: B Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission and other factors involved in the etiology of bipolar disorder.

This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select an appropriate outcome. The patient will: a. ask staff for assistance with feeding with-in 4 days. b. drink six servings of a high-calorie, high-protein drink each day. c. consistently sit with others for at least 30 minutes at meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

ANS: B High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen? It will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. be used for long-term control of hyperactivity.

ANS: B Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium will be used for longterm control.

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's appropriate response. a. "You will be able to stop the medication in about 1 month." b. "Taking the medication every day helps reduce the risk of a relapse." c. "Usually patients take medication for approximately 6 months after discharge." d. "It's unusual that the health care provider hasn't already stopped your medication."

ANS: B Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression as well as one experiencing acute mania? a. Deficient diversional activity b. Disturbed sleep pattern c. Fluid volume excess d. Defensive coping

ANS: B Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is deficient fluid volume.

To best assure safety, the nurse's first intervention is to: a. tell the patient, "You need to be secluded." b. clear the room of all other patients. c. help the patient down from the table. d. assemble a show of force.

ANS: B Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

A patient waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and four pairs of shoes." Select the nurse's appropriate intervention. The nurse: a. suggests the patient have a friend do the shopping and bring purchases to the unit. b. invites the patient to sit together and look at new fashion magazines. c. tells the patient computer use is not allowed until self-control improves. d. asks whether the patient has enough money to pay for the purchases.

ANS: B Situations such as this offer an opportunity to use the patient's distractibility to staff's advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on: a. developing an optimistic outlook. b. distorted thought self-control. c. interest in the environment. d. sleep pattern stabilization.

ANS: B The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate? a. An extra-large window with a view of the street b. Neutral walls with pale, simple accessories c. Brightly colored walls and print drapes d. Deep colors for walls and upholstery

ANS: B The environment for a manic patient should be as simple and non-stimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse will advise the patient to: a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the patient to the clinic immediately. c. drink a large glass of water with 1 tea-spoon of salt added. d. take one dose of an over-the-counter anti-diarrheal medication now.

ANS: B The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient's symptoms.

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention? a. Allow the patient to act out feelings. b. Set limits on patient behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

ANS: B This intervention provides support through the nurse's presence and provides structure as necessary while the patient's control is tenuous. Acting out may lead to loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially? a. Confer with the health care provider to consider use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

ANS: B When staff members are at their wits' end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff split-ting and feelings of anger, helplessness, confusion, and frustration.

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

ANS: B, C People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

A person was online continuously for over 24 hours, posting rhymes on official government web-sites and inviting politicians to join social networks. The person has not slept or eaten for 3 days. What features of mania are evident? a. Increased muscle tension and anxiety b. Vegetative signs and poor grooming c. Poor judgment and hyperactivity d. Cognitive deficits and paranoia

ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government web-sites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks" and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making

ANS: C Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient's life.

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by: a. quietly asking the patient, "Why don't you put your clothes on?" b. firmly telling the patient, "Stop dancing and put on your clothing." c. putting a blanket around the patient and walking with the patient to a quiet room. d. letting the patient stay in the group room and moving the other patients to a different area.

ANS: C Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

Consider these three anticonvulsant medications: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which medication also belongs to this classification? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (La-mictal) d. aripiprazole (Abilify)

ANS: C The three drugs in the stem of the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs. See relationship to audience response question.

Which dinner menu is best suited for a patient with acute mania? a. Spaghetti and meatballs, salad, and a banana b. Beef and vegetable stew, a roll, and chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, and an apple d. Chicken casserole, green beans, and flavored gelatin with whipped cream

ANS: C These foods provide adequate nutrition, but more important they are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The patient threatens to hit another patient. Which comment by the nurse is appropriate? a. "Stop that! No one did anything to provoke an attack by you." b. "If you do that one more time, you will be secluded immediately." c. "Do not hit anyone. If you are unable to control yourself, we will help you." d. "You know we will not let you hit anyone. Why do you continue this behavior?"

ANS: C When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to deescalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

The plan of care for a patient in the manic state of bipolar disorder should include which inter-ventions? Select all that apply. a. Touch the patient to provide reassurance. b. Invite the patient to lead a community meeting. c. Provide a structured environment for the patient. d. Ensure that the patient's nutritional needs are met. e. Design activities that require the patient's concentration.

ANS: C, D People with mania are hyperactive, grandiose, and distractible. It's most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behavior. Leading a community meeting would be appropriate when the patient's behavior is less grandiose. Activities that require concentration will produce frustration.

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

ANS: D A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behavior has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviors is impaired by the illness.

A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. risperidone (Risperdal) d. carbamazepine (Tegretol)

ANS: D Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant. See relationship to audience response question.

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient's behavior? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient's speech patterns and motor activity. c. Ask the health care provider to prescribe an increased dose and frequency of lithium. d. Consider the need to check the lithium level. The patient may not be swallowing medications.

ANS: D The patient is continuing to exhibit manic symptoms. The lithium level may be low from "cheeking" (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

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

A newly diagnosed patient is prescribed lithium. Which information from the patient's history indicates that monitoring of serum concentrations of the drug will be challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Heart failure

ANS: D The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

Which is an advanced sign of lithium toxicity?

Blurred vision Rationale: Blurred vision is a sign of advanced lithium toxicity that is seen when the blood plasma level of lithium is 2 - 2.5 mEq/L. Sedation and polyuria are early signs of lithium toxicity that are seen when the blood plasma level of lithium is 1.5-2 mEq/dL. 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, hyper-irritability, and gastrointestinal upset are signs seen in patients when blood levels of lithium are 1.5 to 2.0 mEq/L.

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?

Bone marrow suppression Rationale: Carbamazepine is an anti-convulsive drug. On chronic administration, it can cause bone marrow suppression and liver inflammation because of an increase in liver enzymes

The patient treated with lithium carbonate repeatedly requests water to drink and has slurred speech. What is the priority nursing action in this case?

Check the patient's blood lithium level Rationale: Excessive thirst, slurred speech, and polyuria are early signs of lithium toxicity. The nurse should check the lithium level of the patient frequently. Mannitol can be administered to eliminate the drug in case of severe toxicity.

What must be avoided for patients with bipolar disorder because chocolate contains cocoa, which has caffeine?

Chocolate Rationale: Caffeine causes central nervous system stimulation and can cause anxiety.

Which symptom related to communication is likely to be present in a patient experiencing mania?

Clang associations Rationale: 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

Which food should be incorporated in the diet of patients with bipolar disorder that would also help in mood regulation?

Cod liver oil Rationale: 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.

The nurse can expect a patient demonstrating typical manic behavior to be attired in clothing that is

Colorful and outlandish Rationale: Manic patients often manage to dress and apply makeup in ways that create a colorful, even bizarre, appearance.

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?

Consider the need to obtain a lithium level. The patient may not be swallowing the medication. Rationale: Lithium must reach therapeutic levels in the blood to be effective, which usually takes 7 to 14 days.

A person who has numerous hypomanic and dysthymic episodes can be assessed as demonstrating characteristics of

Cyclothymia

Impaired verbal communication

Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols A diagnosis that applies to pressured speech, clang associations, and flight of ideas.

Which side effects of lithium can be expected at therapeutic levels?

Fine hand tremor and polyuria

Which behavior would be most characteristic of a patient during a manic episode?

Going rapidly from one activity to another Rationale: Hyperactivity and distractability are basic to manic episodes.

The nurse is assessing a patient receiving chronic lithium therapy. Which assessment finding is an expected side effect of the therapy?

Goiter Rationale: 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.

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

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

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?

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. Rationale: 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.

A patient with mania reports inability to sleep. What appropriate action does the nurse take to help the patient sleep better?

Instruct the patient to perform slow exercises Rationale: 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, because caffeine can interfere with sleep. Manic patients are usually overactive, so they must be provided high-calorie and high-protein foods.

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 Rationale: Risk for injury is a diagnosis of high priority for manic patients because of their hyperactivity. Lack of injury is a highly desirable outcome.

The first-line drug used to treat mania is ______________?

Lithium carbonate Rationale: Lithium, a mood stabilizer, is the first-line drug for use in treating bipolar disorder.

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?

Maintaining a stable cardiac status Rationale: 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.

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?

Mania can result in irresponsible and physically risky behaviors.

Which patients can be safely prescribed lithium therapy to treat bipolar disorder?

Patients with erectile dysfunction Rationale: 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.

When a patient experiences four or more mood episodes in a 12-month period, the patient is said to be

Rapid cycling Rationale: Rapid cycling implies four or more mood episodes in a 12-month period, as well as more severe symptomology.

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?

Recommend frequent rest periods during the day.

Which behavior of the nurse is appropriate while caring for a patient experiencing acute mania?

Redirecting the patient's energy into alternate channels Rationale: 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.

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?

Serum creatinine 1.95 mg/dL Rationale: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.

When a hyperactive manic patient expresses the intent to strike another patient, the initial nursing intervention would be to

Set verbal limits

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 reports the patient's behavior in the staff meeting.

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

The rate of bipolar disorder is higher in relatives of people with bipolar disorder Rationale: This understanding will allow the nurse to directly address the question.

Which principle should the nurse use when communicating with a patient experiencing an elated mood and euphoria?

Use a calm, firm approach. Rationale: 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. Distractability reduces the patient's ability to understand abstract concepts or pay attention to detailed explanations.

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 Rationale: 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.

When a patient reports that lithium causes an upset stomach, the nurse suggests taking the medication

With meals Rationalize: Many patients find that taking lithium with or shortly after meals minimizes gastric distress.

2. Which statement made by the patient demonstrates an understanding of the effective use of newly prescribed lithium to manage bipolar mania? Select all that apply. a. "I have to keep reminding myself to consistently drink six 12-ounce glasses of fluid every day." b. "I discussed the diuretic my cardiologist prescribed with my psychiatric care provider." c. "Lithium may help me lose the few extra pounds I tend to carry around." d. "I take my lithium on an empty stomach to help with absorption." e. "I've already made arrangements for my monthly lab work."

a. "I have to keep reminding myself to consistently drink six 12-ounce glasses of fluid every day." b. "I discussed the diuretic my cardiologist prescribed with my psychiatric care provider." e. "I've already made arrangements for my monthly lab work."

1. Which nursing response demonstrates accurate information that should be discussed with the female patient diagnosed with bipolar and her support system? Select all that apply. a. "Remember that alcohol and caffeine can trigger a relapse of your symptoms." b. "Due to the risk of a manic episode, antidepressant therapy is never used with bipolar disorder. c. "It's critical to let your healthcare provider know immediately if you aren't sleeping well." d. "Is your family prepared to be actively involved in helping manage this disorder?" e. "The symptoms tend to come and go and so you need to be able to recognize the early signs."

a. "Remember that alcohol and caffeine can trigger a relapse of your symptoms." c. "It's critical to let your healthcare provider know immediately if you aren't sleeping well." d. "Is your family prepared to be actively involved in helping manage this disorder?" e. "The symptoms tend to come and go and so you need to be able to recognize the early signs."

5. Which intervention should the nurse implement when caring for a patient demonstrating manic behavior? Select all that apply. a. Monitor the patient's vital signs frequently. b. Keep the patient distracted with group-oriented activities. c. Provide the patient with frequent milkshakes and protein drinks. d. Reduce the volume on the television and dim bright lights in the environment. e. Use a firm but calm voice to give specific concise directions to the patient.

a. Monitor the patient's vital signs frequently. c. Provide the patient with frequent milkshakes and protein drinks. d. Reduce the volume on the television and dim bright lights in the environment. e. Use a firm but calm voice to give specific concise directions to the patient.

6. Substance abuse is often present in people diagnosed with bipolar disorder. Laura, a 28-year-old with a diagnosis of bipolar disorder, drinks alcohol instead of taking her prescribed medications. The nurse caring for this patient recognizes that: a. Anxiety may be present. b. Alcohol ingestion is a form of self-medication. c. The patient is lacking a sufficient number of neurotransmitters. d. The patient is using alcohol because she is depressed.

b. Alcohol ingestion is a form of self-medication.

9. Tatiana has been hospitalized for an acute manic episode. On admission the nurse suspects lithium toxicity. What assessment findings would indicate the nurse's suspicion as correct? a. Shortness of breath, gastrointestinal distress, chronic cough b. Ataxia, severe hypotension, large volume of dilute urine c. Gastrointestinal distress, thirst, nystagmus d. Electroencephalographic changes, chest pain, dizziness

b. Ataxia, severe hypotension, large volume of dilute urine

4. A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially? a. Reinforce that the level is considered therapeutic. b. Instruct the patient to hold the next dose of medication and contact the prescriber. c. Have the patient go to the hospital emergency room immediately. d. Alert the patient to the possibility of seizures and appropriate precautions.

b. Instruct the patient to hold the next dose of medication and contact the prescriber.

8. A 33-year-old female diagnosed with bipolar I disorder has been functioning well on lithium for 11 months. At her most recent checkup, the psychiatric nurse practitioner states, "You are ready to enter the maintenance therapy stage, so at this time I am going to adjust your dosage by prescribing": a. A higher dosage b. Once a week dosing c. A lower dosage d. A different drug

c. A lower dosage

7. Ted, a former executive, is now unemployed due to manic episodes at work. He was diagnosed with bipolar I 8 years ago. Ted has a history of IV drug abuse, which resulted in hepatitis C. He is taking his lithium exactly as scheduled, a fact that both Ted's wife and his blood tests confirm. To reduce Ted's mania the psychiatric nurse practitioner recommends: a. Clonazepam (Klonopin) b. Fluoxetine (Prozac) c. Electroconvulsive therapy (ECT) d. Lurasidone (Latuda)

c. Electroconvulsive therapy (ECT)

3. The nurse is providing medication education to a patient who has been prescribed lithium to stabilize mood. Which early signs and symptoms of toxicity should the nurse stress to the patient? Select all that apply. a. Increased attentiveness b. Getting up at night to urinate c. Improved vision d. An upset stomach for no apparent reason e. Shaky hands that make holding a cup difficult

d. An upset stomach for no apparent reason e. Shaky hands that make holding a cup difficult

10. Luc's family comes home one evening to find him extremely agitated and they suspect in a full manic episode. The family calls emergency medical services. While one medic is talking with Luc and his family, the other medic is counting something on his desk. What is the medic most likely counting? a. Hypodermic needles b. Fast food wrappers c. Empty soda cans d. Energy drink containers

d. Energy drink containers

Serum levels of 2.5 and 3.4 mEq/L indicate severe toxicity. What are the symptoms of severe toxicity?

oliguria, convulsions, severe hypotension, and death.