Ch 26: Bipolar Disorders: Management of Mood Lability
b) During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse Pg. 454-455 To help link the importance of taking medication with relapse prevention, the nurse lists target symptoms and identifies signs of imminent relapse. The nurse engages in problem solving with the client about early management of symptoms so severity does not increase.
1. A 35-year-old client with bipolar disorder has a history of discontinuing medication when feeling well and then becoming manic again. During the client's last episode of mania, the client lost several thousand dollars in risky investments. Which intervention will be most helpful in achieving medication adherence? a) Remind the client that the client owes it to the client's spouse and children to stay well b) During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse c) Ensure that a family member takes responsibility for administering medications d) Point out that each time the client stops taking medication, the client becomes manic again
d) Monitoring blood levels of the medication Pg. 448 Lithium is the drug of choice for clients with bipolar illness and has a high antimanic effectiveness. Lithium decreases the intensity, frequency, and duration of manic and depressive episodes. Blood levels need to be monitored for therapeutic levels during the acute phase (1.0-1.5 mEq/L) and during longer term maintenance. Other treatments that could be expected for clients during mania include sedatives or antipsychotics. Electroconvulsive therapy, phototherapy, and monoamine oxidase inhibitors are not typically indicated during manic phases.
10. A client in an acute manic phase is pacing the halls and talking in a loud voice with pressured speech. The client is overly involved with coclients and frequently threatens and disrupts others on the unit. After administering lithium treatment for the client, the nurse can expect the plan of care to include which additional intervention? a) Teaching the client to avoid foods with tyramine b) Assessing for post-electroconvulsive therapy disorientation and confusion c) Monitoring phototherapy response d) Monitoring blood levels of the medication
d) Bananas Pg. 446 For a client who is unable to sit long enough to eat, snacks and high-energy foods that can be eaten while moving should be provided.
11. Which is a food that might be incorporated into the plan of care for a client diagnosed in the manic phase of bipolar disorder? a) Spaghetti b) Steak c) Broccoli d) Bananas
c) A client stays awake for several days and nights before "crashing" and sleeping for a long period Pg. 438-439 During a manic episode, an individual will typically go several nights without sleep before collapsing from exhaustion.
12. Which sleep pattern is suggestive of a manic episode? a) A client takes multiple short naps at varied times throughout the day and night b) A client reports having fitful sleep that is characterized by frequent awakenings and nightmares c) A client stays awake for several days and nights before "crashing" and sleeping for a long period d) A client experiences day-night reversal, sleeping until late in the afternoon and going to bed near dawn
c) The higher the sodium level, the lower the lithium level will be Pg. 448 Lithium is a salt, so the interaction between lithium and sodium levels in the body and between lithium level and fluid volume in the body are crucial issues to consider. The higher the sodium levels, the lower the lithium level will be and vice versa. The other options do not represent correct information.
13. A client who has just been prescribed lithium for bipolar disorder is being given education from the nurse about this medication. Which is important for the nurse to include in teaching? a) The higher the potassium level, the lower the lithium level will be b) Lithium has few interactions with other drugs c) The higher the sodium level, the lower the lithium level will be d) Changes in diet will not affect lithium levels
d) Expansive and grandiose Pg. 436 The client is demonstrating an expansive and grandiose mood state. Although the client also exhibits aspects of belligerence, the client does not have a blunted affect. The client is not demonstrating anxious or unpredictable behavior, suspicion, or paranoia.
14. On admission to the psychiatric unit, a client is dressed in a red leotard and exercise bra, with an assortment of chains and brightly colored scarves on the client's head, waist, wrists, and ankles. The client's first words to the nurse are, "I'll punch you, munch you, crunch you," as the client dances into the room, shadow boxing. The client shakes the nurse's hand and says cheerfully, "We need to become better acquainted. I have the world's greatest intellect, and you are probably an intellectual midget." How can the nurse document the client's mood? a) Suspicious and paranoid b) Anxious and unpredictable c) Belligerent and blunted d) Expansive and grandiose
a) Decrease the client's environmental stimuli Pg. 446 When the client is agitated, decreasing stimuli is the priority because it is likely to reduce the client's agitation. Giving an agitated client feedback about his or her behavior may provoke confrontation. Similarly, making reference to rules and policies may make the client reactive or defensive, exacerbating the situation. Introducing the client to other staff does nothing to address the client's agitation.
15. A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first? a) Decrease the client's environmental stimuli b) Give the client feedback about the client's behavior c) Introduce the client to other staff on the unit d) Tell the client about hospital rules and policies
d) 1.0 mEq/L Pg. 448 Serum plasma lithium levels should range from 0.6 to 1.2 mEq/L. Levels above that suggest toxicity (moderate toxicity for levels 1.5 to 2.5 mEq/L; severe toxicity for levels greater than 2.5 mEq/L).
16. A client with bipolar disorder is receiving lithium therapy. The nurse is reviewing the client's serum plasma drug levels and determines that the client's level is therapeutic based on what? a) 1.6 mEq/L b) 2.6 mEq/L c) 2.0 mEq/L d) 1.0 mEq/L
b) Appropriate; the spouse needs support in setting boundaries Pg. 455 It is therapeutic and appropriate for the nurse to work with families to help the clients manage their behavior. Nurses are not prohibited from giving advice. The wife is not legally or morally responsible for her husband's action simply because he has a mental illness. The husband has the legal right to spend money, but this does not mean that the nurse is not permitted to provide interventions to address problematic behavior.
17. The spouse of a client with bipolar disorder calls the nurse expressing distress about recent spending patterns of the client. The nurse suggests the spouse implement the limit-setting skills the spouse has learned in family therapy. In this instance, the nurse's action would be considered... a) Appropriate; the spouse is responsible for the client's actions since the client has a mental illness b) Appropriate; the spouse needs support in setting boundaries c) Inappropriate; the nurse should not give advice to the spouse d) Inappropriate; the client has the legal right to spend personal money
b) Increased plasma concentration Pg. 448 Hepatic and renal impairments increase plasma concentration of lithium.
18. A client who has liver damage is receiving lithium for treatment of bipolar disorder. The nurse understands that which of the following may occur when the client is receiving lithium? a) Decreased plasma concentration b) Increased plasma concentration c) No alteration in plasma levels d) Monitoring of plasma levels is not needed
d) Anticonvulsants Pg. 448-450 Several anticonvulsants traditionally used to treat seizure disorders have proved helpful in stabilizing the moods of people with bipolar illness.
19. A client has been diagnosed with bipolar disorder. After teaching the client about the different medication classifications used to help stabilize mood, the nurse determines that the teaching was successful when the client identifies which class of medications? a) Anticoagulants b) Antianxiety c) Antibiotics d) Anticonvulsants
a) Ibuprofen Pg. 449 NSAIDs such as ibuprofen can lead to increased serum lithium levels. Salt pills and high energy sports drinks (high in caffeine) and acetazolamide can lead to decreased serum lithium levels.
2. A nurse is reviewing the medication profile of a client who recently began lithium therapy for bipolar disorder. Which prescription or over-the-counter (OTC) medication/substance should alert the nurse for an increased likelihood of toxicity? a) Ibuprofen b) Acetazolamide c) High energy sports drink d) Salt pills
c) Anticonvulsants Pg. 448-450 Several anticonvulsants traditionally used to treat seizure disorders have proved helpful in stabilizing the moods of people with bipolar illness.
20. A nurse is reviewing information about medications used to treat bipolar disorders. The nurse demonstrates understanding by identifying which medication classification as effective in stabilizing moods in people with bipolar disorder? a) Antibiotics b) Antianxiety c) Anticonvulsants d) Anticoagulants
d) Euphoria Pg. 436-437 An elevated mood can be expressed as euphoria, which is exaggerated feelings of well-being or elation. Examples include feeling high, ecstatic, and on top of the world. An expansive mood is characterized by lack of restraint in expressive feelings. Paranoia is rooted in suspicions about others, or delusions of persecution. For some, an irritable mood is feeling easily annoyed and provoked to anger, especially when their wishes are challenged or thwarted.
21. A nursing student learning about mood disorders correctly identifies which of the following to mean exaggerated feelings of well-being? a) Expansiveness b) Irritability c) Paranoia d) Euphoria
b) Bipolar II c) Cyclothymic d) Bipolar I Pg. 456-457 Bipolar disorder is characterized by mania or hypomania alternating with depression. The bipolar disorder group of disorders includes bipolar I (periods of major depressive, manic, or mixed episodes), bipolar II (periods of major depression and hypomania), and cyclothymic disorder (periods of hypomanic episodes and depressive episodes that do not meet the full criteria for a major depressive episode). While there are episodes that include a mix of depressive and manic behaviors, they are considered in the bipolar 1 category; there is no stand alone category identified as either Bipolar III or Bipolar mixed.
22. A nursing instructor is teaching about mood disorders and informs the class that bipolar disorder is divided into types/groups related to demonstrated characteristics. What are these groups/types? Select all that apply. a) Bipolar III b) Bipolar II c) Cyclothymic d) Bipolar I e) Bipolar mixed
d) "Are you planning to commit suicide?" Pg. 455 The nurse never ignores any hint of suicidal ideation regardless of how trivial or subtle it seems and the client's intent or emotional status. Asking clients directly about thoughts of suicide is important. Asking about the family's worries or their love for the client does not directly address the client's risk for suicide. Asking, "Where are you going?" is less direct and less effective than asking explicitly about suicide.
23. A client who is depressed states, "I think my family would be better off without me. They don't need to worry." Which would be the most appropriate response by the nurse? a) "What do you think they are worried about?" b) "You don't mean that. Your family loves you" c) "Where are you going?" d) "Are you planning to commit suicide?"
a) Liver function Pg. 448-450 Baseline liver function tests and a complete blood count with platelets should be obtained before starting therapy, and clients with known liver disease should not be given divalproex sodium. There is a boxed warning for hepatotoxicity. Thyroid level, WBC count, and cardiac enzymes do not have to be performed routinely before starting this medication.
24. A nurse is caring for a client diagnosed with bipolar disorder who has been prescribed divalproex. The nurse knows that the client should have which test completed before initiation of drug therapy? a) Liver function b) Cardiac enzymes c) Thyroid level d) White blood cell (WBC) count
b) Minimal mood swings Pg. 446 Mood-stabilizing drugs are used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Weight gain is a common side effect, and fatigue and lethargy may indicate mild toxicity. Inflated self-worth is a target symptom of bipolar disorder, which should diminish with effective treatment.
25. A client with bipolar disorder takes lithium 300 mg 3 times daily. The nurse is educating the client on its use, side effects, and need for compliance. The nurse evaluates that the dose is appropriate when the client reports what? a) Weight gain of 7 pounds in the last 6 months b) Minimal mood swings c) Feeling sleepy and less energetic d) Increased feelings of self-worth
d) Ham sandwich, cheese slices, milk Pg. 446 Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible. Sandwiches and cheese are finger foods and are calorie-dense. Chips and cola are not nutritious, even though they are high in calories. Fried chicken, potatoes and spaghetti cannot be eaten while the client is moving.
26. Which meal would the nurse provide to best meet the nutritional needs of a client who is manic? a) Peanut butter sandwich, chips, cola b) Spaghetti, garlic bread, salad, tea c) Fried chicken, mashed potatoes, milk d) Ham sandwich, cheese slices, milk
d) Approximately 2 weeks after starting antidepressant medication Pg. 456 Observe the client closely for suicide potential, especially after antidepressant medication begins to raise the client's mood. Risk for suicide increases as the client's energy level is increased by medication. The other choices are not significantly associated with increased risk for suicide.
27. A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm? a) During the first few days after admission b) Immediately after a family visit c) On the anniversary of significant life events in the client's life d) Approximately 2 weeks after starting antidepressant medication
c) "Let's go to the conference room and talk for a while" Pg. 446 Redirecting the client to a quieter, smaller room will decrease external stimuli and promote calmness so the client will eventually rest and sleep. It is more effective and therapeutic for the nurse to suggest an alternative rather than adopting a reprimanding or confrontational tone. Making a new suggestion is likely more effective than asking a client who is manic to simply stop what he or she is doing. Stating "turn down the radio" is more likely to provoke a confrontation than suggesting that they go to a different room. The client is manic, so is unlikely to respond to a reason-based argument about the need for rest.
28. During report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. Which would be the most appropriate statement by the nurse? a) "Turn the radio down so we can hear ourselves talk" b) "Do you think you could sit still for a few minutes so we can talk?" c) "Let's go to the conference room and talk for a while" d) "How are you ever going to get any rest if you keep that music on?"
c) Pour the soda into a plastic cup Pg. 455 For clients who are suicidal, staff members remove any item they can use to commit suicide, such as sharp objects, shoelaces, belts, lighters, matches, pencils, pens, and even clothing with drawstrings. The client could tear open the soda can and commit self-harm with the sharp metal edges. The soda itself is not a threat so there is no need to withhold the beverage from the client.
29. A visitor comes to see a client who is suicidal. Upon entering the unit, the nurse notices that the visitor has brought the client a can of the client's favorite soda. Which action should the nurse take at his time? a) Confiscate the soda can as a restricted item b) Ask the visitor to place the soda can at the nurse's desk until he or she leaves c) Pour the soda into a plastic cup d) Ask the visitor not to bring outside items on the unit in the future
b) Moderate lithium toxicity Pg. 446 Side effects associated with moderate lithium toxicity include severe diarrhea, dry mouth, nausea and vomiting, mild to moderate ataxia, lack of coordination, dizziness, slurred speech, tinnitus, blurred vision, increasing tremors, muscle rigidity, asymmetric deep tendon reflexes, and increased muscle tone.
3. A client who has been taking lithium for bipolar disorder is admitted to the hospital with the following symptoms: dry mouth, nausea and vomiting, blurred vision, dizziness, and muscle twitching. What should the nurse suspect? a) Interaction of lithium with another medication b) Moderate lithium toxicity c) Need for an increased dose of medication d) Common side effects of the drug
a) Divalproex b) Lithium carbonate c) Carbamazepine d) Lamotrigine Pg. 446-448 The mainstays of pharmacotherapy for bipolar disorder are mood-stabilizing drugs, including lithium, divalproex, carbamazepine, and lamotrigine. Antidepressants, such as fluoxetine, are not recommended in those with bipolar depression because of a risk of switching to mania.
30. A nurse is developing a plan of care for a client with bipolar disorder. When preparing to administer medications, which agent would the nurse anticipate as being prescribed as the mainstay of pharmacotherapy? Select all that apply. a) Divalproex b) Lithium carbonate c) Carbamazepine d) Lamotrigine e) Fluoxetine
b) Client is avoiding eye contact and visibly shaking Pg. 455-456 Clients with bipolar disorder need to be evaluated according to the continuum of care. Not all recurrent episodes of mania/depression will require emergency care or inpatient care. The client who is avoiding eye contact and visibly shaking should be referred to the emergency room for appropriate assessment to maintain safety and hydration. The other presented client information does not require emergent care and can be handled by going through established community resources.
31. The client's spouse calls the health clinic stating that the client is having a manic episode. What information should alert the nurse to recommend that the client should go to the emergency room for treatment? a) Client has stayed up most of the night watching television b) Client is avoiding eye contact and visibly shaking c) Client has experienced work-related stress d) Client is pacing around the bedroom
a) Patients who take ACE inhibitors Pg. 449 Lithium interacts with several different medications and foods. Clients who take ACE inhibitors should not take lithium, because the combination can increase the serum lithium level, leading to toxicity and impaired kidney function.
32. A nurse who works primarily with clients who have bipolar disorder identifies which group of clients as not being candidates to take lithium as treatment? a) Patients who take ACE inhibitors b) Patients who take bronchodilators c) Patients who drink decaffeinated coffee d) Patients with diabetes who take oral antidiabetic agents
a) Nausea, diarrhea, and confusion Pg. 448 Serum lithium levels of less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic. The client would show signs of toxicity with a lithium level of 2.0 mEq/L. Toxic effects of lithium are severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination.
33. A client with bipolar disorder has been taking lithium, and today the client's serum lithium level is 2.0 mEq/L. What effects would the nurse expect to see? a) Nausea, diarrhea, and confusion b) Constipation and postural hypotension c) None; the serum level is in therapeutic range d) Fever, muscle rigidity, and disorientation
b) Move to a chair a little further away and say, "We can just sit together quietly" Pg. Moving away gives the client more personal space; staying with the client indicates acceptance and genuine interest. It is not necessary for the nurse to talk to the client the entire time; rather, silence can convey that clients are worthwhile even if they are not interacting. Pressuring or pushing the client to speak has the potential to cause the client to withdraw even more. The nurse may eventually need to leave the client alone, but should first attempt to establish therapeutic rapport through silent presence.
34. The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, "I saw you sitting alone and thought I might keep you company." The client turns away from the nurse. Which would be the most therapeutic nursing intervention? a) Move to another chair closer to the client and say, "The staff is here to help you" b) Move to a chair a little further away and say, "We can just sit together quietly" c) Remain in place and say, "How are you feeling today?" d) Say, "I'll visit with you a little later," and leave the client alone for a while
d) Substance use Pg. 444 The effects of illicit substance use can mimic the symptoms of mania. The use of substances must be ruled out through the use of blood and urine diagnostics. Once determined that the signs and symptoms are not the result of substances, the client can be further investigated for mania.
35. To confirm that a client is experiencing a manic episode, the nurse must eliminate the possibility that the client's symptoms are related to which problem? a) Overexcitment b) Inflated self-esteem or grandiosity c) Insomnia d) Substance use
a) The mania symptoms of bipolar II disorder have little effect on functioning Pg. 456-457 With bipolar I, at least one manic episode or mixed episode and a depressive episode have to occur. Bipolar II is not as easily recognized as bipolar I because the symptoms are less dramatic. Hypomania, a mild form of mania, is characteristic of bipolar II. A hypomanic episode is less intense, and there is little impairment in social or occupational functioning. The risk for suicide is present with both disorders.
36. When teaching a group of new mental health nurses about the major difference between bipolar I and bipolar II disorders, which would be most appropriate for the nurse to include? a) The mania symptoms of bipolar II disorder have little effect on functioning b) Both disorders are the same, except the risk for suicide is greater with bipolar I disorder c) Unlike bipolar II, bipolar I disorder involves no symptoms of mania, but only depression d) Bipolar II is more often recognized than bipolar I
b) Accompany the client to his or her room to get dressed Pg. Redirecting the client to appropriate behavior without confrontation is most effective. Seclusion is not an appropriate intervention for this situation. Ignoring the behavior is not indicated. The client is in the manic phase; telling him or her to stop the behavior may make the behaviors escalate.
37. A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time? a) Tell the client that the behaviors have to stop right now b) Accompany the client to his or her room to get dressed c) Tell other clients to ignore the behavior because it is harmless d) Put the client in seclusion for his or her own protection
a) "I need to cut back on my salt intake when it's really hot outside" Pg. 453 Clients should increase their intake of salt during periods of perspiration (e.g., when it is hot outside) and periods of increased exercise and dehydration. Severe diarrhea and slurred speech suggest moderate toxicity, which needs to be evaluated. Alcohol interacts with lithium, causing increased serum concentrations of the drug, placing the client at risk for toxicity. Sugarless candies and throat lozenges can help to combat metallic taste.
38. After educating a client with bipolar disorder on his prescribed lithium therapy, the nurse determines that additional education is needed when the client states which of the following? a) "I need to cut back on my salt intake when it's really hot outside" b) "I need to avoid drinking any alcohol" c) "I need to report any problems with severe diarrhea or slurred speech" d) "I can use sugarless candies to help with any metallic taste"
b) An elevated mood that lasts for at least 1 week Pg. 436-437 During manic episodes that characterize bipolar disorder, the individual exhibits an abnormal, persistently elevated, or irritable mood that lasts for at least 1 week. Failure to respond to treatment, the presence of signs of depression without anhedonia, and the client's admission of a mood disorder are neither diagnostic nor typical of bipolar disorder.
39. The nurse is seeing a 26-year-old client and the client's family. The client's family describes the client as being "very, very different." The family describes a history of periods of unpredictable behavior and disregard for consequences occurring a few times each year. The client has recently been diagnosed with bipolar I disorder, a condition that is characterized by what? a) The client's admission of a mood disorder b) An elevated mood that lasts for at least 1 week c) The presence of objective signs of depression without the presence of anhedonia d) Failure to respond to conventional pharmacological treatments for mood disorders
d) Poor judgment and hyperactivity Pg. 443-444 Symptoms of poor judgment (e.g., directing traffic, making obscene gestures at cars) and hyperactivity (e.g., not sleeping or eating) are assessment findings in this scenario that relate to mania. Increased muscle tension and anxiety are symptoms of anxiety disorders, and vegetative signs and poor grooming are notable in major depressive episodes. Although disinhibition and elevated mood can be assessed in the manic phase of bipolar disorder, these symptoms are not described in this scenario.
4. Police officers bring a client to the mental health unit for admission. The client had been directing traffic on a busy city street, shouting rhymes such as "to work, you jerk, for perks" and making obscene gestures at cars that came close to the client. When the client's spouse is contacted at work, the spouse reports that the client stopped taking lithium 3 weeks ago and has not slept or eaten for 3 days. With which two features characteristic of the manic phase of bipolar disorder can the nurse identify? a) Disinhibition and elevated mood b) Increased muscle tension and anxiety c) Vegetative signs and poor grooming d) Poor judgment and hyperactivity
c) Neuromuscular disturbances Pg. 451 Symptoms include neuromuscular disturbances, dizziness, stupor, agitation, disorientation, nystagmus, urinary retention, nausea and vomiting, tachycardia, hypotension or hypertension, cardiovascular shock, coma, and respiratory depression. Tinnitus does not occur with lethal doses of these drugs.
40. Both valproate and carbamazepine may be lethal if high doses are ingested. Toxic symptoms appear in 1 to 3 hours and include what? a) Tinnitus b) Urinary frequency c) Neuromuscular disturbances d) Bradycardia
a) Nausea and diarrhea Pg. 448 Nausea and diarrhea are adverse effect of lithium.
41. Which of the following is an adverse effect of lithium? a) Nausea and diarrhea b) Constipation and insomnia c) Ataxia and urinary retention d) Anxiety and motor retardation
c) Lithium toxicity Pg. 446-448 Lisinopril is an ACE inhibitor; hydrochlorothiazide is a thiazide diuretic. Both drugs interact with lithium to increase serum lithium levels. Therefore, the nurse should be especially alert for signs and symptoms of lithium toxicity. Hypokalemia and hyponatremia are possible effects of hydrochlorothiazide when given alone but these wouldn't be as great a concern as the increased risk for lithium toxicity. Hypertensive crisis would be more commonly associated with the use of MAOIs and tyramine foods.
42. A client is prescribed lithium to treat mania. The client also has a history of hypertension for which the client takes lisinopril and hydrocholorothiazide. When monitoring this client, the nurse would be especially alert for signs and symptoms of which condition? a) Hypernatremia b) Hypertensive crisis c) Lithium toxicity d) Hypokalemia
d) Maintain daily sodium intake Pg. 453 Consistent sodium intake is critical with lithium therapy. A serum therapeutic level of 0.8mEq/L is within the therapeutic range of 0.6-1.2 mEq/L. Fluid intake on lithium therapy should be increased to 2 L/day. Switching to a DASH diet is used to treat HTN. Monitoring weight pattern should be included but it is not the current priority.
43. A client taking lithium therapy has a serum therapeutic level of 0.8 mEq/L. What priority dietary instruction should the nurse include in the teaching plan? a) Switch to a DASH diet b) Limit fluid intake to 6-8 oz (180-340 mL) glasses a day c) Monitor weight pattern d) Maintain daily sodium intake
d) Bipolar I Pg. 436-437 Bipolar I disorder is characterized by one or more manic episodes, usually alternating with major depressive episodes.
44. A client is admitted to the unit in an acute manic episode. The client has had three major depressive episodes in the past 10 years and two other hospitalizations for mania. Which disorders would reflect the client's symptom profile? a) Bipolar II b) Cyclothymic disorder c) Euthymic state d) Bipolar I
c) "I will restrict my intake of processed foods high in sodium" Pg. 446-448 Clients taking lithium must maintain a normal sodium intake or risk symptoms of lithium toxicity. The client should have 2 to 3 liters of fluid daily. Taking lithium with food minimizes gastrointestinal side effects. Regular monitoring of lithium levels is important to prevent toxicity.
45. Which statement by a client would indicate the need for additional education regarding a prescribed lithium treatment regimen? a) "I will drink 8 to 12 glasses of liquids daily" b) "I will have my blood drawn on schedule" c) "I will restrict my intake of processed foods high in sodium" d) "I will take my medications with food"
a) Confirm baseline labs have been ordered prior to starting therapy Pg. 450 Prior to the initiation of divalproex sodium therapy, baseline CBC with differential and liver function tests should be taken. Because this medication can lead to hepatotoxicity, it is important to both establish a baseline and continue to monitor on a weekly basis to verify therapeutic levels. Finding out the name of the client's pharmacy may be needed to fill the prescription. Weight gain is an associated side effect of therapy, not weight loss.
46. The nurse is providing client education to an individual who has recently been diagnosed with bipolar disorder and is starting divalproex sodium therapy. What priority information should the nurse include in the plan of care? a) Confirm baseline labs have been ordered prior to starting therapy b) Monitor for weight loss c) Find out the name of the client's pharmacy d) Draw weekly blood levels to monitor serum levels
c) Inpatient admission Pg. 456 Inpatient admission is the treatment setting of choice for clients who are severely psychotic, or who are an immediate threat to themselves or others. Intensive outpatient programs, such as partial hospitalization, and residential apartments would not be immediate options for this client.
47. Which of the following is the treatment setting of choice for persons who are severely psychotic? a) Intensive outpatient programs b) Residential apartments c) Inpatient admission d) Partial hospitalization
c) Ability to concentrate and process the information Pg. 454-455 To best assure successful outcomes related to client education of an individual experiencing a manic episode, the nurse's initial assessment is focused on the client's ability to concentrate and process the information.
48. A nurse is providing psycho-education to a client who has been admitted to the inpatient mental health unit for a manic episode. In order to ensure the teaching is effective, the nurse must first determine which regarding the client? a) Interest in learning about the disorder b) Likelihood to assume responsibility for self-care c) Ability to concentrate and process the information d) Cognitive awareness and intellectual abilities
c) 1.2 mEq/L Pg. Maintenance and treatment levels range from 0.5 to 1.5 mEq/L. There is a narrow safety range among maintenance levels and toxic levels. Less than 1.5 mEq/L is considered safe, with only mild side effects. 1.5 mEq/L to 2.5 mEq/L can cause moderate toxicity. Greater than 2.5 mEq/L can cause severe toxicity.
49. Which lab value is within the range of safety for maintenance or treatment with lithium? a) 1.6 mEq/L b) 2.0 mEq/L c) 1.2 mEq/L d) 2.4 mEq/L
d) Self-esteem Pg. 436 These characteristics reflect issues related to self-esteem, or more specifically low self-esteem. The findings are unrelated to anxiety, coping, or denial.
5. The nurse is reviewing the history of a client diagnosed with bipolar I disorder. The history reveals that the client, in between manic episodes, consistently uses self-negating statements when describing the self, expresses feelings of being ashamed, and describes self as being unable to deal with events. The client also demonstrates little to any eye contact during interactions. The nurse interprets this information as reflecting a problem in which area? a) Denial b) Coping c) Anxiety d) Self-esteem
b) Pressured speech, combative behavior, and impaired judgment Pg. 436 A manic episode would be characterized by pressured speech, potentially combative behavior, and impaired judgment. Neither psychomotor retardation is present nor are recurrent illusions. Self-destructive behavior is not a classic symptom of mania; more often, clients may have accidents caused by their lack of judgment and psychomotor agitation.
50. A client was admitted to the psychiatric unit after being picked up by police officers who found the client frantically running back and forth across the freeway. The client's spouse reports that the client stayed up all night, ate very little, and talked incessantly. Additional assessment findings that indicate a manic episode include what? a) Catatonic excitement, loose associations, and recurrent illusions b) Pressured speech, combative behavior, and impaired judgment c) Self-destructive behavior, overidealization, and devaluation d) Psychomotor retardation, fatigue, and apathy
c) "I can't call the psychiatrist now, but you and I can talk about your request for a pass" Pg. 446 This response states a limit on an unreasonable request while providing the opportunity to discuss the request. Answers A, B, and D are not therapeutic.
6. At 1 a.m., the client with mania rushes to the nurses' station and demands that the psychiatrist come to the unit now to write an order for a pass to go home. Which response by the nurse would be the most therapeutic? a) "Go to the day room and wait while I call your psychiatrist" b) "Don't be unreasonable. I can't call the psychiatrist at this time of night" c) "I can't call the psychiatrist now, but you and I can talk about your request for a pass" d) "You must really be upset to want a pass immediately; I'll give you a PRN medication"
c) Flight of ideas d) Statements of self-importance e) Easily distractible Pg. 436 Mania is one of the primary symptoms of bipolar disorders. It is evidenced by an elevated, expansive, or irritable mood. Elevated self-esteem is expressed as grandiosity (exaggerating personal importance) and may range from unusual self-confidence to grandiose delusions. Speech is pressured (push of speech) the person is more talkative than usual and at times is difficult to interrupt. There is often a flight of ideas (illogical connections between thoughts) or racing thoughts. Distractibility increases.
7. A nurse is assessing a client who is brought to the emergency department. The nurse suspects that the client is experiencing mania. Which finding would support the nurse's suspicion? Select all that apply. a) Slowness of speech b) Sleepiness c) Flight of ideas d) Statements of self-importance e) Easily distractible
d) Hyperactivity, dismissing meals, and sleep disturbance Pg. 436 Safety needs are always the first priority in care planning. A client who has not eaten or slept for several days and has been extremely hyperactive may be at risk for exhaustion and malnutrition and the implications of those states. Although thought disorder, expansive mood, and dress are important assessment information, priority interventions must center on the basic needs of hyperactivity, dismissing meals, and sleep disturbance.
8. Which behavior is the priority concern as the nurse begins a care plan for a client in the manic phase of bipolar disorder? a) Grandiose thinking and poor concentration b) Insulting, provocative behavior directed at staff c) Bizarre, colorful, inappropriate dress d) Hyperactivity, dismissing meals, and sleep disturbance
d) "Do not swing at me again. If you cannot control yourself, we will help you" Pg. 446 Stating, "Do not swing at me again. If you cannot control yourself, we will help you," firmly states behavioral expectations and lets the client know his behavior will be safely controlled if he is unable to do so. Arguing that the nurse does not deserve the attack provokes confrontation rather than communicating clear expectations. Stating "If you do that one more time, you will be put in seclusion immediately" is likely to be perceived as a threat rather than an assertive statement. Similarly, stating "Why do you continue that kind of behavior? You know I won't let you do it" may be perceived as a challenge or threat.
9. The client with mania attempts to hit the nurse. Which is the best response by the nurse? a) "Why do you continue that kind of behavior? You know I won't let you do it" b) "If you do that one more time, you will be put in seclusion immediately" c) "Stop that. I didn't do anything to provoke an attack" d) "Do not swing at me again. If you cannot control yourself, we will help you"
