Chapter 13: Bipolar and Related Disorders

A client 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 client having a manic episode, the priority lies with the client's physiological safety. Hyperactivity and poor judgment put the client at risk for injury.

The nurse receives a laboratory report indicating a client's serum level is 1 mEq/L. The client's last dose of lithium was 8 hours ago. What does this result indicate? 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 0.6 to 1.2 mEq/L.

A health teaching plan for a client taking lithium should include which instructions? a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluid. 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

Four new clients were admitted to the behavioral health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these clients for safety. Which client diagnosis will need the most watchful supervision? 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 client with bipolar I disorder is more unstable than a client diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

A client diagnosed with bipolar disorder will be discharged tomorrow. The client is taking a mood stabilizing medication. What is the priority nursing intervention for the client as well as the client'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 client 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.

A client diagnosed with bipolar disorder who takes lithium carbonate 300 mg three times daily reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with what? a. food. b. an antacid. c. an antiemetic. d. a large glass of juice.

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

While the exact cause of bipolar disorder has not been determined; however, what is consistent for most clients? 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.

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

ANS: A The client 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 client's mood. Suspiciousness is not evident.

Which documentation indicates that the treatment plan for a client 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 client is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

A client diagnosed with bipolar disorder commands other clients, "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 clients 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 client toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the client or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger.

Which suggestions are appropriate for the family of a client 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. Supervise medication administration. e. Monitor the client's sleep patterns.

ANS: A, B, D, E A client with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is over-stimulated by a busy environment. Providing structure helps the client 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. The family should supervise medication administration to prevent deterioration to a full manic episode and because the client is at risk to omit medications.

A client 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 client's statements. No data support the other diagnoses.

A client experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the client 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 for a client 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.

A client diagnosed with bipolar disorder is in the maintenance phase of treatment. The client asks, "Do I have to keep taking this lithium even though my mood is stable now?" What is the nurse's most 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. "Most clients 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 Clients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the client understand this need will promote medication adherence.

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

ANS: B Clients 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 clients with depression. Defensive coping is more relevant for clients with mania. Fluid volume excess is less relevant for clients with mood disorders than is deficient fluid volume.

The spouse of a client 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 clients with bipolar disorders are found among creative writers." b. "A higher rate of relatives with bipolar disorder is found among clients with bipolar disorder." c. "Clients 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 by lifetime prevalence statistics. 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 client experiencing 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. What is an appropriate outcome for this client? a. ask staff for assistance with feeding within 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 mealtime 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 client's extreme hyperactivity. Sitting with others or asking for assistance does not mean the client ate or drank. The other indicator is unrelated to the nursing diagnosis.

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

A client experiencing acute mania is dancing atop a pool table in the recreation room. The client waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." To best assure safety, what is the nurse's first intervention? a. tell the client, "You need to be secluded." b. clear the room of all other clients. c. help the client down from the table. d. assemble a show of force.

ANS: B The client's behavior demonstrates a clear risk of dangerousness to others. Safety is of primary importance. Once other clients are out of the room, a plan for managing this client can be implemented. Threatening the client or assembling a show of force is likely to exacerbate the tension.

A client 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." What is the nurse's appropriate intervention? a. suggesting the client have a friend do the shopping and bring purchases to the unit. b. inviting the client to sit together and look at new fashion magazines. c. telling the client computer use is not allowed until self-control improves. d. asking whether the client has enough money to pay for the purchases.

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

Outcome identification for the treatment plan of a client experiencing grandiose thinking associated with acute mania will focus on what? 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 client will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Clients 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 clients 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 client should be as simple and non-stimulating as possible. Manic clients are highly sensitive to environmental distractions and stimulation.

A client diagnosed with bipolar disorder is prescribed lithium. The client 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?" What advise will they give to the client? a. restrict food and fluids for 24 hours and stay in bed. b. have someone bring the client to the clinic immediately. c. drink a large glass of water with 1 teaspoon of salt added. d. take one dose of an over-the-counter antidiarrheal medication now.

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

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

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

A client 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 client. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all staff and clients to discuss the behavior. d. Explain to the client that the behavior is unacceptable.

ANS: B When staff members are exhausted, the client has succeeded in keeping the environment unsettled and avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration.

A nurse prepares the plan of care for a client experiencing an acute manic episode. Which nursing diagnoses are most likely? (Select all that apply.) a. Imbalanced nutrition: more than body requirements b. Impaired mood regulation 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. The mood evidences euphoria and is labile. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic

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

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

A nurse assesses a client 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 person was online continuously for over 24 hours, posting rhymes on official government websites 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 websites) are characteristic of manic episodes. The distracters do not specifically apply to

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 client'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 Safety and physiological needs have the highest priority. Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the client. The other behaviors are less threatening to the client's life.

Consider these three anticonvulsant medications: divalproex, carbamazepine, and gabapentin. Which medication also belongs to this classification? a. clonazepam b. risperidone c. lamotrigine d. aripiprazole

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.

Which dinner menu is best suited for a client 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 importantly, they are finger foods that the hyperactive client could eat while in motion. The foods in the incorrect options cannot be eaten without utensils.

A client diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. The client threatens to hit another client. 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 client 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 de-escalate the situation. Limits should be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance to the client, threaten the client with seclusion as punishment, and ask a rhetorical question.

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

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

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

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

A client 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 b. clonidine c. risperidone d. carbamazepine

ANS: D Some clients diagnosed 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 clients with rapid cycling and in severely paranoid, angry manic clients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant.

A client 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 client's behavior? a. Educate the client about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the client'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 client may not be swallowing medications.

ANS: D The client continues to exhibit manic symptoms. Nonadherence to the medication regime is a common problem for clients diagnosed with bipolar disorder. The lithium level should be approaching a therapeutic range after 7 days but 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 client does not address the problem.

A client newly diagnosed with bipolar disorder is prescribed lithium. Which information from the client's medical 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 client with heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. None of the other options would present such a challenge.