Psych: Bipolar Illness

Which observations, if documented in the medical record, would indicate that the treatment plan for a client with acute mania has been effective? a. "Converses appropriately, clothing matched, participates in activities." b. "Irritable, suggestible, distractible, napped for 10 minutes in afternoon." c. "Attention span short, writing copious notes, intrudes in conversations." d. "Heavily made up, seductive toward male staff, pressured speech."

a. "Converses appropriately, clothing matched, participates in activities." The descriptors given indicate the client is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. Options B, C, and D reflect manic behavior.

Of the dinner menus below, which one is best suited for a bipolar client with acute mania? a. Broiled chicken breast on a roll, an ear of corn, and an apple b. Spaghetti and meatballs, salad, and a banana c. Beef and vegetable stew, a roll, and chocolate pudding d. Goulash, green beans, and flavored gelatin with whipped cream

a. Broiled chicken breast on a roll, an ear of corn, and an apple These foods provide adequate nutrition, but more importantly they are finger foods that the hyperactive client could "eat on the run." The foods listed in the other options cannot be eaten without utensils.

A client with bipolar disorder who had a relapse after discontinuing lithium has orders for chlorpromazine (Thorazine) four times daily and twice-daily lithium. The nurse's planning will be aided if he understands that use of the phenothiazine will a. bring hyperactivity under rapid control. b. enhance the antimanic action of lithium. c. minimize the side effects of lithium. d. be used for long-term control of hyperactivity.

a. bring hyperactivity under rapid control. 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. Options B and C: Phenothiazines neither enhance lithium's antimanic activity nor minimize the side effects. Option D: Lithium will be used for long-term control.

A health teaching plan for a client taking lithium should include instructions to 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.

a. maintain normal salt and fluids in the diet. Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

Lithium citrate 600 mg 3 times daily po is ordered for a client with acute mania who is being treated as an outpatient. The client calls the mental health nurse, stating he is nauseated. To lessen the nausea, the nurse can suggest that the lithium can be taken with a. meals. b. an antacid. c. an antiemetic. d. a large glass of juice.

a. meals. Some clients find taking lithium with meals diminishes nausea. The other options are less helpful.

The nurse in the medication clinic receives the following lithium level for a client: 1.0 mEq/L. The nurse should assess this as a. within therapeutic limits. b. below therapeutic limits. c. above therapeutic limits. d. completely incorrect because of inaccurate testing.

a. within therapeutic limits. Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1.0 mEq/L.

A client with bipolar disorder who became hyperactive after discontinuing lithium has not eaten or slept for 3 days. Which of the following nursing diagnoses would be of priority importance? a. Ineffective coping b. Risk for injury c. Caregiver role strain d. Impaired social interaction

b. Risk for injury 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 high risk for injury.

A manic client has been diagnosed as a "rapid cycler." The psychiatrist decides to prescribe an anticonvulsant medication that has been found to have mood-stabilizing properties. To prepare health teaching materials, the drug the nurse should anticipate being prescribed is a. sulindac (Clinoril). b. carbamazepine (Tegretol). c. clonidine (Catapres). d. chlorpromazine (Thorazine).

b. carbamazepine (Tegretol). Some clients 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.

A client with bipolar disorder is commanding another client to "Get me that book; take this other stuff out of here," and so forth. The nurse wants to interrupt this behavior without entering into a power struggle with the client. The best approach would be to use a. humor: "How much are you paying servants these days?" b. distraction: "Let's go to the dining room for a snack." c. limit setting: "You must stop ordering other clients around." d. honest feedback: "Your behavior is annoying other clients."

b. distraction: "Let's go to the dining room for a snack." 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 to a labile client and may incite anger.

During periods of laughter, talkativeness, and banter, a client with manic behavior is noted to abruptly become irritable. Such changes in mood should be assessed as a. dissociation. b. lability. c. undoing. d. flight of ideas.

b. lability. The mood of the manic client is often unstable. Rapid mood shifts are called mood lability. Options A and C: Dissociation and undoing are ego defense mechanisms. Option D: Flight of ideas is a speech pattern in which speech is delivered rapidly and with abrupt changes of topic.

A client with bipolar disorder who became hyperactive after discontinuing lithium has not eaten or slept for 3 days. Mood and behavior are labile, changing rapidly from playful to aggressive. If the client threatens to hit another client or a staff member, which response would constitute an appropriate intervention? a. "Stop that! No one did anything to provoke an attack by you." b. "If you try that one more time, you will be placed in seclusion immediately." c. "Do not hit me/him/her. 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 such self-defeating behavior?"

c. "Do not hit me/him/her. If you are unable to control yourself, we will help you." 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 deescalate the situation. Limits should be set in simple, concrete terms. Option A does not offer appropriate assistance to the client. Option B threatens the client with seclusion as punishment. Option D asks a rhetorical question.

The client receiving lithium should be assessed for a. alopecia, purpura, and drowsiness. b. pharyngitis, mydriasis, and dystonia. c. diaphoresis, weakness, and nausea. d. ascites, dyspnea, and edema.

c. diaphoresis, weakness, and nausea. The symptoms listed in option C are early signs of lithium toxicity. All other problems mentioned are unrelated to lithium therapy.

A client displaying acute mania has driven staff to the end of their tolerance by noon. The client has joked, manipulated, insulted, and fought his way through the morning. Staff are feeling defensive and exhausted. The best action to take is to a. call the physician to come to the unit to evaluate the client and write a seclusion order. b. seclude the client, then call the physician to come to the unit to write a seclusion order. c. hold a staff meeting to discuss staff consistency and limit-setting approaches. d. explain to the client that his behavior is unacceptable and seek his cooperation.

c. hold a staff meeting to discuss staff consistency and limit-setting approaches. When staff members are at their wits' end, 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.

Three policemen bring a client to the mental health unit for admission. She had been directing traffic on a busy city street and shouting rhymes such as "to work, you jerk, for perks" and making obscene gestures at cars that came too close to her. When her husband was contacted at work, he reported that his wife had stopped taking her lithium 3 weeks ago and had not slept or eaten for 3 days, telling her husband she was "too busy." When making an assessment, the two features characteristic of the disorder the nurse can identify are a. increased muscle tension and anxiety. b. cognitive deficit and low mood. c. poor judgment and hyperactivity. d. vegetative signs and poor grooming.

c. poor judgment and hyperactivity. Hyperactivity (directing traffic) and poor judgment (putting herself in a dangerous position) are characteristic of manic episodes. None of the other characteristics is specifically alluded to in this scenario.

A client, brought to the mental health unit by police, had been directing traffic and shouting rhymes on a busy city street. Her husband reported that she had stopped taking her lithium 3 weeks ago and had not slept or eaten for 3 days. She was dressed in a red leotard, an exercise bra, and an assortment of chains and brightly colored scarves on her head, waist, wrists, and ankles. Her first words to the nurse were "I'll punch you, munch you, crunch you," as she danced into the room, shadow boxing. Then she shook the nurse's hand and said gaily, "We need to become better acquainted. I have the world's greatest intellect and you are probably an intellectual midget." The nurse should assess the client's mood as a. irritable and belligerent b. excessively happy and confident c. unstable and unpredictable. d. highly suspicious and haughty

c. unstable and unpredictable. The client has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Mood swings are often rapid and seemingly without understandable reason in manic clients. Options A and B are not entirely correct. Option D is not described in the scenario.

A client displaying behaviors consistent with acute mania approaches the nurse, waves a newspaper, and says "I need to make a phone call right this minute. I need to call this department store while their sale is going on. I am going to order 10 dresses and four pairs of shoes." The most appropriate intervention would be for the nurse to a. tell the client she is not allowed to use the phone until she is in better control. b. suggest the client have someone shop for her and bring purchases to the unit. c. ask whether the client has enough money to pay for the purchases. d. invite the client to go to her room to see a new fashion magazine.

d. invite the client to go to her room to see a new fashion magazine. Situations such as this offer an opportunity to use the client's distractability to staff's advantage. Clients become frustrated when staff deny requests (option A) that the client sees as entirely reasonable. Distracting the client can avoid power struggles. Option B would not satisfy the client's need for immediacy and would ultimately result in the extravagant expenditure. Option C would likely precipitate an angry response.