Ch. 26

20. A client who has been diagnosed with bipolar I disorder states, "God has taught me how to decode the Bible." The nurse should anticipate which combination of medications would be ordered to address this client's symptoms? 1. Lithium carbonate (Lithobid) and risperidone (Risperdal) 2. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) 3. Valproic acid (Depakote) and sertraline (Zoloft) 4. Valproic acid (Depakote) and lamotrigine (Lamictal)

ANS: 1 This is correct. The nurse should anticipate lithium carbonate (Lithobid) and risperidone (Risperdal) to be ordered. Lithium carbonate is a mood stabilizer, and risperidone is an atypical antipsychotic. Risperidone will address the client's symptoms of psychosis (delusions of grandeur) and has sedative effects to reduce symptoms of agitation, hyperactivity, and/or insomnia. Lithium takes 1 to 3 weeks to take its full effect.

24. A client diagnosed with bipolar disorder states, "I hate oatmeal. Let's get everybody together to do exercises. I'm thirsty and I'm burning up. Get out of my way; I have to see that guy." Which is the priority nursing action? 1. Assess the client's vital signs. 2. Offer to have the dietitian discuss food preferences. 3. Encourage the client to lead the exercise program in the community meeting. 4. Acknowledge the client briefly, and then walk away.

ANS: 1 This is correct. The nurse should obtain vital signs to assess the client's physical status. The client's statement of "I'm thirsty and I'm burning up" may indicate that the client is dehydrated or has an infection or another physical illness. Symptoms of mania may mask a comorbid physical illness. Assessment is the first step of the nursing process.

13. A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention should be implemented to achieve the outcome of "Client will gain 2 lb by the end of the week?" 1. Provide client with high-calorie finger foods throughout the day. 2. Accompany client to cafeteria to encourage adequate dietary consumption. 3. Initiate parenteral nutrition (PN) to meet dietary needs. 4. Teach the importance of a varied diet to meet nutritional needs.

ANS: 1 This is correct. The nurse should provide the client with high-protein, high-calorie, nutritious finger foods and drinks that can be consumed "on the run" throughout the day. Because of the client's hyperactive state, the client has difficulty sitting still long enough to eat a meal.

28. A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention is most therapeutic for this client? 1. Use a calm, unemotional approach during client interactions. 2. Focus primarily on enforcing limits. 3. Limit interactions to decrease external stimuli. 4. Encourage the client to establish social relationships with peers.

ANS: 1 This is correct. The nurse's most therapeutic action is to maintain a calm, unemotional approach during client interactions. Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Accelerated thinking proceeds to racing thoughts, overconnection of ideas, and rapid, abrupt movement from one thought to another.

15. The nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, "You can't do this to me. Do you know who I am?" Which is the priority nursing action in this situation? 1. To provide self and client with a safe environment 2. To redirect the client to the needed assessment information 3. To provide high-calorie finger foods to meet nutritional needs 4. To reorient the client to person, place, time, and situation

ANS: 1 This is correct. The priority nursing action is to protect the client and staff from injury. Clients experiencing mania demonstrate excessive psychomotor activity, low frustration tolerance, and impulsivity, which can lead to aggressive behavior. Hallucinations and delusions are common in acute mania.

4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. Which should be the priority nursing diagnosis for this client? 1. Risk for suicide R/T hopelessness 2. Anxiety: severe R/T hyperactivity 3. Imbalanced nutrition: less than body requirements R/T refusal to eat 4. Dysfunctional grieving R/T loss of employment

ANS: 1 This is correct. The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses based on physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose.

10. Which condition appears to have a connection to bipolar disorder in youth? 1. Attention deficit-hyperactivity disorder (ADHD) 2. Disruptive mood dysregulation disorder 3. Nonepisodic irritability 4. Schizophrenia

ANS: 1 This is correct. There appears to be a connection between ADHD and bipolar disorder in youth.

33. Which of the following explanations should the nurse include when teaching parents why it is difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply. 1. Symptoms of bipolar disorder are similar to those of attention deficit-hyperactivity disorder. 2. Children are naturally active, energetic, and spontaneous. 3. Neurotransmitter levels vary considerably in accordance with age. 4. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18 years. 5. Genetic predisposition is not a reliable diagnostic determinant.

ANS: 1, 2 1.This is correct. It is difficult to diagnose children and adolescents because symptoms of bipolar disorder are similar to those of attention deficit-hyperactivity disorder. 2. This is correct. It is difficult to diagnose children and adolescents, as children are naturally active, energetic, and spontaneous.

32. Which of the following instructions regarding lithium therapy should be included in the nurse's discharge teaching? Select all that apply. 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2500 to 3000 mL of fluid per day. 4. Restrict potassium-containing foods. 5. Take medication on an empty stomach.

ANS: 1, 2, 3 1. This is correct. The client taking lithium should avoid excessive use of caffeine. 2. This is correct. The client taking lithium should maintain a consistent sodium intake. 3. This is correct. The client taking lithium should consume at least 2,500 to 3,000 mL of fluid per day.

34. A client and a nurse therapist are developing a treatment plan that includes strategies to manage bipolar disorder. Which should be included? Select all that apply. 1. Maintain a consistent sleep schedule. 2. Become an expert on the disorder. 3. Create a daily medication schedule. 4. Set a time frame to achieve remission. 5. Develop an emergency plan.

ANS: 1, 2, 3, 5 1. This is correct. One strategy to help the individual with bipolar disorder take control of and manage their illness is to manage lifestyle factors, such as sleep time. 2. This is correct. One strategy to help the individual with bipolar disorder take control of and manage their illness is to become an expert on the disorder. 3. This is correct. One strategy to help the individual with bipolar disorder take control of and manage their illness is to take medications regularly. 5. This is correct. One strategy to help the individual with bipolar disorder take control of and manage their illness is to develop a plan for emergencies.

35. The clinic nurse is reviewing the medication list of a client diagnosed with medication-induced bipolar disorder. The nurse recognizes which may have precipitated the client's mood disturbance? Select all that apply. 1. Oral contraceptives 2. Antihypertensives 3. Dopamine agonists 4. Corticosteroids 5. Alpha-adrenergics

ANS: 1, 2, 4 1. This is correct. Oral contraceptives have been known to evoke mood symptoms. 2. This is correct. Antihypertensives have been known to evoke mood symptoms. 4. This is correct. Corticosteroids have been known to evoke mood symptoms.

8. A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates learning has occurred? 1. "This disorder is more prevalent in lower socioeconomic groups." 2. "This disorder is more prevalent in higher socioeconomic groups." 3. "This disorder is equally prevalent in all socioeconomic groups." 4. "This disorder is unpredictable based on socioeconomic groups."

ANS: 2 This is correct. Bipolar disorder is more prevalent in higher socioeconomic groups.

25. A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to find on assessment? 1. Pacing 2. Flight of ideas 3. Lability of mood 4. Irritability

ANS: 2 This is correct. Clients diagnosed with bipolar disorder: manic episode experience fragmented cognition and perception, often accompanied by psychosis. Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speech and abrupt changes from topic to topic.

27. A client's spouse asks, "What evidence supports the possibility of genetic transmission of bipolar disorder?" Which is the best nursing reply? 1. "Clients diagnosed with bipolar disorders have alterations in neurochemicals that affect behaviors." 2. "Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder." 3. "Higher rates of relatives of clients diagnosed with bipolar disorder respond in an exaggerated way to daily stress." 4. "More individuals diagnosed with bipolar disorder come from higher socioeconomic and educational backgrounds."

ANS: 2 This is correct. Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. If both parents are diagnosed with the disorder, the risk is two to three times as great.

30. Which carries a warning label stating that the use of the medication increases risk for suicidal thoughts and behaviors? 1. Antipsychotics 2. Antiepileptics 3. Mood stabilizers 4. Anxiolytics

ANS: 2 This is correct. The U.S. Food and Drug Administration requires that all antiepileptic (anticonvulsant) drugs carry a warning label indicating that use of the drugs increases risk for suicidal thoughts and behaviors. Clients treated with these medications should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior.

18. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. Which lithium level should the nurse correlate with these symptoms? 1. 1.3 meq/L 2. 1.7 meq/L 3. 2.3 meq/L 4. 3.7 meq/L

ANS: 2 This is correct. The client's symptoms are correlated with a lithium level of 1.7 meq/L. The therapeutic level of lithium carbonate is 1.0 to 1.5 meq/L for acute mania and 0.6 to 1.2 meq/L for maintenance therapy. Symptoms of lithium toxicity include persistent nausea and vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive urine output, increasing tremors, and mental confusion. Lithium toxicity can lead to renal failure and death.

2. A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the past 3 nights and a 12-lb weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? 1. Knowledge deficit related to (R/T) bipolar disorder as evidenced by (AEB) concern about symptoms 2. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss 3. Risk for suicide R/T powerlessness AEB insomnia and anorexia 4. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

ANS: 2 This is correct. The client's weight loss indicates that the body's metabolic needs have not been met. The nurse should prioritize interventions to ensure proper nutrition and health. The assessment data does not indicate that the client is at risk for self-harm.

16. A client is diagnosed with cyclothymic disorder. Which client behaviors should the nurse expect to find on assessment? 1. The client expresses "feeling blue most of the time." 2. The client has endured periods of elation and dysphoria for more than 2 years. 3. The client continually fixates on hopelessness and thoughts of suicide. 4. The client has labile moods with periods of acute mania.

ANS: 2 This is correct. The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years' duration, involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for bipolar I or II disorder.

29. As clients are leaving the dayroom following a group therapy session, the nurse notices that a client admitted for acute mania is clenching and unclenching both fists, swearing, and glaring at a staff member. Which action should the nurse take first? 1. Calmly ask the client to go to the "quiet room." 2. Instruct clients to return to the dayroom. 3. Prepare to administer a sedative medication. 4. Ask a staff member to call hospital security.

ANS: 2 This is correct. The nurse should intervene at the first sign of increased anxiety, agitation, or verbal or behavioral aggression and should remove others from the environment to ensure client and others' safety.

21. The nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement provides supportive evidence of this symptom? 1. "I can't stop my sexual urges. They have led me to numerous affairs." 2. "I'm the world's most perceptive attorney." 3. "My spouse is distraught about my overspending." 4. "The Federal Bureau of Investigation (FBI) is out to get me."

ANS: 2 This is correct. The statement "I'm the world's most perceptive attorney" indicates the client is experiencing delusions of grandeur. Hallucinations and delusions (usually paranoid and grandiose) are common symptoms during acute mania. Grandiosity is defined as an unrealistic sense of superiority (a sustained view of oneself as better than others).

22. Which client statement indicates to the nurse that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? 1. "I will limit my intake of fluids daily." 2. "I will maintain normal salt intake." 3. "I will take Lithobid on an empty stomach." 4. "I will increase my caloric intake to prevent weight loss."

ANS: 2 This is correct. The statement indicates that the client understands there is no need to restrict sodium intake while taking Lithobid.

17. After teaching a client about lithium carbonate (Lithane), the nurse would conclude teaching was successful based on which client statement? 1. "I should expect to feel better in a couple of days." 2. "I'll call my doctor immediately if I experience any diarrhea or ringing in my ears." 3. "If I forget a dose, I can double the dose the next time I take this drug." 4. "I need to restrict my intake of any food containing salt."

ANS: 2 This is correct. This statement indicates that the nurse's teaching was effective. Signs of lithium toxicity include ataxia, blurred vision, severe diarrhea, persistent nausea and vomiting, and tinnitus.

5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? 1. Sertraline (Zoloft) 2. Valproic acid (Depakote) 3. Trazodone (Desyrel) 4. Paroxetine (Paxil)

ANS: 2 This is correct. Valproic acid (Depakote) is an anticonvulsant. For many years, the drug of choice for treatment and management of bipolar mania was lithium carbonate; however, in recent years, anticonvulsant drugs have been found to have mood-stabilizing effects, either alone or in combination with lithium.

14. A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? 1. The client will accomplish activities of daily living (ADLs) independently by discharge. 2. The client will verbalize feelings during group sessions by discharge. 3. The client will remain safe from harm throughout hospitalization. 4. The client will use problem-solving to cope adequately after discharge.

ANS: 3 This is correct. A client diagnosed with bipolar disorder is at risk for injury in either pole of this disorder. In the manic phase, the client is hyperactive and can inadvertently injure self or others. In the depressive phase, the client is at risk for self-harm.

3. The nurse is planning care for a client diagnosed with bipolar disorder: manic episode. Which should be the first priority of the listed client outcomes? 1. Maintains nutritional status 2. Interacts appropriately with peers 3. Remains free from injury 4. Sleeps 6 to 8 hours per night

ANS: 3 This is correct. Safety of the client and others is the priority over physical and social needs.

23. A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. Which should be the nurse's initial intervention? 1. Ask the group to take a vote on alternative weekend events. 2. Remind the client to quiet down or leave the dayroom. 3. Assist the client to move to a calmer location. 4. Discuss impulse control problems with the client.

ANS: 3 This is correct. The nurse's initial action should be to move the client to a calmer environment, as overstimulation can exacerbate symptoms of acute mania. The client's agitation and extreme hyperactivity place the client and others at risk for injury. The nurse's priority is always safety.

19. A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client? 1. Ineffective individual coping R/T hospitalization AEB alcohol abuse 2. Altered nutrition: less than body requirements R/T mania AEB weight loss 3. Risk for violence: directed toward others R/T agitation and hyperactivity 4. Sleep pattern disturbance R/T flight of ideas AEB sleeping 1 to 2 hours per night

ANS: 3 This is correct. The priority nursing diagnosis is risk for violence: self-directed or other directed. Clients experiencing mania demonstrate excessive psychomotor activity, low frustration tolerance, and impulsivity, which can lead to aggressive behavior. Hallucinations and delusions are common in acute mania.

11. An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal) 400 mg three times a day for mood stabilization. Which statement about this medication order is true? 1. "This dosage is within the recommended dosage range." 2. "This dosage is lower than the recommended dosage range." 3. "This dosage is more than twice the recommended dosage range." 4. "This dosage is four times higher than the recommended dosage range."

ANS: 3 This is correct. The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients 100-200 mg per day; 400 mg three times daily is well above the recommended dose.

7. A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 lb in this time frame. Which is the appropriate nursing reply? 1. "That's strange. Weight loss is the typical pattern." 2. "What have you been eating? Weight gain is not usually associated with lithium." 3. "Weight gain is a common but troubling side effect." 4. "Weight gain occurs only during the first month of treatment with this drug."

ANS: 3 This is correct. Weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication compliance and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.

31. The psychiatric-mental health nurse is providing discharge teaching for a client diagnosed with bipolar disorder. Which statement indicates that the nurse's teaching is effective? 1. "I shouldn't take my lithium when I have the flu." 2. "I am looking forward to having real coffee in the morning." 3. "I can get off medication in 5 years if I am stable." 4. "I'll be the designated driver since I shouldn't have alcohol with lamotrigine."

ANS: 4 This is correct. Clients taking lamotrigine (Lamictal), an antiepileptic mood stabilizer, should avoid consuming alcoholic beverages.

26. The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom decor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate? 1. Rooms should contain extra-large windows with views of the street. 2. Rooms should contain brightly colored walls with printed drapes. 3. Rooms should be painted deep colors and located close to the nurse's station. 4. Rooms should be painted with neutral colors and contain pale-colored accessories.

ANS: 4 This is correct. Neutral colors and pale accessories are most appropriate for a client experiencing mania. Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying, making it necessary to maintain low levels of stimuli in the client's environment (low lighting, few people, simple decor, low noise levels). Anxiety levels rise in a stimulating environment.

6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing reply? 1. "Zyprexa in combination with Eskalith cures manic symptoms." 2. "Zyprexa prevents extrapyramidal side effects." 3. "Zyprexa ensures a good night's sleep." 4. "Zyprexa calms hyperactivity until the Eskalith takes effect."

ANS: 4 This is correct. Olanzapine (Zyprexa) is an atypical antipsychotic used in acute manic episodes to reduce hyperactivity until the lithium carbonate (Eskalith) takes effect. Lithium carbonate may take 1 to 3 weeks to reach a therapeutic level and decrease hyperactivity.

9. A client diagnosed with bipolar disorder has taken lithium carbonate (Lithane) for 1 year; this client presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. The nurse should interpret these symptoms to be indicative of which of the following? 1. Consumption of foods high in tyramine 2. Common side effects of lithium carbonate 3. Lithium carbonate tolerance 4. Lithium carbonate toxicity

ANS: 4 This is correct. The client's symptoms indicate lithium carbonate toxicity. Symptoms of lithium carbonate toxicity include persistent nausea and vomiting, severe diarrhea, ataxia, blurred vision, tinnitus, excessive urine output, increasing tremors, and/or mental confusion. These symptoms require a physician to be notified.

12. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? 1. "Treatment is compromised when clients have difficulty sleeping." 2. "Treatment is compromised when irritability interferes with social interactions." 3. "Treatment is compromised when clients have no insight into their problems." 4. "Treatment is compromised when clients choose not to take their medications"

ANS: 4 This is correct. The most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose to not take their medications.

1. A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? 1. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." 2. "Mood euthymic. Exhibiting magical thinking. Restless." 3. "Mood labile. Exhibiting delusions of reference. Hyperactive." 4. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

ANS: 4 This is correct. The nurse should document that this client's behavior is "Agitated and pacing. Exhibiting grandiosity. Mood labile." The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity.