MH ATI exam
Complications Grandma's Famous Pie Was Really Good. Her Baking Has Love.
Some adverse effects resolve after a few weeks GI distress, Fine hand tremors, Polyuria, Weight Gain, Renal Toxicitiy, Goiter, hypothyroidism, bradydysrythmias, hypotension, Lithium toxicity
seizures
a neurological dysfunction caused by a sudden episode of uncontrolled electrical activity in the brain that may result in the involuntary, uncontrolled muscle contractions. usually characterized by LOC and involuntary spasmodic muscle twitching.
time
daily, 30-40 minutes for 4-6 weeks, outpaitent
indications
depression not responding to meds
What are the causes of alcoholism (genetics)?
genetics: If you have a close relative who had alcohol dependency problems the chances that you will have problem also are greatly increased. Alcoholism runs in families. Poverty and physical/sexual abuse are two factors that can contribute to alcoholism addiction. Traits such as impulsiveness, low self-esteem and need for approval all can lead to alcohol dependence. Depression Peer pressure and easy availability of alcohol can aid some users, particularly younger ones, in becoming alcoholics.
considerations for admission
- CIWA-Ar >/= 8-15 - history of withdrawal seizures or delirium tremens - decompensated medical condition or major electrolyte disturbances
difulfiram
- MOA: inhibits aldehyde dehydrogenase causing increase levels of acetaldehyde - flushing, throbbing, headache, nausea, vomiting, sweating, hypotension, confusion - uses: chronic alcoholism management - dose: 125-500 mg PO QD - drug interactions: phenytoin, warfarin, isoniazid - adverse effects: fatigue, headache, skin rash, hepatic failure
naltrexone
- MOA: u-opioid receptor antagonist - uses: alcohol dependence - dose: 50 mg PO QD, 380 mg IM Q4 WKs - ADEs: headache, syncope, dizziness, vomiting, diarrhea, increased ALT/AST - patient should be opioid free
acamprosate
- MOA: weak NMDA receptor antagonist, increases activity of GABA system - uses: alcohol abstinence - dose: 333-666 mg PO TID - ADEs: NV, diarrhea, rash
other medication
- clonidine - beta blockers - baclofen
CAGE questionnaire
- do you ever feel the need to cut down on your alcohol use - have you ever been annoyed by others telling you that you drink too much - have you ever felt guilty about your drinking or something you did while drinking - did you ever have an eye opener
pharmacotherapy overview
- first line: benzodiazepines - alternative: phenobarbital - other: propofol, dexmedetomidine, carbamazepine, anticonvulsants, antipsychotics (haloperidol, olanzapine)
alcohol withdrawal syndrome management
- hydration: diaphoresis and vomiting = hypovolemia - thiamine (B1) 50-100 mg/day x 3-5 days: prevention of Wernicke-Korsakoff syndrome (mental confusion, ataxia, eye movement disorders) - folic acid - multivitamin - electrolyte abnormalities: hypokaleia, hypomagnesemia, hypophosphatemia - monitor blood glucose and treat hypoglycemia
Stage 3
-Mild decline -family and physician able to detect -cognitive decline -hard time finding the words to say something -remembering names -planning and organizing
Stage 4
-Moderate decline -clear cut symptoms -forget details about life stories -poor short term memory -inability to manage finance and bills
Stage 5
-Moderately severe decline -assist with ADLs (dressing) -significant confusion -can't recall simple details
Stage 1
-No impairment -No symptoms -Memory intact
Stage 2
-Very mild decline -may notice mild memory loss (trouble finding some things) -not detected -Can still do well on memory tests
11. A client's latest lab result shows her plasma lithium level is 0.2 mEq/L. The nurse can expect to implement which of the following nursing interventions? A. Administer an additional oral dose of lithium B. Infuse 1 L of 0.9% sodium chloride over 4 hr C. Prepare to give emergency resuscitation D. Prepare the client immediate for another laboratory draw
Answer: A This plasma level is subtherapeutic and the client should be given an additional dose. Emergency resuscitation may be indicated if the client's laboratory value indicates toxicity. There is no indication that the client need supplemental fluids. There is no reason to question the laboratory results.
4. A client diagnosed with bipolar disorder has been prescribed with lithium (carbonate) by his physician. Which question will help the nurse identify signs of early lithium toxicity? A. Have you been experiencing any nausea, vomiting or diarrhea? B. Do you have frequent headache? C. Have you been urinating excessively/frequently? D. Do you experience leg aches over the past few days?
Answer: A The most common early signs of lithium toxicity is gastrointestinal (GI) disturbance including nausea,vomiting, or diarrhea. B, C, D assessment question is unrelated to lithium toxicity.
25. A client with bipolar disorder was prescribed with lithium (Eskalith). Upon giving teaching, the nurse instructed the client to report severe signs of toxicity? Select all that apply. A. Seizures B. Blurred vision C. Slurred speech D. Ataxia E. Tinnitus
Answer: A, B, D, E Slurred speech can be seen as early signs of toxicity
18. Which discharge instructions is most important for a client taking lithium (Eskalith)? A. Limit fluid to 1,500 ml daily B. Maintain a high fluid intake C. Take advantage of the warm weather by exercising outside whenever possible D. When feeling a cold coming, it's okay to take over-the-counter (OTC) remedies
Answer: B Client taking lithium need to maintain a high fluid intake. Exercising outside may not be safe; photosensitivity occurs with lithium use, and activity in warm weather could increase sodium loss, predisposing the client to lithium toxicity. The client shouldn't take OTC drugs without the physician's approval.
20. A man is prescribed with lithium to manage bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings? A. Manic episodes a week ago B. Having diarrhea every day C. Client has rashy pruritis on his arms and legs D. The client presents as severely depressed
Answer: B Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity. Rashy pruritis is not a symptoms of lithium toxicity. Having a depressive or manic episodes is not an indication of lithium toxicity—these findings indicates that the lithium is not effective or is not at a therapeutic level.
7. A client under lithium medication reduce his dietary salt intake. Which of the following is expected to show in his blood work? A. Decreased lithium level B. Increased lithium level C. Increased then decrease in the next result of the lithium blood work D. No significant changes
Answer: B There is a direct relationship between the amount of salt and the plasma levels of lithium. Lithium plasma levels increase when there is a decrease in dietary salt. Increase in dietary salt causes the opposite effect of decreasing lithium plasma. That's why it is important that the nurse monitor dietary sodium intake.
9. A client receiving lithium carbonate has a lithium level of 2.3 mEq/L. The nurse will immediately assess the client for which of the following symptoms? A. Weakness B. Diarrhea C. Blurred Vision D. Fecal incontinence
Answer: C At lithium levels of 2 -2.5 mEq/L the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. With levels between 1.5 and 2 mEq/L the client experiencing vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death.
21. In giving discharge teaching to a client with a home med lithium carbonate. Which of the following should be included: A. Advising the client to watch the diet carefully B. Suggesting that the client take the pills with milk C. Reminding the client that a CBC must be done once a month D. Encouraging the client to have blood levels checked as ordered
Answer: C Blood levels must be checked monthly or bimonthly when the client is on maintenance therapy because there is only a small range between therapeutic and toxic levels.
16. A client with bipolar disorder has been receiving lithium (Eskalith) for 2 weeks. She also has been taking chemotherapeutic drugs that cause her to feel nauseated and anorexic, making it difficult to distinguish early signs of lithium toxicity. Which of the following signs would indicate lithium toxicity at serum drug levels below 1.5 mEq/L? A. Hyperpyrexia B. Marked analgesics and lethargy C. Hypotonic reflexes with muscle weakness D. Oliguria
Answer: C Lithium alters sodium transport in nerve and muscle cells, slowing the speed of impulse transmission, so look for hypotonic reflexes and muscle weakness. Lithium has no known effect on body temperature nor on the transmission of pain impulses. The drug doesn't cause lethargy. Oliguria and other signs of renal failure occur late in sever lithium toxicity.
17. A client came to the psychiatric unit 2 days ago. She has a history of bipolar disorder, is in the manic phase, and stopped taking lithium (Eskalith) 2 weeks ago. Which finding would the nurse be least likely to see? A. Flight of ideas B. Delusions of grandeur C. Increased appetite D. Restlessness
Answer: C The manic client is usually unwilling or unable to slow down enough to eat. Flight of ideas, delusions of grandeur and restlessness are associated with the manic phase.
15. What information is important to include in the nutritional counseling of a family with a member who has bipolar disorder? A. If sufficient roughage isn't eaten while taking lithium, bowel problems will occur. B. If the intake of carbohydrate increases, the lithium level will increase C. If the intake of calories is reduced, the lithium level will increase D. If the intake of sodium increases, the lithium level will decrease.
Answer: D Any time the level of sodium increases, such as with a change in dietary intake, the level of lithium will decrease. The intake of roughage and carbohydrates in the diet isn't related to metabolism of lithium. Reducing the number of calories the client eats don't affect the lithium level in the body.
23. A client on lithium has suffered from diarrhea and vomiting. Which of the following is the priority nursing intervention of the nurse in-charge? A. Reassure the client that these are common side effects of lithium therapy B. Recognized this as a drug interaction C. Give the client Cogentin D. Hold the next dose and obtain an order for a stat serum lithium level
Answer: D Diarrhea and vomiting are manifestations of lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. These manifestations are not due to drug interaction. Cogentin is used to manage extrapyramidal symptom side effects of antipsychotics. The common side effects of lithium are fine hand tremors, nausea, polyuria and polydipsia.
Contraindications
Birth Defect risk for pregnancy Breastfeeding Cardiac, hepatic or renal disease schizophrenia caution use in older clients
BAC
Blood alcohol concentration
BLOOD ALCOHOL LEVELS
legally drunk: .08% 3-5 drinks lethal: .5% 25 drinks
non-invasive therapy
magnetic pulsations stimulate specific areas of the brain
systemic adverse reactions
none
seizures
rare but possible
lithium therapeutic levels <0.4-1
side effect signs of toxicity : mild nausea, weight gain, mild thirst, fine hand tremors
sever toxicity >2.0
signs and symptoms: ataxia, serial EEG changes blurred vision, seizures, stupor, large output of diluted urine , coma
moderate lithium toxicity 1.5-2.0
signs and symptoms: coarse hand tremors, persistent GI upset, confusion, muscle hyperirritability, sedation, EEG changes.
symptom triggered versus fixed schedule treatment
symptoms triggered: - medications given in response to symptoms - assess patient hourly using CIWA-Ar - less over sedation - potentially shorter treatment fixed schedule treatment: - consider in severe withdrawal
alcohol withdrawal syndrome
the physical effects that may occur when an alcoholic stops consuming alcohol Anxiety, insomnia, tremor, seizures, visual hallucinations, delirium A person who has developed a physiologic dependence and quits drinking for whatever reason, SxS mild tremor, hallucinations, diaphoresis, N/V, disoriented.....tremors usually happen 6-48 hours after stopping, they may last for 3-5 days, and seizures may happen 12 -24 hours after stopping
signs and symptoms
- anxiety, insomnia, tremor, palpitations, nausea, anorexia -- 1-9+ days after discontinuation - withdrawal seizures -- 1-4 days after discontinuation - alcoholic hallucinations -- 1-4 days after discontinuation - delirium tremens (tachycardia, hypertension, low-grade fever, tremor, diaphoresis, delirium, agitation) -- 2-9 days after discontinuation
learning objectives
- assess signs and symptoms of alcohol withdrawal - understand the clinical institute withdrawal assessment of alcohol (CIWA-Ar) score - given a list of medications, identify the FDA approved medications for alcohol dependence - recommend appropriate treatment options for alcohol withdrawal
summary
- withdrawal symptoms may start early after the last drink - utilize CIWA-Ar score to assess alcohol withdrawal severity - treatment: IV fluids, vitamins, PRN benzodiazepines, other pharmacologic agents, electrolyte replacement as necessary
What are the effects of alcohol on the body systems?
0.00 BAC - lowered inhibitions - some loss of muscular coordination - reduced social inhibitions - impaired ability to drive - increased coordination loss - slowed reaction time - clumsiness, exaggerated emotions - unsteadiness - hostile or aggressive behavior - slurred speech - severe intox - inability to walk - confused - incapacitated, loss of feeling - arousal difficulty - coma - death 0.50 BAC
alcoholic hallucinosis
24-72 hours aduitory and visual hallucinations and illusions without autonomic signs
19. The client taking lithium carbonate (Eskalith) is having difficulty time walking, is confused, agitated and is complaining of blurred vision. The nurse checks the lithium level drawn earlier in the day, expecting the level to be within which of the following ranges? A. 0.5 to .8 mEq/L B. 1.2 to 1.5 mEq/L C. 1.5 to 1.8 mEq/L D. 2.0 to 3.0 mEq/L
Answer: D The symptoms listed are those of lithium toxicity, and are seen when the serum level is 2 to 3 mEq/L.
treatment for alcohol dependence
FDA approved for alcohol dependence: - disulfiram (Antabuse) - acamprosate (Campral) - naltrexone (ReVia)
Lithium Ranges (What they SHOULD be)
Initial Levels at start of treatment - 0.8-1.4 Maintenance Levels : 0.4- 1.0 Levels higher than 1.5 indicate toxicity.
tremors
continuous quivering or shaking.
alternative therapies
phenobarbital - moa: binds GABA receptor -> prolongs Cl- channel opening -> enhances GABA inhibitory effects - onset IV: 5 minutes, max effect 30 minutes, duration of action 4-10 hours - limited evidence, may possibly be used in addition to benzodiazepines - dosing 260 mg IV, then 130 mg IV PRN - therapeutic range: 10-40 mcg/mL - adverse effects: bradycardia, hypotension, respiratory depression
electromagnet
plced on scalp. Cleint is alert, may experience tingling/lightheadedness
Lithium Carbonate - Action
produces neurochemical changes in the brain - blocks serotinin Decreases neuronal atrophy used to treat bipolar disorder and control acute mania. Prevents mania/depression and decreases risk of suicide.
mild lithium toxicity 1.0-1.5
signs and symptoms: nausea, vomiting,diarrhea, thirst, polyuria, lethargy, slurred speech, fine hand tremors
alcohol related complications
- cardiovascular: arrhythmias, CAD - liver: hepatitis, cirrhosis, fibrosis - pancreatitis - peripheral neuropathy - gastrointestinal bleeding
treatment goals
- early recognition - treat withdrawal symptoms - prevent progression to more severe symptoms - alcohol dependence treatment program after discharge
BAC
0.03 - slight euphoria 0.06 - relaxed, lower inhibition, minor reasoning impairment 0.09 - slight balance, speech, vision, reaction time impairment 0.125 - significant motor coordination impairment, loss of judgement, slurred speech 0.15 - lack of physical control, blurry vision, loss of balance 0.20 - dysphoria (anxiety, restlessness) 0.25 - mental confusion, nausea, vomiting 0.30 - loss of consciousness > 0.04 - coma, death
abstinence syndrome
A characteristic cluster of symptoms that results from sudden decrease in an addictive drugs level of usage Lacrimation, rhinorrhea, yawning, sweating, weakness, gooseflesh, nausea, and vomiting, tremor, muscle jerks, and hyperpnea are signs of this syndrome a characteristic cluster of symptoms that results from sudden decreases in an addictive drug's level of usage
8. A female client was prescribed with lithium carbonate 600 mg p.o t.i.d to manage her bipolar disorder. The nurse would be aware that the teaching given to the client with regards to the medication side effects was understood when the client make which of the following statement? "I will call my doctor immediately once I notice any: A. Sensitivity to bright light or sun B. Fine hand tremors or slurred speech C. Sexual dysfunction or breast enlargement D. Inability to urinate or difficulty when urinating
Answer: B These are the common adverse effects of lithium carbonate
AW Symptoms
Symptoms: Develop 3-8 hours after they are deprived from alcohol. - Increased NorE (Hyperhidrosis, tachycardia, hypertension, tremor). - Increased dopamine (psychotic symptoms). - Increased glutamate (epileptic seizures). Withdrawal symptoms typically last 5-7 days. 5% develop delirium 2-3 days after they've stopped drinking & in some cases it can be fatal.
delirium tremens
an acute organic brain syndrome due to alcohol withdrawal that is characterized by sweating, tremor, restlessness, anxiety, mental confusion, and hallucinations , a disorder involving sudden and severe mental changes or seizures caused by abruptly stopping the use of alcohol , a violent delirium with tremors induced by alcoholic liquors
pathophysiology
- binds to GABA - chronic drinking causes down-regulation of GABA and upregulation of glutamate, when pts stop drinking will have less GABA and excess of glutamate - causes symptoms like sweating, tachycardia, HTN, seizures
alcohol withdrawal seizures
- up to 10% of patient develop seizures, usually within 48 hours - treatment: -- supportive treatment -- no acute pharmacologic treatment unless status epilepticus -- benzodiazepines: first line to prevent seizures
Regarding the choice of benzodiazepine:
1. Chlordiazepoxide (Librium) is the benzodiazepine of choice in uncomplicated alcohol withdrawal due to its long half-life. 2. Lorazepam or diazepam is available as an injection for patients who cannot safely take medications by mouth. 3. Lorazepam and oxazepam are indicated in patients with impaired liver function because they are metabolised outside of the liver.
A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care? a. Suggest a move into an assisted living facility. b. Schedule the patient for more frequent appointments. c. Ask family members to supervise the patient's daily activities. d. Discuss the preventive use of acetylcholinesterase medications.
ANS: B-Schedule the patient for more frequent appointments
Alcohol Detoxification
Alcohol detoxification, or detox, for individuals with alcohol dependence, is the abrupt cessation of alcohol intake coupled with substitution of cross-tolerant drugs that have effects similar to the effects of alcohol in order to prevent alcohol withdrawal. As such, the term "detoxification" is somewhat of a misnomer since the process does not in any way involve the removal of toxic substances from the body. Detoxification may or may not be necessary depending upon an individual's age, medical status, and history of alcohol intake. For example, a young man who binge drinks and seeks treatment one week after his last use of alcohol may not require detoxification before beginning treatment for alcoholism. Benzodiazepines are the most common family of drugs used for this, followed by barbiturates.
1. A 9-year-old child has been prescribed with lithium as a mood stabilizer. His lab results shows his lithium level of 1.5 mmol/L. The priority nursing diagnosis for this child should be: A. Activity Intolerance B. Risk for Aspiration C. Ineffective Therapeutic Regimen Management D. Disturbed Thought Process
Answer: B Children who develop lithium toxicity are prone to seizures and coma. Due to the seizures that can occur the child is at risk for aspiration during seizure. This can also occur if the child is comatose. Based on Maslow's hierarchy of needs, maintaining a paten airway is the priority nursing diagnosis.
A client prescribed lithium carbonate (Lithium) 300mg qam and 600mg qhs presents to the ED with impaired consciousness, nystagmus, arrhythmias, and history of recent seizures. which serum lithium would the nurse expect to assess? A. 3.7 mEq/L B. 3.0 mEq/L C. 2.5 mEq/L D. 1.9 mEq/L
Correct Answer: A clients with a serum level greater than 3.5 mEq/L may show signs such as impaired consciousness, Nystagmus, seizures, coma, Oliguria/ anuria, arrhythmias, myocardial infarction, or cardiovascular collapse
Interactions
Diuretics - encourage 1.5-3L of fluid a day but caution if pt is losing too much sodium (sweat, frequent diarrhea, polyuria ect) this inhibits lithium excretion. Can lead to toxicity. NSAIDs- concurrent use increases renal abosorption and can lead to toxicity. (Aspirin as a mild analgesic is ok) Anticholinergenics (antihistamines and antidepressants) - combined use can lead sodium imbalances which result in toxicity.
Lithium Toxicity Signs/Ranges
Early Indication 1.5 or less slurred speech lethargy,. diarrhea, tremors, weakness or polyuria. Advanced Indications: 1.5 -2 mental confusion, sedation, coarse tremors, ongoing GI Distress/diarrhea Withold the Medication Severe Toxicity 2-2.5 Extreme polyuria, tinnitus, giddy, jerking, blurred vision, ataxia, severe hypotension, stupor, coma, seizures 2.5 or greater leads to rapid progression of symptoms can be fatal. Hemodialysis may be necessary.
Benzodiazepines such as chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan) or oxazepam (Serax) are the most commonly used drugs used to reduce alcohol withdrawal symptoms. There are several treatment patterns in which it is used.
The first option takes into consideration the varying degrees of tolerance. In it, a standard dose of the benzodiazepine is given every half hour until light sedation is reached. Once a baseline dose is determined, the medication is tapered over the ensuing 3-10 days. Another option is to give a standard dose of benzodiazepine based on history and adjust based on withdrawal phenomenon. A third option is to defer treatment until symptoms occur. This method should not be used in patients with prior, alcohol-related seizures. This has been effective in randomized controlled trials. A non-randomized, before and after, observational study found that symptom triggered therapy was advantageous. Dosing of the benzodiazepines can be guided by the CIWA scale.
Nursing Considerations
This med takes effect in 5-7 days but max benefit will not happen for 2-3 weeks. Short half life of med means it is usually rx at 3x a day Take with food/milk to minimize GI distress. Start of treatment ranges must be monitored every 2-3 days until stable then every 1-3 months.
Gender differences of metabolism of alcohol
Women absorb and metabolize alcohol differently from men. They have higher BAC's after consuming the same amount of alcohol as men and are more susceptible to alcoholic liver disease, heart muscle damage, and brain damage. The difference in BAC's between women and men has been attributed to women's smaller amount of body water, likened to dropping the same amount of alcohol into a smaller pail of water. An additional factor contributing to the difference in BAC's may be that women have lower activity of the alcohol metabolizing enzyme ADH in the stomach, causing a larger proportion of the ingested alcohol to reach the blood. The combination of these factors may render women more vulnerable than men to alcohol-induced liver and heart damage.
DSM-V alcohol withdrawal
- cessation of or reduction in alcohol intake, which has previously been prolonged/heavy - any 2 of the following symptoms developing within several hours to a few days: autonomic hyperactivity, worsening tremor, insomnia, vomiting and nausea, hallucinations, psychomotor agitation, anxiety, generalized tonic-clonic seizures - the above symptoms cause clinically significant distress or impairment and are not attributable to other causes
benzodiazepines
- first line treatment in alcohol withdrawal: improve symptoms, decrease risk of seizure - mechanism: bind to GABAa receptors enhancing inhibitory effects - no benzodiazepine preferred - choose based on dose form, pharmacokinetics, cost, duration of action, metabolism - chlordiazepoxide: PO/IV/IM, 50-100 mg, PO onset 30-120 minutes, half life 10h (long acting), hepatic metabolism by CYP3A4 (active metabolite) - diazepam: PO/IV/IM, 5-10 mg, IV onset 2-5 minutes, half life 43 hours (long acting), hepatic metaboism by CYP3A4 (active metabolite) - lorazepam: PO/IV/IM, 2-4 mg, IV onset 15-20 minutes, half life 14h (intermediate), hepatic metabolism (inactive metabolite) - oxazepam: PO, 15-30 mg, onset 120-180 minutes, half life 8h (short acting), hepatic metabolism (inactive metabolite)
CIWA alcohol scale
- withdrawal assessment in pts able to communicate evaluating 10 parameters: nausea or vomiting, tremors, paroxysmal sweats, anxiety, tactile disturbances, auditory disturbances, visual disturbances, headache, agitation, orientation - items scored 0-7; max total score 67 - mild alcohol withdrawal: <8 (medications not likely needed) - moderate withdrawal: 8-15 - severe withdrawal: > 15
delirium tremens
- withdrawal delirium - usually occurs 48-72 hours after last drink - diagnosable if patient meets criteria for alcohol withdrawal and delirium - symptoms: tachycardia, HTN, fever, tremor, diaphoresis, delirium, agitation - goals: control agitation, decrease risk of seizure injury, death
A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years
ANS: A-The patient was oriented and alert when admitted The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.
Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? a. Administer the Mini-Mental Status Exam. b. Use the Confusion Assessment Method tool. c. Determine whether there is a family history of dementia. d. Obtain a list of the medications that the patient usually takes.
ANS: B The Confusion Assessment Method tool has been extensively tested in assessing delirium
A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? a. Encourage the patient to discuss events from the past. b. Maintain a consistent daily routine for the patient's care. c. Reorient the patient to the date and time every 2 to 3 hours. d. Provide the patient with current newspapers and magazines.
ANS: B Providing a consistent routine will decrease anxiety and confusion for the patient.
The nurse is administering a mental status examination to a 48-year-old patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with a. "Is that right?" b. "I don't know." c. "Wait, let me think about that." d. "Who are those people over there?"
ANS: B-"I don't know." Answers such as "I don't know" are more typical of depression than dementia. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia.
Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? a. Setting the medications up monthly in a medication box b. Having the patient's family member administer the medication c. Posting reminders to take the medications in the patient's house d. Calling the patient weekly with a reminder to take the medication
ANS: B-Having the patient's family member administer the medication Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug.
Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.
ANS: B-Remind the patient frequently about being in the hospital. The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.
A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b. difficulty eating and swallowing. c. loss of recent and long-term memory. d. fluctuating ability to perform simple tasks.
ANS: C Loss of both recent and long-term memory is characteristic of moderate dementia
A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a. the most important risk factor for AD is a family history of the disorder. b. new drugs have been shown to reverse AD dramatically in some patients. c. a diagnosis of AD is made only after other causes of dementia are ruled out. d. the presence of brain atrophy detected by magnetic resonance imaging (MRI) will confirm the diagnosis of AD.
ANS: C The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD
When administering a mental status examination to a patient with delirium, the nurse should a. wait until the patient is well-rested. b. administer an anxiolytic medication. c. choose a place without distracting stimuli. d. reorient the patient during the examination.
ANS: C-choose a place without distracting stimuli. Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.
A 72-year-old female patient is brought to the clinic by the patient's spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? a. "Are you sad?" b. "How is your self-image?" c. "Where were you were born?" d. "What did you eat for breakfast?"
ANS: D-"What did you eat for breakfast?" This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia
The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a. secure the patient in bed using a soft chest restraint. b. ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d. assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.
ANS: D-assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.
6. A client newly diagnosed with bipolar disorder was prescribed with lithium meds. While giving the health teaching the client keeps asking about why there is a need for frequent blood works. Which of the following statement of the nurse addressing the client's question is true: A. "It will help determine if the medication dosage is still within the therapeutic level" B. "Frequent blood works is unnecessary once medication is taken as ordered" C. "It will help identify if the liver has been working properly" D. "It will monitor if the medication already pass the blood brain barrier"
Answer: A Lithium levels determine whether an effective dose of lithium is being given to maintain a therapeutic level of the drug. Lithium blood work aren't drawn for the reason of figuring out whether the drug pass through the blood brain barrier or if the liver is working properly. Taking the medication as ordered doesn't kill the requirement for blood work.
3. A nurse was giving health teaching to a client newly prescribed with lithium medication. Which of the following statement of the client indicates understanding about the medication? A. "When my mood fluctuates, I can increase the dosage of the medication" B. "I can still eat my favorite salty food" C. "I can crush an extended-release tablet, if ever it will be difficult for me to take it whole by mouth" D. "Drinking too much cranberry juice will help maintain a desirable lithium level"
Answer: B Clients under lithium therapy don't need to limit their sodium intake, instead it is recommended to keep salt intake the same as before prescription of the lithium medication. Increasing the dose of lithium without evaluating the client's lab works can cause lithium toxicity, overdose, and renal failure. Extended-releasetablet should be taken whole, it is uniquely made to release the medication slowly in the body, breaking the pill would cause the drug to be release at one time. Watermelon, cantaloupe, grapefruit juice, and cranberry juice will not therapeutically help in maintaining desirable lithium level because of its diuretic effect.
13. Which of the following is an adverse effect of lithium carbonate taken by a client with bipolar disorder. A. Alopecia B. Tremors C. Urinary retention D. Constipation
Answer: B Fine hand tremors are a common adverse effect in clients who take lithium. Alopecia is not an adverse effect of lithium. Diarrhea and polyuria are side effects of lithium.
22. A female client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering the medication? A. Calcium B. Sodium C. Chloride D. Potassium
Answer: B Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium shouldn'trestrict their intake of sodium and should drink adequate amounts of fluid each day. The other electrolytes are important for normal body functions but sodium is most important to the absorption of lithium.
24. A physician prescribes lithium for a client diagnosed with bipolar disorder. The nurse needs to provide appropriate education for the client on this drug. Which topic should the nurse cover? Select all that apply. A. The potential for addiction B. Signs and symptoms of drug toxicity C. The potential for tardive dyskinesia D. A low-tyramine diet E. The need for consistently monitor blood levels F. Changes in his mood that may take 7 to 21 days
Answer: B, E, F Client education should cover the signs and symptoms of drug toxicity as well as the need to report them to the physician. The client should be instructed to monitor his lithium levels on regular basis to avoid toxicity. The nurse should explain that 7 to 21 days may pass before the client notes a change in his mood. Lithium does not have addictive properties. Tyramine is a potential concern to clients taking monoamine-oxidase inhibitors.
2. A client receiving lithium therapy for the treatment of his bipolar disorder has a lithium level of 0.85 mEq/L. The appropriate nursing action is: A. Notify the physician immediately B. Observe the client for signs of toxicity C. Record the laboratory result in the client's chart D. Hold the next dose of lithium
Answer: C The client's laboratory result of lithium is within the therapeutic rage 0.4 - 1 mEq/L.
12. A client under your care as a nurse was newly prescribed with lithium carbonate. To prevent lithium toxicity, the nurse should advise the client to do which of the following? A. Avoid the use of acetaminophen for headaches B. Decrease fluid intake to less than 1,500 mL daily C. Restrict intake of foods rich in sodium D. Limit aerobic activity in hot weather
Answer: D Activities that could cause sodium/water depletion should be avoided in order to prevent lithium carbonate toxicity. Acetaminophen, rather than NSAIDs such as ibuprofen, should be used for headaches because NSAIDs interact with lithium and could cause increased blood levels of lithium. The client should make sure to take in enough sodium and increase, rather than decrease fluid intake to prevent toxicity
10. A client under lithium medication suffered from diarrhea and vomiting. Which of the following nursing intervention should the nurse in charge do first? A. Recognize this as a drug interaction B. Give the client Cogentin C. Reassure the client that these are common side effects of lithium therapy D. Hold the next dose and obtain an order for a stat serum lithium level
Answer: D Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld and test is done to validate the observation. A. The manifestations are not due to drug interaction. B. Cogentin is used to manage the extrapyramidal symptom side effects of antipsychotics. C. The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia.
5. A client who has been taking lithium medication for the past few years, recently got pregnant, and she is so concerned of the effects of the medication to her child. Which of the following statement is true that would address the client's concern? A. Lithium does not cross the placental barrier and poses no risk for the fetus B. Pregnant woman with diagnosed with bipolar disorder should not take lithium meds C. Oral contraceptive and lithium medication may result to a false-positive pregnancy test. D. Lithium should be avoided during the latter part of the first trimester if possible.
Answer: D Lithium crosses placental barrier and poses the risk for developing birth defects to a fetus. To minimize any risk to the fetus, lithium should be avoided in the latter part of the first trimester if possible. Option B is incorrect because it can help control the mother's manic symptoms with little risk to the fetus in the second and third trimester. Option C is also incorrect because it is only true with carbamazepine (Tegretol).
14. A client has been taking lithium carbonate for the management of bipolar disorder. Which of the following adverse reaction does the client need to report? A. Black tongue B. Increased lacrimation C. Periods of disorientation D. Persistent GI upset
Answer: D Persistent GI upset indicates a mild-to-moderate toxic reaction. Black tongue is an adverse reaction of mirtazapine (Remeron), not lithium. Increased lacrimation isn't an adverse effect of lithium. Periods of disorientation don't tend to occur with the use of lithium.
A Client prescribed lithium carbonate (Eskalith) is experiencing an excessive output of diluted urine, tremors, and muscular irritability. these symptoms would lead the nurse to expect to assess which serum lithium level? A. 0.6 mEq/L B. 1.5 mEq/L C. 2.6 mEq/L D. 3.5mEq/L
correct answer:C Rational: A client with serum level 2.6 mEq/L may experience excessive diluted urine, tremors, muscular irritability, psychomotor retardation, and mental confusion. the client's symptoms described in the question supports a serial level of 2.6 mEq/L.
adjunctive therapies
propofol - moa: GABA agonist -> hyperpolarization of neurons -> sedation, NMDA glutamate receptor antagonist - uses: severe withdrawal refractory to benzodiazepine therapy, mechanical ventilation - mixed evidence in outcomes: some studies show no difference in length of stay while other studies show increased ICU and hospitalization stays - dose: 5-10 mcg/kg/min continuous infusion - adverse effects: hypertriglyceridemia, hypotension, bradycardia - propofol infusion syndrome: risk factors include sepsis and high doses (>70 mcg/kg/min). onset within 4 days. symptoms- bradycardia or tachycardia, heart failure, hyperkalemia, hyperlipidemia, metabolic acidosis, renal faliure. management- discontinue propofol, manage symptoms. consequences- mortality. dexmedetomidine: - moa: centrally acting alpha2 agoinst -> decrease NE synthesis and sympathetic outflow. causes sedation, anxiolysis, analgesia, sympatholysis, increases parasympathetic tone - uses: sedation, lowers benzodiazepine requirement - dose: 0.2-0.7 mcg/kg/hr continuous infusion - adverse effects: respiratory depression, agitation, nausea, constipation, hypotension, bradycardia, tachycardia, hypertension neuroleptics: - haloperidol 0.5-5mg PO/IM/IV every hour - olanzapine 10 mg IM - uses: agitation, hallucinations, delirium - ADRs: QTc prolongation anticonvulsants: - carbamazepine: used for symptoms treatment, but insufficient evidence. dosed 600-800 mg x 1 day with taper to 200 mg over 5 days. ADRs include NV, agranulocytosis, aplastic anemia
