Chapter 22. Bipolar and Related Disorders

A client asks the nurse if he needs to alter any of his activities because he is taking lithium carbonate. Which of the following responses would be most appropriate? A) ​Increase your salt intake if an activity causes you to perspire heavily.​ B) ​Wear sunscreen when you are going to be outdoors in the summer time.​ C) ​Drink less fluid than usual now because you are taking this drug.​ D) No changes are necessary for strenuous activities you do outdoors.​

A

A client with bipolar disorder having experienced a depressive episode is prescribed lamotrigine. After teaching the client about this medication, the nurse determines that the teaching was successful when the client states which of the following? A) ​I need to notify my physician if I develop a skin rash.​ B) ​I need to have my blood tested about once a month.​ C) ​I have to watch how much salt I use every day.​ D) ​This drug can affect my liver function.​

A Black box label for rash. Skin rashes can be severe and could possibly indicate Steven Johnson's Syndrome (SJS).

A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client? A. Using a calm, unemotional approach during client interactions B. Focusing primarily on enforcing limits C. Limiting interactions to decrease external stimuli D. Encouraging the client to establish social relationships with peers

ANS: A Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain a calm, unemotional approach during client interactions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A 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? A. To provide self and client with a safe environment B. To redirect the client to the needed assessment information C. To provide high-calorie finger foods to meet nutritional needs D. To reorient the client to person, place, time, and situation

ANS: A During a manic episode the client's mood is elevated, expansive, and irritable. Providing a safe environment should be prioritized to protect the client and staff from potential injury. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 pounds by the end of the week?" A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs.

ANS: A The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 pounds by the end of the week. Because of hyperactivity, the client will have difficulty sitting still to consume large meals. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity

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

ANS: A The patient who is experiencing psychosis (in this case, delusions of grandeur) may be benefited by the addition of an antipsychotic medication (risperidone) to the mood stabilizer (lithium). In addition, since lithium does not immediately reach therapeutic levels, the sedative properties of an antipsychotic may be useful in reducing agitation, hyperactivity, and/or insomnia. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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. What should be the priority nursing diagnosis for this client? A. Risk for suicide R/T hopelessness B. Anxiety: severe R/T hyperactivity C. Imbalanced nutrition: less than body requirements R/T refusal to eat D. Dysfunctional grieving R/T loss of employment

ANS: A The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses on the basis of physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose. KEY: Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care

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." What should be the priority nursing action? A. Assess the client's vital signs. B. Offer to have the dietitian discuss food preferences. C. Encourage the client to lead the exercise program in the community meeting. D. Acknowledge the client briefly and then walk away.

ANS: A When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that co-occurring physical problems could be masked by hyperactive, manic, or both behaviors. The client's statement of "I'm thirsty and I'm burning up" could be a symptom of either infection or dehydration and must be assessed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of CareANS: A When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that co-occurring physical problems could be masked by hyperactive, manic, or both behaviors. The client's statement of "I'm thirsty and I'm burning up" could be a symptom of either infection or dehydration and must be assessed. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

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

ANS: A, B It is difficult to diagnose a child or adolescent with bipolar disorder because bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

Which of the following instructions regarding lithium therapy should be included in a nurse's discharge teaching? Select all that apply. A. Avoid excessive use of beverages containing caffeine. B. Maintain a consistent sodium intake. C. Consume at least 2,500 to 3,000 mL of fluid per day. D. Restrict sodium content. E. Restrict fluids to 1,500 mL per day.

ANS: A, B, C The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high due to the narrow margin between therapeutic doses and toxic levels. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? A. "I will limit my intake of fluids daily." B. "I will maintain normal salt intake." C. "I will take Lithobid on an empty stomach." D. "I will increase my caloric intake to prevent weight loss."

ANS: B A client taking Lithobid should be taught not to skimp on dietary sodium intake. He or she should take Lithobid on a full stomach to avoid gastrointestinal upset and choose lower-calorie foods to prevent weight gain. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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? A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil)

ANS: B Although lithium is a prototype drug in the treatment of bipolar disorders, anticonvulsants such as valproic acid also have demonstrated efficacy for mood stabilization. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess? A. Pacing B. Flight of ideas C. Lability of mood D. Irritability

ANS: B Clients diagnosed with bipolar disorder: manic episode experience cognition and perception fragmentation often with psychosis during acute mania. Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speak with abrupt changes from topic to topic. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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

ANS: B 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. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom? A. "I can't stop my sexual urges. They have led me to numerous affairs." B. "I'm the world's most perceptive attorney." C. "My wife is distraught about my overspending." D. "The FBI is out to get me."

ANS: B Grandiosity is defined as a belief that personal abilities are better than anyone else's. This client is experiencing delusions of grandeur, which are commonly experienced in mania. KEY: Cognitive Level: Application | Integrated Processes: Evaluation | Client Need: Psychosocial Integrity

What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? A. "Risky Activity" tool B. "FIND" tool C. "Consensus Committee" tool D. "Monotherapy" tool

ANS: B The Consensus Group recommends that clinicians use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client is diagnosed with cyclothymic disorder. What client behaviors should the nurse expect to assess? A. The client expresses "feeling blue most of the time." B. The client has endured periods of elation and dysphoria lasting for more than 2 years. C. The client fixates on hopelessness and thoughts of suicide continually. D. The client has labile moods with periods of acute mania.

ANS: B 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. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

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

ANS: B The initial signs of lithium toxicity include ataxia, blurred vision, severe diarrhea, persistent nausea and vomiting, and tinnitus. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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

ANS: B The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the client's rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Physiological Integrity

A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred? A. "This disorder is more prevalent in the lower socioeconomic groups." B. "This disorder is more prevalent in the higher socioeconomic groups." C. "This disorder is equally prevalent in all socioeconomic groups." D. "This disorder's prevalence cannot be evaluated on the basis of socioeconomic groups."

ANS: B The nursing student is accurate when stating that bipolar disorder is more prevalent in higher socioeconomic groups. Theories consider both hereditary and environmental factors in the etiology of bipolar disorder. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Health Promotion and Maintenance

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. The nurse should correlate these symptoms with which lithium level? A. 1.3 mEq/L B. 1.7 mEq/L C. 2.3 mEq/L D. 3.7 mEq/L

ANS: B 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. There is a narrow margin between the therapeutic and toxic levels. The symptoms presented in the question can be correlated with a lithium level of 1.7 mEq/L. Levels of 2.3 mEq/L and 3.7 mEq/L would produce more extreme symptoms of intensified toxicity, eventually leading to death. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem-solving to cope adequately after discharge.

ANS: C 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 injure self inadvertently, and in the depressive phase the client can be at risk for suicide. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment

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. What should be the nurse's initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems.

ANS: C During a manic episode, the client experiences increased agitation and extreme hyperactivity that can lead to a risk for injury. Overstimulation can exacerbate these symptoms. Therefore, the nurse's initial action should focus on removing the client from the stimulating environment to a calmer location. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment: Management of Care

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? A. Ineffective individual coping R/T hospitalization AEB alcohol abuse B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss C. Risk for violence: directed toward others R/T agitation and hyperactivity D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night

ANS: C Some signs and symptoms of mania include manic excitement, delusional thinking, and hallucinations, which may predispose the client to aggressive behavior. Nurses should be alert to the risk for self or other directed violence and intervene immediately at the first signs of agitation or aggression. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Safe and Effective Care Environment: Management of Care

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 pounds in this time frame. Which is the appropriate nursing reply? A. "That's strange. Weight loss is the typical pattern." B. "What have you been eating? Weight gain is not usually associated with lithium." C. "Weight gain is a common but troubling side effect." D. "Weight gain occurs only during the first month of treatment with this drug."

ANS: C The nurse should explain to the client that 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. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes? Client Outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night. A. 2, 1, 3, 4 B. 4, 1, 2, 3 C. 3, 1, 4, 2 D. 1, 4, 2, 3

ANS: C The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the client's physical and safety needs. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning | Client Need: Safe and Effective Care Environment: Management of Care

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

ANS: C The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients should not exceed 400 mg daily. KEY: Cognitive Level: Application | Integrated Processes: Implementation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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

ANS: D Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain low levels of stimuli in the client's environment (low lighting, few people, simple décor, low noise levels). Anxiety levels rise in a stimulating environment. Neutral colors and pale accessories are most appropriate for a client experiencing mania. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

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? A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." B. "Mood euthymic. Exhibiting magical thinking. Restless." C. "Mood labile. Exhibiting delusions of reference. Hyperactive." D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."

ANS: D 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. KEY: Cognitive Level: Application | Integrated Processes: Communication and Documentation | Client Need: Safe and Effective Care Environment

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? A. "Zyprexa in combination with Eskalith cures manic symptoms." B. "Zyprexa prevents extrapyramidal side effects." C. "Zyprexa ensures a good night's sleep." D. "Zyprexa calms hyperactivity until the Eskalith takes effect."

ANS: D The nurse should explain to the client's spouse that Zyprexa can calm hyperactivity until the Eskalith takes effect. Eskalith may take 1 to 3 weeks to begin to decrease hyperactivity. Zyprexa is classified as an antipsychotic and can be used to immediately to reduce hyperactive symptoms in acute manic episodes. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? A. Symptoms indicate consumption of foods high in tyramine. B. Symptoms indicate lithium carbonate discontinuation syndrome. C. Symptoms indicate the development of lithium carbonate tolerance. D. Symptoms indicate lithium carbonate toxicity.

ANS: D The nurse should interpret that the client's symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly during maintenance therapy to ensure proper dosage. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

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? A. "Treatment is compromised when clients can't sleep." B. "Treatment is compromised when irritability interferes with social interactions." C. "Treatment is compromised when clients have no insight into their problems." D. "Treatment is compromised when clients choose not to take their medications."

ANS: D The nursing student should understand that 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. Symptoms of bipolar disorder will reemerge if medication is stopped. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies

A client diagnosed with bipolar disorder and experiencing mania is admitted to the inpatient psychiatric setting. During the acute phase of mania, which medication would the nurse expect to most likely administer? A) Lithium carbonate (Lithium) B) Haloperidol lactate (Haldol) C) Fluoxetine (Prozac) D) Paroxetine (Paxil)

B

A nurse is preparing to administer medications to a female client with bipolar disorder who is experiencing acute mania. Which of the following would be most appropriate for the nurse to do? A) Tell the client firmly that she must take her medication. B) Allow the client to participate in the treatment decision. C) Restrain the client before administering the medication. D) Notify the physician about the client's refusal of the medication.

B

A client with bipolar disorder has had a history of multiple episodes and states, ​I'm so frustrated with what's happened because of these episodes.​ Which of the following would the nurse encourage to help support this client's recovery? A) codependence B) hope C) self control D) independent decision making

B Emphasizing the recovery concept of hope will support the person who has had multiple episodes and is frustrated with the impact of several episodes. Recovery is promoted through engaging the client in partnership and empowering the person to make decisions in setting overall goals of care. Shared decision making has been shown to improve outcomes.

A nurse is developing a presentation for families who have members that have been diagnosed with bipolar disorders. When describing this condition to the group, which of the following would the nurse most likely include? A) As the person ages, the episodes tend to decrease over time. B) Environmental stressors are a key cause of these disorders. C) The risk for suicide is high with either depression or mania. d) Risk-taking behaviors are more common with a depressive episode.

C

A client who is receiving lithium comes to the clinic for an evaluation. During the visit, the client reports a fine hand tremor. Which action by the nurse would be most appropriate? A) Immediately obtain a specimen to determine the client's blood drug level. B) Suggest that the client take the medication with meals or snacks. C) Assist the client in minimizing exposure to stressors. D) Encourage the client to elevate the affected hand on a pillow.

Fine hand tremor is a side effect of lithium therapy that can worsen with anxiety and intentional movement. The nurse would provide support and reassurance , and encourage the patient the client to minimize their exposure to stressors. If the client is experiencing difficult at work the provider should be notified. There is no need to obtain a drug level.

The nurse is assessing a client with bipolar disorder who is experiencing mania. The client states, ​I'm just so beautiful. Everyone just stops and stares at how gorgeous I am. Men constantly want to have sex with me.​ The nurse interprets these statements as indicative of which type of mood? A) irritable B) elevated C) expansive D) euphoric

The client's statements reflect an expansive mood, which is characterized by lack of restraint in expressing feelings; an overvalued sense of self-importance; and a constant and indiscriminate enthusiasm for interpersonal, sexual, or occupational interactions. An irritable mood is characterized by easy annoyance and provocation to anger, particularly when wishes are challenged or thwarted. An elevated mood can be expressed as euphoria (exaggerated feelings of well-being) or elation

A client with bipolar disorder is receiving divalproex sodium as part of the treatment plan. When monitoring the client's blood level for this drug, which level would alert the nurse to the need to change the dosage? A) 30 ng/mL B) 55 ng/mL C) 75 ng/mL D) 115 ng/mL

a

The nurse is reviewing the medical record of a client with bipolar disorder. The nurse would most likely expect to find a history of which of the following? A) panic disorder B) schizophrenia C) delusional disorder D) post traumatic stress disorder

a

A client is to receive lithium therapy as part of the treatment plan for bipolar disorder. When reviewing the client's medication history, which agents would alert the nurse to the possibility that a decrease in lithium dosage may be needed? Select all that apply. A) Lisinopril B) Hydrochlorothiazide C) Indomethacin D) Caffeine E) Aspirin

a, b, c

A client with bipolar disorder has a lithium drug level of 1.2 mEq/L. Which of the following would the nurse expect to assess? Select all that apply. a) metallic taste B) ataxia C) diarrhea D) slurred speech E) fascicultations F) muscle weakness

a, c, f

23. Which documentation indicates that the treatment plan for a patient experiencing acute mania has been effective? a. "Converses without interrupting; 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."

a. "Converses without interrupting; clothing matches; participates in activities." The descriptors given indicate the patient is functioning at an optimal level, using appropriate behavior, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behavior.

10. A patient diagnosed with bipolar disorder commands other patients, "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. Select the best initial approach by the nurse. 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 patients around." d. Honest feedback: "Your controlling behavior is annoying others."

a. Distraction: "Let's go to the dining room for a snack." The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into a power struggle. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed to a labile patient and may incite anger.

2. A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then the patient says gaily, "Do you like my scarves? Here...they are my gift to you." How should the nurse document the patient's mood? a. Labile and euphoric b. Irritable and belligerent c. Highly suspicious and arrogant d. Excessively happy and confident

a. Labile and euphoric The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile. Irritability, belligerence, excessive happiness, and confidence are not entirely correct terms for the patient's mood. A high level of suspicion is not evident.

35. A patient tells the nurse, "I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, there's no guarantee I won't have a relapse. I am such 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

a. Powerlessness c. Chronic low self-esteem Chronic low self-esteem and powerlessness are interwoven in the patient's statements. No data support the other diagnoses.

33. A patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family? Select all that apply. a. Provide structure b. Limit credit card access c. Encourage group social interaction d. Limit work to half days e. Monitor the patient's sleep patterns

a. Provide structure b. Limit credit card access e. Monitor the patient's sleep patterns A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is overstimulated by a busy environment. Providing structure helps the patient 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. A full leave of absence from work is necessary to limit stimuli and to prevent problems associated with poor judgment and the inappropriate decision making that accompany hypomania.

3. A patient experiencing mania has not eaten or slept for 3 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management

a. Risk for injury Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient's physiologic safety. Hyperactivity and poor judgment place the patient at risk for injury

19. A health teaching plan for a patient taking lithium should include instructions to: a. maintain normal salt and fluids in the diet. b. drink twice the usual daily amount of fluids. c. double the lithium dose if diarrhea or vomiting occurs. d. avoid eating aged cheese, processed meats, and red wine.

a. maintain normal salts and fluids in the diet Sodium depletion and dehydration increase the chance for developing lithium toxicity. The incorrect options offer inappropriate information.

18. A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with: a. meals. b. an antacid. c. a large glass of juice. d. an antiemetic medication.

a. meals. Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

8. The cause of bipolar disorder has not been determined, but: a. several factors, including genetics, are implicated. b. brain structures were altered by stresses early in life. c. excess norepinephrine is probably a major factor. d. excess sensitivity in dopamine receptors may exist.

a. several factors, including genetics, are implicated At this time, the interplay of complex independent variables is most likely the best explanation of the cause for bipolar disorder. Various theories implicate genetics, endocrine imbalance, early stress, and neurotransmitter imbalances.

11. A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: lithium level 1 mEq/L. This result is: a. within therapeutic limits b. below therapeutic limits c. above therapeutic limits d. incorrect because of inaccurate testing

a. within therapeutic limits The normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

9. The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurse's best response. a. "A high proportion of patients diagnosed with bipolar disorders are found among creative writers." b. "A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder." c. "Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses." d. "More individuals diagnosed with bipolar disorder come from high socioeconomic and educational backgrounds.

b. "A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder" Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission of bipolar disorder.

31. A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse should advise the patient: a. "Restrict oral fluids for 24 hours and stay in bed." b. "Have someone bring you to the clinic immediately." c. "Drink a large glass of water with 1 teaspoon of salt added." d. "Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides."

b. "Have someone bring you to the clinic immediately." The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurologic symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not address the patient's symptoms. Restricting oral fluids will make the situation worse.

30. A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's most appropriate response. a. "You will be able to stop the medication in approximately 1 month." b. "Taking the medication every day helps prevent relapses and recurrences." c. "Usually patients take this medication for approximately 6 months after discharge." d. "It's unusual that the health care provider has not already stopped your medication."

b. "Taking the medication everyday helps prevent relapses and recurrences." Patients diagnosed with bipolar disorder may be indefinitely maintained on lithium to prevent recurrences. Helping the patient understand this need promotes medication compliance. The incorrect options offer incorrect or misleading information.

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

b. Disturbed sleep pattern Patients diagnosed 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 patients diagnosed with MDD. Defensive coping is more relevant for patients experiencing mania. Fluid volume excess is less relevant for patients diagnosed with mood disorders than is deficient fluid volume.

34. A nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses are most likely? Select all that apply. a. Imbalanced nutrition: more than body requirements b. Disturbed thought processes c. Sleep deprivation d. Chronic confusion e. Social isolation

b. Disturbed though processes c. Sleep deprivation People with mania are hyperactive and often do not take the time to eat and drink properly. Their high levels of activity consume calories; therefore deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

15. A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action? a. Confer with the health care provider regarding use of seclusion for this patient. b. Hold a staff meeting to discuss consistency and limit-setting approaches. c. Conduct a meeting with all patients to discuss the behavior. d. Explain to the patient that the behavior is unacceptable.

b. Holding a staff meeting to discuss consistency and limit-setting approaches When staff members are overwhelmed, the patient 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. Criteria for seclusion have not been met.

17. A patient experiencing acute mania 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." Select the nurse's most appropriate intervention. a. Suggest to the patient to ask a friend do the shopping and bring purchases to the unit. b. Invite the patient to sit with the nurse and look at new fashion magazines. c. Tell the patient that computer use is not allowed until self-control improves. d. Ask whether the patient has enough money to pay for the purchases.

b. Invite the patient to sit with the nurse and look at new fashion magazines Situations such as this offer an opportunity to use the patient's distractibility to the staff's advantage. Patients become frustrated when staff members deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient's need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

14. At a unit meeting, staff members discuss the decor for a special room for patients experiencing mania. Select the best option. a. 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

b. Neutral walls with pale, simple accessories The environment for a patient experiencing mania should be as simple and as nonstimulating as possible. Patients experiencing mania are highly sensitive to environmental distractions and stimulation. Draperies present a risk for injury.

24. A patient experiencing mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation? a. Monitor physiologic functioning b. Provide a subdued environment c. Supervise personal hygiene d. Observe for mood changes

b. Provide a subdued environment All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping balance activity and rest.

13. When a hyperactive patient experiencing acute mania is hospitalized, what initial nursing intervention is a priority? a. Allow the patient to act out his or her feelings. b. Set limits on the patient's behavior as necessary. c. Provide verbal instructions to the patient to remain calm. d. Restrain the patient to reduce hyperactivity and aggression.

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

6. A patient develops mania after discontinuing lithium. New prescriptions are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will: a. minimize the side effects of lithium. b. bring hyperactivity under rapid control. c. enhance the antimanic actions of lithium. d. provide long-term control of hyperactivity.

b. 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. Antipsychotic drugs neither enhance lithium's antimanic activity nor minimize the side effects. Lithium is used for long-term control.

5. This nursing diagnosis applies to a patient experiencing mania: Imbalanced nutrition: less than body requirements, related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will: 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 in the psychiatric unit.

b. drink six servings of a high-calorie, high-protein drink each day High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient will eat or drink. Appropriate attire is unrelated to the nursing diagnosis.

A client is brought to the emergency department by his brother. The client has a history of bipolar disorder for which he is taking divalproex. The brother reports that he watched his brother take the medication about 2 hours ago. He stated, ​A little while ago, he got very disoriented and agitated.​ The nurse suspects toxicity based on assessment of which of the following? Select all that apply. A) Tachypnea B) Bradycardia C) Hypotension D) Nystagmus E) V omiting

c, d, e

The nurse is preparing a teaching plan for the family of a client who has been diagnosed with bipolar disorder. After teaching them about potential indicators for relapse, the nurse determines that the teaching was effective when they identify which of the following as suggesting mania? Select all that apply. A) Avoiding people B) Sleeping more than usual C) Talking faster than usual D) Being hungry all the time E) Reading several books at once

c, d, e

4. A patient diagnosed with bipolar disorder is hyperactive and manic after discontinuing lithium. The patient threatens to hit another patient. 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?"

c. "Do not hit anyone. If you are unable to control yourself, we will help you." When the patient 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 patient and threaten the patient with seclusion as punishment. Asking "why" does not provide for environmental safety.

21. Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania? a. Spaghetti and meatballs, salad, a banana b. Beef and vegetable stew, a roll, chocolate pudding c. Broiled chicken breast on a roll, an ear of corn, apple d. Chicken casserole, green beans, flavored gelatin with whipped cream

c. Broiled chicken breast on a roll, an ear of corn, apple The correct foods provide adequate nutrition but, more importantly, are finger foods that the hyperactive patient could "eat on the run." The foods in the incorrect options cannot be eaten without utensils.

29. A patient receiving lithium should be assessed for which evidence of complications? a. Pharyngitis, mydriasis, and dystonia b. Alopecia, purpura, and drowsiness c. Diaphoresis, weakness, and nausea d. Ascites, dyspnea, and edema

c. Diaphoresis, weakness, and nausea Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

1. A person is directing traffic on a busy street while shouting and making obscene gestures at passing cars. 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 deficit and sad mood

c. Poor judgment and hyperactivity Hyperactivity (directing traffic) and poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distractors do not specifically apply to mania.

7. A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed? a. phenytoin (Dilantin) b. clonidine (Catapres) c. carbamazepine (Tegretol) d. chlorpromazine (Thorazine)

c. carbamazepine (Tegretol) Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Phenytoin is also an anticonvulsant but is not used for mood stabilization. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients with manic episodes.

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

c. clear the room of all other patients. Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. A show of force is likely to frighten the patient and increase this risk for violence.

12. Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group? a. clonazepam (Klonopin) b. risperidone (Risperdal) c. lamotrigine (Lamictal) d. aripiprazole (Abilify)

c. lamotrigine (Lamictal) The three drugs in the stem of this question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs.

16. A patient experiencing acute mania undresses in the group room and dances. The nurse's first intervention would be to: a. quietly ask the patient, "Why don't you put on your clothes?" b. firmly tell the patient, "Stop dancing, and put on your clothing." c. put a blanket around the patient, and walk with the patient to a quiet room. d. allow the patient stay in the group room. Move the other patients to a different area.

c. put a blanket around the patient, and walk with the patient to a quiet room Patients must be protected from the embarrassing consequences of their poor judgment whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff members to avoid argument and provide control is an effective approach.

22. Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on: a. maintaining an interest in the environment. b. developing an optimistic outlook. c. self-control of distorted thinking. d. stabilizing the sleep pattern.

c. self-control of distorted thinking The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients 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.

A client's blood level of carbamazepine is increased. When reviewing the client's medication history, which of the following would alert the nurse to a possible interaction? A) Phenobarbital B) Primidone C) Phenytoin D) Diltiazem

d

32. Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical? a. Arthritis b. Epilepsy c. Psoriasis d. Congestive heart failure

d. Congestive heart failure The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. Arthritis, epilepsy, and psoriasis do not directly involve fluid balance and kidney function.

25. A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention? a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing. b. Continue to monitor and document the patient'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 patient may not be swallowing medications.

d. Consider the need to check the lithium level. The patient may not be swallowing medications. The patient is continuing to exhibit manic symptoms. The lithium level may be low as a result of "cheeking" the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased.

28. After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patient's family? a. Decreasing physical activity b. Increasing food and fluids c. Meeting self-care needs d. Psychoeducation

d. Psychoeducation During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, the treatment focuses on maintaining medication compliance and preventing a relapse, both of which are fostered by ongoing psychoeducation.

26. A patient experiencing acute mania has disrobed in the hall three times in 2 hours. The nurse should: a. direct the patient to wear clothes at all times. b. ask if the patient finds clothes bothersome. c. tell the patient that others feel embarrassed. d. arrange for one-on-one supervision.

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