Mood Disorders Practice Questions (Test #3, Fall 2020)

The physician orders lithium carbonate 600 mg tid for a newly diagnosed client with Bipolar I Disorder. There is a narrow margin between the therapeutic and toxic levels of lithium. Therapeutic range for acute mania is a. 1.0 to 1.5 mEq/L. b. 10 to 15 mEq/L. c. 0.5 to 1.0 mEq/L. d. 5 to 10 mEq/L

A

A nurse is educating a client about his lithium therapy. She is explaining signs and symptoms of lithium toxicity. Which of the following would she instruct the client to be on the alert for? a. Fever, sore throat, malaise b. Tinnitus, severe diarrhea, ataxia c. Occipital headache, palpitations, chest pain d. Skin rash, marked rise in blood pressure, bradycardia

B

A client experiencing mania states, "Everything I do is great." Using a cognitive approach, which nursing response would be most appropriate? 1. "Is there a time in your life when things didn't go as planned?" 2. "Everything you do is great." 3. "What are some other things you do well?" 4. "Let's talk about the feelings you have about your childhood."

1 1. By asking, "Is there a time in your life when things didn't go as planned?" the nurse is using a cognitive approach to challenge the thought processes of the client. 2. By stating, "Everything you do is great," the nurse is using the therapeutic technique of restating. This is a general communication technique and is not considered a cognitive communication approach, which would challenge the client's thought processes. 3. By asking, "What are some other things you do well?" the nurse is using a cognitive approach by encouraging further discussion about strengths. However, the content of this communication is inappropriate because it reinforces the grandiosity being experienced by the client. 4. By stating, "Let's talk about the feelings you have about your childhood," the nurse is using an intrapersonal, not cognitive, approach by assessing the client's feelings rather than thoughts. TEST-TAKING HINT: There are two aspects of this question of which the test taker must be aware. First, the test taker must choose a statement by the nurse that is cognitive in nature and then ensure the appropriateness of the statement.

A nurse working with a client diagnosed with bipolar I disorder attempts to recognize the motivation behind the client's use of grandiosity. Which is the rationale for this nurse's action? 1. Understanding the reason behind a behavior would assist the nurse to accept and relate to the client, not the behavior. 2. Change cannot occur until the client can accept responsibility for behaviors. 3. As self-esteem is increased, the client will meet needs without the use of manipulation. 4. Positive reinforcement would enhance self-esteem and promote desirable behaviors.

1 1. Grandiosity, which is defined as an exaggerated sense of self-importance, power, or status, is used by clients diagnosed with bipolar affective disorder to help reduce feelings of insecurity by increasing feelings of power and control. When the nurse understands the origin of this behavior, the nurse can better work with, and relate to, the client. 2. It is true that change cannot occur until the client accepts responsibility for behaviors, but this is not a rationale for the nurse's action of attempting to recognize the motivation behind the client's use of grandiosity. Accepting responsibility for behaviors would assist the client with the process of change, but does nothing to assist the nurse to recognize the motivation behind grandiose behavior. 3. It is true that as self-esteem is increased, the client will meet needs without the use of manipulation, but this is not a rationale for the nurse's action of attempting to recognize the motivation behind the client's use of grandiosity. Increasing self-esteem would assist the client to avoid future use of manipulation, but does nothing to assist the nurse to recognize the motivation behind this behavior. 4. It is true that positive reinforcement would enhance self-esteem and promote desirable behaviors, but this is not a rationale for the nurse's action of attempting to recognize the motivation behind the client's use of grandiosity. Positive reinforcement would promote desirable behaviors, but does nothing to assist the nurse to recognize the motivation behind this behavior. TEST-TAKING HINT: The test taker first must note the nursing action being addressed in the question (attempting to recognize the motivation behind the client's use of grandiosity), and then look for a specific reason the nurse implements this action (to accept and relate to the client, not the behavior)

A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority? 1. Calmly redirect and remove the client from the milieu. 2. Administer prescribed PRN intramuscular injection for agitation. 3. Notify the client to lower voice. 4. Obtain an order for seclusion to help decrease external stimuli.

1 1. When a client experiencing mania is yelling at other peers, it is the nurse's priority to address this situation immediately. Behaviors of this type can escalate into violence toward clients and staff members. By using a calm manner, the nurse avoids generating any further hostile behaviors, and by removing the client from the milieu, the nurse protects other clients on the unit. 2. Administering a prescribed PRN intramuscular injection for agitation could be an appropriate intervention, but only after all less restrictive measures have been attempted. 3. When the nurse notifies an agitated client in a manic phase of bipolar I disorder to lower voice, the nurse has lost sight of the fact that these behaviors are inherent in this client's diagnosis. The client who is yelling at another peer does not have the ability to alter behaviors in response to simple direction. 4. Obtaining an order for seclusion to help decrease external stimuli could be an appropriate intervention, but only after all less restrictive measures have been attempted. TEST-TAKING HINT: The test taker must remember that all less restrictive measures must be attempted before imposing chemical or physical restraints. Understanding this would help the test taker to eliminate "2" and "4" immediately.

A client newly admitted to an in-patient psychiatric unit who is experiencing a manic episode. The client's a nursing diagnosis is imbalanced nutrition, less than body requirements. Which meal is most appropriate for this client? 1. Chicken fingers and French fries. 2. Grilled chicken and a baked potato. 3. Spaghetti and meatballs. 4. Chili and crackers.

1 Clients experiencing mania have excessive psychomotor activity that leads to an inability to sit still long enough to eat. Increased nutritional intake is necessary because of a high metabolic rate. 1. Chicken fingers and French fries are finger foods, which the client would be able to eat during increased psychomotor activity, such as pacing. Because these foods are high in caloric value, they also meet the client's increased nutritional needs. 2. Although grilled chicken and a baked potato would meet the client's increased nutritional needs, the baked potato is not a finger food and would be difficult for the client to eat during periods of hyperactivity 3. Although spaghetti and meatballs would meet the client's increased nutritional needs, this dinner would be difficult for the client to eat during periods of hyperactivity. 4. Although chili and crackers would meet the client's increased nutritional needs, this dinner would be difficult for the client to eat during periods of hyperactivity. TEST-TAKING HINT: To answer this question correctly, the test taker must understand that the symptom of hyperactivity during a manic episode affects the client's ability to meet nutritional needs. The test taker should look for easily portable foods with high caloric value to determine the most appropriate meal for this client.

Which milieu activity should the nurse recommend to a client with acute mania? Select all that apply. 1.Scheduled rest periods. 2.Relaxation exercises. 3.Listening to soft music. 4.Watching television. 5.Aerobic exercises.

1, 2, 3, 5 Scheduled rest periods, relaxation exercises, and listening to soft music are activities that reduce environmental stimuli for the client who is hyperactive, talkative, easily distracted, irritable, and angry. Aerobic exercise is also beneficial to discharge some of the client's need to be active. Watching television is not therapeutic because it would stimulate the client with acute mania.

The client with bipolar disorder, manic phase, has a valproic acid level of 15 mg/mL (104 μmol/L). Which of the following client behaviors should the nurse judge to be due to this level of valproic acid? Select all that apply. 1.Irritability. 2.Grandiosity. 3.Anhedonia. 4.Hypersomnia. 5.Flight of ideas.

1, 2, 5. The therapeutic level of valproic acid is 50 to 100 mg/mL (347 to 693 μmol/L). A level of 15 mg/mL (104 μmol/L) is not considered therapeutic. Therefore, the client would be manifesting symptoms of mania. Irritability, euphoria, grandiosity, pressured speech, flight of ideas, distractibility, and a decreased need for sleep are some characteristics of a manic episode. Anhedonia and hypersomnia are related to a depressive illness and not mania.

A client diagnosed with bipolar I disorder experienced an acute manic episode and was admitted to the in-patient psychiatric unit. The client is now ready for discharge. Which of the following resource services should be included in discharge teaching? Select all that apply. 1. Financial and legal assistance. 2. Crisis hotline. 3. Individual psychotherapy. 4. Support groups. 5. Family education groups.

1,2,3,4,5 1. During a manic episode, clients are likely to experience impulse control problems, which may lead to excessive spending. Having access to financial and legal assistance may help the client assess the situation and initiate plans to deal with financial problems. 2. During a manic episode, a client may not eat or sleep and may abuse alcohol or other drugs. The client's hyperactivity may lead to ambivalence regarding his or her desire to live. Having access to a crisis hotline may help the client to de-escalate and make the difference between life and death decisions. 3. During a manic episode, a client most likely would have had difficulties in various aspects of interpersonal relationships, such as family, friends, and coworkers. Individuals experiencing mania may be difficult candidates for psychotherapy because of their inability to focus. When the acute phase of the illness has passed, the client may decide to access an available resource to deal with interpersonal problems. Psychotherapy, in conjunction with medication maintenance treatment, and counseling may be useful in helping these individuals. 4. During a manic episode, a client would not be a willing candidate for any type of group therapy. However, when the acute phase of the illness has passed, this individual may want to access support groups to benefit therapeutically from peer support. 5. During a manic episode, a client may have jeopardized marriage or family functioning. Having access to a resource that would help this client restore adaptive family functioning may improve not only relationships, but also noncompliance issues and dysfunctional behavioral patterns, and ultimately may reduce relapse rates. Family therapy is most effective with the combination of psychotherapeutic and pharmacotherapeutic treatment. TEST-TAKING HINT: To answer this question correctly, the test taker must understand that during the manic phase of bipolar I disorder, clients engage in inappropriate behaviors that lead to future problems. It is important to provide outpatient resources to help clients avoid or minimize the consequences of their past behaviors.

The husband of a client who is experiencing acute mania and is swearing and using profanity apologizes to the nurse for his wife's behavior. Which of the following replies by the nurse is most therapeutic? 1."This must be difficult for you." 2."It's okay. We've heard worse." 3."How long has she been like this?" 4."She needs some medication."

1. Stating that this must be difficult for the husband conveys empathy and understanding and offers him the opportunity to voice his feelings to the nurse. Telling the husband that it is okay and that the nurse has heard worse is inappropriate and minimizes the impact of the wife's illness on the husband. Asking about the length of the client's illness or telling the husband that his wife needs some medication ignores the husband's feelings, thereby minimizing his self-respect.

During morning community meeting, a client with bipolar disorder, manic phase, interrupts others to the point where no one can finish their statements. The nurse should tell the client: 1."Please stop interrupting others. You can speak when it's your turn." 2."Stop talking. It's time for you to leave the meeting." 3."If you can't control yourself, we'll have to take action." 4."Please behave like an adult. Your behavior is childish."

1. For this client, the nurse needs to set limits on the client's intrusive, interruptive behavior by saying, "Please stop interrupting others; you can speak when it's your turn." This statement also clearly points out to the client the specific unacceptable behavior. The nurse helps the client to attain control and helps the other clients become more tolerant of the situation. Saying, "Stop talking; it's time for you to leave the meeting," is not helpful because it leaves the client unaware of what has happened or the behavior that is unacceptable. Also, such a statement may seem punitive. The statement, "If you can't control yourself, we'll have to take action," is threatening to the client and diminishes the client's self-worth. Using the statement, "Please behave like an adult. Your behavior is childish," is demeaning and scolding to the client, thereby diminishing the client's self-esteem.

A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client's daily assessment, the nurse should be especially alert for which of the following findings? 1.Exhaustion. 2.Vertigo. 3.Gastritis. 4.Bradycardia.

1. The client in the manic phase experiences insomnia, as evidenced by his sleeping only for about 4 hours a night for the past 5 days. The client experiencing an acute manic episode is not capable of judging the need for sleep. Therefore, the nurse should assess the amount of rest the client is receiving daily to prevent exhaustion. The development of vertigo, gastritis, or bradycardia typically does not result from acute mania.

The client with acute mania is prescribed 600 mg of lithium (lithium carbonate) PO three times per day. The primary health care provider also prescribes 5 mg of haloperidol (Haldol) PO at bedtime. Which action should the nurse take? 1.Administer the medication as prescribed. 2.Question the primary health care provider about the prescription. 3.Administer the Haldol, but not the lithium. 4.Consult with the nursing supervisor before administering the medications.

1. The nurse should administer the medication as prescribed. Lithium has a clinical response lag time of 1 to 2 weeks. Haloperidol is prescribed temporarily to produce a neuroleptic effect until the lithium starts to produce a clinical response. Haldol is usually discontinued when the lithium starts to take effect.

A client with acute mania exhibits euphoria, pressured speech, and flight of ideas. The client has been talking to the nurse nonstop for 5 minutes and lunch has arrived on the unit. Which of the following should the nurse do next? 1.Excuse self while telling the client to come to the dining room for lunch. 2.Tell the client he needs to stop talking because it's time to eat lunch. 3.Do not interrupt the client but wait for him to finish talking. 4.Walk away and approach the client in a few minutes before the food gets cold.

1. The nurse would excuse herself, showing respect and regard for the client, while telling the client to come to the dining room for lunch. Acutely manic clients need clear, concise comments and directions. Telling the client that he needs to stop talking because it's lunchtime is disrespectful and does not give the client directions for what he needs to do. Using the familiar skill of waiting without interrupting until the person pauses would not be effective with the very talkative, manic client. Walking away and approaching the client after a few minutes before the food gets cold is not helpful because the client would probably continue talking

A health care provider has prescribed valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. The nurse should instruct the client about which of the following? 1.Follow-up blood tests are necessary while on this medication. 2.The extended-release tablet can be crushed if necessary for ease of swallowing. 3.Tachycardia and upset stomach are common side effects. 4.Consumption of a moderate amount of alcohol is safe if the medication is taken in the morning.

1. Valproic acid can cause hepatotoxicity, so regular liver function tests are needed. Other side effects include nausea and drowsiness. Extended-release tablets should not be split or crushed; doing so changes their absorption. Alcohol should never be mixed with this medication. There will be medication in the client's body at all times.

The nurse is prioritizing nursing diagnoses in the plan of care for a client experiencing a manic episode. Number the diagnoses in order of the appropriate priority. ______ a. Disturbed sleep pattern evidenced by sleeping only 4 to 5 hours per night ______ b. Risk for injury related to manic hyperactivity ______ c. Impaired social interaction evidenced by manipulation of others ______ d. Imbalanced nutrition: Less than body requirements evidenced by loss of weight and poor skin turgor

1. B 2.D 3.A 4.C

A client newly admitted with bipolar I disorder has a nursing diagnosis of risk for injury R / T extreme hyperactivity. Which nursing intervention is appropriate? 1. Place the client in a room with another client experiencing similar symptoms. 2. Use PRN antipsychotic medications as ordered by the physician. 3. Discuss consequences of the client's behaviors with the client daily. 4. Reinforce previously learned coping skills to decrease agitation.

2 1. Placing a hyperactive client diagnosed with bipolar I disorder with another hyperactive client would only serve to increase hyperactivity in both clients. When a client is in a manic phase of the disorder, the best intervention is to reduce environmental stimuli, assign a private room, and keep lighting and noise level low. 2. A newly admitted client experiencing an extremely hyperactive episode as the result of bipolar I disorder would benefit from an antipsychotic medication to sedate the client quickly. Lithium carbonate (lithium) should be given concurrently for maintenance therapy and to prevent or diminish the intensity of subsequent manic episodes. 3. A client experiencing an extremely hypermanic episode as the result of bipolar I disorder would be a difficult candidate for a meaningful interaction. This client also would have difficulty comprehending the cause and effect of behaviors. 4. Reinforcing previously learned coping skills with a client experiencing a hypermanic episode would increase, not decrease, agitation. This client is unable to focus on review of learned behaviors because of the distractibility inherent in mania. TEST-TAKING HINT: To answer this question correctly, the test taker needs to understand that a client experiencing a manic episode must be deescalated before any teaching, confronting, or enforcing can occur

A client will be discharged on lithium carbonate 600 mg three times daily. When teaching the client and his family about lithium therapy, the nurse determines that teaching has been effective if the client and family state that they will notify the prescribing health care provider immediately if which of the following occur? Select all that apply. 1.Nausea. 2.Muscle weakness. 3.Vertigo. 4.Fine hand tremor. 5.Vomiting. 6.Anorexia.

2, 3, 5. Serious side effects that may indicate lithium toxicity include muscle weakness, vertigo, vomiting, extreme hand tremor, and sedation. The prescribing health care provider should be notified immediately when these symptoms occur. When lithium is initiated, mild or transient side effects can occur, such as nausea, fine hand tremor, anorexia, increased thirst and urination, and diarrhea or constipation.

In a pre discharge program to educate clients with bipolar disorder and their family members, the nurse emphasizes that the most significant indicators for the onset of relapse include which of the following symptoms? 1.A sense of pleasure and motivation for new endeavors. 2.Decreased need for sleep and racing thoughts. 3.Self-concern about increase in energy. 4.Leaving a good job to start a new business.

2. Decreased need for sleep and racing thoughts are the most prominent hallmarks of mania. Feelings of pleasure, motivation, and increased energy, within reason, are desired experiences. Also leaving a job to start a new business is not, in itself, a sign of impending illness.

A nurse observes a male client who is hyperactive and intrusive sitting very close to a female client with his arm around her shoulders. The nurse hears the male client tell a sexually explicit joke. The nurse approaches the client and asks him to walk down the hallway. Which of the following statements by the nurse should benefit the client? 1."She will not want to be around you with that kind of talk." 2."Telling sexual jokes and touching others is not permitted here." 3."You need to be careful about what you say to other people." 4."I think a time-out in your room would be appropriate now.

2. The nurse clearly informs the client about behavior that is unacceptable on the unit, such as voicing jokes with sexual content and touching others. Setting limits on behavior provides safety and security to the client and conveys to the client that he is worthy of help. Saying "she will not want to be around you with that kind of talk" and "you need to be careful about what you say to others" does not clearly inform the client about behaviors that are unacceptable and implies that the client can control behaviors if he chooses. A time-out in the client's room does not inform the client about the inappropriateness of his behaviors and could be interpreted by the client as punitive as well as diminishing his self-esteem

A client with bipolar disorder, manic phase, is scheduled for a chest radiograph. Before taking the client to the radiology department, the nurse should: 1.Give a thorough explanation of the procedure. 2.Explain the procedure in simple terms. 3.Call security to be on standby for possible problems. 4.Cancel the appointment until the client can go unescorted

2. The nurse needs to explain the procedure in simple terms because the client in a manic phase has difficulty concentrating, is easily distracted, and can misinterpret what the nurse states. Giving a thorough explanation of the procedure is not helpful and can confuse the client. Calling security to be on standby is inappropriate. If the nurse judges that the client might elope or become agitated, the nurse should schedule the appointment for another time. Canceling the appointment until the client can go unescorted is impractical and may not follow unit or hospital policy and the client's treatment plan.

The client with bipolar disorder is approaching discharge after being hospitalized with her first episode of acute mania. The client's husband asks the nurse what he can do to help her. Which of the following recommendations for the husband should the nurse anticipate including in the teaching plan? 1.Help the client to be free from worry and anxiety. 2.Communicate openly and offer support. 3.Relieve the client of all responsibilities. 4.Remind the client to control her symptoms.

2. The nurse should encourage the husband to support and communicate openly with his wife to maintain effective family-client interactions. During any illness, open communication and support helps the relationship between husband and wife. It is unrealistic for any individual to be free from anxiety or worry and impossible for the husband to be able to control what his wife may think or feel. Relieving the client of all responsibilities is unrealistic and not helpful. The client needs to resume activities as soon as she can manage them. Reminding his wife to control her symptoms is not appropriate and indicates that the husband needs further teaching about this condition.

A client's wife states, "I don't know what to do sometimes. It's so hard having a husband with a mental illness like bipolar disorder." After talking with the client's wife about her feelings and difficulties, which of the following actions is most appropriate? 1.Suggest that the wife see her primary health care provider. 2.Give the wife information about a support group. 3.Recommend that the wife talk with her close friend. 4.Have the wife share her feelings with her husband.

2. The nurse's most appropriate action is to give the wife information about a support group in her area. Family members need and want education and support. Suggesting that the wife see a primary health care provider is not necessary in this situation. She needs support and education. Recommending that she talk with her close friend may be helpful if she so chooses. However, this is not as helpful as attending a support group. Here the wife can learn, share, obtain support from, and provide support to others with similar situations. Having the wife share her feelings with her husband may or may not be appropriate or helpful to her or her husband. The husband may be unable to help his wife with adaptive coping, and therefore the client's self-esteem could be diminished.

A client diagnosed with bipolar disorder asks the nurse why it is necessary to have a serum lithium level drawn every 3 to 4 months. The nurse's response should be based on which of the following? 1.To monitor compliance with the medication. 2.To prevent toxicity related to the drug's therapeutic range. 3.To monitor the client's white blood cell count. 4.To comply with the drug manufacturer's requirements.

2. The serum lithium level has nothing to do with the client's white blood cell count and the drug manufacturers have no specific requirement for blood testing. While a periodic serum lithium level could monitor whether or not a client was taking the prescribed medication, the most important reason for the blood test is to periodically assess the client's lithium level and prevent even mild toxicity on an ongoing basis.

After the nurse teaches a client with bipolar disorder about lithium therapy, which of the following client statements indicates the need for additional teaching? 1."It's important to keep using a regular amount of salt in my diet." 2."It's okay to double my next dose of lithium if I forget a dose." 3."I should drink about 8 to 10 eight-ounce glasses (240 to 300 mL) of water each day." 4."I need to take my medicine at the same time each day.

2. The therapeutic and toxic range of lithium is very narrow. If the client forgets to take a scheduled dose of lithium, the client needs to wait until the next scheduled time to take it, because taking twice the amount of lithium can cause lithium toxicity. The client needs to maintain a regular diet and regular salt intake. Lithium and sodium are eliminated from the body through the kidneys. An increase in salt intake leads to decreased plasma lithium levels because lithium is excreted more rapidly. A decrease in salt intake leads to increased plasma lithium levels. The client needs to drink 8 to 10 eight-ounce glasses (240 to 300 mL) of water daily to maintain fluid balance and decrease thirst. Decreased water intake can lead to an increase in the lithium level and consequently a risk of toxicity. Lithium must be taken on a regular basis at the same time each day to ensure maximum therapeutic effect.maintain fluid balance and decrease thirst.

A young adult client diagnosed with bipolar disorder has been managing the disorder effectively with medication and treatment for several years. The client suddenly becomes manic. The nurse reviews the client's medication record. Which of the following medications may have contributed to the development of his manic state? 1.Amitriptyline. 2.Prednisone. 3.Buspirone. 4.Gabapentin.

2. The use of prednisone or other steroids can initiate a manic state in a bipolar client even if he is well controlled on medication. The other medications would decrease the client's depression, mood swings, and anxiety, making him calmer rather than more agitated.

A client prescribed lithium carbonate (Eskalith) is experiencing an excessive output of dilute urine, tremors, and muscular irritability. These symptoms would lead the nurse to expect that the client's lithium serum level would be which of the following? 1. 0.6 mEq/L. 2. 1.5 mEq/L. 3. 2.6 mEq/L. 4. 3.5 mEq/L.

3 1. A client with a lithium serum level of 0.6 mEq/L would not experience any negative symptoms because this level indicates that the client's serum concentration is at the low end of normal. 2. A client with a lithium serum level of 1.5 mEq/L may experience blurred vision, ataxia, tinnitus, persistent nausea and vomiting, and severe diarrhea. The client's symptoms described in the question do not support a lithium serum level of 1.5 mEq/L. 3. A client with a lithium serum level of 2.6 mEq/L may experience an excessive output of dilute urine, tremors, muscular irritability, psychomotor retardation, and mental confusion. The client's symptoms described in the question support a lithium serum level of 2.6 mEq/L. 4. A client with a lithium serum level of 3.5 mEq/L may experience impaired consciousness, nystagmus, seizures, coma, oliguria or anuria, arrhythmias, and myocardial infarction. The client's symptoms described in the question do not support a lithium serum level of 3.5 mEq/L. TEST-TAKING HINT: To answer this question correctly, the test taker must be aware of the symptoms associated with various lithium serum levels

A provocatively dressed client diagnosed with bipolar I disorder is observed laughing loudly with peers in the milieu. Which nursing action is a priority in this situation? 1. Join the milieu to assess the appropriateness of the laughter. 2. Redirect clients in the milieu to structured social activities, such as cards. 3. Privately discuss with the client the inappropriateness of provocative dress during hospitalization. 4. Administer PRN antianxiety medication to calm the client.

3 1. Although it is important for the nurse to gather any significant data related to client behaviors in the milieu, this nurse already has made the determination that the client is provocatively dressed. Dressing provocatively can precipitate sexual overtures that can be dangerous to the client and must be addressed immediately. 2. By redirecting clients to structured social activities, the nurse is not dealing with the assessed, critical problem of provocative dress. 3. Because dressing provocatively can precipitate sexual overtures that can be dangerous to the client, it is the priority of the nurse to discuss with the client the inappropriateness of this clothing choice. 4. When the nurse administers antianxiety medications in an attempt to calm the client, the nurse is ignoring the assessed critical problem of the client's provocative dress. TEST-TAKING HINT: The test taker should note that "1," "2," and "4" all address the observed behavior of potentially insignificant laughter in the milieu. Only "3" addresses the actual critical problem of provocative dress.

A nursing instructor is teaching about the cause of mood disorders. Which statement by a nursing student best indicates an understanding of the etiology of mood disorders? 1. "When clients experience loss, they learn that it is inevitable and become hopeless and helpless." 2. "There are alterations in the neurochemicals, such as serotonin, which cause the client's symptoms." 3. "Evidence continues to support multiple causations related to an individual's susceptibility to mood symptoms." 4. "There is a genetic component affecting the development of mood disorders."

3 1. Learning theorists believe that learned helplessness predisposes individuals to depression by imposing a feeling of lack of control over their life situations. They become depressed because they feel helpless; they have learned whatever they do is futile. However, this theory is only one of the possible causes of mood disorders. 2. Neurobiological theorists believe that there are alterations in the neurochemicals, such as serotonin, which cause mood disorder symptoms. However, this theory is only one of the possible causes of mood disorders. 3. When the student states that there is support for multiple causations related to an individual's susceptibility to mood symptoms, the student understands the content presented about the etiology of mood disorders. 4. Genetic theorists believe there is a strong genetic component affecting the development of mood disorders. However, this theory is only one of the possible causes of mood disorders. TEST-TAKING HINT: All answers presented are possible theories for the cause of mood disorders. To choose the correct answer, the test taker must understand that no one theory has been accepted as a definitive cause of mood disorders.

Which nursing charting entry is documentation of a behavioral symptom of mania? 1. "Thoughts fragmented, flight of ideas noted." 2. "Mood euphoric and expansive. Rates mood a 10/10." 3. "Pacing halls throughout the day. Exhibits poor impulse control." 4. "Easily distracted, unable to focus on goals."

3 1. When the nurse documents, "Thoughts fragmented, flight of ideas noted," the nurse is charting a cognitive, not behavioral, symptom of mania. 2. When the nurse documents, "Mood euphoric and expansive. Rates mood a 10/10," the nurse is charting an affective, not behavioral, symptom of mania. 3. When the nurse documents, "Pacing halls throughout the day. Exhibits poor impulse control," the nurse is charting a behavioral symptom of mania. Psychomotor activities and uninhibited social and sexual behaviors are classified as behavioral symptoms. 4. When the nurse documents, "Easily distracted, unable to focus on goals," the nurse is charting a cognitive, not behavioral, symptom of mania. TEST-TAKING HINT: The test taker must be able to differentiate the symptoms of mania as affective, cognitive, psychomotor, and behavioral to answer this question correctly.

A young woman comes to the mental health clinic for her routine medication follow-up. She has been married for 2 years and reports that she and her husband are ready to start a family. She has a diagnosis of bipolar I disorder and has been well managed on divalproex sodium (Depakote) for at least 3 years. What is the most essential counsel for the nurse to give her? 1."Schedule an appointment for a complete gynecological exam if you have not had one in the past year." 2."Pay careful attention to eating healthy from this point on in order to maximize the health of both mother and baby." "Check with your prescriber today as Depakote carries an increased risk for birth defects, especially during the first 3 months of pregnancy." 4."It is very important for you to take steps to reduce your stress and this will help you to stay in balance during your pregnancy and reduce your chances of developing post-partum depression.

3. All of these options need to be addressed. However, it is vital that this young woman receive counseling about the serious birth defects that have an increased incidence with the taking of Depakote during the first trimester of pregnancy. These problems include craniofacial abnormalities (cleft palate), organ malformations (holes in the heart and urinary tract problems), limb deficiencies, and developmental delays. The chances of preeclampsia and premature labor are also increased.

A client with acute mania fails to respond to a nurse's interventions to decrease his agitation. The nurse has attempted to defuse the client's anger, but the client refuses to participate in interventions that would lower anxiety. Which action should the nurse take next? 1.Seclude the client. 2.Restrain the client. 3.Medicate the client. 4.Control the client.

3. The nurse should medicate the client who does not respond to verbal interventions and whose anxiety is escalating. This will reduce the client's anxiety and agitation and prevent harm or injury to the client and others. Seclusion, restraint, and controlling the client are a last resort and require a primary health care provider's prescription and close assessment for when the prescriptions can be discontinued.

The primary health care provider prescribes determination of the serum lithium level tomorrow for a client with bipolar disorder, manic phase, who has been receiving lithium 300 mg PO three times daily for the past 5 days. At which of the following times should the nurse plan to have the blood specimen obtained? 1.Before bedtime. 2.After lunch. 3.Before breakfast. 4.During the afternoon.

3. Because lithium reaches peak blood levels in 1 to 3 hours, blood specimens for serum lithium concentration determinations are usually drawn before the first dose of lithium in the morning (which is usually 8 to 12 hours after the previous dose) or before breakfast. Stat lithium levels can be drawn at any time, usually when toxicity is suspected.

The wife of a client with bipolar disorder, manic phase, states to the nurse, "He's acting so crazy. What did he do to get this way?" The nurse bases the response on the understanding of which of the following about this disorder? 1.It is caused by underlying psychological difficulties. 2.It is caused by disturbed family dynamics in the client's early life. 3.It is the result of an imbalance of chemicals in the brain. 4.It is the result of a genetic inheritance from someone in the family.

3. Bipolar disorder is a biochemical disorder caused by an imbalance of neurotransmitters in the brain. Manic episodes seem to be related to excessive levels of norepinephrine, serotonin, and dopamine. Psychopharmacologic therapy aims to restore the balance of neurotransmitters. In the past, it was thought that bipolar disorder may have been caused by early psychodynamics or disturbed families, but the current view emphasizes the role of biology. Bipolar disorder could be genetic or inherited from someone in the family, but it is best for the client and family to understand the disease concept related to neurotransmitter imbalance. This understanding also helps them to refrain from placing blame on anyone. Siblings and close relatives have a higher incidence of bipolar disorder and mood disorders in general when compared with the general population.

A female client with acute mania brings six suitcases and three shopping bags of personal belongings on admission to the unit. When informed that some of the suitcases and bags need to be returned home with her husband because of a lack of storage space, the client begins to use profanity against the nurse. Which of the following responses by the nurse is most therapeutic? 1."You're acting inappropriately." 2."I won't tolerate your talking to me like that." 3."Swearing and profanity are unacceptable here." 4."We don't want to put you in seclusion yet.

3. By stating to the client, "Swearing and profanity is unacceptable here," the nurse is setting limits in a nonpunitive manner for behavior that is inappropriate or threatening to other clients and staff. Setting limits helps the client regain self-control, prevents alienation from others, and preserves self-esteem. It is common for the irritable manic client to misperceive the nurse's and other's statements and intentions, feel threatened, and respond in a manner that is out of character for the client when not in a manic phase. Stating that the client is acting very inappropriately or that the nurse will not tolerate the client's swearing and profanity or threatening to put the client in seclusion is threatening and punitive and thus nontherapeutic.

A nurse is assessing a client experiencing hypomania who wants to stop her mood stabilizing medication because she is "feeling good," has a high energy level, "and thinks she is productive at work. Which response by the nurse is most appropriate? 1."Maybe you really don't need your medication anymore." 2."If you stop your medication, your behavior will quickly spiral out of control." 3."I believe you were hospitalized the last time you stopped your medication." 4."Why don't you cut your medication dosage in half for a while and see how you respond?

3. Reminding the client of past consequences of stopping the medication may help her realize the risks of stopping the medication again. Options 1 and 4 encourage the client's misperception that she only needs medication when she feels depressed or manic rather than recognizing that her mood stabilizer can prevent her from experiencing those extreme highs and lows. Option 2 describes what will happen if she stops her medication, but if the client had recognized the consequences, she wouldn't be contemplating stopping the medication.

The nurse overhears a client with acute mania who is euphoric and flirtatious attempting to be sexually inappropriate with other clients by talking about a sexual exploit to a group of clients seated at a table. Which of the following should the nurse do next? 1.Continue walking down the hall, ignoring the conversation. 2.Speak to the client later in private while saying nothing at this time. 3.Tell the client others may not want to hear about sex and invite him to play a game of ping-pong. 4.Inform the client that if he continues to talk about sex no one will want to be around him.

3. Telling the client that others may not want to hear about sex and inviting him to play a game of ping-pong with the nurse informs the client that even though his behavior is unacceptable, the nurse considers him worthy of help. The client's thoughts and actions are out of control, and directing him to an activity with the nurse is an appropriate way of regaining control. The nurse is responsible for providing safety and security to this client and others on the unit. Continuing to walk down the hall while ignoring the conversation does nothing to meet the needs of this or other clients. Doing so also diminishes trust in the nurse. Speaking to the client later in private while saying nothing at the time allows the client to continue his provocative behavior instead of focusing his energy toward productive activity. Informing the client that if he continues to talk about sex, no one will want to be around him is not helpful because his behavior is a symptom of his illness and the statement diminishes his self-worth.

After the nurse administers haloperidol (Haldol) 5 mg PO to a client with acute mania, the client refuses to lie down on her bed, runs out on the unit, pushes clients in her vicinity out of the way, and screams threatening remarks to the staff. Which of the following should the nurse do next? 1.Follow the client and ask her to calm down. 2.Tell the client to lie down on the sofa in the community room. 3.Seclude the client and use restraints if necessary. 4.Tell the staff to ignore the client's remarks

3. The client is visibly out of control, and other measures have not helped. Therefore, the nurse needs to seclude the client and use restraints if necessary to protect the client and others from harm. Following the client and asking her to calm down or telling the client to lie down on the sofa is not helpful because the client's level of anxiety is too high for her to attempt to calm down on her own and she cannot control her behavior. Telling the staff to ignore the client's remarks is not helpful because the client needs external means of control to protect the client, other clients on the unit, and the staff. Safety is the priority.

The client with acute mania has been admitted to the inpatient unit voluntarily. The nurse approaches the client with medication to be taken orally as prescribed by the primary health care provider. The client states, "I don't need that stuff." Which response by the nurse is best? 1."You can't refuse to take this medication." 2."If you don't take it orally, I'll give you a shot." 3."The medication will help you feel calmer." 4."I'll get you some written information about the medication.

3. The nurse should first attempt a collaborative approach to increasing adherence to the prescribed medication regimen. Giving written medication information to a client with acute mania is poor nursing judgment, because a client with acute mania cannot benefit from written information as a result of impaired ability to focus and concentrate

A client states to a nurse, "Hey sweetie, you're looking good today." Which of the following responses by the nurse is best? 1."Thank you for being so kind and thoughtful." 2."I know you are only teasing me." 3."My name is Molly, and I am a nurse on the unit today." 4."I am not here to receive compliments from clients."

3. The nurse states her identity and purpose for being on the unit to clarify any misperception by the client. "Thank you for being so kind," "I know you are only teasing me," and "I am not here to receive compliments from clients" are nontherapeutic statements and do not clarify the nurse's identity and purpose.

The primary health care provider prescribes valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. Which of the following should the nurse include in the client's medication teaching plan? 1.Follow-up blood tests are unnecessary. 2.The tablet can be crushed if necessary. 3.Drowsiness and upset stomach are common side effects. 4.Consumption of a moderate amount of alcohol is safe.

3. Valproic acid, an anticonvulsant agent, is used as a mood stabilizer in the client with bipolar disorder. Common side effects include drowsiness and gastrointestinal upset. The client needs to be cautioned not to drive or perform tasks requiring alertness and to take the medication with food or milk or eat frequent, small meals. Blood tests are required to evaluate the serum level and to check for possible hematologic effects. Valproic acid can cause changes in liver function and blood dyscrasias. The tablet must be swallowed whole and not chewed or crushed to prevent irritation of the mouth and throat. Alcohol as well as over-the-counter drugs and sleep-inducing agents must be avoided to prevent oversedation.

As the nurse is turning off the television, a client with bipolar disorder, manic phase, says, "I want the television on so I can watch the late show. I'm not tired and you can't tell me what to do. I want it on!" The nurse should tell the client: 1."I'll let you watch television just this once. Don't tell anyone about this." 2."I'll turn the television off when you get sleepy. Don't ask me to do this again." 3."Television hours are from 7 pm to 10 pm. It's 10 pm, and the television goes off so everyone can sleep." 4."The television goes off at 10 pm. I've been telling you this for the past three evenings."

3. When the client in a manic state attempts to manipulate the nurse or demands privileges, the nurse must restate the unit rules in a calm and matter-of-fact manner. "The television hours are from 7 pm to 10 pm. It is 10 pm, and the television goes off so everyone can sleep" is the most therapeutic response because it restates the rules and is nonthreatening. During a manic phase, the client is impulsive and has difficulty concentrating. The client needs consistency and structure from the staff. The statement, "I'll let you watch television just this once; don't tell anyone about this," allows the client to manipulate the nurse, as does "I'll turn the television off when you get sleepy. Don't ask me to do this again." In addition, the last portion of the statement is a threat. The statement, "The television goes off at 10 pm; I've been telling you this for the past three evenings," is inappropriate because it is authoritative and demeaning to the client.

A client diagnosed with bipolar disorder and experiencing acute mania states to the nurse, "Where is my son? I love Lucy. Rain, rain go away. Dogs eat dirt." Another client approaches the nurse and says, "Man, is he ever nuts! He's driving me crazy with all his weird talk." Which response by the nurse to the second client is most appropriate? 1."I agree. He's a little hard to take sometimes." 2."Just walk away and leave him alone. There is nothing else you can do." 3."I realize his behavior bothers you, but he can't control it right now." 4."I'll give him some medication so he won't bother you."

3. While the client who is psychotic can upset other clients, the nurse must respond to the second client with both empathy for his feelings and a general explanation that the behavior is out of the psychotic client's control. Agreeing with the second client or giving medication to the psychotic client does not help the complaining client gain empathy for his peer and only temporarily deals with the problem.

A client diagnosed with bipolar I disorder is experiencing auditory hallucinations and flight of ideas. Which medication combination would the nurse expect to be prescribed to treat these symptoms? 1. Amitriptyline (Elavil) and divalproex sodium (Depakote). 2. Verapamil (Calan) and topiramate (Topamax). 3. Lithium carbonate (Eskalith) and clonazepam (Klonopin). 4. Risperidone (Risperdal) and lamotrigine (Lamictal).

4 1. Divalproex sodium (Depakote) is a mood stabilizer commonly prescribed to treat clients diagnosed with bipolar I disorder. Amitriptyline (Elavil), a tricyclic antidepressant, would not address the symptoms described in the question and may precipitate a manic episode in clients diagnosed with bipolar I disorder. 2. Both verapamil (Calan) and topiramate (Topamax) are used as mood stabilizers in the treatment of bipolar I disorder, but neither medication would address the auditory hallucinations exhibited by the client in the question. 3. Lithium carbonate (Eskalith) is a mood stabilizer commonly prescribed to treat clients diagnosed with bipolar I disorder. Clonazepam (Klonopin), an antianxiety medication, may treat agitation and anxiety, but would not address the auditory hallucinations experienced by the client. 4. Risperidone (Risperdal), an antipsychotic, directly addresses the auditory hallucinations experienced by the client. Lamotrigine (Lamictal), a mood stabilizer, would address the classic symptoms of bipolar I disorder. TEST- TAKING HINT: The test taker first must recognize risperidone (Risperdal) as an antipsychotic and lamotrigine (Lamictal) as a mood stabilizer. Understanding the classification and action of these medications helps the test taker link them to the symptoms experienced by the client.

A nursing instructor is teaching about the psychosocial theory related to the development of bipolar disorder. Which student statement would indicate that learning has occurred? 1. "The credibility of psychosocial theories in the etiology of bipolar disorder has strengthened in recent years." 2. "Bipolar disorder is viewed as a purely genetic disorder." 3. "Following steroid, antidepressant, or amphetamine use, individuals can experience manic episodes." 4. "The etiology of bipolar disorder is unclear, but it is possible that biological and psychosocial factors are influential."

4 1. The credibility of psychosocial theories that deal with the etiology of bipolar disorder has weakened, not strengthened, in recent years. 2. The etiology of bipolar disorder is affected by genetic, biochemical, and physiological factors. If bipolar disorders were purely genetic, there would be a 100% concordance rate among monozygotic twins. Research shows the concordance rate among monozygotic twins is only 60% to 80%. 3. Following steroid, antidepressant, or amphetamine use, individuals can experience manic episodes. The response to these medications, which cause these symptoms, is physiological, not psychosocial. 4. The etiology of bipolar disorder is unclear; however, research evidence shows that biological and psychosocial factors are influential in the development of the disorder. TEST-TAKING HINT: The test taker needs to understand the various theories that are associated with the development of bipolar disorders to answer this question correctly.

A nursing instructor is teaching about the criteria for the diagnosis of bipolar II disorder. Which student statement indicates that learning has occurred? 1. "Clients diagnosed with bipolar II disorder experience a full syndrome of mania and have a history of symptoms of depression." 2. "Clients diagnosed with bipolar II disorder experience numerous episodes of hypomania and dysthymia for at least 2 years." 3. "Clients diagnosed with bipolar II disorder have mood disturbances that are directly associated with the physiological effects of a substance." 4. "Clients diagnosed with bipolar II disorder experience recurrent bouts of depression with episodic occurrences of hypomania."

4 1. When a client experiences a full syndrome of mania with a history of symptoms of depression, the client meets the criteria for bipolar I, not bipolar II, disorder. 2. When a client has experienced numerous episodes of hypomania and dysthymia for the last 2 years, the client meets the criteria for cyclothymia, not bipolar II disorder. Cyclothymia is chronic in nature, and the symptoms experienced must be of insufficient severity or duration to meet the criteria for bipolar I or bipolar II disorder. 3. When disturbances of mood can be associated directly with the physiological effects of a substance, the client is likely to be diagnosed with a substance-induced mood disorder, not bipolar II disorder. 4. Recurrent bouts of depression and episodic occurrences of hypomania are diagnostic criteria for bipolar II disorder. Experiencing a full manic episode would indicate a diagnosis of bipolar I disorder and rule out a diagnosis of bipolar II disorder. TEST-TAKING HINT: The test taker must be able to distinguish the criteria for various mood disorders to answer this question correctly

A client with acute mania is to receive lithium carbonate 600 mg PO three times daily and 2 mg of haloperidol (Haldol) PO at bedtime. The nurse should: 1.Refuse to give the medications as prescribed. 2.Give the lithium only. 3.Request a decreased dosage of lithium. 4.Give the medications as prescribed.

4. Lithium commonly is combined with an antipsychotic agent, such as haloperidol, or a benzodiazepine such as lorazepam (Ativan). Antipsychotic agents, such as Haldol, are prescribed to produce a neuroleptic effect until the lithium, which has a clinical response lag time of 1 to 2 weeks, produces a clinical response. After a clinical response is achieved, the antipsychotic agent usually is discontinued. Additionally, the dosages of each drug listed are appropriate. Therefore, the nurse would administer the drugs as prescribed.

The client with rapid-cycling bipolar disorder who is about to receive his 5 pm dose of carbamazepine (Tegretol) tells the nurse he has a sore throat and chills. Which of the following should the nurse do next? 1.Administer the prescribed dose of carbamazepine. 2.First, give the client acetaminophen (Tylenol) as prescribed PRN. 3.Report the symptoms to the primary health care provider in the morning. 4.Call the primary health care provider to report the symptoms.

4. The nurse should call the primary health care provider to report symptoms of a sore throat, fever, and chills because these symptoms may be signs of serious adverse effects of the medication, including potentially fatal hematologic, cardiovascular, and hepatic complications. Giving the dose of carbamazepine is contraindicated in this situation. Giving the acetaminophen would be inappropriate and potentially detrimental to the client's health. Waiting until morning to report the client's symptoms is a serious error in judgment.

The client with bipolar disorder, manic phase, states, "You're looking good. I'm taking you out to dinner." Which of the following replies by the nurse is most therapeutic? 1."I don't want to go out to dinner." 2."I can't go out to dinner with you." 3."It doesn't matter how I look, the answer is no." 4."I'm Chris Smith, a nurse working on this unit."

4. The nurse should state her name and purpose on the unit to clarify her identity and to counteract other beliefs the client may have. Stating that the nurse doesn't want to or can't go out to dinner is not therapeutic because it fails to clarify the client's misperceptions or erroneous beliefs, as is the statement, "It doesn't matter how I look, the answer is no.

The client is laughing and telling jokes to a group of clients. Suddenly, the client is crying and talking about a death in the family. A moment later, the client is laughing and joking again. The nurse should: 1.Call the psychiatrist for a prescription for lorazepam (Ativan) as needed. 2.Place the client in seclusion and call the psychiatrist for a prescription for the seclusion. 3.Ignore the client's behavior in order not to give the client too much attention. 4.Ask the client to come to a quiet area to talk to the nurse individually.

4. Decreasing external stimuli is the intervention most likely to decrease the emotional lability and minimize its effect on other clients. While the client is displaying emotional lability, this behavior has not reached the level where involuntary isolation (seclusion) or physical restraint is needed. The client is not totally out of control or threatening others. However, ignoring the behavior will not result in a decrease in the lability.

The client with mania is skipping up and down the hallway practically running into other clients. The nurse should include which of the following activities in the client's plan of care? 1.Leading a group activity. 2.Watching television. 3.Reading the newspaper. 4.Cleaning the dayroom tables.

4. The client with mania is very active and needs to have this energy channeled in a constructive task such as cleaning or tidying the dayroom. Because the client is distracted easily and can concentrate only for short periods, the successful completion of a helpful task would give the nurse the opportunity to thank the client for the help, thereby enhancing the client's self-esteem. Leading a group activity is too stimulating for the client. Participating in this type of activity also may cause the client to be disruptive. Watching television or reading the newspaper would be inappropriate for the client who cannot sit for a period of time.

After the nurse teaches a client about bipolar disorder, which of the following statements indicates that the client has developed insight about the diagnosis? 1."I enjoy feeling high. I don't need much sleep then and get really creative." 2."My medicine really helped me. I know I won't need it in about another week." 3."I'm cured now. I was really wild for a while even though I got into trouble." 4."I know I'm getting sick when I don't need much sleep and start buying things.

4. The client's statement, "I know I'm getting sick when I don't need much sleep and start buying things," indicates insight into her illness because the client recognizes symptoms that can lead to relapse. The statement, "I enjoy feeling high; I don't need much sleep then and get really creative," gives no indication that the client recognizes the detrimental effects of bipolar disorder. The statements about not needing medicine in another week or being cured indicate the client's lack of understanding about the chronic nature of the disorder. The client is not cured from bipolar disorder, but symptoms of the disorder are usually managed when she is stabilized on medication. Medication may be needed by the client for many years or throughout her life.

The client with an Axis I diagnosis of bipolar disorder, manic phase, states to the nurse, "I'm the Queen of England. Bow before me." The nurse interprets this statement as important to document as which of the following areas of the mental status examination? 1.Psychomotor behavior. 2.Mood and affect. 3.Attitude toward the nurse. 4.Thought content.

4. The client's statement, "I'm the Queen of England. Bow before me," is an example of a grandiose delusion and refers to thought content of the mental status examination. Examples of psychomotor behavior to be documented would include excited, typically exaggerated and repetitive physical movements, and excessive talking and gesturing. Mood is a subjective state, and affect is an observable expression of emotion. Mood is what a client tells you she is feeling, and affect is what you see the client feeling. For example, the client may state that she feels sad or happy in reference to mood. Affect refers to the display of physical emotion, commonly described as "appropriate" or "flat." Attitude toward the nurse refers to the client's behavior in the presence of the nurse during the mental status examination (pleasant and cooperative, irritable, and guarded).

A client comes to the mental health clinic saying that he feels so down and lacking in energy with "loss of interest in everything." He tells the nurse that he received some samples of a new medication from his primary care physician last week to relieve his depression. The nurse recalls that this client has a history of bipolar I disorder with hospitalization for a significant manic episode. With this knowledge, the nurse would have special concern if he is taking which of the following categories of medication? 1.Atypical antipsychotics. 2.Mood stabilizers/antimanics. 3.Antianxiety agents (benzodiazepines). 4.Selective serotonin reuptake inhibitor (SSRI) antidepressant.

4. The most urgent consideration for intervention and for teaching is the fact that for individuals with a history of bipolar disorder, antidepressants when taken alone can push the person into mania. Antipsychotics are sometimes prescribed for clients with bipolar disorder and would not pose a special concern. Individuals with bipolar disorder are typically treated with mood stabilizers, and benzodiazepines are sometimes used in the short term to give a client relief before the mood stabilizers can take effect.

The client with bipolar disorder, manic phase, appears at the nurse's station wearing a transparent shirt, miniskirt, high heels, 10 bracelets, and eight necklaces. Her makeup is overdone, and she is not wearing underwear. A pair of inverted underpants is on her head. The nurse should: 1.Tell the client to dress appropriately while out of her room. 2.Ask the client to put on hospital pajamas until she can dress appropriately. 3.Instruct the client to go to her room and change clothes. 4.Escort the client to her room and assist with choosing appropriate attire.

4. The nurse escorts the client to her room and assists with choosing appropriate attire to preserve the client's dignity and self-esteem and prevent ridicule from others on the unit. It is common for a client with bipolar disorder, manic phase, to exhibit poor judgment, provocative behavior, and hyperactivity. The client in the manic phase commonly dresses inappropriately and changes clothes many times throughout the day. The nurse needs to assist the client with hygiene, grooming, and proper attire until her judgment improves. Telling the client to dress appropriately while out of her room may be perceived by the client as an attack. Additionally, the client may be incapable of making that decision. Asking the client to put on hospital pajamas until she can dress appropriately is punitive and demeaning. Because of the client's cognitive difficulties, the client may not understand the instructions to go to her room to change clothes. Additionally, the client may become distracted by stimuli on the unit and may not reach her room.

The client with mania is irritable and insulting to a nursing assistant. The nursing assistant states, "I can't believe Mark is so rude. Shouldn't he be overly happy?" Which of the following responses by the nurse should help the nursing assistant understand the client's behavior? 1."It's our responsibility to listen to him even though we might not like what he's saying." 2."We must reprimand Mark for doing that because there is no reason for him to behave like that." 3."I will go and speak to him about his behavior and make sure he understands that he needs to control what he is saying." 4."I know it's difficult but Mark is a client whose irritable mood is a symptom of his mania.

4. The nurse should help the nursing assistant understand the client's behavior by stating that his irritable mood is a symptom of mania. Not all clients with mania are euphoric or have an expansive mood. Saying, "It's our responsibility to listen to him even though we might not like what he's saying" does not help the nursing assistant understand the client with mania. Reprimanding the client for his behavior and asking him to control his behavior are inappropriate actions and show poor nursing judgment and a lack of understanding of the manic client.

The client with acute mania states to the nurse, "I'm the prince of peace and can save the world. Those against me will find me and take me to another world. They will come. I know it." The client is beginning to scan the room and starts to repeat his delusion. Which of the following responses by the nurse is most therapeutic? "1."Describe the people who will come." 2."The staff and I will protect you." 3."You are not the prince of peace. Your name is Joe." 4."Let's walk around the unit for a while."

4. The nurse suggests an activity such as walking around the unit to distract the client from the paranoid grandiose delusion that could result in loss of control. This action interrupts the client's anxious state and helps to redirect energy and focus on an activity based in reality. The focus must be on the underlying need or feeling of the delusion and not on the content. Asking the client to describe the people who will come challenges the client and forces the client to cling to the delusion. Stating that the nurse and staff will protect the client conveys agreement with the client's belief system, reinforcing the client's delusion. Telling the client that he is not the prince of peace and repeating his name challenges the client and his present belief system. Doing so may lead to decreased trust in the nurse and an aggressive response, or it may force the client to defend his beliefs.

A client has just been admitted to the hospital for medication adjustment after outpatient treatment failure of his bipolar disorder and returning mania. He tells his primary nurse about his medications and treatment. Which of his following statements would raise the most urgent need for more medication instruction about his lithium therapy? 1."My doctor tells me that my lithium level is 1.0 so I don't have to worry about my levels." 2."I've been getting a lot of good exercise playing on a local soccer team." 3."I'm trying hard to watch my diet and eat healthy." 4."I have learned to take my lithium even when I'm not feeling well, like when I had the stomach flu."

4. The therapeutic serum level for lithium is 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L). Levels due fluctuate with fluid intake and output, however. Therefore, the most urgent matter for teaching is the client's comment about taking his lithium during excessive loss of fluids during an episode of "stomach flu" with diarrhea. Exercising is only concerning if the client becomes dehydrated. A healthy diet is indicated while taking lithium.

Although historically lithium has been the medication of choice for mania, several others have been used with good results. Which of the following are used in the treatment of bipolar disorder? Select all that apply. a. Olanzepine (Zyprexa) b. Paroxetine (Paxil) c. Carbamazepine (Tegretol) d. Gabapentin (Neurontin) e. Tranylcypromine (Parnate)

A, C, D

Margaret, a 68-year-old widow experiencing a manic episode, is admitted to the psychiatric unit after being brought to the ED by her sister-in-law. Margaret yells, "My sister-in-law is just jealous of me! She's trying to make it look like I'm insane!" This behavior is an example of a a. delusion of grandeur. b. delusion of persecution. c. delusion of reference. d. delusion of control or influence

B

Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sister-in-law reports that Margaret quit taking her medication a few months ago, thinking she didn't need it anymore. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats very little, is losing weight, and almost never sleeps. "I'm afraid she's going to just collapse!" Margaret is admitted to the psychiatric unit. The priority nursing diagnosis for Margaret is a. imbalanced nutrition: less than body requirements related to not eating. b. risk for injury related to hyperactivity. c. disturbed sleep pattern related to agitation. d. ineffective coping related to denial of depression.

B

A child with bipolar disorder also has attention-deficit/hyperactivity disorder (ADHD). How would these comorbid conditions most likely be treated? a. No medication would be given for either condition. b. Medication would be given for both conditions simultaneously. c. The bipolar condition would be stabilized first before medication for the ADHD would be given. d. The ADHD would be treated before consideration of the bipolar disorder.

C

A client experiencing a manic episode enters the milieu area dressed in a provocative and physically revealing outfit. Which of the following is the most appropriate intervention by the nurse? a. Tell the client she cannot wear this outfit while she is in the hospital. b. Do nothing and allow her to learn from the responses of her peers. c. Quietly walk with her back to her room and help her change into something more appropriate. d. Explain to her that if she wears this outfit she must remain in her room.

C

Margaret, age 68, is diagnosed with Bipolar I Disorder, Current episode manic. She is extremely hyperactive and has lost weight. One way to promote adequate nutritional intake for Margaret is to a. sit with her during meals to ensure that she eats everything on her tray. b. have her sister-in-law bring all her food from home because she knows Margaret's likes and dislikes. c. provide high-calorie, nutritious finger foods and snacks that Margaret can eat "on the run." d. tell Margaret that she will be on room restriction until she starts gaining weight.

C

The most common comorbid condition in children with bipolar disorder is a. schizophrenia. b. substance disorder. c. oppositional defiant disorder. d. attention-deficit/hyperactivity disorder

D

A client experiencing a manic episode has been talking loudly, pacing the unit and trying to draw other clients into debates about the value of self-determination. Arrange in order the steps a nurse should take to help calm this client. 1. Use oral medication to decrease anxiety and increase appropriate social interaction. 2. Talk with the client about the anxiety and stress the client is feeling. 3. Take client to a quiet area, such as his or her room, to decrease stimuli. 4. Teach the client coping strategies to deal with stressors.

Take client to a quiet area, such as his or her room, to decrease stimuli. Use oral medication to decrease anxiety and increase appropriate social interaction. Talk with the client about the anxiety and stress the client is feeling. Teach the client coping strategies to deal with stressors. None of the other interventions will be successful unless the stimuli that fuel the client's mania are removed or decreased. Once the client is in a quieter setting, oral medication will help calm the client so he or she can be calmer. Once the medication has taken effect, the nurse can help the client explore the client's feelings and problem. Finally, teaching coping techniques can be effective to address client problems after he or she has become calmer.