Chapter 22: Bipolar Disorders: Nursing Care of Persons with Mood Lability

A nurse is caring for a client diagnosed with bipolar disorder who has been prescribed divalproex. The nurse knows that the client should have which test completed before initiation of drug therapy? A.) Liver function B.) Thyroid level C.) White blood cell (WBC) count D.) Cardiac enzymes

Answer: A.) Liver function

The nurse is reviewing the history of a client diagnosed with bipolar I disorder. The history reveals that the client, in between manic episodes, consistently uses self-negating statements when describing the self, expresses feelings of being ashamed, and describes self as being unable to deal with events. The client also demonstrates little to any eye contact during interactions. The nurse interprets this information as reflecting a problem in which area? A.) Self-esteem B.) Anxiety C.) Denial D.) Coping

Answer: A.) Self-esteem

A psychiatric-mental health nurse is preparing a review class for a group of nurses at the community mental health center. The topic is mood-stabilizing drugs. After teaching the class about the different drugs that may be prescribed, the nurse determines that the teaching was successful when the group identifies which drug as being prescribed most often? A.) Lithium B.) Divalproex C.) Carbamazepine D.) Lamotrigine

Answer: A.) Lithium

A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm? A.) Immediately after a family visit B.) On the anniversary of significant life events in the client's life C.) During the first few days after admission D.) Approximately 2 weeks after starting antidepressant medication

Answer: D.) Approximately 2 weeks after starting antidepressant medication Rationale: Observe the client closely for suicide potential, especially after antidepressant medication begins to raise the client's mood. Risk for suicide increases as the client's energy level is increased by medication. The other choices are not significantly associated with increased risk for suicide.

Which is an anticonvulsant used as a mood stabilizer? A.) Divalproex B.) Venlafaxine C.) Bupropion D.) Phenelzine

Answer: A.) Divalproex

A client with a diagnosis of bipolar disorder is described by a family member as "flip-flopping between being happy and loving to irritable and hostile." Which characteristic symptoms of this disorder is the family member referring to? A.) Euthymic mood B.) Emotional lability C.) Manic episode D.) Grandiosity

Answer: B.) Emotional lability

Which of the following is an adverse effect of lithium? A.) Nausea and diarrhea B.) Anxiety and motor retardation C.) Constipation and insomnia D.) Ataxia and urinary retention

Answer; A.) Nausea and diarrhea

A client diagnosed with bipolar disorder and experiencing mania is admitted to the inpatient psychiatric setting. During the acute phase of mania, which medication(s) would the nurse expect to administer? Select all that apply. - Lithium carbonate - Carbamazepine - Fluoxetine - Paroxetine - Divalproex sodium

Answer: - Lithium carbonate - Carbamazepine - Divalproex sodium Rationale: The goal of treatment in the acute phase is symptom reduction and stabilization. Therefore, mood stabilizers, such as lithium carbonate, carbamazepine, and divalproex sodium, are the mainstays of pharmacotherapy. Antidepressants, such as fluoxetine or paroxetine, are not recommended in bipolar depression because of a risk of switching to mania.

A nurse is assessing a client who is brought to the emergency department. The nurse suspects that the client is experiencing mania. Which finding would support the nurse's suspicion? Select all that apply. - Statements of self-importance - Slowness of speech - Flight of ideas - Easily distractible - Sleepiness

Answer: - Statements of self-importance - Flight of ideas - Easily distractible

A psychiatric-mental health nurse is teaching a client with mania and family about signs and symptoms associated with relapse. The nurse determines that the teaching was successful when the patient and family identify which sign or symptom? Select all that apply. - Talking faster than usual - Loss of appetite - Decreased energy level - Inability to concentrate on a topic - Irritability

Answer: - Talking faster than usual - Inability to concentrate on a topic - Irritability Rationale: Common indicators of relapse for mania include reading several books or newspapers at once, inability to concentrate on one topic, talking faster than usual, feeling irritable, being hungry all the time, friends remarking on changes in mood, and having more energy than usual.

The client with mania attempts to hit the nurse. Which is the best response by the nurse? A.) "Do not swing at me again. If you cannot control yourself, we will help you." B.) "If you do that one more time, you will be put in seclusion immediately." C.) "Stop that. I didn't do anything to provoke an attack." D.) "Why do you continue that kind of behavior? You know I won't let you do it."

Answer: A.) "Do not swing at me again. If you cannot control yourself, we will help you." Rationale: Stating, "Do not swing at me again. If you cannot control yourself, we will help you," firmly states behavioral expectations and lets the client know his behavior will be safely controlled if he is unable to do so. Arguing that the nurse does not deserve the attack provokes confrontation rather than communicating clear expectations. Stating "If you do that one more time, you will be put in seclusion immediately" is likely to be perceived as a threat rather than an assertive statement. Similarly, stating "Why do you continue that kind of behavior? You know I won't let you do it" may be perceived as a challenge or threat.

A client with bipolar disorder is receiving lithium therapy. The nurse is reviewing the client's serum plasma drug levels and determines that the client's level is therapeutic based on what? A.) 1.0 mEq/L B.) 1.6 mEq/L C.) 2.0 mEq/L D.) 2.6 mEq/L

Answer: A.) 1.0 mEq/L Rationale; Serum plasma lithium levels should range from 0.6 to 1.2 mEq/L. Levels above that suggest toxicity (moderate toxicity for levels 1.5 to 2.5 mEq/L; severe toxicity for levels greater than 2.5 mEq/L).

A nurse is providing psycho-education to a client who has been admitted to the inpatient mental health unit for a manic episode. In order to ensure the teaching is effective, the nurse must first determine which regarding the client? A.) Ability to concentrate and process the information B.) Likelihood to assume responsibility for self-care C.) Cognitive awareness and intellectual abilities D.) Interest in learning about the disorder

Answer: A.) Ability to concentrate and process the information Rationale: To best assure successful outcomes related to client education of an individual experiencing a manic episode, the nurse's initial assessment is focused on the client's ability to concentrate and process the information.

When teaching a client who is recently diagnosed bipolar I disorder, the nurse correctly tells the client that the difference between bipolar I disorder and bipolar II disorder is what? A.) Bipolar I disorder is often more disruptive than bipolar II disorder. B.) Bipolar I disorder more often effects women. C.) Bipolar I disorder is characterized by hypomanic episodes. D.) Bipolar I disorder involves altered moods of anger and paranoia.

Answer: A.) Bipolar I disorder is often more disruptive than bipolar II disorder. Rationale: Bipolar I disorder is often more severe, thus symptoms tend to create more disruption in functioning compared to bipolar II disorder. Bipolar I disorder is characterized by one or more manic or mixed episodes in which the individual experiences rapidly alternating moods accompanied by symptoms of a manic mood and a major depressive episode.

A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first? A.) Decrease the client's environmental stimuli. B.) Give the client feedback about the client's behavior. C.) Introduce the client to other staff on the unit. D.) Tell the client about hospital rules and policies.

Answer: A.) Decrease the client's environmental stimuli. Rationale: When the client is agitated, decreasing stimuli is the priority because it is likely to reduce the client's agitation. Giving an agitated client feedback about his or her behavior may provoke confrontation. Similarly, making reference to rules and policies may make the client reactive or defensive, exacerbating the situation. Introducing the client to other staff does nothing to address the client's agitation.

A nurse is caring for a client diagnosed with bipolar disorder. The client is experiencing a manic episode. The nurse would be especially alert for signs indicating what? A.) Self-injury B.) Sleep disruption C.) Dehydration D.) Weight loss

Answer: A.) Self-injury Rationale: During a manic episode, client safety is a priority. Risk of suicide is always present for those having a depressive or manic episode. During a depressive episode, the client may believe that life is not worth living. During a manic episode, the client may believe that he or she has supernatural powers, such as the ability to fly. Although changes in sleep, fluid balance (such as dehydration), and inadequate nutrition manifested by weight loss would be important to assess, safety and prevention of self-injury are the priority.

The nurse is seeing a 26-year-old client and the client's family. The client's family describes the client as being "very, very different." The family describes a history of periods of unpredictable behavior and disregard for consequences occurring a few times each year. The client has recently been diagnosed with bipolar I disorder, a condition that is characterized by what? A.) The presence of objective signs of depression without the presence of anhedonia B.) An elevated mood that lasts for at least 1 week C.) Failure to respond to conventional pharmacological treatments for mood disorders D.) The client's admission of a mood disorder

Answer: B.) An elevated mood that lasts for at least 1 week

A 35-year-old client with bipolar disorder has a history of discontinuing medication when feeling well and then becoming manic again. During the client's last episode of mania, the client lost several thousand dollars in risky investments. Which intervention will be most helpful in achieving medication adherence? A.) Point out that each time the client stops taking medication, the client becomes manic again. B.) During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse. C.) Ensure that a family member takes responsibility for administering medications. D.) Remind the client that the client owes it to the client's spouse and children to stay well.

Answer: B.) During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse.

On admission to the psychiatric unit, a client is dressed in a red leotard and exercise bra, with an assortment of chains and brightly colored scarves on the client's head, waist, wrists, and ankles. The client's first words to the nurse are, "I'll punch you, munch you, crunch you," as the client dances into the room, shadow boxing. The client shakes the nurse's hand and says cheerfully, "We need to become better acquainted. I have the world's greatest intellect, and you are probably an intellectual midget." How can the nurse document the client's mood? A.) Belligerent and blunted. B.) Expansive and grandiose. C.) Anxious and unpredictable. D.) Suspicious and paranoid.

Answer: B.) Expansive and grandiose.

The police bring a client to the hospital. They found the client in a hospital gown, swimming in a local creek. The client states that the client was "being baptized by Mother Nature, who loves and worships me." How would the nurse describe the client's current alterations in mental status? A.) Visual hallucinations B.) Grandiose delusions C.) Neologisms D.) Dysphoria

Answer: B.) Grandiose delusions

A patient with bipolar disorder is prescribed divalproex. Before initiating this therapy, which laboratory test would be most important for the nurse to obtain? A.) Clotting function tests B.) Liver function tests C.) Renal function tests D.) Blood glucose level

Answer: B.) Liver function tests

A client in an acute manic phase is pacing the halls and talking in a loud voice with pressured speech. The client is overly involved with coclients and frequently threatens and disrupts others on the unit. After administering lithium treatment for the client, the nurse can expect the plan of care to include which additional intervention? A.) Monitoring phototherapy response. B.) Monitoring blood levels of the medication. C.) Teaching the client to avoid foods with tyramine. D.) Assessing for post-electroconvulsive therapy disorientation and confusion.

Answer: B.) Monitoring blood levels of the medication.

Which medication classification is considered first-line drug therapy for bipolar disorder? A.) Antipsychotics B.) Mood stabilizers C.) Anticonvulsants D.) Antidepressants

Answer: B.) Mood stabilizers

A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale? A.) As soon as lunch is over, the client will calm down. B.) Other clients need to be protected from the intrusive behavior. C.) The client's behavior is not an imminent threat to anyone's physical safety. D.) The client needs food and fluids in any way possible.

Answer: B.) Other clients need to be protected from the intrusive behavior. Rationale: The nurse must set limits on this intrusive behavior because other clients have the right to be protected. The client is in the manic phase; the client may not calm down after lunch. The behavior could be an imminent threat to individual safety for many reasons, infection control included. The client's need for food and fluids does not supersede any of the other clients' needs for food and fluids.

A nurse who works primarily with clients who have bipolar disorder identifies which group of clients as not being candidates to take lithium as treatment? A.) Patients who take bronchodilators B.) Patients who take ACE inhibitors C.) Patients who drink decaffeinated coffee D.) Patients with diabetes who take oral antidiabetic agents

Answer: B.) Patients who take ACE inhibitors Rationale: Lithium interacts with several different medications and foods. Clients who take ACE inhibitors should not take lithium, because the combination can increase the serum lithium level, leading to toxicity and impaired kidney function.

A client was admitted to the psychiatric unit after being picked up by police officers who found the client frantically running back and forth across the freeway. The client's spouse reports that the client stayed up all night, ate very little, and talked incessantly. Additional assessment findings that indicate a manic episode include what? A.) Psychomotor retardation, fatigue, and apathy B.) Pressured speech, combative behavior, and impaired judgment C.) Catatonic excitement, loose associations, and recurrent illusions D.) Self-destructive behavior, overidealization, and devaluation

Answer: B.) Pressured speech, combative behavior, and impaired judgment Rationale: A manic episode would be characterized by pressured speech, potentially combative behavior, and impaired judgment. Neither psychomotor retardation is present nor are recurrent illusions. Self-destructive behavior is not a classic symptom of mania; more often, clients may have accidents caused by their lack of judgment and psychomotor agitation.

A client who has just been prescribed lithium for bipolar disorder is being given education from the nurse about this medication. Which is important for the nurse to include in teaching? A.) The higher the potassium level, the lower the lithium level will be. B.) The higher the sodium level, the lower the lithium level will be. C.) Changes in diet will not affect lithium levels. D.) Lithium has few interactions with other drugs.

Answer: B.) The higher the sodium level, the lower the lithium level will be. Rationale: Lithium is a salt, so the interaction between lithium and sodium levels in the body and between lithium level and fluid volume in the body are crucial issues to consider. The higher the sodium levels, the lower the lithium level will be and vice versa. The other options do not represent correct information.

After educating a client with bipolar disorder on his prescribed lithium therapy, the nurse determines that additional education is needed when the client states which of the following? A.) "I need to report any problems with severe diarrhea or slurred speech." B.) "I need to avoid drinking any alcohol." C.) "I need to cut back on my salt intake when it's really hot outside." D.) "I can use sugarless candies to help with any metallic taste."

Answer: C.) "I need to cut back on my salt intake when it's really hot outside." Rationale: Clients should increase their intake of salt during periods of perspiration (e.g., when it is hot outside) and periods of increased exercise and dehydration. Severe diarrhea and slurred speech suggest moderate toxicity, which needs to be evaluated. Alcohol interacts with lithium, causing increased serum concentrations of the drug, placing the client at risk for toxicity. Sugarless candies and throat lozenges can help to combat metallic taste.

During report, the nurse learns that a client with mania has not slept since admission 2 days ago. On entering the day room, the nurse finds this client dancing to loud music. Which would be the most appropriate statement by the nurse? A.) "Do you think you could sit still for a few minutes so we can talk?" B.) "How are you ever going to get any rest if you keep that music on?" C.) "Let's go to the conference room and talk for a while." D.) "Turn the radio down so we can hear ourselves talk."

Answer: C.) "Let's go to the conference room and talk for a while."

Which meal would the nurse provide to best meet the nutritional needs of a client who is manic? A.) Peanut butter sandwich, chips, cola B.) Fried chicken, mashed potatoes, milk C.) Ham sandwich, cheese slices, milk D.) Spaghetti, garlic bread, salad, tea

Answer: C.) Ham sandwich, cheese slices, milk Rationale: Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible. Sandwiches and cheese are finger foods and are calorie-dense. Chips and cola are not nutritious, even though they are high in calories. Fried chicken, potatoes and spaghetti cannot be eaten while the client is moving.

A client with bipolar disorder takes lithium 300 mg 3 times daily. The nurse is educating the client on its use, side effects, and need for compliance. The nurse evaluates that the dose is appropriate when the client reports what? A.) Feeling sleepy and less energetic. B.) Weight gain of 7 pounds in the last 6 months. C.) Minimal mood swings. D.) Increased feelings of self-worth.

Answer: C.) Minimal mood swings.

A client with bipolar disorder has been taking lithium, and today the client's serum lithium level is 2.0 mEq/L. What effects would the nurse expect to see? A.) Constipation and postural hypotension B.) Fever, muscle rigidity, and disorientation C.) Nausea, diarrhea, and confusion D.) None; the serum level is in therapeutic range

Answer: C.) Nausea, diarrhea, and confusion Rationale: Serum lithium levels of less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic. The client would show signs of toxicity with a lithium level of 2.0 mEq/L. Toxic effects of lithium are severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination.

A client has been admitted to a psychiatric-mental health facility in a manic state. The client's spouse accompanies the client to the facility and informs the nurse that the client has been displaying manic symptoms for the past 2 weeks. The spouse reports that the client has not slept for the past 2 days and that the client has not eaten anything for at least 3 days. Which would be the priority nursing diagnosis for this client? A.) Ineffective health maintenance B.) Risk for other-directed violence C.) Risk for imbalanced nutrition D.) Risk for suicide

Answer: C.) Risk for imbalanced nutrition

A client admitted to the inpatient psychiatric unit changes clothes eight or nine times a day, wears heavy eye makeup, is intrusive with other clients, and makes inappropriate sexual advances toward staff members. Which goal would be most appropriate for this client? A.) The client will identify two trusted staff members of the opposite sex to help choose appropriate dress. B.) The client will record the number of clothing changes per day. C.) The client will refrain from being intrusive with others and change clothing only twice per day. D.) The client will verbalize feelings of low self-esteem with nursing staff.

Answer: C.) The client will refrain from being intrusive with others and change clothing only twice per day. Rationale: The focus should be on symptom management and containment until the client recovers enough to participate in more structured nursing interventions. Small limitations relative to hugging and wardrobe changes are realistic, offer a measure of change/stability, and help decrease overall hypomanic behaviors. Recording the number of clothing changes per day is not realistic. Having staff members of the opposite sex help the client choose appropriate dress is incorrect because this behavior will encourage continued inappropriate sexual advances. The client does not have difficulties with low self-esteem.

A client has been diagnosed with bipolar disorder. After teaching the client about the different medication classifications used to help stabilize mood, the nurse determines tha the teaching was successful when the client identifies which class of medications? A.) Antianxiety B.) Anticoagulants C.) Antibiotics D.) Anticonvulsants

Answer: D.) Anticonvulsants

Which behavior is the priority concern as the nurse begins a care plan for a client in the manic phase of bipolar disorder? A.) Bizarre, colorful, inappropriate dress B.) Grandiose thinking and poor concentration C.) Insulting, provocative behavior directed at staff D.) Hyperactivity, dismissing meals, and sleep disturbance

Answer: D.) Hyperactivity, dismissing meals, and sleep disturbance Rationale: Safety needs are always the first priority in care planning. A client who has not eaten or slept for several days and has been extremely hyperactive may be at risk for exhaustion and malnutrition and the implications of those states. Although thought disorder, expansive mood, and dress are important assessment information, priority interventions must center on the basic needs of hyperactivity, dismissing meals, and sleep disturbance.

The spouse of a client with bipolar disorder calls the nurse expressing distress about recent spending patterns of the client. The nurse suggests the spouse implement the limit-setting skills the spouse has learned in family therapy. In this instance, the nurse's action would be considered ... A.) inappropriate; the nurse should not give advice to the spouse. B.) inappropriate; the client has the legal right to spend personal money. C.) appropriate; the spouse is responsible for the client's actions since the client has a mental illness. D.) appropriate; the spouse needs support in setting boundaries.

Answer: D.) appropriate; the spouse needs support in setting boundaries. Rationale: It is therapeutic and appropriate for the nurse to work with families to help the clients manage their behavior. Nurses are not prohibited from giving advice. The wife is not legally or morally responsible for her husband's action simply because he has a mental illness. The husband has the legal right to spend money, but this does not mean that the nurse is not permitted to provide interventions to address problematic behavior.

To confirm that a client is experiencing a manic episode, the nurse must eliminate the possibility that the client's symptoms are related to which problem? A.) Substance use B.) Inflated self-esteem or grandiosity C.) Insomnia D.) Overexcitment

Answer; A.) Substance use