(PrepU) Bipolar Disorder
The nurse is providing teaching about the potential side effects of lithium for the parents of a girl recently diagnosed with bipolar disorder. Which statement by the parents indicates a need for additional teaching?
"If she loses weight, then we know the medication is working." Weight gain, not weight loss, is a side effect of the drug. An increased appetite occurs with lithium. Lithium is associated with tremors and nausea. Polyuria occurs with lithium.
A client is to receive three treatments of electroconvulsive therapy (ECT) per week for 3 weeks. After the third treatment, the client is forgetful and confused. When the client's spouse arrives to take the client home, the nurse discusses the client's condition with the spouse. Which statement is best?
"Some people experience mild confusion after ECT. Generally it clears in a few days, though it may take longer." A frequent consequence of ECT is memory impairment, ranging from mild forgetfulness of details to severe confusion. This may persist for weeks or months after treatment but usually resolves.
A client in the clinic appears to have elevated self-esteem, is more talkative than usual, and is easily distracted. This client is exhibiting symptoms of what?
Grandiosity Grandiosity is elevated self-esteem and may range from unusual self-confidence to grandiose delusions. Speech is pressured; the person is more talkative than usual and at times is difficult to interrupt. There is often a flight of ideas or racing thoughts.
Which would be a finding related to perceptual disturbances during the mental status exam in the client with mania?
Hallucinations Perceptual disturbances include hallucinations and delusions, anxiety, and grandiose delusions involving power, wealth, fame, or knowledge. Increased motor activity is assessed in appearance and general behavior. Inappropriate affect is assessed in mood and affect. Limited insight is part of the judgment and insight assessment.
Which behavior is the priority concern as the nurse begins a care plan for a client in the manic phase of bipolar disorder?
Hyperactivity, dismissing meals, and sleep 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.
A nurse is reviewing a bipolar client's serum lithium level, which is 1.8 mEq/L. What is the nurse's best action?
Inform the prescriber and monitor for GI and CNS effects Therapeutic serum lithium levels range from 0.6 to 1.2 mEq/L. A level of 1.8 mEq/L would be considered toxic, but would be unlikely to warrant admission to intensive care. The nurse should report the finding and assess for common adverse effects of toxicity, which include GI and CNS effects more often than respiratory effects.
Which is considered the first-line treatment for bipolar disorder?
Lithium Lithium is considered the first-line treatment for bipolar disorder. Lithium is the most established mood stabilizer.
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?
The higher the sodium level, the lower the lithium level will be. 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.
A nurse is reading a journal article about anticonvulsant agents used in psychiatric-mental health commonly used to treat clients with bipolar disorder. Which medication would the nurse most likely find being discussed in the article? Select all that apply.
Valproate Carbamazepine Lamotrigine Lithium Valproate (valproic acid; Depakote), carbamazepine (Equetro), and lamotrigine (Lamictal) have FDA approval for the treatment of bipolar disorder, mania, or mixed episodes. Lithium is the gold standard for treatment of acute mania and bipolar disorders. Clozapine is an antipsychotic.
The nurse working on a mental health unit is teaching a nursing student. The student asks the nurse about what constitutes a diagnosis for major depressive disorder. What is the nurse's best response?
"The primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present." Normal variations in mood (such as sadness, euphoria, and anxiety) occur in response to life events; they are time limited and not usually associated with significant functional impairment. The primary diagnostic criterion for major depressive disorder is one or more major depressive episodes (either a depressed mood or a loss of interest of pleasure in nearly all activities) for at least 2 weeks. Four of seven other symptoms must be present. Thus, the best response from the nurse is "the primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present."
For maintenance therapy of mania, the therapeutic serum level of lithium is ...
0.6-1.2 mEq/L. For maintenance therapy, lithium serum level should be 0.6 to 1.2 mEq/L. The serum levels should be monitored every 2 months once the client's condition is stabilized. Toxicity occurs with serum lithium levels of 1.5 mEq/L or above.
Which client is most likely to benefit from electroconvulsive therapy (ECT)?
A client whose major depression has not responded appreciably to antidepressants While ECT is used to treat an increasing range of psychiatric-mental health problems, individuals with major depression are often among the best candidates for the treatment. ECT would not be used as a response to noncompliance, and a person who is currently experiencing a manic episode is less commonly treated with ECT. Cyclothymic disorder is less severe than bipolar II disorder and is consequently less likely to warrant ECT.
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?
Ability to concentrate and process the information 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.
Carbamazepine has a boxed warning for which adverse effect?
Agranulocytosis Carbamazepine has a boxed warning for aplastic anemia and agranulocytosis, but frequent, clinically unimportant decreases in white blood cell counts occur. The increased risk of birth defects may occur with use of divalproex. Lamotrigine has a boxed warning for skin rash. Liver damage may occur with carbamazepine but is not noted with a boxed warning.
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?
An elevated mood that lasts for at least 1 week During manic episodes that characterize bipolar disorder, the individual exhibits an abnormal, persistently elevated, or irritable mood that lasts for at least 1 week. Failure to respond to treatment, the presence of signs of depression without anhedonia, and the client's admission of a mood disorder are neither diagnostic nor typical of bipolar disorder.
A client is experiencing hallucinations and delusions. The nurse would expect the physician to order which classification of medication?
Antipsychotic Antipsychotic agents are indicated for the treatment of schizophrenia, mania, and autism and to treat the symptoms of psychosis, such as hallucinations, delusions, bizarre behavior, disorganized thinking, and agitation. Mood stabilizers are indicated to treat mania in patients with bipolar disorders. Antianxiety agents are used to anxiety disorders. Stimulants are used to treat narcolepsy and attention deficit hyperactivity disorders.
A client with bipolar disorder has been ordered a medication that is classified as an anticonvulsant. Which drug does the nurse know falls within this class of medications?
Carbamazepine Carbamazepine is an anticonvulsant with mood-stabilizing effects. Lithium is a mood stabilizer. Mannitol and methyldopa are not used in the treatment of bipolar disorder.
The major difference between bipolar I and bipolar II disorder is what?
Clients with bipolar II disorder do not have symptoms of mania that interfere enough to cause marked functional disturbances. Bipolar II disorder is characterized by a major depressive episode (either current or past) and at least one hypomanic episode. Bipolar II disorder differs from bipolar I in that the client has never had a manic or mixed episode but may have had an episode in which he/she experienced a persistently elevated, expansive, or irritable mood. The hypomanic symptoms are not severe enough to cause marked social or occupational dysfunction.
When assessing a client immediately following electroconvulsive therapy (ECT), the nurse expects what in a client?
Confusion After ECT treatment, the client may be mildly confused or briefly disoriented. He or she is very tired and often has a headache. The client will have some short-term memory impairment. Numbness and tingling in the extremities is not an expected symptom of ECT.
Which is an anticonvulsant used as a mood stabilizer?
Divalproex Divalproex is an anticonvulsant that may be used as a mood stabilizer. Venlafaxine, bupropion, and phenelzine are antidepressants.
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?
During stabilization, discuss the client's individual signs, symptoms, and consequences of relapse. To help link the importance of taking medication with relapse prevention, the nurse lists target symptoms and identifies signs of imminent relapse. The nurse engages in problem solving with the client about early management of symptoms so severity does not increase.
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?
Emotional lability Emotional lability is alterations in moods with little or no change in external events. It is a term used for the rapid shifts in moods that often occur in bipolar disorder.
A client has bipolar disorder and has just begun a regimen of lithium, 600 mg tid. Which is the most critical management issue for the client during the first 2 weeks of treatment?
Ensuring the client's blood levels reach a therapeutic and safe dose Lithium has few side effects if maintained within a therapeutic range. Adverse reactions begin to occur with toxic levels.
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?
Liver function Baseline liver function tests and a complete blood count with platelets should be obtained before starting therapy, and clients with known liver disease should not be given divalproex sodium. There is a boxed warning for hepatotoxicity. Thyroid level, WBC count, and cardiac enzymes do not have to be performed routinely before starting this medication.
A 30-year-old woman has been brought to the emergency department after causing a disturbance. She is wearing a pair of tight, pink yoga pants, high heels, a sports bra, and a bright-colored hat. The woman's care providers would recognize that the woman's dress may suggest what?
Mania Physical appearance is a factor that influences communication; the client with mania may dress in brightly colored clothes with several items of jewelry and excessive makeup.
Limit setting is most appropriate in which client population?
Manic Most of the time, anxious, depressed, and suicidal clients do not test the limits of the caregiver.
A client who has been taking lithium for bipolar disorder is admitted to the hospital with the following symptoms: dry mouth, nausea and vomiting, blurred vision, dizziness, and muscle twitching. What should the nurse suspect?
Moderate lithium toxicity Side effects associated with moderate lithium toxicity include severe diarrhea, dry mouth, nausea and vomiting, mild to moderate ataxia, lack of coordination, dizziness, slurred speech, tinnitus, blurred vision, increasing tremors, muscle rigidity, asymmetric deep tendon reflexes, and increased muscle tone.
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?
Monitoring blood levels of the medication. Lithium is the drug of choice for clients with bipolar illness and has a high antimanic effectiveness. Lithium decreases the intensity, frequency, and duration of manic and depressive episodes. Blood levels need to be monitored for therapeutic levels during the acute phase (1.0-1.5 mEq/L) and during longer term maintenance. Other treatments that could be expected for clients during mania include sedatives or antipsychotics. Electroconvulsive therapy, phototherapy, and monoamine oxidase inhibitors are not typically indicated during manic phases.
Which medication classification is considered first-line drug therapy for bipolar disorder?
Mood stabilizers Mood stabilizers are first-line drugs for bipolar disorders. They stabilize depressive and manic cycles.
After observing a bipolar client on the mental health unit, the nurse determines that the client is at risk for violence. Which would be an appropriate intervention?
Restrict the client to the client's room until the client can calm down. If clients are determined to be at risk for violence, establishing geographic boundaries, such as room or half-hall restriction, is part of ongoing monitoring. Other environmental approaches include reducing stimuli and opportunities for interaction with other clients. Nurses remove all dangerous items from client rooms and monitor closely for use of any dangerous items. A pen or pencil that is used to write a letter can be a dangerous object.
Which would be the priority diagnosis for the client in the manic phase of bipolar disorder who is exhibiting aggressive behavior?
Risk for other-directed violence The priority nursing diagnosis is risk for other-directed violence. The other diagnoses are utilized for the client in the manic phase of bipolar disorder but are not the priority in this situation.
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?
Self-injury 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.
A client taking lithium for bipolar disorder is having mild diarrhea. The nurse informs the client that this is an example of what?
Side effect Lithium has many side effects that can be handled with interventions. For diarrhea, the nurse can instruct the client to take the medication with meals and provide for fluid replacement. The nurse should tell the client to notify the prescriber if the diarrhea becomes severe—this development can be an early sign of lithium toxicity, which would warrant a change in medication. Diarrhea is not a toxic or desired effect. The therapeutic effect is the intended effect of a drug.
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?
Substance use The effects of illicit substance use can mimic the symptoms of mania. The use of substances must be ruled out through the use of blood and urine diagnostics. Once determined that the signs and symptoms are not the result of substances, the client can be further investigated for mania.
When teaching a group of new mental health nurses about the major difference between bipolar I and bipolar II disorders, which would be most appropriate for the nurse to include?
The mania symptoms of bipolar II disorder have little effect on functioning. With bipolar I, at least one manic episode or mixed episode and a depressive episode have to occur. Bipolar II is not as easily recognized as bipolar I because the symptoms are less dramatic. Hypomania, a mild form of mania, is characteristic of bipolar II. A hypomanic episode is less intense, and there is little impairment in social or occupational functioning. The risk for suicide is present with both disorders.
Which is a true statement regarding depressive disorders?
The neurotransmitters norepinephrine, dopamine, and serotonin have been implicated. The neurotransmitters norepinephrine, dopamine, and serotonin have been associated with depression. Individuals between the ages of 18 to 29 years have a three times higher prevalence rate than those age 60 and older. The prevalence rates for females and males differ with females experiencing "a 1.5 - 3-fold higher rate than males beginning in early adolescence." Depressive symptomatology in older adults is more difficult to diagnose because it may be confused with symptoms of dementia or cerebrovascular accidents. Depression is the leading cause of years lost because of disability.
A nurse is developing a presentation for families who have members diagnosed with bipolar disorders. When describing this condition to the group, which would the nurse most likely include?
The risk for suicide is high with either depression or mania. The risk of suicide is always present for those having a depressive or manic episode. During a depressive episode, the client may feel that life is not worth living. During a manic episode, the client may believe that they have supernatural powers, such as the ability to fly. As clients recover from a manic episode, they may be so devastated by the consequences of their impulsive behavior and poor judgment that suicide seems like the only option. Manic or depressive episodes tend to accelerate over time, with each episode leaving a trace and increasing the person's vulnerability (or sensitizing the person to have another episode with less stimulation). Environmental conditions contribute to the timing of an episode of the illness but are not a cause of the illness. During a manic episode, poor judgment and impulsivity lead to risk-taking behaviors.
The genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should ...
assess for depression in the client's family history. The genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should assess for depression in the client's family history.
A 16-year-old client is highly disruptive in class and has been in trouble at home. The parent recently found the adolescent torturing a cat. When questioned, the adolescent laughed. What condition might the client be suffering from?
conduct disorder Adolescents with conduct disorder are often unmanageable at home and disruptive in the community. They have little empathy or concern for others. They may be callous and lack appropriate feelings of guilt, although they may express remorse superficially to avoid punishment. They often blame others for their actions. Risk-taking behaviors such as drinking, smoking, using illegal substances, experimenting with sex, and participating in crime are typical. Cruelty to animals or people, destruction of property, theft, and serious violation of rules are diagnostic criteria. Asperger syndrome is on the autism spectrum, where the child is extremely high in intelligence. Bipolar symptoms consist of wide swings between depression and mania. Tourette syndrome is a condition where motor and vocal tics occur.
The nurse is caring for a child who has been hospitalized repeatedly at multiple hospitals. There is no clear medical diagnosis and the parent is threatening to leave the hospital against medical advice. The nurse suspects what issue?
medical child abuse (formerly Munchausen syndrome by proxy) Repeated hospitalizations that fail to produce a medical diagnosis, transfers to other hospitals, and discharges against medical advice are warning signs of medical child abuse (formerly Munchausen syndrome by proxy).
