13 - Bipolar and Related Disorders

Question 1

The first-line drug used to treat mania is

a. ) lithium carbonate (Lithium).
b. ) carbamazepine (Tegretol).
c. ) lamotrigine (Lamictal).
d. ) clonazepam (Klonopin).

Answer 1

a.) lithium carbonate (Lithium).

Lithium, a mood stabilizer, is the first-line drug for use in treating bipolar disorder.

Question 2

A person who has numerous hypomanic and dysthymic episodes can be assessed as demonstrating characteristics of

a. ) bipolar II disorder.
b. ) bipolar I disorder.
c. ) cyclothymia.
d. ) seasonal affective disorder.

Answer 2

c.) cyclothymia.

Cyclothymia refers to mood swings involving hypomania and dysthymia of 2 years’ duration.

The mood swings are not severe enough to prompt hospitalization.

Question 3

A bipolar client tells the nurse, “I have the finest tenor voice in the world. The three tenors who do all those TV concerts are going to retire because they can’t compete with me.” The nurse would make the assessment that the client is displaying

a. ) flight of ideas.
b. ) distractibility.
c. ) limit testing.
d. ) grandiosity.

Answer 3

d.) grandiosity.

Exaggerated belief in one’s own importance, identity, or capabilities is seen with grandiosity.

Question 4

Which behavior would be most characteristic of a client during a manic episode?

a. ) Going rapidly from one activity to another
b. ) Taking frequent rest periods and naps during the day
c. ) Being unwilling to leave home to see other people
d. ) Watching others intently and talking little

Answer 4

a.) Going rapidly from one activity to another

Hyperactivity and distractibility are basic to manic episodes.

Question 5

The nurse can expect a client demonstrating typical manic behavior to be attired in clothing that is

a. ) dark colored and modest.
b. ) colorful and outlandish.
c. ) compulsively neat and clean.
d. ) ill-fitted and ragged.

Answer 5

b.) colorful and outlandish.

Manic clients often manage to dress and apply makeup in ways that create a colorful, even bizarre, appearance.

Question 6

An outcome for a manic client during the acute phase that would indicate that the treatment plan was successful would be that the client

a. ) reports racing thoughts.
b. ) is free of injury.
c. ) is highly distractible.
d. ) ignores food and fluid.

Answer 6

b.) is free of injury.

Risk for injury is a diagnosis of high priority for manic clients because of their hyperactivity.

Lack of injury is a highly desirable outcome.

Question 7

When a client experiences four or more mood episodes in a 12-month period, the client is said to be

a. ) dyssynchronous.
b. ) incongruent.
c. ) cyclothymic.
d. ) rapid cycling.

Answer 7

d.) rapid cycling.

Rapid cycling implies four or more mood episodes in a 12-month period, as well as more severe symptomatology.

Question 8

Which room placement would be best for a client experiencing a manic episode?

a. ) A shared room with a client with dementia
b. ) A single room near the unit activities area
c. ) A single room near the nurses’ station
d. ) A shared room away from the unit entrance

Answer 8

c.) A single room near the nurses’ station

The room placement that provides a nonstimulating environment is best.

Nearness to the nurses’ station means close supervision can be provided.

Question 9

When a hyperactive manic client expresses the intent to strike another client, the initial nursing intervention would be to

a. ) question the client’s motive.
b. ) set verbal limits.
c. ) initiate physical confrontation.
d. ) prepare the client for seclusion.

Answer 9

b.) set verbal limits.

Verbal limit setting should always precede more restrictive measures.

Question 10

When a client reports that lithium causes an upset stomach, the nurse suggests taking the medication:

a. ) with meals
b. ) with an antacid
c. ) 30 minutes before meals
d. ) 2 hours after meals

Answer 10

a.) with meals

Many clients find that taking lithium with or shortly after meals minimizes gastric distress.

Question 11

The priority nursing diagnosis for a hyperactive manic client during the acute phase is

a. ) risk for injury.
b. ) ineffective role performance.
c. ) risk for other-directed violence.
d. ) impaired verbal communication.

Answer 11

a.) risk for injury.

Risk for injury is high, related to the client’s hyperactivity and poor judgment.

Question 12

An acute phase nursing intervention aimed at reducing hyperactivity is redirecting the client to

a. ) write in a diary.
b. ) exercise in the gym.
c. ) direct unit activities.
d. ) orient a new client to the unit.

Answer 12

a.) write in a diary.

Manic clients often respond well to the invitation to write.

They will fill reams of paper.

While writing they are less physically active.

Question 13

A bipolar client whose continuing phase treatment consists of lithium therapy and cognitive-behavioral therapy may become noncompliant with medication. Which factor would be of least concern to the nurse developing a psychoeducation plan to foster compliance?

a. ) The side-effects are unpleasant.
b. ) The voices tell the client to stop taking it.
c. ) The client prefers to feel “high” and energetic.
d. ) The client feels well and denies the possibility of recurrence.

Answer 13

b.) The voices tell the client to stop taking it.

Manic clients may hallucinate during the delirious state but generally do not hear voices.

Psychoeducation would not be going on during the time the client is delirious.

Question 14

A manic client tells a nurse “Bud. Crud. Dud. I’m a real stud! You’d like what I have to offer. Let’s go to my room.” The best approach for the nurse to use would be

a. ) “What an offensive thing to suggest!”
b. ) “I don’t have sex with clients.”
c. ) “It’s time to work on your art project.”
d. ) “Let’s walk down to the seclusion room.”

Answer 14

c.) “It’s time to work on your art project.”

Distractibility works as the nurse’s friend.

Rather than discuss the invitation, the nurse may be more effective by redirecting the client.

Question 15

A desired outcome for the maintenance phase of treatment for a manic client would be that the client will

a. ) exhibit optimistic, energetic, playful behavior.
b. ) adhere to follow-up medical appointments.
c. ) take medication more than 50% of the time.
d. ) use alcohol to moderate occasional mood “highs.”

Answer 15

b.) adhere to follow-up medical appointments.

The client would be living in the community during the maintenance phase.

Keeping follow-up appointments is highly desirable.

Question 16

What action should the nurse take on learning that a manic client’s serum lithium level is 1.8 mEq/L?

a. ) Withhold medication and notify the physician.
b. ) Continue to administer medication as ordered.
c. ) Advise the client to limit fluids for 12 hours.
d. ) Advise the client to curtail salt intake for 24 hours.

Answer 16

a.) Withhold medication and notify the physician.

The client’s lithium level has exceeded desirable limits.

Additional doses of the medication should be withheld and the physician notified.

Question 17

To plan care for a manic client the nurse must consider that lithium cannot be started until

a. ) the physical examination and laboratory tests are analyzed.
b. ) the initial doses of antipsychotic medication have brought behavior under control.
c. ) seclusion has proven ineffective as a means of controlling assaultive behavior.
d. ) electroconvulsive therapy can be scheduled to coincide with lithium administration.

Answer 17

a.) the physical examination and laboratory tests are analyzed.

Lithium should not be given to clients with impaired renal or thyroid function.

A thorough physical examination and various laboratory tests are necessary to rule out other organic causes for the behavior and to ensure that the lithium can be excreted normally.

Question 18

A desirable short-term goal for the nursing diagnosis Defensive coping related to biochemical changes as evidenced by aggressive verbal and physical behaviors would be

a. ) making no attempts at self-harm within 12 hours of admission.
b. ) sleeping soundly for 12 of the next 24 hours.
c. ) willingly taking prescribed medication as offered by staff within 24 hours of admission.
d. ) demonstrating psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission.

Answer 18

a.) making no attempts at self-harm within 12 hours of admission.

Whenever aggressive verbal or physical behaviors are demonstrated, a desirable goal is cessation of those behaviors.

Verbal and physical aggression are most apt to occur when staff are trying to structure the client’s behavior for his or her own safety or the safety of others.

Question 19

Which side effects of lithium can be expected at therapeutic levels?

a. ) Fine hand tremor and polyuria
b. ) Nausea and thirst
c. ) Coarse hand tremor and gastrointestinal upset
d. ) Ataxia and hypotension

Answer 19

a.) Fine hand tremor and polyuria

The fact that fine hand tremor and polyuria are present at therapeutic levels is quite annoying to some clients.

These and other side effects are factors in noncompliance.

Question 20

When the wife of a manic client asks about genetic transmission of bipolar disorder, the nurse’s answer should be predicated on the knowledge that

a. ) no research exists to suggest genetic transmission.
b. ) much depends on the socioeconomic class of the individuals.
c. ) highly creative people tend toward development of the disorder.
d. ) the rate of bipolar disorder is higher in relatives of people with bipolar disorder.

Answer 20

d.) the rate of bipolar disorder is higher in relatives of people with bipolar disorder.

This understanding will allow the nurse to directly address the question.

Responses based on the other statements would be tangential or untrue.

Question 21

Which of the following is true of the relationship between bipolar disorder and suicide?

a. ) Patients need to be monitored only in the depressed phase because this is when suicides occur.
b. ) Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide.
c. ) Patients with bipolar disorder are not considered high risk for suicide.
d. ) As long as patients with bipolar disorder adhere to their medication regimen, there is little risk for suicide.

Answer 21

b.) Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide.

Mortality rates for bipolar disorder are severe because 25% to 60% of individuals with bipolar disorder will make a suicide attempt at least once in their lifetime, and nearly 20% of all deaths among this population are from suicide.

Suicides occur in both the depressed and the manic phase.

Bipolar patients are always considered high risk for suicide because of impulsivity while in the manic phase and hopelessness when in the depressed phase.

Although staying on medications may decrease risk, there is no evidence to suggest that only patients who stop medications commit suicide.

Question 22

Tyler is a 31-year-old patient admitted with acute mania. He tells the staff and the other patients that he is on a secret mission given to him by the President of the United States to monitor citizens for terrorist activity. He states, “I am the only one he trusts, because I am the best!” For documentation purposes you know that this behavior is referred to as:

a. ) unpredictability.
b. ) rapid cycling.
c. ) grandiosity.
d. ) flight of ideas.

Answer 22

c.) grandiosity.

Grandiosity is inflated self-regard.

People with mania may exaggerate their achievements or importance, state that they know famous people, or believe they have great powers.

Although patients with mania are unpredictable, the scenario does not describe unpredictability: Rapid cycling is switching between mania and depression in a given time period.

The scenario does not describe flight of ideas, which means a continuous flow of speech with abrupt topic changes.

Question 23

Tyler is being discharged home to his family. Which of the following is important teaching to include for the patient and the family to recognize possible signs of impending mania?

a. ) Increased appetite
b. ) Decreased social interaction
c. ) Increased attention to bodily functions
d. ) Decreased sleep

Answer 23

d.) Decreased sleep

Changes in sleep patterns are especially important because they usually precede mania.

Even a single night of unexplainable sleep loss can be taken as an early warning of impending mania.

The other options do not indicate impending mania.

Question 24

Which of the following describe the symptoms of the manic phase of bipolar disorder? (select all that apply):

a. ) Excessive energy
b. ) Fatigue and increased sleep
c. ) Low self-esteem
d. ) Pressured speech
e. ) Purposeless movement
f. ) Racing thoughts
g. ) Withdrawal from environment
h. ) Distractibility

Answer 24

a.) Excessive energy

d.) Pressured speech

e.) Purposeless movement

f.) Racing thoughts

h.) Distractibility

All these options describe mania. The other options more aptly describe the opposite of what happens in mania.

Question 25

Tyler’s nursing care plan has several nursing diagnoses listed. Match the nursing diagnosis to the level of priority (1 to 4):

a. ) Knowledge, deficient
b. ) Nonadherence
c. ) Risk for injury
d. ) Self-care deficit, bathing and hygiene

Answer 25

1 = Risk for injury

2 = Self-care deficit, bathing and hygiene

3 = Knowledge, deficient

4 = Nonadherence

Question 26

A major principle the nurse should observe when communicating with a patient experiencing elated mood is to:

a. ) Use a calm, firm approach.
b. ) Give expanded explanations.
c. ) Make use of abstract concepts.
d. ) Encourage lightheartedness and joking.

Answer 26

a.) Use a calm, firm approach.

Question 27

Nadia has been diagnosed with bipolar disorder. Which is an outcome for Nadia in the continuation of treatment phase of bipolar disorder?

a. ) Patient will avoid involvement in self-help groups.
b. ) Patient will adhere to medication regimen.
c. ) Patient will demonstrate euphoric mood.
d. ) Patient will maintain normal weight.

Answer 27

b.) Patient will adhere to medication regimen.

Question 28

A medication teaching plan for a patient receiving lithium should include:

a. ) Periodic monitoring of renal and thyroid function.
b. ) Dietary teaching to restrict daily sodium intake.
c. ) The importance of blood draws to monitor serum potassium level.
d. ) Discontinuing the drug if weight gain and fine hand tremors are noticed.

Answer 28

a.) Periodic monitoring of renal and thyroid function.

Question 29

Which symptom related to communication is most likely to be present in a patient experiencing mania?

a. ) Mutism
b. ) Verbosity
c. ) Poverty of ideas
d. ) Confabulation

Answer 29

b.) Verbosity

Question 30

For assessment purposes, the nurse should identify the body system most at risk for decompensation during a severe manic episode as:

a. ) Renal
b. ) Cardiac
c. ) Endocrine
d. ) Pulmonary

Answer 30

b.) Cardiac