Bipolar Disorders

Question 1

What is the acute phase?

Answer 1

The earliest of three phases of mania, during which the person experiences poor judgement, excessive and constant motor activity, probable dehydration, and difficulty evaluating reality. The overall outcome of the acute phase is injury prevention.

Question 2

Anticonvulsant drugs.

Answer 2

A group of drugs (e.g., carbamazepine, valproic acid) used especially in treating people with mania that has been refractory to lithium therapy. These drugs are also useful in treating people who need rapid de-escalation and do not respond to other treatment approaches.

Question 3

Bipolar I disorder

Answer 3

A chronic, recurrent illness marked by shifts in mood, energy, and ability to function and in which at least one episode of mania alternates with major depression. Psychosis may accompany the manic episode.

Question 4

Bipolar II disorder

Answer 4

A chronic, recurrent illness marked by shifts in mood, energy, and ability to function and in which hypomanic episode(s) alternate with major depression. Psychosis is not present. Hypomania tends to be euphoric and often increases functioning; depression in this disorder tends to put people at particular risk for suicide.

Question 5

Clang associations

Answer 5

The stringing together of words because of their rhyming sounds, without regard to their meaning.

Question 6

Continuation phase

Answer 6

The second of three phases of bipolar disorder, lasting four to nine months, during which the overall outcome is relapse prevention. Many other outcomes must be accomplished to achieve this outcome.

Question 7

Cyclothymic disorder

Answer 7

Symptoms of hypomania alternate with symptoms of mild to moderate depression for at least 2 years in adults and 1 year in children.

Question 8

Euphoric mood

Answer 8

When associated with mania, unstable mood during which the patient may describe an intense feeling of well-being. The overly joyous mood may seem out of proportion to the situation, and cheerfulness may be inappropriate for the circumstances, considering that the person is full of energy but has had little or no sleep.

Question 9

Flight of ideas

Answer 9

A nearly continuous flow of accelerated speech, with abrupt changes from topic to topic that are usually based on understandable associations or plays on words.

Question 10

Grandiosity

Answer 10

A state in which people with mania may exaggerate their achievements or importance, say that they know famous people, or believe they have great powers. Grandiosity is also apparent in behaviour. Boasts of exceptional powers and status can take delusional proportions. Also called inflated self-regard.

Question 11

Hypomania

Answer 11

State in which people have voracious appetites for social engagement, spending, activity, and even indiscriminate sex. During hypomania, constant activity and a reduced need for sleep prevent proper rest.

Question 12

Maintenance phase

Answer 12

Focuses on supporting and consolidating the gains made during the action stage and continued focus on avoiding lapse or more significant relapse.

Question 13

Mania

Answer 13

An exaggerated euphoria or irritability.

Question 14

Manic episode

Answer 14

Individuals experiencing a manic episode feel euphoric and energized, don’t sleep or eat, and are in perpetual motion. They often take significant risks and engage in hazardous activities.

Question 15

Rapid cycling

Answer 15

Four or more mood episodes in a 12-month period. The term is used to indicate more severe symptoms, such as poorer global functioning, high recurrence risk, and resistance to conventional somatic treatments.

Question 16

Seclusion protocol

Answer 16

An outline of the proper reporting procedure, through the appropriate channels, to be used when seclusion is used as a treatment.

Question 17

What is the average age of onset for a Bipolar Disorder?
10–15 years
16–20 years
21–25 years
26–30 years

Answer 17

16–20 years

Question 18

Which of the following is the first-line drug used to treat mania?
Lithium carbonate (Lithium)
Carbamazepine (Tegretol)
Lamotrigine (Lamictal)
Clonazepam (Rivotril)

Answer 18

Lithium carbonate (Lithium)

Question 19

A person who has numerous hypomanic and dysthymic episodes can be assessed as demonstrating characteristics of which of the following?
Bipolar II disorder
Bipolar I disorder
Cyclothymia
Seasonal affective disorder

Answer 19

Cyclothymia

Question 20

Which behaviour would be most characteristic of a patient during a manic episode?
Going rapidly from one activity to another
Taking frequent rest periods and naps during the day
Being unwilling to leave home to see other people
Watching others intently and talking little

Answer 20

Going rapidly from one activity to another

Question 21

The nurse can expect a patient demonstrating typical manic behaviour to be attired in which of the following types of clothing?
Dark coloured and modest
Colourful and outlandish
Compulsively neat and clean
Ill-fitted and ragged

Answer 21

Colourful and outlandish

Question 22

A bipolar patient tells the nurse, “I have the best 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 patient is displaying which of the following?
Flight of ideas
Distractibility
Limit testing
Grandiosity

Answer 22

Grandiosity

Question 23

When a patient experiences four or more mood episodes in a 12-month period, the patient is said to be which of the following?
Dyssynchronous
Incongruent
Cyclothymic
Rapid cycling

Answer 23

Rapid cycling

Question 24

Which room placement would be best for a patient experiencing a manic episode?
A shared room with a patient with dementia
A single room near the unit activities area
A single room near the nurses’ station
A shared room away from the unit entrance

Answer 24

A single room near the nurses’ station

Question 25

When a hyperactive manic patient expresses the intent to strike another patient, the initial nursing intervention would be to do which of the following?
Question the patient’s motive
Set verbal limits
Initiate physical confrontation
Prepare the patient for seclusion

Answer 25

Set verbal limits

Question 26

When a patient reports that lithium causes an upset stomach, the nurse suggests taking the medication in which of the following ways?
With meals
With an antacid
30 minutes before meals
2 hours after meals

Answer 26

With meals

Question 27

Which behaviour exhibited by a person with mania should the nurse choose to address first?
a. Indiscriminate sexual relations
b. Excessive spending of money
c. Declaration of “being at one with the world”
d. Demonstration of flight of ideas

Answer 27

a. Indiscriminate sexual relations

Question 28

True or false: Bipolar disorder frequently goes unrecognized.

Answer 28

True

Question 29

Is Bipolar I disorder characterized by manic or hypomanic episodes?

Answer 29

Bipolar I disorder is characterized by the presence or history of at least one manic episode, whereas bipolar II disorder is characterized by the presence or history of at least one hypomanic episode

Question 30

True or false: Genetics do not play a strong role in the risk for the bipolar disorders.

Answer 30

False. They do play a strong role.

Question 31

Why is early detection and treatment of bipolar disorder important?

Answer 31

Early detection of bipolar disorder can help diminish comorbid substance abuse, suicide, and decline in social and personal relationships and may help promote more positive outcomes.

Question 32

What percentage of Canadians will experience bipolar disorder?

Answer 32

approx 1%

Question 33

What are three types of bipolar and related disorders?

Answer 33

Bipolar I
Bipolar II
Cyclothymic disorder

Question 34

What are the DSM-5 criteria for Bipolar I disorder, manic phase?

Answer 34

A. A distinct period of abnormally and persistently elevated, expansive, or irritable
mood and abnormally and persistently increased goal-directed activity or energy,
lasting at least 1 week and present most of the day, nearly every day (or any duration
if hospitalization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to a
significant degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant
external stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually)
or psychomotor agitation (i.e., purposeless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions,
or foolish business investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social or
occupational functioning or to necessitate hospitalization to prevent harm to self or
others, or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication, other treatment) or to another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond
the physiological effect of that treatment is sufficient evidence for a manic episode
and, therefore, a bipolar I diagnosis.
Note: Criteria A–D constitute a manic episode. At least one lifetime manic episode is
required for the diagnosis of bipolar I disorder.

Question 35

Which of the following is the priority nursing diagnosis for a hyperactive manic patient during the acute phase?
Risk for injury
Ineffective role performance
Risk for other-directed violence
Impaired verbal communication

Answer 35

Risk for injury is high, related to the patient’s hyperactivity and poor judgement.

Question 36

A manic patient 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.” Which of the following would be the best approach for the nurse to use?
“What an offensive thing to suggest!”
“I don’t have sex with patients.”
“No thanks, let’s go work on your art project.”
“Let’s walk down to the seclusion room.”

Answer 36

No thanks, let’s go work on your art project.”

Question 37

Which of the following would be a desired outcome for the maintenance phase of treatment for a manic patient?
The patient would exhibit optimistic, energetic, playful behaviour
The patient would adhere to follow-up medical appointments
The patient would take medication more than 50% of the time
The patient would use alcohol to moderate occasional mood “highs”

Answer 37

The patient would adhere to follow-up medical appointments

Question 38

What action should the nurse take on learning that a manic patient’s serum lithium level is 1.8 mEq/L?
Withhold medication and notify the physician.
Continue to administer medication as ordered.
Advise the patient to limit fluids for 12 hours.
Advise the patient to curtail salt intake for 24 hours.

Answer 38

Withhold medication and notify the physician.

Question 39

To plan care for a manic patient, the nurse must consider that lithium cannot be started until which of the following?
The physical examination and laboratory tests are analyzed
The initial doses of antipsychotic medication have brought behaviour under control
Seclusion has proven ineffective as a means of controlling assaultive behaviour
Electroconvulsive therapy can be scheduled to coincide with lithium administration

Answer 39

The physical examination and laboratory tests are analyzed

Question 40

Which of the following would be a desirable short-term goal for the nursing diagnosis Defensive coping related to biochemical changes as evidenced by aggressive verbal and physical behaviours?
Making no attempts at self-harm within 12 hours of admission
Sleeping soundly for 12 of the next 24 hours
Willingly taking prescribed medication as offered by staff within 24 hours of admission
Demonstrating psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission

Answer 40

Making no attempts at self-harm within 12 hours of admission

Question 41

Which adverse effects of lithium can be expected at therapeutic levels?
Fine hand tremor and polyuria
Nausea and thirst
Coarse hand tremor and gastrointestinal upset
Ataxia and hypotension

Answer 41

Fine hand tremor and polyuria

Question 42

When the wife of a manic patient asks about genetic transmission of bipolar disorder, the nurse’s answer should be predicated on knowledge of which of the following?
No research exists to suggest genetic transmission.
Much depends on the socioeconomic class of the individuals.
Highly creative people tend toward development of the disorder.
The rate of bipolar disorder is higher in relatives of people with bipolar disorder.

Answer 42

The rate of bipolar disorder is higher in relatives of people with bipolar disorder

Question 43

A patient taking lithium carbonate therapy is states “I think I will stop taking my lithium and only do the cognitive-behavioural therapy.” Which factors would the nurse expect to be contributing to that patient’s decision? (Select all that apply.)
The adverse effects are unpleasant.
The voices tell the patient to stop taking it.
The patient prefers to feel “high” and energetic.
The patient feels well and denies the possibility of recurrence.

Answer 43

The adverse effects are unpleasant
The patient prefers to feel “high” and energetic.

Question 44

What are the most appropriate nursing outcomes for a patient experiencing the acute phase or a manic, hypomanic, or depressive episode? (Select all that apply.)
Be well hydrated.
Maintain stable respiratory status.
Demonstrate thought self-control.
Make no attempt at self-harm.

Answer 44

Be well hydrated.
Demonstrate thought self-control.
Make no attempt at self-harm.

Question 45

What are key nursing Dx with manic phase bipolar?

Answer 45

Risk for Suicide
Risk for Injury
Risk for Violence (self and others)
Ineffective Coping, Impulse control

Question 46

What are the goals for acute phase of bipolar depression or mania?

Answer 46

Stabilize
- Maintain safety
- Self-care needs (sleeping and eating)

Question 47

What are the goals of the continuation phase of bipolar?

Answer 47

Aim for medication adherence
- Teaching
- Referrals

Question 48

What is the goal for the maintenance phase for bipolar disorder?

Answer 48

How to prevent a relapse

Question 49

What are treatments for bipolar disorder?

Answer 49

ECT
Support Groups
Health teaching and promotion
Psychotherapy
Medication

Question 50

What nursing care is involved for patients taking lithium?

Answer 50

• Ensure baseline physical and labs done prior to initiation: renal function, thyroid function, cardiac function.
• Encourage normal salt intake
• Monitor for signs of toxicity and teach patient what it looks like and what to do
• Monitor serum levels: always ensure you know what their last level was before administering. This is a priority.
• No diuretics, Teach to eliminate or decrease caffeine.
• To discontinue taper off.

Question 51

What other category of medication is used as a mood stabilizer (off label use)?

Answer 51

anticonvulsants

Question 52

How do anticonvulsants work to treat mood disorders?

Answer 52

In the 1980’s it was discovered that anticonvulsants are useful in treating mood disorders, specifically for rapid or continuously
cycling moods.They decrease neuronal excitability (GABA and Glutamate). Primarily for people with an absent family history of
bipolar. These meds diminish impulsivity and aggression.
Also used for treatment of anxiety (GABA neurotransmitter involved)

Question 53

What are important aspects to remember with bipolar disorder?

Answer 53

When stabilizing mania the patient is at high risk for injury. There is a loss of judgment and insight. Nurses will need to keep the patients dignity and safety intact. Distraction, limit setting, therapeutic alliance and, if warranted, restraints.

Lithium remains a first line treatment. Know expected adverse effects, what toxicity is and when to expect to see therapeutic effects after initiation.

Know the names of the anticonvulsants used to stabilize mood.

Question 54

What percentage of people with bipolar disorder have a concurrent substance use disorder?

Answer 54

50% or more have a concurrent substance abuse disorder

Question 55

Why are we worried when a patient using lithium has excessive diarrhea, vomiting or sweating?

Answer 55

Can lead to dehydration. Dehydration can raise lithium levels to toxic levels. Stop taking lithium and inform physician.

Question 56

Is bipolar I more common in men or women?

Answer 56

Men

Question 57

Is bipolar II more common in men or women?

Answer 57

Women

Question 58

When does cyclothemia usually begin?

Answer 58

Cyclothymia usually begins in adolescence or early adulthood

Question 59

What are critical to assess in the manic phase?

Answer 59

SLEEP and eating

Question 60

Why can hyponatremia increase the risk of lithium toxicity?

Answer 60

Hyponatremia can increase risk of toxicity because increased kidney reabsorption of sodium leads to increased
reabsorption of lithium as well*

Question 61

Why is thyroid function monitored?

Answer 61

THYROID FUNCTION monitored (long term use possible enlargement and possible hypothyroidism)

Question 62

What should the nurse always do before administering lithium?

Answer 62

Always ensure you know what their last level was before
administering. This is a priority.