Ch. 16 Flashcards
A person is directing traffic on a busy street and shouting, “To work, you jerk, for perks,” and making obscene gestures at cars. The person has not slept or eaten for 3 days. What features of mania are evident?
a.
Increased muscle tension and anxiety
b.
Vegetative signs and poor grooming
c.
Poor judgment and hyperactivity
d.
Cognitive deficit and sad mood
ANS: C
Hyperactivity (directing traffic) and poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distracters do not specifically apply to mania.
DIF: Cognitive Level: Application REF: Pages: 281-282
A patient with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, “I’ll punch you, munch you, crunch you,” while twirling and shadowboxing. Then the patient says gaily, “Do you like my scarves? Here…they are my gift to you.” How should the nurse document the patient’s mood?
a.
Labile and euphoric
b.
Irritable and belligerent
c.
Highly suspicious and arrogant
d.
Excessively happy and confident
ANS: A
The patient has demonstrated angry behavior and pleasant, happy behavior within seconds of each other. Excessive happiness indicates euphoria. Mood swings are often rapid and seemingly without understandable reason in patients who are manic. These swings are documented as labile. Irritability, belligerence, excessive happiness, and confidence are not entirely correct terms for the patient’s mood. A high level of suspicion is not evident.
DIF: Cognitive Level: Application REF: Pages: 279-282
A person is directing traffic on a busy street and rapidly shouting, “To work, you jerk, for perks,” and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient’s plan of care?
a.
Insulting, provocative behavior
b.
Pressured speech and grandiosity
c.
Hyperactivity; not eating and sleeping
d.
Poor concentration and decision making
ANS: C
Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient’s life.
DIF: Cognitive Level: Analysis REF: Pages: 283-285
A patient with mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?
a.
Risk for injury
b.
Ineffective coping
c.
Impaired social interaction
d.
Ineffective therapeutic regimen management
ANS: A
Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient’s physiologic safety. Hyperactivity and poor judgment place the patient at risk for injury.
DIF: Cognitive Level: Application REF: Pages: 283-285
A patient with bipolar disorder is hyperactive after discontinuing lithium and has not slept for 3 days. The patient threatens to hit another patient. Which comment by the nurse is appropriate?
a.
“Stop that! No one did anything to provoke an attack by you.”
b.
“If you do that one more time, you will be secluded immediately.”
c.
“Do not hit anyone. If you are unable to control yourself, we will help you.”
d.
“You know we will not let you hit anyone. Why do you continue this behavior?”
ANS: C
When the patient is unable to control his or her behavior and violates or threatens to violate the rights of others, limits must be set in an effort to de-escalate the situation. Limits should be set in simple, concrete terms. The first response does not offer appropriate assistance to the patient. The second response threatens the patient with seclusion as punishment. The fourth response asks a rhetorical question.
DIF: Cognitive Level: Application REF: Pages: 286-289
This nursing diagnosis applies to a patient with mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will:
a.
ask staff for assistance with feeding within 4 days.
b.
drink six servings of a high-calorie, high-protein drink each day.
c.
consistently sit with others for at least 30 minutes at mealtime within 1 week.
d.
consistently wear appropriate attire for age and sex within 1 week while in the psychiatric unit.
ANS: B
High-calorie, high-protein food supplements will provide the additional calories needed to offset the patient’s extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient will eat or drink. The other indicator is unrelated to the nursing diagnosis.
DIF: Cognitive Level: Application REF: Page: 290
A patient with mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will:
a.
minimize the side effects of lithium.
b.
bring hyperactivity under rapid control.
c.
enhance the antimanic actions of lithium.
d.
be used for long-term control of hyperactivity.
ANS: B
Manic symptoms are controlled by lithium only after a therapeutic serum level is attained. Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce the hyperactivity initially. Antipsychotic drugs neither enhance lithium’s antimanic activity nor minimize the side effects. Lithium is used for long-term control.
DIF: Cognitive Level: Application REF: Page: 287|Page: 293
A patient with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed?
a.
phenytoin (Dilantin)
b.
clonidine (Catapres)
c.
carbamazepine (Tegretol)
d.
chlorpromazine (Thorazine)
ANS: C
Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favorable response to the anticonvulsants carbamazepine and valproate. Phenytoin is also an anticonvulsant but is not used for mood stabilization. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry patients with manic episodes.
DIF: Cognitive Level: Application REF: Pages: 292-293
The cause of bipolar disorder has not been determined, but:
a.
several factors, including genetics, are implicated.
b.
brain structures were altered by stresses early in life.
c.
excess norepinephrine is probably a major factor.
d.
excess sensitivity in dopamine receptors may exist.
ANS: A
At this time, the interplay of complex independent variables is most likely the best explanation of the cause for bipolar disorder. Various theories implicate genetics, endocrine imbalance, early stress, and neurotransmitter imbalances.
DIF: Cognitive Level: Comprehension REF: Pages: 278-279
The spouse of a patient with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurse’s best response.
a.
“A high proportion of patients with bipolar disorders are found among creative writers.”
b.
“A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder.”
c.
“Patients with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses.”
d.
“More individuals with bipolar disorder come from high socioeconomic and educational backgrounds.”
ANS: B
Evidence of genetic transmission is supported when twins or relatives of patients with a particular disorder also show an incidence of the disorder that is higher than the incidence in the general public. The incorrect options do not support the theory of genetic transmission of bipolar disorder.
DIF: Cognitive Level: Application REF: Page: 278
A patient with bipolar disorder commands other patients, “Get me a book. Take this stuff out of here,” and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial approach by the nurse.
a.
Distraction: “Let’s go to the dining room for a snack.”
b.
Humor: “How much are you paying servants these days?”
c.
Limit setting: “You must stop ordering other patients around.”
d.
Honest feedback: “Your controlling behavior is annoying others.”
ANS: A
The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into a power struggle. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed to a labile patient and may incite anger.
DIF: Cognitive Level: Application REF: Page: 287
A nurse receives this laboratory result: lithium level 1 mEq/L. This result is:
a.
within therapeutic limits
b.
below therapeutic limits
c.
above therapeutic limits
d.
incorrect because of inaccurate testing
ANS: A
The normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.
DIF: Cognitive Level: Comprehension REF: Page: 291
Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group?
a.
clonazepam (Klonopin)
b.
risperidone (Risperdal)
c.
lamotrigine (Lamictal)
d.
aripiprazole (Abilify)
ANS: C
The three drugs in the stem of this question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs.
DIF: Cognitive Level: Analysis REF: Page: 294
When a hyperactive patient with acute mania is hospitalized, what initial nursing intervention is a priority?
a.
Allow the patient to act out his or her feelings.
b.
Set limits on patient behavior as necessary.
c.
Provide verbal instructions to the patient to remain calm.
d.
Restrain the patient to reduce hyperactivity and aggression.
ANS: B
This intervention provides support through the nurse’s presence and provides structure as necessary while the patient’s control is tenuous. Acting out may lead to the loss of behavioral control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.
DIF: Cognitive Level: Application REF: Pages: 286-289
At a unit meeting, staff members discuss the decor for a special room for patients with mania. Select the best option.
a.
Extra-large window with a view of the street
b.
Neutral walls with pale, simple accessories
c.
Brightly colored walls and print drapes
d.
Deep colors for walls and upholstery
ANS: B
The environment for a patient with mania should be as simple and nonstimulating as possible. Patients with mania are highly sensitive to environmental distractions and stimulation.
DIF: Cognitive Level: Application REF: Pages: 285-287
