Chapter 15: Bipolar Disorders

Question 1

A person was online continuously for over 24 hours, posting rhymes on official government Web sites and inviting politicians to join social networks. 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 judgement and hyperactivity
d. Cognitive deficits and paranoia

Answer 1

ANS: C
Hyperactivity (activity without sleep) and poor judgement (posting rhymes on government Web sites) are characteristic of manic episodes. The distracters do not specifically apply to mania.

Question 2

A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. 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. Euphoric
b. Irritable
c. Suspicious
d. Confident

Answer 2

ANS: A
The patient has demonstrated clang associations and pleasant, happy behaviour. Excessive happiness indicates euphoria. Irritability and confidence are not the best terms for the patient’s mood. Suspiciousness is not evident.

Question 3

A person was directing traffic on a busy street, 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, aggressive behaviour
b. Pressured speech and grandiosity
c. Hyperactivity; not eating and sleeping
d. Poor concentration and decision making

Answer 3

ANS: C
Hyperactivity, poor nutrition, poor hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviours are less threatening to the patient’s life.

Question 4

A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority?

a. Risk for injury
b. Ineffective coping
c. Impaired social interaction
d. Ineffective therapeutic regimen management

Answer 4

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 physiological safety. Hyperactivity and poor judgement put the patient at risk for injury.

Question 5

A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium. 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 behaviour?”

Answer 5

ANS: C
When the patient is unable to control his or her behaviour 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 incorrect responses do not offer appropriate assistance to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical question.

Question 6

This nursing diagnosis applies to a patient with acute 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 an appropriate outcome.

a. The patient will ask staff for assistance with feeding within 4 days.
b. The patient will drink six servings of a high-calorie, high-protein drink each day.
c. The patient will consistently sit with others for at least 30 minutes at meal time within 1 week.
d. The patient will consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.

Answer 6

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 eats or drinks. The other indicator is unrelated to the nursing diagnosis.

Question 7

A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is the rationale for the addition of olanzapine to the medication regimen?

a. It minimizes the side effects of lithium.
b. It brings hyperactivity under rapid control.
c. It enhances the antimanic actions of lithium.
d. It is used for long-term control of hyperactivity.

Answer 7

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.

Question 8

A patient diagnosed with bipolar disorder has rapidly changing mood 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. Gabapentin (Neurontin)
c. Risperidone (Risperdal)
d. Carbamazepine (Tegretol)

Answer 8

ANS: D
Some patients with bipolar disorder, especially those who have only short periods between episodes, have a favourable response to the anticonvulsants carbamazepine and valproate. Carbamazepine seems to work better in patients with rapid cycling and in severely paranoid, angry manic patients. Phenytoin is also an anticonvulsant but not used for mood stabilization. Risperidone is not an anticonvulsant. Gabapentin is an anticonvulsant that is used primarily for maintenance treatment of bipolar disorder.

Question 9

The exact cause of bipolar disorder has not been determined; however, for most patients, which of the following is true?

a. Several factors, including genetics, are implicated.
b. Brain structures were altered by stress early in life.
c. Excess sensitivity in dopamine receptors may trigger episodes.
d. Inadequate norepinephrine reuptake disturbs circadian rhythms.

Answer 9

ANS: A
The best explanation at this time is that bipolar disorder is most likely caused by interplay of complex independent variables. Various theories implicate genetics, endocrine imbalance, environmental stressors, and neurotransmitter imbalances.

Question 10

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Which response should the nurse provide?

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 stress.”
d. “More individuals with bipolar disorder come from high socioeconomic and educational backgrounds.”

Answer 10

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 and other factors involved in the etiology of bipolar disorder.

Question 11

A patient diagnosed 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 behaviour without entering into a power struggle. Which initial approach should the nurse select?

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 behaviour is annoying others.”

Answer 11

ANS: A
The distractibility characteristic of manic episodes can assist the nurse to direct the patient toward more appropriate, constructive activities without entering into power struggles. Humor usually backfires by either encouraging the patient or inciting anger. Limit setting and honest feedback may seem heavy-handed and may incite anger.

Question 12

The nurse receives a laboratory report indicating a patient’s serum lithium level is 1 mEq/L. The patient’s last dose of lithium was 8 hours ago. How should the nurse interpret this result?

a. This result is within therapeutic limits.
b. This result is below therapeutic limits.
c. This result is above therapeutic limits.
d. This result is invalid because of the time lapse since the last dose.

Answer 12

ANS: A

Normal range for a blood sample taken 8 to 12 hours after the last dose of lithium is 0.4 to 1 mEq/L.

Question 13

Consider these three anticonvulsant medications used in mood stabilization: divalproex sodium (Epival), carbamazepine (Tegretol), and gabapentin (Neurontin). Which of the following medications also belongs to this classification?

a. Clonazepam (Rivotril)
b. Risperidone (Risperdal)
c. Lamotrigine (Lamictal)
d. Aripiprazole (Abilify)

Answer 13

ANS: C
The three drugs in the question are all anticonvulsants. Lamotrigine is also an anticonvulsant. Clonazepam is an anxiolytic; aripiprazole and risperidone are antipsychotic drugs.

Question 14

When a hyperactive patient diagnosed with acute mania is hospitalized, what is the initial nursing intervention?

a. Allow the patient to act out feelings.
b. Set limits on patient behaviour as necessary.
c. Provide verbal instructions to the patient to remain calm.
d. Restrain the patient to reduce hyperactivity and aggression.

Answer 14

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 loss of behavioural control. The patient will probably be unable to focus on instructions and comply. Restraint is used only after other interventions have proved ineffective.

Question 15

At a unit meeting, the staff discusses decor for a special room for patients with acute mania. Which suggestion is appropriate?

a. An extra-large window with a view of the street
b. Neutral walls with pale, simple accessories
c. Brightly coloured walls and print drapes
d. Deep colours for walls and upholstery

Answer 15

ANS: B
The environment for a manic patient should be as simple and nonstimulating as possible. Manic patients are highly sensitive to environmental distractions and stimulation.

Question 16

A patient demonstrating behaviours associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action will the staff take initially?

a. Confer with the health care provider to consider use of seclusion for this patient.
b. Hold a staff meeting to discuss consistency and limit-setting approaches.
c. Conduct a meeting with all staff and patients to discuss the behaviour.
d. Explain to the patient that the behaviour is unacceptable.

Answer 16

ANS: B
When staff members are at their wits’ end, the patient has succeeded in keeping the environment unsettled and avoided outside controls on behaviour. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration.

Question 17

A patient experiencing acute mania undresses in the group room and dances. The nurse intervenes initially by doing which of the following?

a. Quietly asking the patient, “Why don’t you put your clothes on?”
b. Firmly telling the patient, “Stop dancing and put on your clothing.”
c. Putting a blanket around the patient and walking with the patient to a quiet room
d. Letting the patient stay in the group room and moving the other patients to a different area

Answer 17

ANS: C
Patients must be protected from the embarrassing consequences of their poor judgement whenever possible. Protecting the patient from public exposure by matter-of-factly covering the patient and removing him or her from the area with a sufficient number of staff to avoid argument and provide control is an effective approach.

Question 18

A patient waves a newspaper and says, “I must have my credit card and use the computer right now. A store is having a big sale, and I need to order 10 dresses and 4 pairs of shoes.” Select the nurse’s appropriate intervention.

a. Suggest the patient have a friend do the shopping and bring purchases to the unit
b. Invite the patient to sit together and look at new fashion magazines
c. Tell the patient computer use is not allowed until self-control improves
d. Ask whether the patient has enough money to pay for the purchases

Answer 18

ANS: B
Situations such as this offer an opportunity to use the patient’s distractibility to staff’s advantage. Patients become frustrated when staff deny requests that the patient sees as entirely reasonable. Distracting the patient can avoid power struggles. Suggesting that a friend do the shopping would not satisfy the patient’s need for immediacy and would ultimately result in the extravagant expenditure. Asking whether the patient has enough money would likely precipitate an angry response.

Question 19

An outpatient diagnosed with bipolar disorder takes lithium carbonate 300 mg three times daily. The patient reports nausea. To reduce the nausea most effectively, the nurse suggests that the lithium be taken with which of the following?

a. Meals
b. An antacid
c. An antiemetic
d. A large glass of juice

Answer 19

ANS: A

Some patients find that taking lithium with meals diminishes nausea. The incorrect options are less helpful.

Question 20

A health teaching plan for a patient taking lithium should include instructions to do which of the following?

a. Maintain normal salt and fluids in the diet
b. Drink twice the usual daily amount of fluid
c. Double the lithium dose if diarrhea or vomiting occurs
d. Avoid eating aged cheese, processed meats, and red wine

Answer 20

ANS: A
Sodium depletion and dehydration increase the chance for development of lithium toxicity. The other options offer inappropriate information.

Question 21

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depression and one experiencing acute mania?

a. Deficient diversional activity
b. Disturbed sleep pattern
c. Fluid volume excess
d. Defensive coping

Answer 21

ANS: B
Patients with mood disorders, both depression and mania, experience sleep pattern disturbances. Assessment data should be routinely gathered about this possible problem. Deficient diversional activity is more relevant for patients with depression. Defensive coping is more relevant for patients with mania. Fluid volume excess is less relevant for patients with mood disorders than is Deficient fluid volume.

Question 22

Which dinner menu is best suited for a patient with acute mania?

a. Spaghetti and meatballs, salad, and a banana
b. Beef and vegetable stew, a roll, and chocolate pudding
c. Broiled chicken breast on a roll, an ear of corn, and an apple
d. Chicken casserole, green beans, and flavoured gelatin with whipped cream

Answer 22

ANS: C
These foods provide adequate nutrition, but more importantly, they are finger foods that the hyperactive patient could “eat on the run.” The foods in the incorrect options cannot be eaten without utensils.

Question 23

Outcome identification for the treatment plan of a patient experiencing grandiose thinking associated with acute mania will focus on which of the following?

a. Development of an optimistic outlook
b. Distorted thought self-control
c. Interest in the environment
d. Sleep pattern stabilization

Answer 23

ANS: B
The desired outcome is that the patient will be able to control the grandiose thinking associated with acute mania as evidenced by making realistic comments about self, abilities, and plans. Patients with acute mania are already unduly optimistic as a result of their use of denial, and they are overly interested in their environment. Sleep stability is a desired outcome but is not related to distorted thought processes.

Question 24

Which documentation indicates that the treatment plan for a patient diagnosed with acute mania has been effective?

a. “Converses with few interruptions; clothing matches; participates in activities.”
b. “Irritable, suggestible, distractible; napped for 10 minutes in afternoon.”
c. “Attention span short; writing copious notes; intrudes in conversations.”
d. “Heavy makeup; seductive toward staff; pressured speech.”

Answer 24

ANS: A
The descriptors given indicate the patient is functioning at an optimal level, using appropriate behaviour, and thinking without becoming overstimulated by unit activities. The incorrect options reflect manic behaviour.

Question 25

A patient experiencing acute mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation?

a. Monitor physiological functioning.
b. Provide a subdued environment.
c. Supervise personal hygiene.
d. Observe for mood changes.

Answer 25

ANS: B
All the options are reasonable interventions with a patient with acute mania, but providing a subdued environment directly relates to the outcome of energy conservation by decreasing stimulation and helping to balance activity and rest.

Question 26

A patient with diagnosed bipolar disorder was hospitalized 7 days ago and has been taking lithium 600 mg tid. Staff observes increased agitation, pressured speech, poor personal hygiene, and hyperactivity. Which action demonstrates that the nurse understands the most likely cause of the patient’s behaviour?
a. Educate the patient about the proper ways to perform personal hygiene and
coordinate clothing.
b. Continue to monitor and document the patient’s speech patterns and motor
activity.
c. Ask the health care provider to prescribe an increased dose and frequency of
lithium.
d. Consider the need to check the lithium level. The patient may not be swallowing medications.

Answer 26

ANS: D
The patient is continuing to exhibit manic symptoms. The lithium level may be low from “cheeking” (not swallowing) the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased. Monitoring the patient does not address the problem.

Question 27

A patient with acute mania has disrobed in the hall three times in 2 hours. Which of the following should the nurse do?

a. Direct the patient to wear clothes at all times.
b. Ask if the patient finds clothes bothersome.
c. Tell the patient that others feel embarrassed.
d. Arrange for one-on-one supervision.

Answer 27

ANS: D
A patient who repeatedly disrobes despite verbal limit setting needs more structure. One-on-one supervision may provide the necessary structure. Directing the patient to wear clothes at all times has not proven successful, considering the behaviour has continued. Asking if the patient is bothered by clothing serves no purpose. Telling the patient that others are embarrassed will not make a difference to the patient whose grasp of social behaviours is impaired by the illness.

Question 28

A patient experiencing acute mania is dancing atop a pool table in the recreation room. The patient waves a cue in one hand and says, “I’ll throw the pool balls if anyone comes near me.” To best assure safety, the nurse’s first intervention is to do which of the following?

a. Tell the patient, “You need to be secluded.”
b. Clear the room of all other patients.
c. Help the patient down from the table.
d. Assemble a show of force.

Answer 28

ANS: B
Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented.

Question 29

A patient diagnosed with bipolar disorder will be discharged tomorrow. The patient is taking a mood stabilizing medication. What is the priority nursing intervention for the patient as well as the patient’s family during this phase of treatment?

a. Attending psychoeducation sessions
b. Decreasing physical activity
c. Increasing food and fluids
d. Meeting self-care needs

Answer 29

ANS: A
During the continuation phase of treatment for bipolar disorder, the physical needs of the patient are not as important an issue as they were during the acute episode. After hospital discharge, treatment focuses on maintaining medication compliance and preventing relapse, both of which are fostered by ongoing psychoeducation.

Question 30

A nurse assesses a patient who takes lithium. Which findings demonstrate evidence of complications?

a. Pharyngitis, mydriasis, and dystonia
b. Alopecia, purpura, and drowsiness
c. Polyuria, weakness, and nausea
d. Ascites, dyspnea, and edema

Answer 30

ANS: C
Nausea, vomiting, diarrhea, thirst, polyuria, lethargy, slurred speech, muscle weakness, and fine hand tremors are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy

Question 31

A patient diagnosed with bipolar disorder is in the maintenance phase of treatment. The patient asks, “Do I have to keep taking this lithium even though my mood is stable now?” Select the nurse’s appropriate response.

a. “You will be able to stop the medication in about 1 month.”
b. “Taking the medication every day helps reduce the risk of a relapse.”
c. “Usually patients take medication for approximately 6 months after discharge.”
d. “It’s unusual that the health care provider hasn’t already stopped your medication.”

Answer 31

ANS: B
Patients diagnosed with bipolar disorder may be maintained on lithium indefinitely to prevent recurrences. Helping the patient understand this need will promote medication compliance.

Question 32

An outpatient diagnosed with bipolar disorder is prescribed lithium. The patient telephones the nurse to say, “I’ve had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?” The nurse will advise the patient to which of the following?

a. Restrict food and fluids for 24 hours and stay in bed
b. Have someone bring the patient to the clinic immediately
c. Drink a large glass of water with 1 teaspoon of salt added
d. Take one dose of an over-the-counter antidiarrheal medication now

Answer 32

ANS: B
The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may require further treatment. Because neurological symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not ameliorate the patient’s symptoms.

Question 33

A newly diagnosed patient is prescribed lithium. Which information from the patient’s history indicates that monitoring of serum concentrations of the drug will be challenging and critical?

a. Arthritis
b. Epilepsy
c. Psoriasis
d. Heart failure

Answer 33

ANS: D
The patient with heart failure will likely need diuretic drugs, which are contraindicated and will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity.

Question 34

Four new patients were admitted to the behavioural health unit in the past 12 hours. The nurse directs a psychiatric technician to monitor these patients for safety. A patient with which of the following diagnoses will need the most watchful supervision?

a. Bipolar I disorder
b. Bipolar II disorder
c. Dysthymic disorder
d. Cyclothymic disorder

Answer 34

ANS: A
Bipolar I is a mood disorder characterized by excessive activity and energy. Psychosis (hallucinations, delusions, and dramatically disturbed thoughts) may occur during manic episodes. A patient with bipolar I disorder is more unstable than a patient diagnosed with bipolar II, cyclothymic disorder, or dysthymic disorder.

Question 35

Which suggestions are appropriate for the family of a patient diagnosed with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply.

a. Limit credit card access.
b. Provide a structured environment.
c. Encourage group social interaction.
d. Suggest limiting work to half-days.
e. Monitor the patient’s sleep patterns.

Answer 35

ANS: A, B, E
A patient with hypomania is expansive, grandiose, and labile; uses poor judgement; spends inappropriately; and is over-stimulated by a busy environment. Providing structure would help the patient maintain appropriate behaviour. Financial irresponsibility may be avoided by limiting access to cash and credit cards. Continued decline in sleep patterns may indicate the condition has evolved to full mania. Group socialization should be kept to a minimum to reduce stimulation. A full leave of absence from work will be necessary to limit stimuli and prevent problems associated with poor judgement and inappropriate decision making that accompany hypomania.

Question 36

A nurse prepares the plan of care for a patient experiencing an acute manic episode. Which nursing diagnoses are most likely? Select all that apply.

a. Imbalanced nutrition: more than body requirements
b. Disturbed thought processes
c. Sleep deprivation
d. Chronic confusion
e. Social isolation

Answer 36

ANS: B, C
People with mania are hyperactive and often do not take time to eat and drink properly. Their high levels of activity consume calories, so deficits in nutrition may occur. Sleep is reduced. Their socialization is impaired but not isolated. Confusion may be acute but not chronic.

Question 37

A patient tells the nurse, “I’m ashamed of being bipolar. When I’m manic, my behaviour embarrasses everyone. Even if I take my medication, there are no guarantees. I’m a burden to my family.” These statements support which nursing diagnoses? Select all that apply.

a. Powerlessness
b. Defensive coping
c. Chronic low self-esteem
d. Impaired social interaction
e. Risk-prone health behaviour

Answer 37

ANS: A, C
Chronic low self-esteem and powerlessness are interwoven in the patient’s statements. No data support the other diagnoses.

Question 38

The plan of care for a patient in the manic state of bipolar disorder should include which of the following interventions? Select all that apply.

a. Touch the patient to provide reassurance.
b. Invite the patient to lead a community meeting.
c. Provide a structured environment for the patient.
d. Ensure that the patient’s nutritional needs are met.
e. Design activities that require the patient’s concentration.

Answer 38

ANS: C, D
People with mania are hyperactive, grandiose, and distractible. It’s most important to ensure the patient receives adequate nutrition. Structure will support a safe environment. Touching the patient may precipitate aggressive behaviour. Leading a community meeting would be appropriate when the patient’s behaviour is less grandiose. Activities that require concentration will produce frustration.