Chapter 16: Bipolar Spectrum Disorders

Question 1

A person is directing traffic on a busy street while shouting and making obscene gestures at passing 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

Answer 1

ANS: C

Hyperactivity (directing traffic) and poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distractors do not specifically apply to mania.

Question 2

A patient diagnosed with bipolar disorder is dressed in a red leotard and brightly colored scarves. The
patient says, Ill 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 patients mood?

a. Labile and euphoric
b. Irritable and belligerent
c. Highly suspicious and arrogant
d. Excessively happy and confident

Answer 2

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 patients mood. A high level of suspicion is not evident.

Question 3

A patient experiencing 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

Answer 3

ANS: A

Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patients physiologic safety. Hyperactivity and poor judgment place the patient at risk for injury.

Question 4

A patient diagnosed with bipolar disorder is hyperactive and manic 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 behavior?

Answer 4

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
incorrect responses do not offer appropriate assistance to the patient and threaten the patient with seclusion as punishment. Asking why does not provide for environmental safety.

Question 5

This nursing diagnosis applies to a patient experiencing 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.

Answer 5

ANS: B

High-calorie, high-protein food supplements will provide the additional calories needed to offset the patients extreme hyperactivity. Sitting with others or asking for assistance does not mean the patient will eat or drink. Appropriate attire is unrelated to the nursing diagnosis.

Question 6

A patient develops mania after discontinuing lithium. New prescriptions 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. provide long-term control of hyperactivity.

Answer 6

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 lithiums antimanic activity nor minimize the side effects. Lithium is used for long-term control.

Question 7

A patient diagnosed 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)

Answer 7

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.

Question 8

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.

Answer 8

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.

Question 9

The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of
genetic transmission of bipolar disorders. Select the nurses best response.

a. A high proportion of patients diagnosed with bipolar disorders are found among creative writers.
b. A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder.
c. Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to
daily stresses.
d. More individuals diagnosed with bipolar disorder come from high socioeconomic and educational
backgrounds.

Answer 9

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.

Question 10

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 behavior without entering into a power struggle. Select the best initial approach by the nurse.

a. Distraction: Lets 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.

Answer 10

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.

Question 11

A nurse receives this laboratory result for a patient diagnosed with bipolar disorder: 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

Answer 11

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.

Question 12

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)

Answer 12

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.

Question 13

When a hyperactive patient experiencing 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 the patients behavior as necessary.
c. Provide verbal instructions to the patient to remain calm.
d. Restrain the patient to reduce hyperactivity and aggression.

Answer 13

ANS: B

This intervention provides support through the nurses presence and provides structure as necessary while the patients 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.

Question 14

At a unit meeting, staff members discuss the decor for a special room for patients experiencing 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

Answer 14

ANS: B

The environment for a patient experiencing mania should be as simple and as nonstimulating as possible. Patients experiencing mania are highly sensitive to environmental distractions and stimulation. Draperies present a risk for injury.

Question 15

A patient experiencing acute mania has exhausted the staff members by noon. The patient has joked,
manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action?

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

Answer 15

ANS: B

When staff members are overwhelmed, the patient has succeeded in keeping the environment unsettled and
avoided outside controls on behavior. Staff meetings can help minimize staff splitting and feelings of anger, helplessness, confusion, and frustration. Criteria for seclusion have not been met.

Question 16

A patient experiencing acute mania undresses in the group room and dances. The nurses first intervention would be to:

a. quietly ask the patient, Why dont you put on your clothes?
b. firmly tell the patient, Stop dancing, and put on your clothing.
c. put a blanket around the patient, and walk with the patient to a quiet room.
d. allow the patient stay in the group room. Move the other patients to a different area.

Answer 16

ANS: C

Patients must be protected from the embarrassing consequences of their poor judgment 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 members to avoid argument and provide control is an effective approach.

Question 17

A patient experiencing acute mania 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 four pairs of shoes. Select the nurses most appropriate intervention.

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

Answer 17

ANS: B

Situations such as this offer an opportunity to use the patients distractibility to the staffs advantage. Patients become frustrated when staff members 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 patients 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 18

A patient diagnosed with bipolar disorder is being treated on an outpatient basis with lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with:

a. meals.
b. an antacid.
c. a large glass of juice.
d. an antiemetic medication.

Answer 18

ANS: A

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

Question 19

A health teaching plan for a patient taking lithium should include instructions to:

a. maintain normal salt and fluids in the diet.
b. drink twice the usual daily amount of fluids.
c. double the lithium dose if diarrhea or vomiting occurs.
d. avoid eating aged cheese, processed meats, and red wine.

Answer 19

ANS: A

Sodium depletion and dehydration increase the chance for developing lithium toxicity. The incorrect options offer inappropriate information.

Question 20

Which nursing diagnosis would most likely apply to both a patient diagnosed with major depressive
disorder (MDD) as well as one experiencing acute mania?

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

Answer 20

ANS: B

Patients diagnosed 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 diagnosed with MDD. Defensive coping is more relevant for patients experiencing mania. Fluid volume excess is less relevant for patients diagnosed with mood disorders than is deficient fluid
volume.

Question 21

Which dinner menu is best suited for the patient diagnosed with bipolar disorder experiencing acute mania?

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

Answer 21

ANS: C

The correct foods provide adequate nutrition but, more importantly, are finger foods that the hyperactive
patient could eat on the run. The foods in the incorrect options cannot be eaten without utensils.

Question 22

Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on:

a. maintaining an interest in the environment.
b. developing an optimistic outlook.
c. self-control of distorted thinking.
d. stabilizing the sleep pattern.

Answer 22

ANS: C

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 23

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

a. Converses without interrupting; 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 23

ANS: A

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

Question 24

A patient experiencing 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 physiologic functioning
b. Provide a subdued environment
c. Supervise personal hygiene
d. Observe for mood changes

Answer 24

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
balance activity and rest.

Question 25

A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg
three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurses best intervention?

a. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing.
b. Continue to monitor and document the patients 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 25

ANS: D

The patient is continuing to exhibit manic symptoms. The lithium level may be low as a result of cheeking the medication. The prescribed dose is high, so one would not expect a need for the dose to be increased.

Question 26

A patient experiencing acute mania has disrobed in the hall three times in 2 hours. The nurse should:

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 26

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 proved successful, considering the behavior has continued. Asking whether 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 behaviors is impaired by the illness.

Question 27

A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves
a cue in one hand and says, Ill throw the pool balls if anyone comes near me. The nurses first intervention is to:

a. tell the patient, You need to be secluded.
b. help the patient down from the table.
c. clear the room of all other patients.
d. assemble a show of force.

Answer 27

ANS: C

Safety is of primary importance. Once other patients are out of the room, a plan for managing this patient can be implemented. A show of force is likely to frighten the patient and increase this risk for violence.

Question 28

After hospital discharge, what is the priority intervention for a patient diagnosed with bipolar disorder who is taking antimanic medication, as well as for the patients family?

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

Answer 28

ANS: D

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, the treatment focuses on maintaining medication compliance and preventing a relapse, both of which are fostered by ongoing psychoeducation.

Question 29

A patient receiving lithium should be assessed for which evidence of complications?

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

Answer 29

ANS: C

Diaphoresis, weakness, and nausea are early signs of lithium toxicity. Problems mentioned in the incorrect options are unrelated to lithium therapy.

Question 30

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 nurses most appropriate response.

a. You will be able to stop the medication in approximately 1 month.
b. Taking the medication every day helps prevent relapses and recurrences.
c. Usually patients take this medication for approximately 6 months after discharge.
d. Its unusual that the health care provider has not already stopped your medication.

Answer 30

ANS: B

Patients diagnosed with bipolar disorder may be indefinitely maintained on lithium to prevent recurrences. Helping the patient understand this need promotes medication compliance. The incorrect options offer incorrect or misleading information.

Question 31

A patient diagnosed with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, Ive had severe diarrhea 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do? The nurse should advise the patient:

a. Restrict oral fluids for 24 hours and stay in bed.
b. Have someone bring you to the clinic immediately.
c. Drink a large glass of water with 1 teaspoon of salt added.
d. Take an over-the-counter antidiarrheal medication hourly until the diarrhea subsides.

Answer 31

ANS: B

The symptoms described suggest lithium toxicity. The patient should have a lithium level drawn and may
require further treatment. Because neurologic symptoms are present, the patient should not drive and should be accompanied by another person. The incorrect options will not address the patients symptoms. Restricting oral fluids will make the situation worse.

Question 32

Lithium is prescribed for a new patient. Which information from the patients history indicates that
monitoring serum concentrations of the drug will be especially challenging and critical?

a. Arthritis
b. Epilepsy
c. Psoriasis
d. Congestive heart failure

Answer 32

ANS: D

The patient with congestive heart failure will likely need diuretic drugs, which will complicate the maintenance of the fluid balance necessary to avoid lithium toxicity. Arthritis, epilepsy, and psoriasis do not directly involve fluid balance and kidney function.

Question 33

A patient diagnosed with bipolar disorder is being treated as an outpatient during a hypomanic episode. Which suggestions should the nurse provide to the family? Select all that apply.

a. Provide structure
b. Limit credit card access
c. Encourage group social interaction
d. Limit work to half days
e. Monitor the patients sleep patterns

Answer 33

ANS: A, B, E

A patient with hypomania is expansive, grandiose, and labile; uses poor judgment; spends inappropriately; and is overstimulated by a busy environment. Providing structure helps the patient maintain appropriate behavior. 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 is necessary to limit stimuli and to prevent problems associated with poor judgment and the inappropriate decision making that accompany hypomania.

Question 34

A nurse prepares the plan of care for a patient having a 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 34

ANS: B, C

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

Question 35

A patient tells the nurse, I am so ashamed of being bipolar. When Im manic, my behavior embarrasses my family. Even if I take my medication, theres no guarantee I wont have a relapse. I am such 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 behavior

Answer 35

ANS: A, C

Chronic low self-esteem and powerlessness are interwoven in the patients statements. No data support the other diagnoses.