Chapter 26 Flashcards
A highly agitated client paces the unit and states, “I could buy and sell this place.” The client’s mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client’s behavior?
“Agitated and pacing. Exhibiting grandiosity. Mood labile.”
A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client’s priority nursing diagnosis?
Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes? Client Outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night.
C. 3, 1, 4, 2
A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client?
Risk for suicide R/T hopelessness
A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders?
Valproic acid (Depakote)
A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client’s spouse questions the Zyprexa order. Which is the appropriate nursing reply?
“Zyprexa calms hyperactivity until the Eskalith takes effect.”
A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply?
“Weight gain is a common but troubling side effect.”
A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred?
“This disorder is more prevalent in the higher socioeconomic groups.”
A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?
Symptoms indicate lithium carbonate toxicity.
What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder?
“FIND” tool
An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which is a true statement about this medication order?
This dosage is more than twice the recommended dosage range.
A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients?
“Treatment is compromised when clients choose not to take their medications.”
A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of “Client will gain 2 pounds by the end of the week?”
Provide client with high-calorie finger foods throughout the day.
A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client?
The client will remain safe throughout hospitalization.
A nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, “You can’t do this to me. Do you know who I am?” Which is the priority nursing action in this situation?
To provide self and client with a safe environment