Chapter 26-T

Question 1

1. 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?
   A. “Rates mood 8/10. Exhibiting looseness of association. Euphoric.”
   B. “Mood euthymic. Exhibiting magical thinking. Restless.”
   C. “Mood labile. Exhibiting delusions of reference. Hyperactive.”
   D. “Agitated and pacing. Exhibiting grandiosity. Mood labile.”

Answer 1

ANS: D
The nurse should document that this client’s behavior is “Agitated and pacing. Exhibiting grandiosity. Mood labile.” The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity.

Question 2

2. 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?
   A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms
   B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
   C. Risk for suicide R/T powerlessness AEB insomnia and anorexia
   D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

Answer 2

ANS: B
The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the client’s rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health.

Question 3

3. 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.
A. 2, 1, 3, 4
B. 4, 1, 2, 3
C. 3, 1, 4, 2
D. 1, 4, 2, 3

Answer 3

ANS: C
The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the client’s physical and safety needs.

Question 4

4. 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?
   A. Risk for suicide R/T hopelessness
   B. Anxiety: severe R/T hyperactivity
   C. Imbalanced nutrition: less than body requirements R/T refusal to eat
   D. Dysfunctional grieving R/T loss of employment

Answer 4

ANS: A
The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses on the basis of physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose.

Question 5

5. 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?
A. Sertraline (Zoloft)
B. Valproic acid (Depakote)
C. Trazodone (Desyrel)
D. Paroxetine (Paxil)

Answer 5

ANS: B
Although lithium is a prototype drug in the treatment of bipolar disorders, anticonvulsants such as valproic acid also have demonstrated efficacy for mood stabilization.

Question 6

6. 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?
   A. “Zyprexa in combination with Eskalith cures manic symptoms.”
   B. “Zyprexa prevents extrapyramidal side effects.”
   C. “Zyprexa ensures a good night’s sleep.”
   D. “Zyprexa calms hyperactivity until the Eskalith takes effect.”

Answer 6

ANS: D
The nurse should explain to the client’s spouse that Zyprexa can calm hyperactivity until the Eskalith takes effect. Eskalith may take 1 to 3 weeks to begin to decrease hyperactivity. Zyprexa is classified as an antipsychotic and can be used to immediately to reduce hyperactive symptoms in acute manic episodes.

Question 7

7. 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?
   A. “That’s strange. Weight loss is the typical pattern.”
   B. “What have you been eating? Weight gain is not usually associated with lithium.”
   C. “Weight gain is a common but troubling side effect.”
   D. “Weight gain occurs only during the first month of treatment with this drug.”

Answer 7

ANS: C
The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication compliance and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.

Question 8

8. A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred?
   A. “This disorder is more prevalent in the lower socioeconomic groups.”
   B. “This disorder is more prevalent in the higher socioeconomic groups.”
   C. “This disorder is equally prevalent in all socioeconomic groups.”
   D. “This disorder’s prevalence cannot be evaluated on the basis of socioeconomic groups.”

Answer 8

ANS: B
The nursing student is accurate when stating that bipolar disorder is more prevalent in higher socioeconomic groups. Theories consider both hereditary and environmental factors in the etiology of bipolar disorder.

Question 9

9. 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?
   A. Symptoms indicate consumption of foods high in tyramine.
   B. Symptoms indicate lithium carbonate discontinuation syndrome.
   C. Symptoms indicate the development of lithium carbonate tolerance.
   D. Symptoms indicate lithium carbonate toxicity.

Answer 9

ANS: D
The nurse should interpret that the client’s symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly during maintenance therapy to ensure proper dosage.

Question 10

10. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? 
A. “Risky Activity” tool
B. “FIND” tool
C. “Consensus Committee” tool
D. “Monotherapy” tool

Answer 10

ANS: B
The Consensus Group recommends that clinicians use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

Question 11

11. 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?
    A. This dosage is within the recommended dosage range.
    B. This dosage is lower than the recommended dosage range.
    C. This dosage is more than twice the recommended dosage range.
    D. This dosage is four times higher than the recommended dosage range.

Answer 11

ANS: C

The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients should not exceed 400 mg daily

Question 12

12. 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?
    A. “Treatment is compromised when clients can’t sleep.”
    B. “Treatment is compromised when irritability interferes with social interactions.”
    C. “Treatment is compromised when clients have no insight into their problems.”
    D. “Treatment is compromised when clients choose not to take their medications.”

Answer 12

ANS: D
The nursing student should understand that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose to not take their medications. Symptoms of bipolar disorder will reemerge if medication is stopped.

Question 13

13. 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?”
    A. Provide client with high-calorie finger foods throughout the day.
    B. Accompany client to cafeteria to encourage adequate dietary consumption.
    C. Initiate total parenteral nutrition to meet dietary needs.
    D. Teach the importance of a varied diet to meet nutritional needs.

Answer 13

ANS: A
The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 pounds by the end of the week. Because of hyperactivity, the client will have difficulty sitting still to consume large meals.

Question 14

14. A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client?
    A. The client will accomplish activities of daily living independently by discharge.
    B. The client will verbalize feelings during group sessions by discharge.
    C. The client will remain safe throughout hospitalization.
    D. The client will use problem-solving to cope adequately after discharge.

Answer 14

ANS: C
A client diagnosed with bipolar disorder is at risk for injury in either pole of this disorder. In the manic phase the client is hyperactive and can injure self inadvertently, and in the depressive phase the client can be at risk for suicide.

Question 15

15. 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?
    A. To provide self and client with a safe environment
    B. To redirect the client to the needed assessment information
    C. To provide high-calorie finger foods to meet nutritional needs
    D. To reorient the client to person, place, time, and situation

Answer 15

ANS: A
During a manic episode the client’s mood is elevated, expansive, and irritable. Providing a safe environment should be prioritized to protect the client and staff from potential injury.

Question 16

16. A client is diagnosed with cyclothymic disorder. What client behaviors should the nurse expect to assess?
    A. The client expresses “feeling blue most of the time.”
    B. The client has endured periods of elation and dysphoria lasting for more than 2 years.
    C. The client fixates on hopelessness and thoughts of suicide continually.
    D. The client has labile moods with periods of acute mania.

Answer 16

ANS: B
The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years’ duration, involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for bipolar I or II disorder.

Question 17

17. After teaching a client about lithium carbonate (Lithane), a nurse would consider the teaching successful on the basis of which client statement?
    A. “I should expect to feel better in a couple of days.”
    B. “I’ll call my doctor immediately if I experience any diarrhea or ringing in my ears.”
    C. “If I forget a dose, I can double the dose the next time I take this drug.”
    D. “I need to restrict my intake of any food containing salt.”

Answer 17

ANS: B
The initial signs of lithium toxicity include ataxia, blurred vision, severe diarrhea, persistent nausea and vomiting, and tinnitus.

Question 18

18. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. The nurse should correlate these symptoms with which lithium level? 
A. 1.3 mEq/L
B. 1.7 mEq/L
C. 2.3 mEq/L
D. 3.7 mEq/L

Answer 18

ANS: B
The therapeutic level of lithium carbonate is 1.0 to 1.5 mEq/L for acute mania and 0.6 to 1.2 mEq/L for maintenance therapy. There is a narrow margin between the therapeutic and toxic levels. The symptoms presented in the question can be correlated with a lithium level of 1.7 mEq/L. Levels of 2.3 mEq/L and 3.7 mEq/L would produce more extreme symptoms of intensified toxicity, eventually leading to death.

Question 19

19. A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client?
    A. Ineffective individual coping R/T hospitalization AEB alcohol abuse
    B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss
    C. Risk for violence: directed toward others R/T agitation and hyperactivity
    D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night

Answer 19

ANS: C
Some signs and symptoms of mania include manic excitement, delusional thinking, and hallucinations, which may predispose the client to aggressive behavior. Nurses should be alert to the risk for self or other directed violence and intervene immediately at the first signs of agitation or aggression.

Question 20

20. A client who has been diagnosed with bipolar I disorder states, “God has taught me how to decode the Bible.” A nurse should anticipate that which combination of medications would be ordered to address this client’s symptoms?
    A. Lithium carbonate (Lithobid) and risperidone (Risperdal)
    B. Lithium carbonate (Lithobid) and carbamazepine (Tegretol)
    C. Valproic acid (Depakote) and sertraline (Zoloft)
    D. Valproic acid (Depakote) and lamotrigine (Lamictal)

Answer 20

ANS: A
The patient who is experiencing psychosis (in this case, delusions of grandeur) may be benefited by the addition of an antipsychotic medication (risperidone) to the mood stabilizer (lithium). In addition, since lithium does not immediately reach therapeutic levels, the sedative properties of an antipsychotic may be useful in reducing agitation, hyperactivity, and/or insomnia.

Question 21

21. A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom?
    A. “I can’t stop my sexual urges. They have led me to numerous affairs.”
    B. “I’m the world’s most perceptive attorney.”
    C. “My wife is distraught about my overspending.”
    D. “The FBI is out to get me.”

Answer 21

ANS: B
Grandiosity is defined as a belief that personal abilities are better than anyone else’s. This client is experiencing delusions of grandeur, which are commonly experienced in mania.

Question 22

22. Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment?
    A. “I will limit my intake of fluids daily.”
    B. “I will maintain normal salt intake.”
    C. “I will take Lithobid on an empty stomach.”
    D. “I will increase my caloric intake to prevent weight loss.”

Answer 22

ANS: B
A client taking Lithobid should be taught not to skimp on dietary sodium intake. He or she should take Lithobid on a full stomach to avoid gastrointestinal upset and choose lower-calorie foods to prevent weight gain.

Question 23

23. A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. What should be the nurse’s initial intervention?
    A. Ask the group to take a vote on alternative weekend events.
    B. Remind the client to quiet down or leave the dayroom.
    C. Assist the client to move to a calmer location.
    D. Discuss with the client impulse control problems.

Answer 23

ANS: C
During a manic episode, the client experiences increased agitation and extreme hyperactivity that can lead to a risk for injury. Overstimulation can exacerbate these symptoms. Therefore, the nurse’s initial action should focus on removing the client from the stimulating environment to a calmer location.

Question 24

24. A client diagnosed with bipolar disorder states, “I hate oatmeal. Let’s get everybody together to do exercises. I’m thirsty and I’m burning up. Get out of my way; I have to see that guy.” What should be the priority nursing action?
    A. Assess the client’s vital signs.
    B. Offer to have the dietitian discuss food preferences.
    C. Encourage the client to lead the exercise program in the community meeting.
    D. Acknowledge the client briefly and then walk away.

Answer 24

ANS: A
When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that co-occurring physical problems could be masked by hyperactive, manic, or both behaviors. The client’s statement of “I’m thirsty and I’m burning up” could be a symptom of either infection or dehydration and must be assessed.

Question 25

25. A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess? 
A. Pacing
B. Flight of ideas
C. Lability of mood
D. Irritability

Answer 25

ANS: B
Clients diagnosed with bipolar disorder: manic episode experience cognition and perception fragmentation often with psychosis during acute mania. Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speak with abrupt changes from topic to topic.

Question 26

26. The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom décor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate?
    A. Rooms should contain extra-large windows with views of the street.
    B. Rooms should contain brightly colored walls with printed drapes.
    C. Rooms should be painted deep colors and located close to the nurse’s station.
    D. Rooms should be painted with neutral colors and contain pale-colored accessories.

Answer 26

ANS: D
Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain low levels of stimuli in the client’s environment (low lighting, few people, simple décor, low noise levels). Anxiety levels rise in a stimulating environment. Neutral colors and pale accessories are most appropriate for a client experiencing mania.

Question 27

27. A client’s spouse asks, “What evidence supports the possibility of genetic transmission of bipolar disorder?” Which is the best nursing reply?
    A. “Clients diagnosed with bipolar disorders have alterations in neurochemicals that affect behaviors.”
    B. “Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder.”
    C. “Higher rates of relatives of clients diagnosed with bipolar disorder respond in an exaggerated way to daily stress.”
    D. “More individuals diagnosed with bipolar disorder come from higher socioeconomic and educational backgrounds.”

Answer 27

ANS: B
Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. If both parents are diagnosed with the disorder, the risk is two to three times as great.

Question 28

28. A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client?
    A. Using a calm, unemotional approach during client interactions
    B. Focusing primarily on enforcing limits
    C. Limiting interactions to decrease external stimuli
    D. Encouraging the client to establish social relationships with peers

Answer 28

ANS: A
Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain a calm, unemotional approach during client interactions.

Question 29

29. Which of the following instructions regarding lithium therapy should be included in a nurse’s discharge teaching? Select all that apply.
    A. Avoid excessive use of beverages containing caffeine.
    B. Maintain a consistent sodium intake.
    C. Consume at least 2,500 to 3,000 mL of fluid per day.
    D. Restrict sodium content.
    E. Restrict fluids to 1,500 mL per day.

Answer 29

ANS: A, B, C
The nurse should instruct the client taking lithium to avoid excessive use of caffeine, maintain a consistent sodium intake, and consume at least 2,500 to 3,000 mL of fluid per day. The risk of developing lithium toxicity is high due to the narrow margin between therapeutic doses and toxic levels.

Question 30

30. Which of the following explanations should a nurse include when teaching parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply.
    A. Bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms.
    B. Children are naturally active, energetic, and spontaneous.
    C. Neurotransmitter levels vary considerably in accordance with age.
    D. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18.
    E. Genetic predisposition is not a reliable diagnostic determinant.

Answer 30

ANS: A, B
It is difficult to diagnose a child or adolescent with bipolar disorder because bipolar symptoms are similar to attention deficit-hyperactivity disorder symptoms and because children are naturally active, energetic, and spontaneous. Symptoms may also be comorbid with other childhood disorders, such as conduct disorder.