NUR210CH14

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TomWruble
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202036
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NUR210CH14
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2013-03-08 10:04:01
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nur210e2 Bipolar Disorders
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Bipolar Disorders
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  1. Which behavior exhibited by a patient with mania should the nurse choose to address first?

    A. Indiscriminate sexual relations
    B. Declaration of “being at one with the world”
    C. Demonstration of flight of ideas
    D. Excessive spending of money
    A. Indiscriminate sexual relations

    The immediate safety of the patient and other patients on the unit is the priority. Limits regarding patient-to-patient contact and relations should be communicated and behavior should be monitored.

    While excessive spending of money is commonly found in mania, it is not an immediate safety issue.

    “Being at one with the world” may be part of a delusional (false thoughts) system that commonly happens during mania. Delusions should be monitored, but this one does not sound dangerous and in need of any particular action.

    Flight of ideas, or jumping from topic to topic, is also a common symptom in mania. While they may make communication difficult, they are not a priority concern.
    (this multiple choice question has been scrambled)
  2. The nurse is caring for a patient experiencing mania. Which is the most appropriate nursing intervention?

    A. Provide consistency among staff members when working with the patient.
    B. Negotiate limits so the patient has a voice in the plan of care.
    C. Allow only certain staff members to interact with the patient.
    D. Attempt to control the patient’s emotions.
    A. Provide consistency among staff members when working with the patient.

    Patients experiencing mania have the ability to staff split, or divide the staff into“good guys” or “bad guys.” Providing consistency among all staff members is imperative.

    Limits must be set and carried out by all staff members if the plan of care is to be effective.

    Because the nurse cannot control the patient’s emotions, the preferred approach is to establish and maintain limits for the duration of admission.
    (this multiple choice question has been scrambled)
  3. The nurse is planning care for a patient experiencing the acute phase of mania. Which is the priority intervention?

    A. Ensure that the patient gets sufficient sleep and rest.
    B. Get the patient to demonstrate thought self-control.
    C. Prevent injury.
    D. Maintain stable cardiac status.
    C. Prevent injury.

    Safety is always the highest priority in planning care. All other interventions may be included in the plan of care, but the priority is to keep the patient safe.
    (this multiple choice question has been scrambled)
  4. What critical information should the nurse provide about the use of lithium?

    A. “You will still have hypersexual tendencies, so be certain to use protection when engaging in intercourse.”
    B. “Lithium will help you to only feel the euphoria of mania but not the anxiety.”
    C. “It will take 1 to 2 weeks and maybe longer for this medication to start working fully.”
    D. “This medication is a cure for bipolar disorder.”
    C. “It will take 1 to 2 weeks and maybe longer for this medication to start working fully.”

    Lithium, although not a cure, is effective in controlling hypersexuality and feelings of anxiety, elation, grandiosity, and expansiveness. It takes 7 to 14 days and sometimes longer to reach therapeutic levels in the patient’s blood.
    (this multiple choice question has been scrambled)
  5. T/F: The (teaching) plan of care has been effective when the patient can identify signs and symptoms of relapse, describe the purpose of his medications, and describe problem-solving techniques.
    True
  6. The first-line drug used to treat mania is 

    A. lamotrigine
    B. lithium.
    C. carbamazepine.
    D. clonazepam.
    B. lithium.

    Lithium, a mood stabilizer, is the first-line drug for use in treating bipolar disorder. Text page: 290
    (this multiple choice question has been scrambled)
  7. A person who has numerous hypomanic and dysthymic episodes can be assessed as having

    A. bipolar I disorder.
    B. seasonal affective disorder.
    C. bipolar II disorder.
    D. cyclothymia.
    D. cyclothymia.

    Cyclothymia refers to mood swings involving hypomania and dysthymia of 2 years' duration. The mood swings are not severe enough to prompt hospitalization. Text page: 281
    (this multiple choice question has been scrambled)
  8. T/F: Hyperactivity and distractibility are basic to manic episodes.
    True
  9. When a client experiences 4 or more mood episodes in a 12 month period, the client is said to be: 

    A. cyclothymic.
    B. dysynchronous.
    C. incongruent.
    D. rapid cycling.
    D. rapid cycling.

    Rapid cycling infers 4 or more mood episodes in a 12 month period as well as more severe symptomology. Text page: 365
    (this multiple choice question has been scrambled)
  10. Which room placement would be best for a client experiencing a manic episode? 

    A. A shared room away from the unit entrance
    B. A single room near the nurse's station
    C. A shared room with a client with dementia
    D. A single room near the unit activities area
    B. A single room near the nurse's station

    The room placement that provides a nonstimulating environment is best. Being near the nurse's station means close supervision can occur. Text page: 289
    (this multiple choice question has been scrambled)
  11. When a hyperactive manic client expresses the intent to strike another client, the initial nursing intervention should be 

    A. verbal limit setting.
    B. questioning client motive.
    C. seclusion.
    D. physical confrontation.
    A. verbal limit setting.

    Verbal limit setting should always precede more restrictive measures. Text page: 290
    (this multiple choice question has been scrambled)
  12. T/F: Many clients find that taking lithium with or shortly before meals minimizes gastric distress.
    False

    Many clients find that taking lithium with or shortly after (not before) meals minimizes gastric distress. Text page: 294
  13. T/F: Manic clients often respond well to the invitation to write. They will fill reams of paper. While writing they are less physically active.
    True
  14. A bipolar client whose continuing phase treatment consists of lithium therapy and cognitive-behavioral therapy may become noncompliant with medication. Which factor would be of least concern to the nurse developing a psychoeducation plan to foster compliance? 

    A. The side-effects are unpleasant
    B. The client prefers to feel "high" and energetic
    C. The voices tell the client to stop taking it
    D. The client feels well and denies the possibility of recurrence
    C. The voices tell the client to stop taking it

    Manic clients may hallucinate during the delirious state but generally do not hear voices. Psychoeducation would not be going on during the time the client is delirious. Text page: 298
    (this multiple choice question has been scrambled)
  15. A manic client tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." The best approach for the nurse to use would be 

    A. "Let's walk down to the seclusion room."
    B. "I don't have sex with clients."
    C. "What an offensive thing to suggest!"
    D. "It's time to work on your art project."
    D. "It's time to work on your art project."

    Distractibility works as the nurse's friend. Rather than discuss the invitation, the nurse may be more effective by redirecting the client. Text page: 291
    (this multiple choice question has been scrambled)
  16. A desired outcome for the maintenance phase of treatment for a manic client would be that the client will 

    A. adhere to follow-up medical appointments.
    B. exhibit optimistic, energetic, playful behavior.
    C. take medication more than 50% of the time.
    D. use alcohol to moderate occasional mood "highs."
    A. adhere to follow-up medical appointments.

    The client would be living in the community during the maintenance phase. Keeping follow-up appointments is highly desirable. Text page: 288
    (this multiple choice question has been scrambled)
  17. What action should the nurse take on learning that a manic client's serum lithium level is 1.8 mEq/L? 

    A. Withhold medication and notify the physician
    B. Advise the client to limit fluids for 12 hours
    C. Continue to administer medication as ordered
    D. Advise the client to curtail salt intake for 24 hours
    A. Withhold medication and notify the physician

    The client's lithium level has exceeded desirable limits.

    Active:           0.8-1.4 mEq/L
    - given as 300-600 mg tid to reach therapeutic level.

    Maintenance: 0.4-1.3 mEq/L

    Additional doses of the medication should be withheld and the physician notified. Text page: 293
    (this multiple choice question has been scrambled)
  18. To plan care for a manic client the nurse must consider that lithium cannot be started until 

    A. electroconvulsive therapy can be scheduled to coincide with lithium administration.
    B. seclusion has proven ineffective as a means of controlling assaultive behavior.
    C. the physical examination and laboratory tests are analyzed.
    D. the initial doses of antipsychotic medication have brought behavior under control.
    C. the physical examination and laboratory tests are analyzed.

    Lithium should not be given to clients with impaired renal or thyroid function. A thorough physical examination and various laboratory tests are necessary to rule out other organic causes for the behavior and to ensure that the lithium can be excreted normally. Text page: 294
    (this multiple choice question has been scrambled)
  19. A manic client in the acute phase is verbally and physically aggressive to himself. The nursing diagnosis Defensive coping related to biochemical changes as evidenced by aggressive verbal and physical behaviors has been identified. A desirable short-term goal would be that the client will 

    A. develop psychomotor retardation associated with sedation from prescribed medication within 6 hours of admission.
    B. sleep soundly for 12 of the next 24 hours.
    C. willingly take prescribed medication as offered by staff within 24 hours of admission.
    D. Making no attempts at self-harm within 12 hrs. of admission.
    D. Making no attempts at self-harm within 12 hrs. of admission.

    Whenever aggressive verbal or physical behaviors are demonstrated, a desirable goal is cessation of those behaviors. Verbal and physical aggression are most apt to occur when staff are trying to structure the client's behavior for his or her own safety or the safety of others. Text page: 288
    (this multiple choice question has been scrambled)
  20. Side effects of Lithium at therapeutic levels:
    <0.4-1.0 mEq/L

    • fine hand tremor
    • polyuria
    • mild thirst
    • mild nausea
    • general discomfort
    • weight gain
  21. Interventions for Lithium at therapeutic levels:
    <0.4-1.0 mEq/L

    • Symptoms may persist throughout therapy.
    • Symptoms often subside during treatment.
    • Weight gain may be helped with diet, exercise, and nutritional management.
  22. Side effects of Lithium at "early toxicity":
    <1.5 mEq/L

    • Nausea
    • vomiting
    • diarrhea
    • thirst
    • polyuria
    • lethargy
    • slurred speech
    • muscle weakness
    • fine hand tremor
  23. Side effects of Lithium at "advanced toxicity":
    1.5-2.0 mEq/L

    • Coarse hand tremor
    • persistent gastrointestinal upset
    • mental confusion
    • muscle hyperirritability
    • electroencephalographic changes
    • incoordination
    • sedation
  24. Side effects of Lithium at sever toxicity:
    2.0-2.5 mEq/L

    • Ataxia
    • confusion
    • large output of dilute urine
    • serious electroencephalographic changes
    • blurred vision
    • clonic movements
    • seizures
    • stupor
    • severe hypotension
    • coma
    • death is usually secondary to pulmonary complications.
  25. Interventions for Lithium at "early toxicity":
    <1.5 mEq/L

    • Medication should be withheld
    • blood lithium levels measured
    • dosage reevaluated
    • Dehydration, if present, should be addressed.
  26. Interventions for Lithium at "advanced toxicity":
    1.5-2.0 mEq/L

    These depending on severity of circumstances, i.e. same as

    • Early
    • Medication should be withheld
    • blood lithium levels measured
    • dosage reevaluated
    • Dehydration, if present, should be addressed.
    • Severe
    • Hospitalization is indicated
    • The drug is stopped, and excretion is hastened
    • If patient is alert, an emetic is administered
  27. Interventions for Lithium at "sever toxicity":
    2.0-2.5 mEq/L

    • Hospitalization is indicated
    • The drug is stopped, and excretion is hastened
    • If patient is alert, an emetic is administered
  28. Lithium Signs and Interventions @ >2.5 mEq/L

    (also considered "sever toxicity")
    Convulsions, oliguria, and death can occur.

    In addition to the interventions above, hemodialysis may be used in severe cases.
  29. Trade name for divalproex sodium
    Depakote, it is an anticonvulsant
  30. Generic name for Depakote
    • valproate
    • valproic acid
    • divalproex sodium

    it is an anticonvulsant
  31. Generic name for Tegretol
    carbamazepine, it is an anticonvulsant
  32. Trade name for carbamazepine
    Tegretol, it is an anticonvulsant
  33. divalproex sodium is recommended for:
    trade name Depakote or valproic acid(Depakene) - both are generic "Valproate"

    • Lithium nonresponders, who are in acute mania, rapid cycling, in dysphoric mania (a "mixed episode" - symptoms of mania and depression occur simultaneously), or have not responded to carbamazepine.
    • extreme manic, including aggressive Pts.

    For severe manic episodes lithium or Depakote may be given with an atypical antipsychotic such as olanzapine (Zyprexa) or riperidone (Risperdal)

    off-label is it used for panic disorders and PTSD.
  34. divalproex sodium side effects
    • trade name Depakote or valproic acid(Depakene) - both are generic "Valproate"
    • for bipolar

    Common: tremor & weight gain

    • Serious: thrombocytopenia (decrease of platelets), pancreatitis, hepatic failure & birth defects.
    • Rarely: bone marrow suppression
  35. divalproex sodium admin guidelines
    trade name Depakote or valproic acid(Depakene) - both are generic "Valproate"

    • baseline liver function & CBC before starting, repeated.
    • therapeutic levels monitored
  36. carbamazepine recommended for
    • trade name Tegretol
    • for bipolar

    Some Pts that are "treatment resistant” for bipolar, i.e. do not respond to lithium alone, improve after taking Tegretol & lithium or Tegretol & and antipsychotic.

    Tegretol seems to work better in rapid cycling and in severely angry paranoid Pts. experiencing manias than in euphoric, overactive, overfriendly Pts. w/ mania.

    off-label is it used for panic disorders and PTSD.
  37. carbamazepine side effects
    • trade name Tegretol
    • for bipolar

    • Common: anticholinergic (e.g. dry mouth , constipation, urinary retention, blurred vision), orthostasis ("standing" - how the hell is this a 'side effect'), sedation & ataxia (lack of voluntary coordination of muscle movements)
    • Rarely: bone marrow suppression
  38. carbamazepine admin guidelines
    • trade name Tegretol
    • for bipolar

    • baseline liver function, CBC, EKG & electrolytes before starting
    • toxic levels (>12 mcg/mL) are monitored
    • There is no established therapeutic levels for bipolar
  39. Three anticonvulsant drugs have demonstrated efficacy and been approved for the treatment of mood disorders:

    valproate, as divalproex sodium(Depakote) or valproic acid(Depakene)
    carbamazepine (Tegretol)
    lamotrigine (Lamictal)

    How?
    • Superior for continuously cycling patients
    • More effective when there is no family history of bipolar disease
    • Effective at dampening affective swings in schizoaffective patients
    • Effective at diminishing impulsive and aggressive behavior in some nonpsychotic patients
    • Helpful in cases of alcohol and benzodiazepine withdrawal
    • Beneficial in controlling mania (within 2 weeks) and depression (within 3 weeks or longer)
  40. Bipolar I
    • At least one episode of mania alternates with major depression
    • Somewhat more common in men
  41. Bipolar II
    • Hypomanic episodes alternate with major depression
    • No psychosis present
    • More common among women
    • Hypomania in II tends to be euphoric and often increases functioning
  42. Women with bipolar
    tend to

    • abuse alcohol
    • commit suicide
    • develop thyroid disease
  43. Men with bipolar
    tend to

    • Have legal problems
    • Commit acts of violence
  44. Cyclothymia
    • Hypomanic episodes alternate with minor depression
    • At least 2 years duration for Dx
    • Irritable (as opposed to euphoric) manic episodes
    • Hospitalization is not usually required
  45. T/F: Either hypomania and mania of a bipolar Pt can be caused by the direct physiological effects of a substance, such as drug abuse, medication or other medical condition.
    False: symptoms are not due to these factors.
  46. Bipolar disorders are XX to YY% heritable.
    80 to 90

    It is likely polygenic.
  47. Neurotransmitters:

    norepinephrine
    dopamine
    serotonin

    Too much?
    Too little?
    • Mania
    • Depression
  48. Hypothyroidism is known to be associated with AAA, and it is seen in some patients experiencing BBB.
    • A. Depression
    • B. Rapid Cycling
  49. T/F: The nonstop physical activity of hypomania as well as "full-blown": mania can lead to physical exhaustion and even death and therefore constitutes an emergency.
    True

    p. 284 right-bottom
  50. Grandiosity can be a symptom in:
    • Manic phase of bipolar
    • Narcissistic personality disorder
  51. Phases and Goals of Bipolar Therapy
    Acute (6-12 weeks):

    • Medically stabilize Pt.
    • Hydration
    • Stable cardiac status
    • Sufficient sleep/rest
    • Thought self-control
    • No self-harm

    Continuation: 4-9 months

    • Relapse prevention
    • Psychoeducation
    • Support groups or interpersonal therapy
    • Communication and problem-solving skills
    • Maintenance (> 1 year):

    • Relapse prevention
    • Limitation of severity & duration of future episodes
  52. A female client who is in a manic state emerges from her room topless while making sexual remarks and lewd gestures toward the staff and her peers. The nurse should initiate which intervention first?

    A. Ask the other clients to ignore her behavior; eventually she will return to her own room.
    B. Confront the client on the inappropriateness of her behavior and offer her a time out.
    C. Approach the client in the hallway and insist that she go to her own room immediately.
    D. Quietly approach the client, escort her to her room, and help her to get dressed.
    D. Quietly approach the client, escort her to her room, and help her to get dressed.

    A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety for the client. Insisting that the client go to her room may cause the nurse to be met with a great deal of resistance. Confronting the client and offering her a consequence of time out may be meaningless to her. Asking other clients to ignore her is inappropriate. A quiet but firm approach while distracting the client (walking her to her room and helping her to get dressed) achieves the goal of having the client dressed appropriately and preserving her psychosocial integrity.
    (this multiple choice question has been scrambled)
  53. What portion of people with bipolar disorder have another Axis I psychiatric disorder?
    More than half

    p. 281
  54. Bipolar II Pts. may not have manic episodes as strong as Bipolar I pts., but ? 
    II has associated with it significant morbidity and mortality as a result of the severe depression. 
  55. Axis II borderline personality disorder pts. are AAA% BBB (more or less) likely to have a comorbid axis I bipolar disorder.
    • A. ~20% (19.4%)
    • B. more
  56. T/F: Religious preoccupation is a common symptom of mania.
    True
  57. T/F Delusions and/or hallucinations, being psychotic symptoms, may be present in a pt. experiencing a hypomanic episode.
    False

    There is no evidence of this.

    p. 287
  58. T/F: Mania may be substance-induced, i.e. caused by use or abuse of a substance or drug or by toxin exposure. 
    True according to p. 288

    This is contrary to the DSM quoted on p. 282: "Symptoms (of mania or hypomania)are not due to direct physiological effects of substance (e.g. drug abuse, medication…"
  59. Pts. that were previously suffering depression, but are now manic may have what done?
    Antidepressants, previously prescribed are often tapered or discontinued to reduce mania or hypomania.
  60. Lithium takes AAA to BBB or longer to be effective. What can be done?
    • A. 7
    • B. 14

    An antipsychotic or benzodiazepine can be used to prevent exhaustion, coronary collapse and death until lithium reaches therapeutic levels.
  61. Lithium Teaching
    • Normal salt and fluid intake. (Lithium decreases sodium reabsorption. Low sodium leads to relative increases in lithium retention raising levels to those that may be toxic.
    • Stop taking lithium if you have excessive diarrhea, vomiting or sweating, since dehydration can also raise lithium to toxic levels.
    • No diuretics.
    • Take with meals
  62. Long-term risks of lithium therapy and necessary monitoring?
    • Hypothyroidism
    • Impairment of kidney's ability to concentrate urine

    Periodic assessment of thyroid and renal function

    Implicit is that thyroid and renal function must be evaluated BEFORE starting on lithium Tx.
  63. Lithium Tx is contraindicated in these pts:
    • Thyroid disease
    • Renal disease
    • Cardiovascular disease
    • Brain damage
    • Myasthenia gravis - neuromuscular disease leading to fluctuating muscle weakness and fatigability
    • Pregnant or breast-feeding
    • Children younger than 12
  64. A nurse is caring for a client who has bipolar disorder and is in a manic state. The nurse determines that which menu choice would be best for this client?

    A. Macaroni and cheese, apple, milk
    B. Scrambled eggs, orange juice, coffee with cream and sugar
    C. Beef stew, fruit salad, tea
    D. Cheeseburger, banana, milk
    D. Cheeseburger, banana, milk

    The client in a manic state often has inadequate food and fluid intake as a result of physical agitation. Foods that the client can eat "on the run" are best because the client is too active to sit at meals and use utensils. Additionally, clients in a manic state should not have any products that contain caffeine.
    (this multiple choice question has been scrambled)
  65. A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit and is planning an on-unit supper. To decrease stimulation, the nurse should encourage the client to:

    A. Engage the help of other clients on the unit to accomplish the task.
    B. Stop the planning and firmly tell the client that this task is inappropriate.
    C. Postpone the dance and engage in a writing activity.
    D. Seek assistance from other staff members.
    C. Postpone the dance and engage in a writing activity.

    Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance or supper may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 3 encourage planning the activity and therefore increase client
    stimulation. Option 4 could result in an angry outburst by the client.
    (this multiple choice question has been scrambled)

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