Bipolar and Other Related Disorders

Multiple Choice

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

ANS: 4
Rationale: The nurse should document that this client’s behavior is “Agitated and pacing. Exhibiting grandiosity. Mood labile.” The client is exhibiting mood swings from euphoria to irritability. Grandiosity refers to the attitude that one’s abilities are better than everyone else’s.

Cognitive Level: Application
Integrated Process: Evaluation

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

ANS: 2
Rationale: 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. Because of the client’s rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and physical health.

Cognitive Level: Analysis
Integrated Process: Diagnosis

3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the client outcomes in the exhibit?

Client Outcomes:
1. Maintains nutritional status
2. Interacts appropriately with peers
3. Remains free from injury
4. Sleeps 6 to 8 hours a night
1. 2, 1, 3, 4
2. 4, 1, 2, 3
3. 3, 1, 4, 2
4. 1, 4, 2, 3

ANS: 3
Rationale: 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 safety and physical health as most important.

Cognitive Level: Analysis
Integrated Process: Planning

4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family members report that the client has experienced anorexia, insomnia, and recent job loss. Which nursing diagnosis should a nurse prioritize?
1. Risk for suicide R/T hopelessness
2. Anxiety: severe R/T hyperactivity
3. Imbalanced nutrition: less than body requirements R/T refusal to eat
4. Dysfunctional grieving R/T loss of employment

ANS: 1
Rationale: The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should always prioritize client safety. This client is at risk for suicide because of his or her recent suicide attempt.

Cognitive Level: Analysis
Integrated Process: Diagnosis

5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate (Lithobid) because of excessive weight gain. In order to increase adherence, which medication should a nurse anticipate that a physician may prescribe?
1. Sertraline (Zoloft)
2. Valproic acid (Depakote)
3. Trazodone (Desyrel)
4. Paroxetine (Paxil)

ANS: 2
Rationale: The nurse should anticipate that the physician may prescribe valproic acid in order to increase this client’s medication adherence. Valproic acid is an anticonvulsant medication that can be used to treat bipolar disorder. One of the side effects of this medication is weight loss.

Cognitive Level: Application
Integrated Process: Planning

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 response?
1. “Zyprexa in combination with Eskalith cures manic symptoms.”
2. “Zyprexa prevents extrapyramidal side effects.”
3. “Zyprexa increases the effectiveness of the immune system.”
4. “Zyprexa calms hyperactivity until the Eskalith takes effect.”

ANS: 4
Rationale: The nurse should explain to the client’s spouse that olanzapine can calm hyperactivity until the lithium carbonate takes effect. Lithium carbonate may take 1 to 3 weeks to begin to decrease hyperactivity. Monotherapy with the traditional mood stabilizers like lithium carbonate, or atypical antipsychotics like olanzapine, has been determined to be the first-line treatment for bipolar I disorder.

Cognitive Level: Application
Integrated Process: Implementation

7. A client began taking lithium carbonate (Lithobid) 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 response?
1. “That’s strange. Weight loss is the typical pattern.”
2. “What have you been eating? Weight gain is not usually associated with lithium.”
3. “Weight gain is a common, but troubling, side effect.”
4. “Weight gain only occurs during the first month of treatment with this drug.”

ANS: 3
Rationale: 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 adherence and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.

Cognitive Level: Application
Integrated Process: Implementation

8. A client diagnosed with bipolar disorder has been taking lithium carbonate (Lithobid) for one year. The client presents in an emergency department with a temperature of 101°F (38°C), severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms?
1. Symptoms indicate consumption of foods high in tyramine.
2. Symptoms indicate lithium carbonate discontinuation syndrome.
3. Symptoms indicate the development of lithium carbonate tolerance.
4. Symptoms indicate lithium carbonate toxicity.

ANS: 4
Rationale: 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 with maintenance therapy to ensure proper dosage.

Cognitive Level: Application
Integrated Process: Evaluation

9. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder?
1. “Risky Activity” tool
2. “FIND” tool
3. “Consensus Committee” tool
4. “Monotherapy” tool

ANS: 2
Rationale: The nurse should 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.

Cognitive Level: Application
Integrated Process: Assessment

10. 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?
1. “Treatment is compromised when clients can’t sleep.”
2. “Treatment is compromised when irritability interferes with social interactions.”
3. “Treatment is compromised when clients have no insight into their problems.”
4. “Treatment is compromised when clients choose not to take their medications.”

ANS: 4
Rationale: The nursing student is accurate when stating that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose not to take their medications. Clients diagnosed with bipolar disorder feel most productive and creative during manic episodes. This may lead to purposeful medication nonadherence. Symptoms of bipolar disorder will reemerge if medication is stopped.

Cognitive Level: Application
Integrated Process: Evaluation

11. A client is diagnosed with bipolar disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of “Client will gain 2 lb by the end of the week?”
1. Provide client with high-calorie finger foods throughout the day.
2. Accompany client to cafeteria to encourage adequate dietary consumption.
3. Initiate total parenteral nutrition to meet dietary needs.
4. Teach the importance of a varied diet to meet nutritional needs.

ANS: 1
Rationale: The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 lb by the end of the week. Because of the hyperactive state, the client will have difficulty sitting still to consume large meals.

Cognitive Level: Application
Integrated Process: Implementation

12. A nursing instructor is teaching about bipolar disorders. Which statement differentiates the DSM-5 diagnostic criteria of a manic episode from a hypomanic episode?
1. During a manic episode, clients may experience an inflated self-esteem or grandiosity, and these symptoms are absent in hypomania.
2. During a manic episode, clients may experience a decreased need for sleep, and this symptom is absent in hypomania.
3. During a manic episode, clients may experience psychosis, and this symptom is absent in hypomania.
4. During a manic episode, clients may experience flight of ideas and racing thoughts, and these symptoms are absent in hypomania.

ANS: 3
Rationale: Three or more of the following symptoms may be experienced in both hypomanic and manic episodes: Inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep), more talkative than usual or pressure to keep talking, flight of ideas and racing thoughts, distractibility, increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments). If there are psychotic features, the episode is, by definition, manic.

Cognitive Level: Analysis
Integrated Process: Assessment

13. A client has been diagnosed with major depressive episode. After treatment with fluoxetine (Prozac), the client exhibits pressured speech and flight of ideas. Based on this symptom change, which physician action would the nurse anticipate?
1. Increase the dosage of fluoxetine.
2. Discontinue the fluoxetine and rethink the client’s diagnosis.
3. Order benztropine (Cogentin) to address extrapyramidal symptoms.
4. Order olanzapine (Zyprexa) to address altered thoughts.

ANS: 2
Rationale: A full manic episode emerging during antidepressant treatment (medication, electroconvulsive therapy, etc.), but persisting beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a Bipolar I diagnosis.

Cognitive Level: Analysis
Integrated Process: Assessment

14. Which is the basic premise of a recovery model used to treat clients diagnosed with bipolar disorder?
1. Medication adherence
2. Empowerment of the consumer
3. Total absence of symptoms
4. Improved psychosocial relationships

ANS: 2
Rationale: The basic premise of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care and to enable a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

Cognitive Level: Application
Integrated Process: Assessment

Multiple Response

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

ANS: 1, 2, 3
Rationale: 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 because of the narrow margin between therapeutic doses and toxic levels. Fluid or sodium restriction can impact lithium levels.

Cognitive Level: Application
Integrated Process: Implementation

16. A nurse is assessing an adolescent client diagnosed with cyclothymic disorder. Which of the following DSM-5 diagnostic criteria would the nurse expect this client to meet? (Select all that apply.)
1. Symptoms lasting for a minimum of two years
2. Numerous periods with manic symptoms
3. Possible comorbid diagnosis of a delusional disorder
4. Symptoms cause clinically significant impairment in important areas of functioning
5. Depressive symptoms that do not meet the criteria for major depressive episode

ANS: 4, 5
Rationale: The following are selected criteria for the diagnosis of cyclothymic disorder. For at least one year in children and adolescents there have been numerous periods with hypomanic, not manic symptoms that do not meet criteria for hypomanic episode and numerous periods with depressive symptoms that do not meet the criteria for a major depressive episode. The symptoms are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not elsewhere classified. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Cognitive Level: Application
Integrated Process: Implementation

17. Which of the following rationales by a nurse explain to parents why is it difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? (Select all that apply.)
1. Bipolar symptoms mimic attention deficit-hyperactivity disorder symptoms.
2. Children are naturally active, energetic, and spontaneous.
3. Neurotransmitter levels vary considerably in accordance with age.
4. The diagnosis of bipolar disorder cannot be assigned prior to the age of 18.
5. Genetic predisposition is not a reliable diagnostic determinant.

Nursing Process: Assessment
Client Need: Psychological Integrity

ANS: 1, 2
Rationale: It is difficult to diagnose a child or adolescent with bipolar disorder, because bipolar symptoms mimic 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.

Cognitive Level: Application
Integrated Process: Assessment

Fill-in-the-Blank

18. ___________________________ is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking.

ANS: Mania
Rationale: Mania is an alteration in mood that is expressed by feelings of elation, inflated self-esteem, grandiosity, hyperactivity, agitation, and accelerated thinking and speaking. Mania can occur as a biological (organic) or psychological disorder, or as a response to substance use or a general medical condition.

Cognitive Level: Application
Integrated Process: Assessment