Chapter 13: Bipolar and Related Disorders |Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

MULTIPLE CHOICE 1. A person was online continuously for over 24 hours, posting rhymes on official government websites and inviting politicians to join social networks. 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 deficits and paranoia ANS: C Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government websites) are characteristic of manic episodes. The distracters do not specifically apply to mania. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 13-11, 12, 15, 16, 44 (Table 13-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2. A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The patient twirls and shadow boxes. The patient says gaily, ―Do you like my scarves? Here they are my gift to you.‖ How should the nurse document the patient‘s mood? a. Euphoric b. Irritable c. Suspicious d. Confident ANS: A The patient has demonstrated clang associations and pleasant, happy behavior. Excessive happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence are not the best terms for the patient‘s mood. Suspiciousness is not evident. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 13-10, 11 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3. A person was directing traffic on a busy street, rapidly shouting, ―To work, you jerk, for perks‖ and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient‘s plan of care? a. Insulting, aggressive behavior b. Pressured speech and grandiosity c. Hyperactivity; not eating and sleeping d. Poor concentration and decision making ANS: C Safety and physiological needs have the highest priority. Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs listed above because they threaten the physical integrity of the patient. The other behaviors are less threatening to the patient‘s life. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 13-18, 19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment 4. A patient diagnosed with acute mania has distributed pamphlets about a new business venture on a street corner for 2 days. Which nursing diagnosis has priority? a. Risk for injury b. Ineffective coping c. Impaired social interaction d. Ineffective therapeutic regimen management ANS: A Although each of the nursing diagnoses listed is appropriate for a patient having a manic episode, the priority lies with the patient‘s physiological safety. Hyperactivity and poor judgment put the patient at risk for injury. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 13-18, 44 (Table 13-2) | Page 13-19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Diagnosis/Analysis MSC: Client Needs: Safe, Effective Care Environment 5. A patient diagnosed with bipolar disorder becomes hyperactive 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?‖ 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, threaten the patient with seclusion as punishment, and ask a rhetorical question. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 13-18, 19, 30, 31, 46 (Table 13-3) | Page 13-19 (Case Study and Nursing Care Plan) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment 6. This nursing diagnosis applies to a patient experiencing acute 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 an 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 meal time within 1 week. d. consistently wear appropriate attire for age and sex within 1 week while on the psychiatric unit.