Nursing Interventions
A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?
A. Set consistent limits for expected client behavior
B. Administer prescribed medications as scheduled
C. Provide the client with step-by-step instructions
D. Monitor the client for escalating behavior
D. Monitor the client for escalating behavior
Monitoring the client for escalating behavior addresses the client's priority need for safety and is therefore the priority nursing action.
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."
4. "Treatment is compromised when clients choose not to take their medications."
A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply).
A. Use caffeine in moderation to prevent relapse.
B. Difficulty sleeping can indicate a relapse.
C. Begin taking your medications as soon as a relapse begins.
D. Participating in psychotherapy can help prevent a relapse.
E. Anhedonia is a clinical manifestation of a depressive relapse.
B. Difficulty sleeping can indicate a relapse.
The client should be alert for sleep disturbances, which can indicate a relapse.
D. Participating in psychotherapy can help prevent a relapse.
The client who has bipolar disorder can participate in psychotherapy to help prevent a relapse.
E. Anhedonia is a clinical manifestation of a depressive relapse.
The client who has bipolar disorder should be aware of manifestations, including anhedonia, which is a depressive characteristic that can indicate a relapse.
A nurse learns at report that a newly admitted client is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom?
A. "I cannot 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 has taped my room and are out to get me."
B. "I am the world's most perceptive attorney."
A client on an inpatient unit is diagnosed with bipolar disorder: manic phase. During a discussion in the dayroom about weekend activities, the client raises 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
C. Assist the client to move to a calmer location.
A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?
A. "ECT is the recommended initial treatment for bipolar disorder."
B. "ECT is contraindicated for clients who have suicidal ideation."
C. "ECT is effective for clients who are experiencing severe mania."
D. "ECT is prescribed to prevent relapse of bipolar disorder."
C. "ECT is effective for clients who are experiencing severe mania."
ECT is appropriate for the treatment of severe mania associated with bipolar disorder.
A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make?
A. "Why do you think you feel the need to give money away?"
B. "I am here to provide care and cannot accept this from you."
C. "I can request that your case manager discuss appropriate charity options with you."
D. "You should know that giving away your money is inappropriate."
B. "I am here to provide care and cannot accept this from you."
The statement is matter-of-fact and concise and is a therapeutic response to a client who has bipolar disorder.
A client is admitted into the psychiatric unit with symptoms of hypomania. The client’s history indicates that the client has never experienced a full manic episode. What should the nurse infer from these findings?
A. The client has schizophrenia.
B. The client has bipolar I disorder.
C. The client has bipolar II disorder.
D. The client has obsessive-compulsive disorder.
C. The client has bipolar II disorder.
The client with bipolar II disorder has symptoms of depression or hypomania, but the client does not experience full manic episodes.
A client is diagnosed with bipolar disorder: manic phase. Which nursing intervention would be implemented to achieve the outcome of "Client will gain 2 lbs 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.
A. Provide the client with high-calorie finger foods throughout the day.
A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following?
A. AST/ALT and LDH
B. Creatinine and BUN
C. WBC and granulocyte counts
D. Serum sodium and potassium
A. AST/ALT and LDH
Routine monitoring of liver function tests is necessary due to the risk for hepatotoxicity.
Which actions by the nurse will help a hyperactive client to achieve much-needed rest?
A. Provide juice and snacks to the client often.
B. Sitting with the client while eating.
C. Providing a structured schedule of activities for the client.
D. Providing stimulating drinks to the client before bedtime.
C. Providing a structured schedule of activities for the client.
Providing a structured schedule of activities, including established times for naps or rest, will help the hyperactive client achieve much-needed rest.
Which statement of the client with bipolar mania indicates personalizing thought?
A. "Everything I do is great."
B. "My teacher thinks I'm wonderful."
C. "My sister is this happy only when she is with me."
D. "None of those mistakes are really important."
C. "My sister is this happy only when she is with me."
This statement by the client represents personalizing thought. The client relates the happiness of his or her sister to the client's own behavior, though they are not related.
A client with mania who is extremely hyperactive and intensely agitated is admitted into the psychiatric ward. During client care, the nurse instructs the client to perform slow exercises. Which risks does the nurse intend to prevent in the client?
A. Risk of physical injury.
B. Risk of weight gain.
C. Risk of harming other individuals.
D. Risk of insomnia.
A. Risk of physical injury.
The client with intense agitation and extreme hyperactivity is at risk for injury. Providing the client calming physical activities or exercises will help to reduce agitation in the client. Therefore, the nurse tries to prevent physical injury.
A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make?
A. "That is a good choice. Ibuprofen does not interact with lithium."
B. "Regular aspirin would be a better choice than ibuprofen."
C. "Lithium decreases the effectiveness of ibuprofen."
D. "The ibuprofen will make your lithium level fall too low."
B. "Regular aspirin would be a better choice than ibuprofen."
Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk of lithium toxicity.
Which findings may be noticed in a client with a manic episode of bipolar disorder?
A. Decreased levels of dopamine.
B. Increased levels of acetylcholine.
C. Enlargement of subcortical white matter.
D. Shrinkage of third ventricles in the brain.
C. Enlargement of subcortical white matter.
A client with bipolar disorder has enlarged subcortical white matter, which is revealed by the magnetic resonance imaging (MRI) of the brain.
While communicating with a client, the nurse suspects that the client has a manic episode of bipolar disorder. Which statement of the client supports the nurse’s suspicion?
A. "I sleep for 8 hours daily."
B. "I pinch myself when I feel guilty."
C. "I communicate better than anyone else."
D. "I participate in debates frequently."
C. "I communicate better than anyone else."
The client feels that he or she is better in communication skills than anyone. This indicates grandiosity, which is a symptom of mania. Therefore, the nurse suspects mania in this client.
A nurse is planning care for a client who is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply).
A. Provide flexible client behavior of expectations
B. Offer concise explanations
C. Establish consistent limits
D. Disregard client complaints
E. Use a firm approach with communication
B. Offer concise explanations
Offering concise explanations improves the client's ability to focus and comprehend the information.
C. Establish consistent limits
Establishing consistent limits decreases the risk for client manipulation
E. Use a firm approach with communication
Using a firm approach with client communication promotes structure and minimizes inappropriate client behaviors.
A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching? (Select all that apply).
A. Confusion
B. Polyuria
C. Rash
D. Muscle weakness
E. Tinnitus
B. Polyuria
D. Muscle weakness
A client with bipolar disorder is at high risk of self-harm. The nurse finds that the client perceives actions of others as threatening. What does the nurse do to ensure safety of this client? (Select all that apply).
A. Use mechanical restraints.
B. Place the patient on 1:1 precautions.
C. Provides additional care by adding new staff.
D. Maintain a low level of stimuli in the client environment.
E. Notify the primary healthcare provider.
B. Place the client on 1:1 precautions.
If a patient may self-harm, it may be necessary to assign a nurse for one on one client care. This intervention is not necessary if mechanical restraints are not used to control the actions of the client.
C. Maintain a low level of stimuli in the client environment.
Maintaining low levels of stimuli, such as low lighting and low noise levels, will reduce the perception of threats in the client; anxiety will rise with a high level of stimuli.
The nurse is caring for a client diagnosed with bipolar disorder. On interaction with the client, the nurse suspects that the client is in the delirious mania stage. Which statement of the client supports the nurse’s conclusion? (Select all that apply).
A. "Go away! Leave me alone."
B. "I don't want to go in that bathroom because someone is there and trying to kill me."
C. "I will kill you if you try to come near me."
D. "I am worthless and I feel like dying."
E. "I saw a demon standing in front of me."
A. "Go away! Leave me alone."
The client’s statement indicates that the client is having auditory hallucinations. Delirious mania is characterized by auditory or visual hallucinations.
B. "I don't want to go in that bathroom because someone is there and trying to kill me."
The client who is in a delirious manic stage experiences delusions of persecution. The client refuses to go in the bathroom because the client feels threatened.
E. "I saw a demon standing in front of me."
Visual hallucinations are evident in a client who is in a delirious mania stage. The client’s statement of seeing a demon standing in front of him or her indicates hallucinations.