Bipolar
A patient experiences euphoria, increased energy, grandiosity, and decreased need for sleep for 7 days. Which condition should the nurse suspect?
A. Cyclothymia
B. Bipolar II
C. Schizophrenia
D. Bipolar I
D. Bipolar I
Mania is characterized by symptoms such as euphoria, increased energy, grandiosity, inflated self-esteem, goal-directed behavior, and decreased need for sleep with Sx lasting at least 7 days. If a patient has an episode that meets the criteria for mania, they will be diagnosed with bipolar I. Patients with bipolar disorders cycle between mood episodes ("highs" and "lows" - mania/hypomania and major depression).
Cyclothymia is a bipolar disorder in which the symptoms do not meet criteria for mood episodes (hypomania/mania and major depression).
Bipolar II is characterized by at least one episode of hypomania and at least one episode of major depression with no H/o mania.
Schizophrenia is a thought disorder characterized by perceptual disturbances, abnormal speech, and abnormal behavior.
Define clang associations versus loose associations
Loose associations: Ideas shift from one unrelated subject to another, individual is unaware that thoughts are unrelated. (e.g., “We wanted to take the bus, but the airport took all the traffic. Driving is the ticket when you want to get somewhere.”)
Clang associations: Speech that takes the form of rhyming. (e.g., “It is very cold. I am cold and bold. The gold has been sold.”)
What screening tool is used to determine severity of alcohol withdrawal?
The Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar)
This is a tool used by many hospitals to assess risk and severity of withdrawal from alcohol. It may be used for initial assessment as well as ongoing monitoring of alcohol withdrawal symptoms.
A client receives a prescription for haloperidol and PRN benztropine. Which of the following symptoms would necessitate use of benztropine?
A. Muscle rigidity
B. Hallucinations
C. Paranoia
D. Anxiety
A. Muscle rigidity
Anticholinergic medications such as benztropine may be prescribed PRN for clients taking antipsychotics (especially 1st generations) to treat extrapyramidal symptoms such as acute dystonia or pseudoparkinsonism. Acute dystonia manifests as muscle rigidity, especially in the face, neck, and back.
Hallucinations, paranoia, and anxiety are symptoms of a thought disorder, which is likely why haloperidol is prescribed, but benztropine will not treat those symptoms.
You are caring for a client who repeatedly states that his neighbor is trying to poison him, which he has been saying for the past 45 days. The client has no hallucinations, speech, affect, mood, and behavior are all otherwise normal. Which is the most likely diagnosis?
A. Schizophrenia
B. Bipolar II
C. Delusional Disorder
D. Schizoaffective Disorder
C. Delusional Disorder
Delusional disorder is characterized by delusions that persist for at least 1 month in the absence of other psychotic symptoms (e.g., hallucinations or other perceptual disturbances, bizarre speech/behavior, other negative symptoms).
Schizophrenia includes other psychotic symptoms and must be present for at least 6 months.
Bipolar II is a mood disorder that includes episodes of hypomania and major depression. Grandiose delusions may be seen in the hypomanic phase of bipolar II, but paranoid delusions are more characteristic of thought disorders (not mood disorders).
In schizoaffective disorder, individuals have symptoms of schizophrenia and a mood disorder (mania or depression).
Which intervention is most appropriate for a client experiencing acute mania or hypomania?
A. Encourage the client to go for a run
B. Ensure the client takes a shower
C. Lower the environmental stimulation
D. Ensure the client attends group therapy
C. Lower the environmental stimulation
Therapeutic interventions for clients experiencing acute mania or hypomania include ensuring safety by monitoring the client closely, decreasing environmental stimuli (remain calm, avoid bright lights, loud noises, etc.), providing nutritious, portable "finger food" snacks, and reinforcing reality. It's also best to communicate clear expectations to these clients. Low-intensity physical activity (e.g., walking) may be appropriate at this time, but high-intensity exercise should be avoided during acute mania or hypomania, as it will lead to further weight loss and energy usage. Providing hygiene care is less of a priority at this time. Group therapy is not appropriate during episodes of acute mania/hypomania until the patient is stable.
Which symptoms are most commonly seen in schizophrenia?
A. Confusion, agitation, and angry affect
B. Sobbing, worthlessness, and recurrent thoughts of death
C. Manipulativeness, insomnia, and increased energy
D. Suspiciousness, hallucinations, and bizarre speech
D. Suspiciousness, hallucinations, and bizarre speech
Schizophrenia is a thought disorder characterized by perceptual disturbances such as hallucinations, abnormal speech, and bizarre behavior. Paranoia (paranoid delusions) is a hallmark sign of schizophrenia. Affect is typically flat and social isolation is common.
Confusion, agitation, and labile affect may suggest delirium, neurocognitive disorder, or substance intoxication.
Sobbing, worthlessness, and recurrent thoughts of death may suggest depression.
Manipulativeness, insomnia, and increased energy may suggest mania or hypomania as seen in bipolar disorder.
Which client would be a good candidate for disulfiram? (select all that apply)
A. A client who abuses hydrocodone
B. A client who uses alcohol and is having transient hallucinations, HTN, N/V and sweating
C. A client being discharged from an inpatient detox center for alcohol use.
D. A client who is experiencing fatigue, cramps, nightmares, irritability and suicidal ideations
C. A client being discharged from an inpatient detox center for alcohol use.
This patient has completed detox so they should be free of alcohol, making it safe to start disulfiram (Antabuse).
Disulfiram is not indicated for opiate addiction.
Patient B is having alcohol withdrawal Sx, so we wouldn't want to start them on disulfiram at this time.
Patient D is having stimulant withdrawal Sx, disulfiram is not indicated to stimulant withdrawal.
You are caring for a client with alcohol use disorder. Which medication do you anticipate the provider ordering to decrease the risk of Wernicke-Korsakoff syndrome?
A. Diazepam
B. Valproic acid
C. Naltrexone
D. Thiamine
D. Thiamine
Korsakoff’s psychosis is identified by a syndrome of confusion, loss of recent memory, and confabulation in alcoholics. It is frequently encountered in individuals recovering from Wernicke’s encephalopathy, a complication of alcohol use disorder resulting from thiamine deficiency. In the United States, the two disorders together are called Wernicke-Korsakoff syndrome. Treatment is parenteral or oral thiamine replacement.
You are caring for a client who is experiencing delusions that include her neighbors wanting to kidnap her. Which response is the most appropriate?
A. That sounds very frightening. Tell me more about what you're feeling.
B. Tell me why you think your neighbors want to kidnap you?
C. Don't be afraid, you're safe here in the hospital, no one will kidnap you here.
D. No one is trying to kidnap you.
A. That sounds very frightening. Tell me more about what you're feeling.
This response shows empathy and asks for more information while avoiding buying into the delusion.
Asking why questions will likely lead to the patient getting defensive. Telling the patient not to feel a certain way or telling them that their beliefs are wrong dismisses their experience and diminishes trust between the patient and the nurse.
A client is talking extremely fast, changing the subject frequently, and not pausing to let anyone else respond. Which of the following symptoms does this describe?
A. Grandiosity
B. Word salad & clang associations
C. Pressured speech
D. Tangentiality
C. Pressured speech
This client is experiencing pressured speech (very fast) and flight of ideas (frequently changing the subject), which are commonly seen in mania.
Grandiosity is characterized by the exaggerated belief of one's power, strength, influence, etc (often associated with overinflated self-esteem).
Word salad is an abnormal speech pattern that includes random words strung together with no meaning (e.g., "hand glasses drive church pencil").
Clang associations are words/sentences that are combined because they rhyme or sound similar, but this speech is incoherent/meaningless (e.g., "The sky is shy. I buy the fly, who lies to guys").
Tangentiality is a speech pattern in which the individual veers off topic and talks at length about a specific unrelated topic without ever getting back to the point. Generally, B and D are seen in thought disorders, whereas A and C are seen in bipolar disorders.
Which nursing education is important to provide to family members of a client newly diagnosed with a thought disorder such as schizophrenia?
A. The pt will be prescribed alprazolam to prevent relapse.
B. The pt can stop taking risperidone when they appear calm and are no longer hallucinating.
C. Family therapy and individual psychotherapy are recommended to help prevent relapse.
D. Antipsychotics will take about 7-10 days to reach peak effectiveness.
C. Family therapy and individual psychotherapy are recommended to help prevent relapse.
Because schizophrenia is a chronic mental illness, the main goal of treatment is to reduce relapse of psychotic episodes. Treatment consists of antipsychotics, psychotherapy, family therapy, and close observation.
Antipsychotics take at least 2 weeks to reduce symptoms, usually about 4-6 weeks to reach peak effectiveness.
It's very important that the client is compliant with their medication regimen and does NOT stop taking his antipsychotics.
Alprazolam is a benzodiazepine, which will not reduce the risk of relapse (although may be ordered PRN in acute situations where the client is extremely anxious and/or at risk of hurting themself or others).
A client is prescribed methadone for opioid use disorder. Which of the following statements requires further education?
A. "Methadone can help you quit using drugs like heroin, hydromorphone, and fentanyl."
B. "I can stop taking methadone immediately if I decide that I no longer want treatment."
C. "Methadone treatment has been effective for me because I have less cravings and now I only use heroin 1x/week.
D. "I should not take methadone that I bought off the street."
B. "I can stop taking methadone immediately if I decide that I no longer want treatment."
Methadone should be tapered off slowly to prevent precipitating opioid withdrawal (this may lead to relapse).
Methadone is an opioid agonist that is used to treat opioid use disorder. Essentially, it replaces their opioid drug of choice (e.g., heroin, fentanyl, hydromorphone, etc.) with another opioid to decrease cravings and reduce intravenous/illicit opioid use (reduce risk of overdose death, endocarditis, legal trouble, etc.).
It is closely regulated and patients should only take what is prescribed to them by a provider, not anything purchased off the street.
Treatment can be considered effective if abstinence is reached or if use is significantly decreased.
Which of the following should the nurse monitor for when taking care of a client who is prescribed clozapine?
A. High drug levels in the blood and blurry vision
B. Fever, sore throat, and decreased WBC count
C. Rash and elevated liver enzymes
D. Hyponatremia and sleep disturbances
B. Fever, sore throat, and decreased WBC count
Clozapine is an antipsychotic medication associated with a risk of agranulocytosis (severely low WBC count). Clients taking clozapine must have their WBC count checked regularly, and should report any flu-like symptoms such as fever, chills, sore throat, etc.
Blurry vision and high serum drug levels should be monitored for clients taking lithium, as these could indicate lithium toxicity. Dark urine and elevated liver enzymes should be monitored for clients taking anticonvulsants such as lamotrigine, as these may cause hepatotoxicity and Stevens-Johnson Syndrome. Hyponatremia and sleep disturbances are associated with use of selective serotonin reuptake inhibitors (SSRIs).
Which of the following elements are included in the mental status exam? Select all that apply.
A. Speech and thought content
B. Food and water intake
C. Behavior and appearance
D. Eye contact and attention
E. Vital signs
A. Speech and thought content
C. Behavior and appearance
D. Eye contact and attention
The mental status exam includes several components such as speech, behavior, appearance, mood, affect, eye contact, attention, memory, orientation, thought process, hallucinations, and thought content (suicidal thoughts, delusions, etc.).
Nutritional intake and vital signs are not assessed in the mental status exam.
Which medications may be used to treat bipolar disorders? Select all that apply.
A. Paroxetine or sertraline
B. Valproic acid, carbamazepine, or lamotrigine
C. Acamprosate or naltrexone
D. Lithium
E. Quetiapine or aripiprazole
B. Valproic acid, carbamazepine, or lamotrigine
D. Lithium
E. Quetiapine, lurasidone, or aripiprazole
Lithium is the "gold standard" mood stabilizer to treat bipolar disorders. Valproic acid, carbamazepine, and lamotrigine are anticonvulsants (anti-seizure/antiepileptics), which can also be used as mood stabilizers. Quetiapine and aripiprazole are atypical antipsychotics that may also be used as mood stabilizers.
Paroxetine and sertraline are SSRIs (antidepressants), which should not be used in bipolar disorders as they can induce mania. Acamprosate and naltrexone are used to treat alcohol use disorder.
A client who knows when they are hallucinating, has a flat affect, has not been hospitalized in two years and has been taking chlorpromazine regularly for two years is likely in which phase of schizophrenia?
A. Premorbid phase
B. Prodromal phase
C. Active psychotic phase
D. Residual phase
D. Residual phase
Premorbid phase - when client shows personality and behavior signs congruent with schizophrenia (like being shy and withdrawn, having poor peer relationships, poor school performance and asocial behavior) before there is clear evidence of illness
Prodromal phase - characterized by significant deterioration in function
Active psychotic phase - when psychotic Sx (hallucinations and delusions) are prominent
Which statements by the nurse would be best for a client being DC'd post inpatient care for opioid use disorder? (select all that apply)
A. Remember that it's important to stay sober
B. We should develop your follow up plan of care during discharge
C. Stay busy with work or social events to keep from relapsing
D. Have a plan to avoid situations where drug use is likely
E. Let's discuss things that could trigger a relapse
B. We should develop your follow up plan of care during discharge
D. Have a plan to avoid situations where drug use is likely
E. Let's discuss things that could trigger a relapse
These comments help the client put concrete plans in place to avoid relapse.
The client already knows sobriety is important, simply remembering that will not deter relapse.
Staying busy, while helpful so the client doesn't "get bored" and start to use again, is not a concrete plan to avoid relapse, especially since the opportunity to relapse could present during social or work activities.
You are caring for a client who has a new prescription for disulfiram. Which of the following should you include in your teaching about this medication? Select all that apply.
A. Disulfiram interacts with alcohol to cause an unpleasant reaction, which deters you from drinking.
B. Alcohol can be enjoyed in moderation while taking disulfiram.
C. Disulfiram only causes a reaction if alcohol is ingested orally.
D. Disulfiram's reaction to alcohol may cause a headache, severe vomiting, and flushing of the face.
E. You will only need to take disulfiram for about a month.
A. Disulfiram interacts with alcohol to cause an unpleasant reaction, which deters you from drinking.
D. Disulfiram's reaction to alcohol may cause a headache, severe vomiting, and flushing of the face.
Disulfiram works by blocking the oxidation of alcohol, which causes a characteristic reaction that is intended to deter clients from consuming alcohol. This reaction may include tachycardia, throbbing headache, severe vomiting, facial flushing, and dyspnea. It is extremely uncomfortable and may be fatal if the client continues to drink alcohol.
While taking this medication, ALL alcohol must be avoided (including those found in health products and cosmetics).
Disulfiram typically needs to be taken for several years to help a client abstain from alcohol long-term.
Which of the following clients are appropriate for group therapy? Select all that apply.
A. A client who has been taking buprenorphine-naloxone for 1 month.
B. A client who was found confused and wandering earlier today.
C. A client who is experiencing acute mania.
D. A client who is experiencing acute withdrawal of methamphetamine.
E. A client with bipolar II admitted yesterday for suicidal ideations during a major depressive episode.
A. A client who has been taking buprenorphine-naloxone for 1 month.
Clients are only appropriate for group therapy if they are stable; not anyone recently admitted, not anyone at high risk of suicide or violence, not anyone currently experiencing mania, psychosis, delirium, or acute substance/alcohol withdrawal. A client who has been taking buprenorphine-naloxone for a month is likely stable and therefore appropriate for group therapy, none of the other clients would be considered stable enough for group therapy.
Which of the following is true regarding lithium? Select all that apply.
A. Diarrhea, blurred vision, and ataxia are expected side effects
B. Lithium withdrawal is the priority nursing concern
C. It may cause weight loss and insomnia
D. If lithium level is >1.5, it should be held and the provider should be notified
E. It is used to treat manic and depressive symptoms and/or prevent episodes of mania
D. If lithium level is >1.5, it should be held and the provider should be notified
E. It is used to treat manic and depressive symptoms and/or prevent episodes of mania
Lithium is a mood stabilizer used to treat bipolar disorders by preventing or decreasing cyclical episodes of mania and depression (characteristics of bipolar disorders). Therapeutic levels are 0.6-1.2. Levels should NOT exceed 1.5, as this puts the client at risk for lithium toxicity which may be fatal.
Diarrhea, blurred vision and ataxia are not expected side effects.
Lithium withdrawal is not a major concern
Which of the following are positive symptoms seen in schizophrenia? Select all that apply.
A. Tangential speech
B. Anhedonia
C. Flat affect
D. Echolalia
E. Neologisms
F. Grandiose delusions
A. Tangential speech
D. Echolalia
E. Neologisms
F. Grandiose delusions
Positive symptoms include those that are "added on" such as paranoia, delusions, hallucinations, and speech disturbances (echolalia, neologisms, word salad, etc)
Negative symptoms are findings that represent something having been "taken from" the patient; a behavior or expression that is absent, dull or diminished. Examples include anhedonia, flat affect (affect should have full range & react appropriately to the topic), avolition (lack of motivation), anergia, etc. (recognize the prefix "a" as meaning without; those are most likely going to be your negative Sx)
Tip: Remember that first generation antipsychotics only treat positive symptoms, whereas atypical antipsychotics treat both positive & negative symptoms.
You are caring for a client with alcohol withdrawal delirium. Which interventions are appropriate? Select all that apply.
A. Administer lorazepam or chlordiazepoxide
B. Instruct the client to take a walk around the unit
C. Initiate seizure precautions
D. Close the client's door and let him sleep for several hours
E. Administer anticonvulsants as ordered
A. Administer lorazepam or chlordiazepoxide
C. Initiate seizure precautions
E. Administer anticonvulsants as ordered
When caring for a client with alcohol withdrawal delirium, priority nursing interventions include checking vital signs, initiating seizure precautions, monitoring the client closely using the CIWA scale, administering benzodiazepines (e.g., chlordiazepoxide, lorazepam, or diazepam), initiating fall precautions, and administering anticonvulsants as ordered.
Clients should not be permitted to get up and walk around unattended because they are at a high risk of falls.
We would not shut the patient in a room, we would need to closely monitor them.
Which of the following medications are matched to the appropriate indication for use? Select all that apply.
A. Risperidone: thought disorders & bipolar disorders
B. Carbamazepine: bipolar disorders & seizures
C. Disulfiram: alcohol withdrawal
D. Buprenorphine-naloxone: cocaine use disorder
E. Chlordiazepoxide: alcohol withdrawal
A. Risperidone: thought disorders & bipolar disorders
B. Carbamazepine: bipolar disorders & seizures
E. Chlordiazepoxide: alcohol withdrawal
Risperidone is an atypical antipsychotic that is used for thought disorders like schizophrenia but may also be used as a mood stabilizer for bipolar disorders.
Carbamazepine is an anticonvulsant which is used as a mood stabilizer for bipolar disorders as well as seizure prophylaxis.
Disulfiram, along with acamprosate and naltrexone, are used to treat alcohol use disorder.
Buprenorphine-naloxone, along with methadone, are used to treat opioid use disorder (there is no approved medication specifically for cocaine use disorder).
Chlordiazepoxide is a benzodiazepine, which is used to treat alcohol withdrawal.
Which of the following are appropriate nursing considerations regarding bipolar I? Select all that apply.
A. The nurse should assess for signs of substance use, such as weight loss and disheveled appearance.
B. These clients are at an increased risk of suicide and may need suicide precautions.
C. A client sleeping for 5 hours per night indicates effective treatment of acute mania
D. Low socioeconomic status is a risk factor for bipolar I.
E. During episodes of acute mania, the nurse should provide portable nutrient-dense snacks.
A. The nurse should assess for signs of substance use, such as weight loss and disheveled appearance.
B. These clients are at an increased risk of suicide and may need suicide precautions.
C. A client sleeping for 5 hours per night indicates effective treatment of acute mania
E. During episodes of acute mania, the nurse should provide portable nutrient-dense snacks.
All are appropriate nursing considerations except D; bipolar I is typically seen in those of high SES