Nokea
A nurse prepares the plan of care for a patient experiencing a manic episode. Which nursing diagnoses are most appropriate?
- A. Imbalanced nutrition: more than body requirements
- B. Disturbed thought processes
- C. Sleep deprivation
- D. Chronic confusion
- E. Social isolation
Correct Answer: B,C
Rationale: Manic patients often experience disturbed thought processes and sleep deprivation due to hyperactivity. Other diagnoses are less relevant or incorrect.
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What is the focus of outcome identification for the treatment plan of a patient presenting with grandiose thinking associated with acute mania?
- A. Maintaining an interest in the environment
- B. Developing an optimistic outlook
- C. Self-control of distorted thinking
- D. Stabilizing the sleep pattern
Correct Answer: C
Rationale: Controlling grandiose thinking is the primary outcome, as it addresses the core symptom of mania. Other options are less directly related.
A patient diagnosed with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed?
- A. Phenytoin
- B. Clonidine
- C. Carbamazepine
- D. Chlorpromazine
Correct Answer: C
Rationale: Carbamazepine is effective for rapid-cycling bipolar disorder. Phenytoin and chlorpromazine are not used for mood stabilization, and clonidine is not an anticonvulsant for this purpose.
A patient diagnosed with bipolar disorder has been hospitalized for 7 days and has taken lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention?
- A. Educate the patient about the proper ways to perform personal hygiene and coordinate clothing.
- B. Continue to monitor and document the patient's speech patterns and motor activity.
- C. Ask the health care provider to prescribe an increased dose and frequency of lithium.
- D. Consider the need to check the lithium level. The patient may not be swallowing medications.
Correct Answer: D
Rationale: Persistent manic symptoms suggest possible nonadherence, warranting a lithium level check. Increasing the dose or other options are less appropriate.
Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be especially challenging and critical?
- A. Arthritis
- B. Epilepsy
- C. Exercise-induced asthma
- D. Congestive heart failure
Correct Answer: D
Rationale: Congestive heart failure and diuretic use complicate fluid balance, increasing lithium toxicity risk. Other conditions do not directly affect lithium monitoring.
A nurse reviewing the laboratory results for a patient diagnosed with bipolar disorder notes the lithium level as 1 mEq/L. How will the nurse interpret this information about the medication level?
- A. It requires no additional nursing intervention.
- B. It is below recognized therapeutic serum limits.
- C. It is above recognized therapeutic serum limits.
- D. It indicates a need for immediate medical intervention.
Correct Answer: A
Rationale: A lithium level of 1 mEq/L is within the therapeutic range (0.4-1 mEq/L), requiring no further intervention.