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A patient experiencing acute mania is dancing atop the pool table in the recreation room. The patient waves a pool cue in one hand and says, 'I'll protect myself if anyone comes near me.' What is the nurse's first intervention?
- A. Telling the patient, 'You need to be secluded.'
- B. Demanding the patient, 'get down from the table.'
- C. Clearing the room of all other patients.
- D. Assembling staff for a show of force.
Correct Answer: C
Rationale: Clearing the room ensures safety, allowing time to plan further interventions. Other options may escalate the situation.
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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.
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.
The spouse of a patient diagnosed with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. What response supported by research should the nurse provide?
- A. A high proportion of patients diagnosed with bipolar disorders are found among creative writers.'
- B. A higher rate of relatives diagnosed with bipolar disorder is found among patients with bipolar disorder.'
- C. Patients diagnosed with bipolar disorder have higher rates of relatives who respond in an exaggerated way to daily stresses.'
- D. More individuals diagnosed with bipolar disorder come from high socioeconomic and educational backgrounds.'
Correct Answer: B
Rationale: Higher incidence of bipolar disorder among relatives supports genetic transmission. Other options do not provide direct evidence for genetic links.
A patient experiencing acute mania undresses in the group room and dances. What should be the nurse's first intervention?
- A. Quietly ask the patient, 'Why don't you put on your clothes?'
- B. Firmly tell the patient, 'Stop dancing, and put on your clothing.'
- C. Put a blanket around the patient and walk with the patient to a quiet room.
- D. Allow the patient stay in the group room while moving the other patients to a different area.
Correct Answer: C
Rationale: Covering the patient and removing them from the area protects them from embarrassment and maintains safety. Other options are less effective or inappropriate.
A patient receiving lithium should be assessed for which evidence of early toxicity?
- A. Pharyngitis, mydriasis, and dystonia
- B. Alopecia, purpura, and drowsiness
- C. Diarrhea, thirst, and vomiting
- D. Ascites, dyspnea, and edema
Correct Answer: C
Rationale: Diarrhea, thirst, and vomiting are early signs of lithium toxicity. Other options are unrelated to lithium therapy.