Mood Disorders Practice Exam/Test (16-23)

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Situation: C., age 36 and single, is brought to the local psychiatric hospital by her brother, who tells the nurse that she has been involved in a whirlwind of activity that began several months ago and that she seems out of control. She told friends that she was devoting all her time to writing a novel that was nearly complete, but at the same time, she began painting the interior of her seven-room home. When her friends tried to get her slow down, she increased her activities, taking little time to sleep or eat, and began spending huge amounts of money. Her admission was necessitated when she wrote a check for $500,000, with a bank balance of only $5.
At admission, C. is agitated, speaking loudly and challenging other patients. Her admitting diagnosis is bipolar reaction, manic phase.

16. Which approach would be most therapeutic in working with C.?

a) teaching the patient about banking procedures, then extending this approach to everyday issues
b) confronting the patient about all her inappropriate behavior
c) kindly but firmly guiding the patient into such activities as bathing and eating
d) showing the patient that she is in a controlled environment so that no difficulties arise later

17. C. lost 15 lb (6.8 kg) last week and now weighs 100 lb (45.4 kg). The nurse formulates a nursing diagnosis based on the diagnostic category Altered Nutrition: less than body requirements. Which goal is most appropriate initially?

a) the patient will consume an adequate diet
b) the patient will maintain her current weight of 100 lb
c) the patient will gain 1 lb (0.5 kg) per week
d) the patient will remain adequately hydrated

18. The best approach to meeting C.'s hydration and nutrition needs would be to:

a) leave finger foods and liquids in her room and let her eat and drink as she moves about
b) bring her to the dining room and encourage her to sit and eat with calm, quiet companions
c) explain mealtime routines and allow her to make her own decisions about eating
d) provide essential nutrition through high-calorie gavage feedings

19. The physician decides to start C. on lithium (Lithane) therapy. Which of the following best describes her dietary requirements while she is receiving this medication?

a) a high-calorie diet with reduced sodium and adequate fluid intake
b) a regular diet with normal sodium and adequate fluid intake
c) a low-calorie diet with reduced sodium and increased fluid intake
d) a regular diet with reduced sodium and adequate fluid intake

20. A few days later, C. tells the nurse, "I'm so ashamed of myself, I don't deserve to be here and be taken care of." Which action best demonstrates the nurse's understanding of the patient's needs?

a) expressing relief that C. has recognized the foolishness of her behavior
b) calling a team conference to increase protection against possible self-destructive behavior by C.
c) reporting to staff members that C. appears to be developing insight into her behavior
d) telling C. that she has done nothing that she should regret

21. C. would benefit most from which activity during the manic phase of her illness?

a) playing a game of badminton
b) attending the unit's weekly bingo game
c) putting together an intricate puzzle
d) drawing or painting in her room

22. One week after C. begins taking lithium, the nurse notes that her serum lithium level is 1 mEq/L. How should the nurse respond?

a) call the physician immediately to report the laboratory results
b) observe the patient closely for signs of lithium toxicity
c) withhold the next dose and repeat the blood work
d) continue administering the medication as ordered

23. Early signs of lithium toxicity include:

a) fine tremors, nausea, vomiting, and diarrhea
b) ataxia, confusion, and seizures
c) elevated white blood cell count and orthostatic hypotension
d) restlessness, shuffling gait, and involuntary muscle movements




ANSWERS AND RATIONALE

16) C
- a soft, kind, but firm approach is least likely to provoke or anger the patient. Confronting the patient about her behavior is not recommended because, at this point, she cannot control her actions. Because the patient is n an agitated state, she is unable to listen or gain insight into her situation; trying to teach her about managing her money or her life is frustrating for both the nurse and the patient. Similarly, focusing on the controlled environment is ineffective while the patient remains agitated; however, this should be carried out later when the patient is less stressed.

17) B
- maintaining the patient's weight at stable level is an appropriate initial goal while the patient is acutely manic. Once the patient is less hyperactive, the goal can be changed to reflect a gradual weight gain. Goals that use such terms as adequate diet or adequate hydration are too vaguely stated to be evaluated.

18) A
- providing easily managed food and drink for the patient to consume as she moves about her room promotes nutrition while demonstrating acceptance of the patient's inability to cease activities long enough to eat in a conventional manner. Eating in the dining room would be too stimulating at this time and might escalate the patient's behavior as well as disturb others. The nurse should not allow the patient to make her own decisions about eating but should encourage her to eat at mealtimes; patients experiencing mania tend to be too "busy" to stop meals. Because the patient would probably view tube feedings as assaultive, they should be avoided unless no alternative is available.

19) B
- while receiving lithium, the patient should maintain a regular diet with adequate fluid intake (about 70 to 100 oz or 2 to 3 liters per day). Lithium is a salt, and its retention in the body is directly influenced by the body's sodium and fluid balance. Sodium depletion must be avoided because lithium will replace sodium in the cells, leading to lithium toxicity. Low-sodium diets and high- and low-calorie diets do not provide adequate balance for proper lithium regulation.

20) B
- the nurse should recognize that the patient is in the depressive phase of bipolar depression (manic-depressive disorder) and needs protection from herself because she is at risk for suicide. The nurse must always be alert for signs of self-destructive behavior and should inform the treatment team immediately so that protective measures, such as suicide precautions, can be instituted if necessary. Expressing relief at the patient's developed insight into her behavior and reporting to staff members that she is developing insight are serious misinterpretations that miss the underlying message. Although the nurse should help C. to recognize that her behavior is a function of her bipolar disorder and not a reflection of her as a person, telling her that she has done nothing she should regret is inappropriate because it devalues her feelings.

21) D
- drawing or painting in a quiet environment provides the patient with an outlet for excess energy and encourages sublimation of feelings (transferring unacceptable aggressive drives into a constructive activity). Badminton would only increase C.'s agitation and aggression because of its competitive nature. During acute mania, the patient would be overstimulated by the noise and activity of a bingo game. Because the patient finds sitting still and concentrating difficult, working on an intricate puzzle would be too frustrating and would increase her already low self-esteem.

22) D
- the serum lithium level should be maintained between 1 and 1.5 mEq/L during the acute manic phase; therefore, the nurse should continue administering the medication. In the absence of other signs of lithium toxicity, the nurse has no need to call the physician, withhold the medication, or repeat the blood work. Nevertheless, she should continue to monitor the patient's lithium level and watch for signs of toxicity if the level begins to rise.

23) A
- the nurse must remain alert for early signs of lithium toxicity, including fine tremors, nausea, vomiting, and diarrhea. When such symptoms are observed, the lithium should be withheld and the blood work repeated until the toxicity is reversed. Ataxia, confusion, and seizures indicate severe toxicity and require prompt medical management. An elevated white blood count, orthostatic hypotension, and extrapyramidal symptoms (involuntary muscle movements, restlessness, and shuffling gait) are side effects of phenothiazines, not lithium.


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