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Situation: Two days ago, M. arrived on the psychiatric unit, exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic, aimless physical activity, and grandiose delusions.
24. M. is in a manic episode. Which assessment finding is most characteristic of this stage of mania?
a) mild elation
b) hypomania
c) acute elation
d) delirium
25.Which nursing diagnostic category would hold the highest priority for M. at this time?
a) ineffective individual coping
b) hopelessness
c) potential for injury
d) personal identity disturbance
26. M. is assigned to a private room that is somewhat removed from the nurse's station. The primary reason for this room assignment is to:
a) decrease environmental stimuli
b) prevent the patient's excessive activity from disturbing others
c) deter the patient from interrupting the nurses
d) provide the patient with a quiet environment for thinking about his problems
Situation: K. is admitted to the acute psychiatric unit after 2 weeks of increasingly erratic behavior. She has not been sleeping, has lost 8 lb (3.6 kg), and is poorly groomed. She is hyperactive and loudly denies her need for hospitalization.
27. A priority nursing intervention for K. is to:
a) provide adequate hygiene
b) administer sedative medication
c) decrease environmental stimuli
d) involve her in unit activities
28. The physician plans to order lithium carbonate for K. Before beginning the lithium treatment regimen, the nurse performs a physical assessment. She is aware that lithium is contraindicated when a patient exhibit dysfunction of the:
a) renal system
b) reproductive system
c) endocrine system
d) respiratory system
29. The physician changes the medication order to lithium carbonate to 300 mg four times a day and chlorpromazine (thorazine) 100 mg four times a day. Which statement best explains the reason for ordering chlorpromazine?
a) a lower dose of lithium can be given
b) chlorpromazine helps control the manic symptoms until the lithium takes effect
c) joint administration makes both drugs more effective
d) joint administration decreases the risk of lithium toxicity
30. After 10 days on the unit, K. can tolerate short periods in the dayroom. One day, the nurse overhears her tell another patient that she is a journalist posting as a patient so that she can gather enough information to write an article about mental hospitals. The nurse should:
a) ignore K.'s delusion
b) confront K.
c) take K. back to her room
d) support K.'s denial of her illness
ANSWERS AND RATIONALE
24) D
- mania is a mood of extreme euphoria. Delirium, the most severe state of mania, is manifested by extreme excitement, disorientation, incoherence, agitation, frantic activity, and grandiose delusions. At this stage, exhaustion, injury and death are possible. Mild elation and hypomania are synonymous terms that refer to a lesser state of hyperactivity. Acute elation, found in severe states of mania, is evidenced by feelings of exaltation, lability, flight of ideas, talkativeness, grandiosity, inappropriate dress and makeup, urgent activity, decreased appetite and sleep, and distractibility.
25) C
- M. is at risk for injury because of his severe hyperactivity, disorientation, and agitation. Although the nursing diagnostic categories of Ineffective individual coping, Hopelessness, and Personal identity disturbance are also appropriate, the patient's safety needs are the highest priority at this time. The nurse should take immediate action to protect the patient from injury.
26) A
- assigning M. to a room that is removed from the nurse's station helps to decrease environmental stimuli, thereby helping to reduce his level of hyperactivity. Although M.'s excessive activity may bother the nurses and other patients, the primary reason for this room assignment is to benefit M., not the others in the unit. Because a patient in any stage of mania has little or no capacity for introspection, a private room is not used for this purpose.
27) B
- the patient in this situation is at risk for injuring herself or others. Administering a sedative as an initial intervention helps protect both the patient and the nurse from injury. Decreasing environmental stimuli is an additional measure that, when combined with medicating the patient, can reduce dangerous hyperactivity. Providing for the patient's hygiene and grooming needs an appropriate nursing intervention, but it is not the initial priority. The overall goal is to reduce hyperactivity, so involvement in unit activities is contraindicated.
28) A
- lithium carbonate does not bind with plasma protein and is excreted exclusively through the kidneys; therefore, it is contraindicated in patients with renal system dysfunction. Lithium also is contraindicated in pregnant women and nursing mothers but not in those with reproductive disorders. Lithium can be used with caution in patients with thyroid or respiratory disorders.
29) B
- an effective serum lithium level is not achieved for 7 to 10 days. Administering chlorpromazine (thorazine) concomitantly helps control the manic symptoms during this time. Once a therapeutic lithium blood level is achieved, the chlorpromazine dosage can be reduced and discontinued. Chlorpromazine has no effect on lithium dosage. Because lithium and chlorpromazine do not have an additive effect, their efficacy is not increased when combined. Lithium toxicity is related to the body's sodium-fluid balance and would not affected by administration of chlorpromazine.
30) B
- once the intensity of the mania has diminished, the nurse can use therapeutic confrontation in response to the patient's denial of her illness. The nurse should approach the patient on a one-to-one basis and say something like, "I overheard you say you were a journalist posing as a patient. Why don't we sit and talk about the reasons for your admission and how you are doing now." While confronting but not arguing with K., the nurse can review the reasons she was admitted and present the reality of the situation. This is more therapeutic than ignoring the comment, isolating the patient, or supporting her denial.
Related Topics:
- Go back to Online Nursing Practice Test about Mood Disorders (1-8) to start the test from the beginning.
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