ATI bipolar disorder scenario Study Guide With All Questions And Complete Answers Well Elaborated|2024.

Nurse Ben performs Ms. Chois intial mental status assessment. Which of the following categories indicates correct nursing assessment findings? - correct answer Thought Content The client is experiencing a manic episode with grandiose thinking, racing thoughts and magical thinking. Nurse Ben continues to collect information related to ms. Choi episode of manic behavior. Which of the following responses to the question asked by the clients mother, Mrs. Choi, is appropriate? - correct answer "According to the literature, there is strong genetic predisposition for bipolar disorders." Bipolar disorders have a strong genetic link. The risk for the development of bipolar disorder may be 5 to 10 times higher for persons who have a relative with this disorder compared to those who do not. Ms. Choi Behaves seductively towards Nurse Ben. Which of the following responses by Ben is appropriate? - correct answer "It is the expectation on this unit that there is no inappropriate physical contact. I need you to stop." The nurse is providing information about unit expectations and is giving clear instructions for the client to stop the inappropriate behavior. Nurse Ben is preparing to administer Olanzapine (Zyprexa) to Ms.Choi who is in the early phase of acute mania. Which of the following are expected outcomes of the medication (select all that apply) - correct answer Promote sedation, decrease agitation, and prevent mania relapse. A client who recieves olanzapine can experience sedation, decreased agitation and fewer mania relapses. Common side effects of olanzapine includes an increase of premenstrual syndrome symptoms and weight gain. Nurse Ben is preparing to administer olanzapine (Zyprexa) 10mg IM to Ms.Choi, who has acute mania. The nruse should reconstitute the medication with 2.1 mL of sterile water to yeild 5mg/ mL. How many mL should Ben administer? (round to the nearest whole number) - correct answer 2mL 10mg x 2mL / 5mg = 20 / 10 = 2mL Nurse Ben is attempting to administer the Olanzapine IM to susan, but she forcefully refuses it. Which of the following actions should Ben take? - correct answer Explain the benefits of the injection. The client has the right to refuse treatment because her admission to the mental health facility was voluntary. Therefore, explaining the benefit of an intramuscular injection can increase the understanding and facilitate adherence. Ben is leading a group therapy session and Susan interrupts the session. Which of the following actions should Ben take to manage Susan's disruptive behavior? - correct answer Ask the AP to assist the client out of the room. The client is experiencing a manic episode and has little ability to benefit from group therapy. Once the client is no longer in an acute state, she can participate in the group and recieve helpful peer support. The admission order indicates Susan is to have several laboratory tests drawn and to start therapy with lithium. Which of the following laboratory tests must be drawn prior to starting lithium therapy? (select all that apply) - correct answer T3, T4, TSH BUN and serum creatinine HCG Lithium can lead to hypothyroidism. Therefore, the nurse should check the client's baseline thyroid function (T3, T4 and TSH) Lithium can lead to kidney damage. Therefore, the nurse should check the client's baseline kidney function (BUN and serum creatinine). Lithium use is contraindicated in pregnancy. There, the client should have a pregnancy test prior to starting therapy (HCG). There is no indication to check the clients baseline blood glucose or albumin levels before intiating lithium therapy. Nurse Ben is preparing to instruct Susan and her family regarding lithium therapy. Which of the following instructions should Ben include in his teaching? (select all that apply) - correct answer Consume 2 to 3 L of fluid per day Maintain consistent sodium intake Take the medication with meals Client taking lithium should consume 2 to 3 L of fluid per day and maintain consistent sodium intake to prevent lithium toxicity. Sodium is reabsorbed through the kidney; lithium decreases sodium reabsoption causing hyponatremia. With low sodium levels, the client retains lithium, producing toxicity. Taking lithium with meals helps prevent gastrointestinal distress. Lithium does no cause orthostatic hypotention so it is not necessary to instruct the client to change positions slowly. Client taking MAOS should avoid foods high in tyramine to prevent hypertensive crisis. Nurse Ben and the nursing staff conduct a care planning conference to discuss nursing actions to promote susans recovery. Which of the following nursing actions should Ben implement? (select all that apply) - correct answer - Use a firm, calm, matter of fact approach - Offer frequent, high- calorie drinks - decrease noise, lights, and interactions - use distraction to redirect the clients energy using a firm, calm, matter of fact approach can provide structure and offer security to a client who is feeling out of control. offering high-calorie drinks can compensate for increased caloric expenditures during hyperactivity and prevent serious dehydration. decreasing of light, noise, and interactions can minimize anxiety and agitation. using distraction to redirect the client to constructive behaviors makes positive use of the client's distractibility. use of open-ended statements does not provide structure or direction for a client experiencing a manic episode. encouraging competitive activities can increase excitability and evoke angry outbursts Nurse Ben develops an intital meal plan for Susan and is preparing to discuss the plan with Susan and her mother. Which of the following menus represents an appropriate diet for Susan (Select the appropriate image) - correct answer Peanut butter jelly sandwhich, chips, bannana and strawberry milkshake in a plast cup with straw. a client who is experiencing a manic episode is hyperactive and typically unable to sit for meals. This meal is appropriate for a client experiencing a manic episode because it offers "Finger foods" which the client can eat while moving around, the non-caffeinated beverage is appropriate. The meal also offers high-protein, high calorie foods with no utensils. Nurse Ben is planning care for Susan and is reviewing signs and symptoms of lithium toxicity. Which of the follwong findings should the nurse monitor - correct answer Ataxia The nurse should monitor for ataxia, blurred vision and oliguria which are signs of severe lithium tocxicity- lithium should be between 2.0 and 2.5 mQg/L Ben reviews Susans assessment data. Which of the following assessment tools should he use to identify suicide risk factors and the need for hospitalization> - correct answer SAFE-T nurses should use the SAFE-T assessment tool to identify suicide risk factors and protective factors. the nurse also conducts a suicide inquiry and assesses the risk level and need for intervention. Nurse Ben is reviewing the adverse effects of lamotrigine (Lamictal). Which of the following is a serious adverse effect of this medication? - correct answer Stevens-Johnsons Syndrome immediately report rashes because it is a life-threatening syndrome Nurse Ben responds to Susans despondent behavior. Which of the following is an appropriate response by Ben? - correct answer "Do you have a plan for how you would end your life?" When the client shares suicidal thoughts, the nurse shoudl ask if there is a specific plan and then determine the lethality of the method and whether or not the client has access to the desired method. Nurse Ben is planning discharge outcomes for susan. Identify client outcomes for susan in the following areas..: - correct answer 1. review education material about bipolar disorder and its management 2. Maintain consisten patterns in sleep, meals and activities. 3. Idenfity strategies for enhancing communication and problem-solving skills. 4. recognize support systems at home (family and friends) 5. carry names and contact information for local bipolar support groups, such as the national alliance for the mentally ill