Chapter 26. Bipolar and Related Disorders
Multiple Choice
1. A highly agitated client paces the unit and states, I could buy and sell this place. The
clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most
accurate documentation of this clients behavior?
A. Rates mood 8/10. Exhibiting looseness of association. Euphoric. B. Mood euthymic.
Exhibiting magical thinking. Restless.
C. Mood labile. Exhibiting delusions of reference. Hyperactive. D. Agitated and pacing.
Exhibiting grandiosity. Mood labile. ANS: D
The nurse should document that this clients behavior is Agitated and pacing.
Exhibiting grandiosity. Mood labile. The client is exhibiting signs of irritation
accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of
power, importance, knowledge, or identity.
KEY: Cognitive Level: Application | Integrated Processes: Communication and
Documentation | Client
Need: Safe and Effective Care Environment
2. A client diagnosed with bipolar I disorder is distraught over insomnia experienced
over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should
be this clients priority nursing diagnosis?
A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms
B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
C. Risk for suicide R/T powerlessness AEB insomnia and anorexia
,D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
ANS: B
The nurse should identify that the priority nursing diagnosis for this client is altered
nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the
clients rapid weight loss, the nurse should prioritize interventions to ensure proper
nutrition and health.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis |
Client Need:
Physiological Integrity
3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode.
In which order should the nurse prioritize the listed client outcomes?
Client Outcomes:
1. Maintains nutritional status.
2. Interacts appropriately with peers.
3. Remains free from injury.
4. Sleeps 6 to 8 hours a night.
A. 2, 1, 3, 4
B. 4, 1, 2, 3
, C. 3, 1, 4, 2
D. 1, 4, 2, 3
ANS: C
The nurse should order client outcomes based on priority in the following order:
Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and
interacts appropriately with peers. The nurse should prioritize the clients physical and
safety needs.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning |
Client Need: Safe and
Effective Care Environment: Management of Care
4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses
on sertraline (Zoloft). Family reports that the client has experienced anorexia,
insomnia, and recent job loss. What should be the priority nursing diagnosis for this
client?
A. Risk for suicide R/T hopelessness
B. Anxiety: severe R/T hyperactivity
C. Imbalanced nutrition: less than body requirements R/T refusal to eat
D. Dysfunctional grieving R/T loss of employment
ANS: A
Multiple Choice
1. A highly agitated client paces the unit and states, I could buy and sell this place. The
clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most
accurate documentation of this clients behavior?
A. Rates mood 8/10. Exhibiting looseness of association. Euphoric. B. Mood euthymic.
Exhibiting magical thinking. Restless.
C. Mood labile. Exhibiting delusions of reference. Hyperactive. D. Agitated and pacing.
Exhibiting grandiosity. Mood labile. ANS: D
The nurse should document that this clients behavior is Agitated and pacing.
Exhibiting grandiosity. Mood labile. The client is exhibiting signs of irritation
accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of
power, importance, knowledge, or identity.
KEY: Cognitive Level: Application | Integrated Processes: Communication and
Documentation | Client
Need: Safe and Effective Care Environment
2. A client diagnosed with bipolar I disorder is distraught over insomnia experienced
over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should
be this clients priority nursing diagnosis?
A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms
B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss
C. Risk for suicide R/T powerlessness AEB insomnia and anorexia
,D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
ANS: B
The nurse should identify that the priority nursing diagnosis for this client is altered
nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the
clients rapid weight loss, the nurse should prioritize interventions to ensure proper
nutrition and health.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis |
Client Need:
Physiological Integrity
3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode.
In which order should the nurse prioritize the listed client outcomes?
Client Outcomes:
1. Maintains nutritional status.
2. Interacts appropriately with peers.
3. Remains free from injury.
4. Sleeps 6 to 8 hours a night.
A. 2, 1, 3, 4
B. 4, 1, 2, 3
, C. 3, 1, 4, 2
D. 1, 4, 2, 3
ANS: C
The nurse should order client outcomes based on priority in the following order:
Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and
interacts appropriately with peers. The nurse should prioritize the clients physical and
safety needs.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Planning |
Client Need: Safe and
Effective Care Environment: Management of Care
4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses
on sertraline (Zoloft). Family reports that the client has experienced anorexia,
insomnia, and recent job loss. What should be the priority nursing diagnosis for this
client?
A. Risk for suicide R/T hopelessness
B. Anxiety: severe R/T hyperactivity
C. Imbalanced nutrition: less than body requirements R/T refusal to eat
D. Dysfunctional grieving R/T loss of employment
ANS: A
