Wednesday, January 13, 2021

Chapter 16: Antimanic Drugs

1. Maintenance of a therapeutic serum level of lithium is dependent on adequate serum levels of
a. sodium
b. chloride
c. potassium
d. magnesium
ANS:
It is believed that lithium substitutes for the sodium (Na) ion in neurons. Reductions or increases
in Na intake affect the serum lithium level. The other options have not been identi ed as critical
to lithium level

2. Select the accurate information about the pharmacokinetics of lithium

a. Wide therapeutic inde
b. Excreted by the kidney
c. Poorly absorbed in the gastrointestinal (GI) trac
d. Provides immediate relief of symptom
ANS:
Lithium is excreted via the kidneys. The other options are incorrect. The nursing implication is
that individuals with renal damage should not be given lithium or should be monitored closely if
lithium must be administered

3. For 2 weeks a patient has taken lithium (Lithane) and risperidone (Risperdal) daily for mania.
The patient now reports diarrhea, vomiting, and blurred vision. The nurse observes a coarse hand
tremor. Select the nurse's priority action.
a. Administer a PRN dose of benztropine (Cogentin) to relieve extrapyramidal symptoms
(EPSEs)
b. Hold the next dose of risperidone to prevent further drug-drug interaction
c. Reassure the patient that these side effects will decrease with time
d. Notify the prescribing physician immediately
ANS:
The symptoms the patient is experiencing are consistent with a serum lithium level above the
therapeutic level. The nurse should withhold the next dose, arrange for a stat serum lithium level
determination, and notify the health care provider. Risperidone can be continued because this is
not a drug-drug interaction problem. Administration of benztropine is inappropriate because
these are not EPSE symptoms. Reassurance would be appropriate, but the patient should not be
told that these symptoms will decrease with time and continued dosing

4. A patient has taken lithium (Lithobid) 300 mg three times daily for 1 week. The patient reports
the presence of ne hand tremors and thirst. Select the nurse's best action
a. Increase sodium in the patient's diet
b. Immediately obtain a serum lithium level determination
c. Comfort the patient that these effects will probably decrease over time
d. Withhold the lithium until the patient no longer exhibits these side effects

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ANS:
These side effects are common and often decrease or disappear over time with continued lithium
therapy. Dietary sodium should remain unchanged to keep the lithium level stable. These side
effects do not suggest the need for determination of a lithium level. Lithium should not be
withheld, because these are not toxic symptoms

5. A patient who has taken lithium for 6 months reports, "I go to the bathroom many times a day
and pass large amounts of very pale urine." The nurse's action should be based on the
understanding that these symptoms may indicate which problem
a. Atactic toxicit
b. Uremic syndrom
c. Diabetes insipidu
d. Interstitial nephriti
ANS:
Symptoms of diabetes insipidus include voiding large amounts of dilute urine many times a day.
Nephrogenic diabetes insipidus is caused by the inhibition of the cyclic adenosine
monophosphate (cAMP)-dependent action of the antidiuretic hormone on the distal-tubule
collecting duct cells. This problem is sometimes associated with lithium therapy. The symptoms
detailed are not consistent with any of the other options

6. Which patient should be assessed most carefully for evidence of lithium toxicity? A patient
taking lithium (Lithobid) and
a. indomethacin (Indocin)
b. risperidone (Risperdal)
c. ziprasidone (Geodon)
d. olanzapine (Zyprexa)
ANS:
The combination of lithium and indomethacin is more likely to produce lithium toxicity than
lithium and any other drug listed. Nonsteroidal antiin ammatory drugs reduce renal elimination
of lithium, thereby increasing serum lithium levels

7. A patient with rapid-cycling bipolar disorder is not responding to lithium therapy. At the next
multidisciplinary team meeting, the nurse should point out that many rapid-cycling patients have
been effectively treated using
a. sertraline (Zoloft)
b. phenytoin (Dilantin)
c. benztropine (Cogentin)
d. divalproex (Depakote)
ANS:
Valproates (like divalproex) are considered rst-line agents in the treatment of mania. Valproates
are especially effective in the treatment of rapid-cycling bipolar disorders. None of the other
drugs mentioned are indicated for treatment of manic states

8. A patient diagnosed with mania begins lithium therapy on October 1. What is the earliest date
a nurse can expect to see clinical improvement in the patient's condition

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a. October
b. October
c. October 2
d. November
ANS:
Lithium must be given for 7 to 10 days before clinical improvement is achieved

9. A patient diagnosed with bipolar disorder asks the nurse, "Why can't I take my lithium just
once a day at bedtime? It's hard to remember to take it three times." The nurse's reply should be
based on what information
a. The half-life of lithium is short
b. Renal excretion is greater at night
c. GI absorption is diminished at night
d. The toxicity potential increases with once-a-day dosing
ANS:
Lithium has a short half-life, high toxicity, and rapid renal excretion, so multiple daily doses are
required. The other statements are incorrect or are not factors considered in dosing

10. A patient has taken lithium (Lithane) 600 mg three times daily for 1 week. A laboratory result
in which range shows that the desired serum lithium level was achieved
a. 0.2 to 0.6 mEq/
b. 0.6 to 1.2 mEq/
c. 1.2 to 2 mEq/
d. 2 to 2.6 mEq/
ANS:
Therapeutic serum lithium levels are 0.6 to 1.2 mEq/L. The other options are either too low or
too high. Serum levels above 1.5 mEq/L can cause symptoms of toxicity

11. The nurse scheduling the serum lithium level blood draw for a patient should arrange for it to
be obtained
a. before the rst morning dose
b. 2 hours after the morning dose
c. at bedtime
d. any time during the day
ANS:
Lithium levels should be drawn 8 to 12 hours after the last dose, making premedication morning
blood draws optimal

12. A patient's serum lithium level is 1.8 mEq/L. Select the nurse's priority action
a. Restrict uid intake
b. Assess for signs of toxicity
c. Encourage intake of high-potassium foods
d. Ensure that the patient is swallowing the capsules
ANS:

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A serum level of 1.8 mEq/L is higher than desirable. It suggests that the patient might be
experiencing toxic effects. Clinical assessment should be conducted. A nurse should not rely
entirely on laboratory tests but should make careful clinical assessments. None of the other
options would be appropriate

13. A patient has mild lithium toxicity with a serum level of 1.6 mEq/L. Which assessment
ndings are most likely
a. Coarse hand tremor, coordination problems, and dizzines
b. Elevated white blood cell count, temperature, and blood pressur
c. Orthostatic hypotension, fainting, and nystagmu
d. Restlessness, shuf ing gait, and tic
ANS:
The symptoms of mild toxicity are often related to central nervous system disturbance. Dif culty
concentrating might also be noted. Mild GI disturbances are also seen. The other options are not
symptoms of early lithium toxicity

14. Before beginning lithium therapy, the nurse should educate a patient about laboratory tests to
assess for adequate function of which system
a. Peripheral vascula
b. Reproductiv
c. Respirator
d. Rena
ANS:
Because lithium is excreted via the kidneys, renal system function must be adequate if lithium
toxicity is to be prevented. Functioning of the other systems has no direct relationship to lithium
therapy

15. A patient who is to be discharged on a maintenance dose of lithium should be taught to report
which symptoms/signs immediately
a. Large amounts of dilute urine and blurred visio
b. Nasal congestion and dry mout
c. Muscle stiffness and anorexi
d. Drowsiness and sweatin
ANS:
Patients must be taught the difference between symptoms of minor toxicity and those of major
toxicity, such as giddiness, tinnitus, blurred vision, dilute urine, and ataxia

16. Teaching for a patient who is to be discharged on a maintenance dose of lithium should
emphasize the importance of
a. keeping appointments for serum lithium level testing
b. engaging in daily cardiotonic exercise
c. reporting anticholinergic side effects
d. maintaining a tyramine-free diet

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ANS:
Regular evaluation of serum lithium levels will be part of the patient's aftercare for as long as he
or she takes lithium. The other items are not included in discharge teaching for a patient taking
lithium

17. The spouse of a patient diagnosed with bipolar disorder tells the nurse, "Every time my
partner recovers from a manic episode, depression follows soon. It's very discouraging." The
nurse's reply should include what information
a. As the partner ages, rapid cycling will decrease
b. Combining lithium with haloperidol (Haldol) might prevent rapid cycling
c. Depression associated with bipolar disorder is usually time-limited, so treatment is not
indicated
d. Recent addition of olanzapine (Zyprexa) to this patient's drug regime can be helpful as a mood
stabilizer
ANS:
Olanzapine, an atypical antipsychotic, has proven effective in controlling mania and acting as a
mood stabilizer to reduce depression following treatment for acute mania. The other statements
are incorrect or irrelevant

18. For patients with bipolar disorder, valproate anticonvulsants are likely to help control rapid-
cycling episodes by
a. inhibition of kindling activity in the brain
b. decreasing availability of norepinephrine
c. increasing dopamine levels at synapses
d. decreasing GABA metabolism
ANS:
The effectiveness of valproate anticonvulsants for management of bipolar disorder may be
related to inhibition of kindling activity, which stabilizes neuronal activity and increases the
threshold of stimulation necessary for cell ring. There is no current research to support any of
the other options

19. A patient with a long history of multiple sclerosis developed psychosis with acute mania. The
nurse should anticipate that the health care provider will probably prescribe which medication to
help stabilize the mania
a. Lithium (Lithobid
b. Amitriptyline (Elavil
c. Divalproex (Depakote
d. Diphenhydramine (Benadryl
ANS:
The valproates are rst-line drugs for treatment of manic episodes associated with bipolar
disorder or resulting from general medical problems. They have a rapid onset and are well
tolerated. Lithium takes 7 to 10 days to modify symptoms. Diphenhydramine and amitriptyline
have sedative side effects but would not stabilize the mania

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20. Which patient would require careful assessment for toxic effects of lithium? The individual
taking lithium and
a. hydrochlorothiazide (HCTZ)
b. lorazepam (Ativan)
c. clozapine (Clozaril)
d. oxazepam (Serax)
ANS:
Hydrochlorothiazide is a diuretic used to treat hypertension. The diuretic effect would increase
serum concentrations of lithium, potentially producing toxicity. Benzodiazepine and
antipsychotic drugs are commonly used concurrently with lithium to control mania

21. A nurse should schedule a weekly complete blood cell count (CBC) for a patient beginning
therapy with which antimanic drug
a. Lithiu
b. Valproate (Depakote
c. Quetiapine (Seroquel
d. Carbamazepine (Tegretol
ANS:
Agranulocytosis is known to be an occasional but potentially dangerous adverse effect of
carbamazepine therapy, hence the need for regular CBCs. The other drugs have a lower risk of
causing this effect

1. Which assessment ndings validate that a patient with bipolar disorder is experiencing mania?
Select all that apply
a. Pacin
b. Agitatio
c. Drowsines
d. Delusional thought
e. Psychomotor retardatio
ANS: A, B,
Agitation, increased motor activity (pacing), and delusional thoughts may all accompany mania.
The patient with mania would have an increased level of alertness rather than drowsiness.
Psychomotor retardation would be expected with depression

2. A nurse prepares to lead a psychoeducational group for patients who take anticonvulsants to
manage bipolar disorder. The nurse should invite patients who take which drugs? Select all that
apply
a. Lithiu
b. Aripiprazole (Abilify
c. Lamotrigine (Lamictal
d. Gabapentin (Neurontin
e. Carbamazepine (Tegretol
ANS: C, D,

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Lamotrigine, carbamazepine, and gabapentin are anticonvulsants. Lithium is effective in
treatment of bipolar disorder, but it is not an anticonvulsant. Aripiprazole is an antipsychotic
medication

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