A client is admitted to the behavioral health unit and diagnosed with bipolar I disorder and has acute mania. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication?

• A. valproic acid

• B. haloperidol

• C. bupropion

• D. fluoxetine

Answer explanation

Choice A is correct. The gold standard for treating bipolar disorder is mood stabilizers. Valproic acid (VPA) is a mood stabilizer and is efficacious in treating mania because it has a fast onset. This medication can be given by mouth or intravenously. When a client receives valproic acid, the nurse must monitor the client's liver function tests to determine if the client is experiencing the adverse effect of hepatotoxicity.

Choice B is incorrect. Haloperidol is a first-generation (typical) antipsychotic. Haloperidol is efficacious in treating psychotic disorders such as schizophrenia - not bipolar disorder. Bipolar disorder is a mood disorder, not a psychotic disorder. Antipsychotics may be used in the treatment of bipolar disorder, but this would be second-generation antipsychotics such as aripiprazole, risperidone, or quetiapine. This is because second-generation antipsychotics may have mood-stabilizing properties.

Choice C is incorrect. Bupropion is an atypical antidepressant. This antidepressant is helpful in giving the client energy because of its modulation of dopamine. This would be detrimental to a client with bipolar disorder because it could induce mania.

Choice D is incorrect. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) and is indicated in treating anxiety and major depressive disorder. This has no utility in bipolar disorder. It could even destabilize the mood and induce mania.

The client taking lithium for bipolar disorder is experiencing vomiting, diarrhea, and blurred vision and their lithium level is 2.5 mEq/L (mmol/L) [0.6 – 1.2 mEq/L, mmol/L]. The nurse suspects which finding is occurring?

• A. Lithium toxicity

• B. An allergic reaction to the medication

• C. A normal reaction to lithium

• D. This lithium level is too low

Answer explanation

Choice A is correct. The average lithium level is 0.6 mEq to 1.2 mEq/L (mmol/L). Any level over 1.5 mEq/L (mmol/L) indicates a toxic serum lithium level. Vomiting, diarrhea, blurred vision, abdominal pain, tremors, and tinnitus are symptoms of lithium toxicity.

Choice B is incorrect. These symptoms do not describe an allergic reaction to lithium.

Choice C is incorrect. Vomiting, diarrhea, and blurred vision are not normal findings in a client taking lithium.

Choice D is incorrect. Evidence suggests that the lithium level is too high, at 2.5 mEq/L (mmol/L), not too low.

The nurse is caring for a client prescribed lithium. Which laboratory tests would be necessary for the nurse to monitor? Select all that apply. 

• A. Troponin

• B. Creatinine

• C.Thyroid-stimulating hormone

• D.Sodium

• E. Potassium

Answer explanation

Choices B, C, and D are correct. Essential labs to monitor while a client takes lithium include the lithium level, thyroid panel (lithium may cause hypothyroidism), creatinine (risk of nephrotoxicity), and sodium (hyponatremia may precipitate lithium toxicity).

Choice A is incorrect. Troponin is a cardiac marker and not relevant to lithium therapy. Potassium levels would not influence lithium the way sodium does. Thus, sodium is the essential electrolyte to monitor.

The nurse is precepting a graduate nurse (GN) who is caring for a client newly prescribed lithium for the treatment of bipolar disorder. What action by the GN indicates a need for further teaching?

• 1. Advises the client to drink 2-3 liters of fluids each day

• 2. Instructs the client to limit intake of soda, tea, and coffee

• 3. Shows the client how to carefully check food labels to follow a low-sodium diet

• 4. Teaches the client that it may take at least one week for mania to subside

Answer explanation

Lithium is a mood stabilizer used to treat bipolar disorder, schizoaffective disorder, and suicidal thinking. Lithium has a narrow therapeutic index (0.8-1.2 mE/L [0.8-1.2mmol/L]) and even a slight increase in lithium levels can result in toxicity. Clients will need to have their lithium levels consistently monitored, especially when beginning treatment.

Sodium levels in the blood affect the ability of the kidneys to excrete lithium. If sodium intake is limited or the body is depleted of its normal sodium levels (eg, excessive perspiration, vomiting, diarrhea), lithium is reabsorbed by the kidneys, increasing the possibility of toxicity. Therefore, clients prescribed lithium must consume adequate (ie, neither more nor less) dietary sodium (Option 3).

(Option 1) Clients prescriber lithium should drink 2-3 liters of fluids each day to maintain normal sodium levels.

(Option 2) Excessive intake of caffeinated beverages (eg, coffee, tea, soda) increases urinary output and can alter lithium levels.

(Option 4) It can take at least one week for manic effects to subside and at least 2-3 weeks for the full therapeutic effects of the medication to be seen.

The nurse is reinforcing discharge instructions for a client who is prescribed lithium for management of bipolar disorder. Which of the following instructions are appropriate?

Select all that apply.

• 1. "Drink at least 8 cups (2 L) of fluid throughout the day."

• 2. "Eat a low-sodium diet as recommended."

• 3. "Expect routine blood tests while starting this medication."

• 4. "Report diarrhea to the health care provider."

• 5. "Take ibuprofen as needed for mild pain relief."

Answer explanation

Lithium is a mood stabilizer used to manage bipolar disorder and reduce suicidal thinking and behaviors. It has a narrow therapeutic index, which increases the risk for toxicity.

Sodium and lithium have an identical ionic charge. When serum sodium levels are low, the kidneys reabsorb both sodium and lithium to reestablish electrolyte balance, which can precipitate life-threatening lithium toxicity.

Client teaching to prevent lithium toxicity should include:

• Preventing dehydration by reporting diarrhea to the health care provider and drinking at least 8-12 cups (2-3 L) of fluid throughout the day. Lithium increases urine output (ie polyuria), and dehydration causes lithium to accumulate in the body (Options 1 and 4).

• Receiving routine blood tests to ensure that lithium levels are within the therapeutic range (0.8-1.2 mEq/L [0.8-1.2 mol/L]). In addition, kidney and thyroid function should be routinely monitored because lithium can cause renal impairment and hypothyroidism (Option 3).

(Option 2) A low-sodium diet can increase lithium retention, resulting in toxicity.

(Option 5) NSAIDs (eg, ibuprofen, naproxen) increase renal reabsorption of lithium and should be avoided