A nurse is planning care for a client who is in the manic phase of bipolar disorder.

Which of the following interventions should the nurse include in the client's plan of care?.

Choice A rationale:

Insomnia is a common symptom of anxiety, but it is not typically seen in mild cases. It is more often associated with moderate to severe anxiety.

When anxiety is mild, individuals may experience difficulty falling asleep or staying asleep, but they are not typically unable to sleep at all.

Other sleep-related symptoms of mild anxiety may include restlessness, nightmares, or early morning awakening.

Choice B rationale:

Chest pain is a serious symptom that can be caused by a variety of medical conditions, including anxiety. However, it is not a common manifestation of mild anxiety.

Chest pain associated with anxiety is typically described as a sharp, stabbing pain or a feeling of tightness in the chest. It may be accompanied by other symptoms such as shortness of breath, palpitations, or sweating.

If a client with anxiety is experiencing chest pain, it is important to rule out other potential causes, such as heart disease or a pulmonary embolism.

Choice D rationale:

Incoherent speech is a sign of severe anxiety or a panic attack. It is not typically seen in mild anxiety.

When a person is experiencing incoherent speech, they may have difficulty speaking in complete sentences or making sense of their thoughts. They may also slur their words or speak in a rapid, disjointed manner.

Choice C rationale:

Irritability is a common manifestation of mild anxiety. It is often characterized by a feeling of being easily annoyed or angered.

Individuals with mild anxiety may also be more impatient, short-tempered, or argumentative than usual.

They may also have a lower tolerance for frustration and stress.

Choice A rationale:

Seizures are a potentially serious complication of alcohol withdrawal. They occur due to the sudden decrease in GABA (gamma-aminobutyric acid), a neurotransmitter that has inhibitory effects on the central nervous system. Chronic alcohol consumption leads to an upregulation of GABA receptors in the brain to compensate for the depressant effects of alcohol. When alcohol is abruptly withdrawn, the brain is left in a hyperexcitable state, as there is less GABA to suppress neuronal activity. This hyperexcitability can manifest as seizures.

Mechanism of seizures in alcohol withdrawal:

Neuroadaptation: Chronic alcohol exposure leads to adaptations in neuronal excitability to counteract the depressant effects of alcohol. These adaptations include:

Upregulation of GABA receptors: The brain increases the number of GABA receptors to enhance the inhibitory effects of GABA.

Downregulation of glutamate receptors: The brain decreases the number of glutamate receptors to reduce the excitatory effects of glutamate.

GABA rebound: When alcohol is abruptly withdrawn, the upregulated GABA receptors become hypersensitive, leading to an excessive inhibitory response. This is known as GABA rebound.

Glutamate rebound: Concurrently, the downregulated glutamate receptors become more sensitive, leading to an enhanced excitatory response. This is known as glutamate rebound.

Imbalance: The combination of GABA rebound (excessive inhibition) and glutamate rebound (excessive excitation) creates a state of neuronal hyperexcitability, which can trigger seizures.

Risk factors for seizures in alcohol withdrawal:

Severity of alcohol dependence: Individuals with a long history of heavy alcohol consumption are at higher risk.

Previous alcohol withdrawal seizures: A history of seizures during past withdrawal episodes increases the likelihood of recurrence.

Comorbid medical conditions: Certain medical conditions, such as electrolyte imbalances, head injuries, or infections, can increase the risk of seizures.

Concurrent medication use: Certain medications, such as benzodiazepines or barbiturates, can lower the seizure threshold.

Management of seizures in alcohol withdrawal:

Benzodiazepines: Benzodiazepines are the mainstay of treatment for alcohol withdrawal seizures. They enhance the effects of GABA, helping to suppress neuronal excitability and prevent seizures.

Anticonvulsants: In some cases, anticonvulsants, such as gabapentin or valproate, may be used in addition to benzodiazepines.

Electrolyte replacement: Electrolyte imbalances, such as hyponatremia or hypomagnesemia, can contribute to seizures and should be corrected.

Monitoring: Close monitoring of vital signs, neurological status, and seizure activity is essential to ensure prompt intervention if seizures occur.

Choice B rationale:

Nystagmus, or involuntary eye movements, is not a common symptom of alcohol withdrawal. While it can occur in some cases, it is not considered a primary feature of the syndrome.

Choice C rationale:

Tremors are a very common symptom of alcohol withdrawal. They are caused by the same underlying mechanism as seizures, namely, the hyperexcitability of the central nervous system due to decreased GABA activity. Tremors typically manifest as shaking hands, arms, or legs, and can range in severity from mild to severe.

Choice D rationale:

Hallucinations, both auditory and visual, can occur in alcohol withdrawal. They are thought to be due to a combination of factors, including the hyperexcitability of the central nervous system, disruptions in neurotransmitter systems, and sleep deprivation. Hallucinations can be very distressing and can lead to agitation, confusion, and disorientation.