A patient with bipolar disorder who wants to minimize the need for drug therapy asks the nurse what else can be done to treat the disorder. The nurse will recommend which measure? (Select all that apply)

Long-term therapy with Lithium for bipolar disorder is associated with several endocrine side effects, particularly thyroid dysfunction. Lithium can interfere with thyroid hormone synthesis and release, leading to goiter formation and hypothyroidism. When hypothyroidism develops, treatment focuses on replacing deficient thyroid hormones while continuing mood stabilization if possible. Management aims to correct metabolic imbalance without abruptly discontinuing psychiatric therapy.

Rationale:
A. Administration of Levothyroxine is the appropriate treatment for lithium-induced hypothyroidism. It replaces deficient thyroid hormone levels, helping restore normal metabolism and reduce symptoms such as fatigue, weight gain, and cold intolerance. This allows continuation of lithium therapy while correcting the endocrine imbalance.

B. Iodine supplements are not indicated because lithium-induced hypothyroidism is not caused by iodine deficiency. Providing iodine would not correct impaired thyroid hormone synthesis caused by lithium’s direct effect on thyroid function. In some cases, excess iodine may even worsen thyroid dysfunction.

C. Increasing the lithium level is contraindicated because higher lithium concentrations would further impair thyroid function. Lithium toxicity can exacerbate endocrine and systemic side effects, including worsening hypothyroidism and potential renal impairment. The goal is to manage side effects, not intensify drug exposure.

D. Referral to an endocrinologist may be appropriate for specialized evaluation, but it is not the primary immediate intervention expected in response to hypothyroidism. The priority treatment is hormone replacement therapy. Specialist referral may occur concurrently but does not replace the need for levothyroxine initiation.

Clozapine is an atypical antipsychotic reserved for treatment-resistant schizophrenia and for patients with persistent suicidal behavior. It is highly effective but carries a serious risk of agranulocytosis, requiring strict hematologic monitoring. Regular assessment of white blood cell (WBC) count and absolute neutrophil count (ANC) is essential to detect bone marrow suppression early. Patient and family education focuses on monitoring schedules and recognizing signs of infection.

Rationale:
A. An ANC below 1000/mcL (moderate neutropenia) requires the medication to be interrupted, but it does not mandate permanentdiscontinuation. Usually, the drug is held and the patient is monitored daily. Once the ANC rises above 1000/mcL, the patient can often be "rechallenged" or restarted on the drug with increased monitoring. Permanent discontinuation is typically only required for "generalized agranulocytosis" (ANC < 500/mcL) or if a patient fails a rechallenge.

B. Blood counts must continue to be monitored for several weeks after discontinuation because neutropenia or agranulocytosis can persist or develop even after the medication is stopped. Ongoing surveillance ensures early detection of delayed complications. This reflects accurate understanding of post-discontinuation care.

C. Weekly blood work is required during the initial phase of clozapine therapy to closely monitor for early signs of neutropenia. Although frequency may later decrease, early intensive monitoring is essential for safety. This statement demonstrates appropriate knowledge of the monitoring protocol.

D. Fever, sore throat, and oral ulcers are key early signs of infection related to neutropenia. Immediate reporting is critical because reduced neutrophil levels impair the body’s ability to fight infections. Recognizing these symptoms supports timely intervention and reflects correct understanding.