A client diagnosed with bipolar disorder is in an acute manic state. The nursing staff is unable to verbally de-escalate the situation, and a physician orders a stat dose of aripiprazole (Abilify®) intramuscularly. Which client behavior indicates that the medication has been effective?

Milieu management in bipolar I disorder, particularly during manic episodes, focuses on maintaining safety, reducing stimulation, and promoting structured engagement. Clients in mania often display disinhibited behavior, excessive socialization, and poor boundaries. Provocative dress and loud laughter may reflect elevated mood and impaired judgment. The priority is to redirect the group to minimize reinforcement of inappropriate behavior and prevent escalation. Structured activities help channel energy and support behavioral containment without confrontation or pharmacologic intervention.

Rationale for correct answer

2. Redirecting to structured activities reduces environmental stimulation and reinforces appropriate social behavior. It protects the therapeutic milieu and helps manage manic symptoms through non-pharmacologic means.

Rationale for incorrect answers

1. Joining the milieu may increase attention to the behavior and inadvertently reinforce it. It does not address the need for behavioral redirection or environmental control.

3. Discussing dress privately may be appropriate later, but it does not address the immediate behavioral disruption. Priority lies in managing group dynamics and preventing escalation.

4. Administering PRN medication without first attempting behavioral interventions bypasses least-restrictive strategies. Medication is reserved for when redirection fails or risk escalates.

Take Home Points

• Structured activities are effective in managing manic behavior and preserving milieu safety.
• Behavioral redirection should precede medication in managing disinhibition and hyperactivity.
• Confrontation or attention may reinforce manic behaviors and disrupt group dynamics.
• Milieu therapy emphasizes environmental control and therapeutic engagement over immediate pharmacologic intervention.

Manic episodes in bipolar I disorder are marked by elevated mood, hyperactivity, and reduced need for sleep, often leading to poor nutritional intake and weight loss. Clients may be too distracted or restless to sit for meals, and their impulsivity can interfere with structured routines. Nutritional strategies must accommodate their erratic behavior while ensuring caloric sufficiency. High-calorie, nutrient-dense finger foods are ideal because they can be consumed quickly and frequently, even during periods of excessive movement or agitation.

Rationale for correct answer

3. Providing finger foods allows Beldine to maintain her hyperactive behavior while still consuming calories. These foods are portable, easy to eat, and can be offered frequently, supporting nutritional intake without requiring her to sit still.

Rationale for incorrect answers

1. Sitting with Beldine may not be effective due to her restlessness. She may resist structured meal times or leave the table prematurely, making this approach impractical during a manic phase.

2. While familiar foods may be comforting, relying on a family member to bring meals does not address the need for accessibility and caloric density. It also lacks consistency and clinical oversight.

4. Room restriction is punitive and may escalate agitation or noncompliance. It does not address the underlying issue of poor intake and may worsen behavioral symptoms during mania.

Take Home Points

• Clients in manic episodes often require flexible, high-calorie nutrition strategies due to hyperactivity and distractibility.
• Finger foods and snacks are more effective than structured meals for promoting intake during mania.
• Punitive measures like room restriction are contraindicated and may exacerbate agitation or noncompliance.
• Nutritional interventions should be tailored to behavioral presentation, especially in psychiatric conditions with fluctuating energy and attention.