A client diagnosed with bipolar I disorder and experiencing a manic episode is newly admitted to the in-patient psychiatric unit. Which nursing diagnosis is a priority at this time?
Risk for violence: other-directed related to poor impulse control.
Altered thought process related to hallucinations.
Social isolation related to manic excitement.
Low self-esteem related to guilt about promiscuity.
The Correct Answer is A
Bipolar I disorder is a chronic psychiatric condition marked by alternating episodes of mania and depression. During manic phases, clients exhibit elevated mood, hyperactivity, grandiosity, and poor impulse control. These episodes often impair judgment and increase risk-taking behaviors, including aggression, self-harm, and harm to others. The manic state may also include psychotic features such as hallucinations or delusions, but the most immediate concern is safety—especially when disinhibition and impulsivity escalate to violent behavior.
Rationale for correct answer
1. During acute mania, impulsivity and poor judgment heighten the risk of aggressive outbursts toward others. The client may misinterpret interactions or act on grandiose beliefs, making violence a priority concern for nursing safety interventions.
Rationale for incorrect answers
2. Although hallucinations may occur in manic episodes, they are not the most immediate threat unless they directly provoke harmful behavior. The priority is safety, not perceptual disturbances.
3. Manic clients are typically hyper-social and intrusive, not withdrawn. Isolation is more characteristic of depressive phases, making this diagnosis less relevant during acute mania.
4. Feelings of guilt and low self-esteem are more prominent in depressive episodes. During mania, clients often display inflated self-worth and lack insight into inappropriate behaviors.
Take Home Points
- In acute mania, safety risks due to impulsivity and aggression take precedence over other psychosocial concerns.
- Bipolar I disorder includes manic episodes that may escalate to psychosis or violence, requiring close monitoring.
- Differentiating manic symptoms from depressive or psychotic features is essential for accurate nursing diagnosis.
- Nursing priorities shift with phase of illness—mania demands safety-focused interventions, while depression may focus on mood and cognition.
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Correct Answer is B
Explanation
Aripiprazole is a second-generation antipsychotic used in the management of acute mania in bipolar I disorder. It acts as a partial agonist at dopamine D2 and serotonin 5-HT1A receptors, and antagonist at 5-HT2A receptors. Its pharmacologic profile allows it to stabilize mood and reduce excitability without excessive sedation. When administered intramuscularly in acute settings, it rapidly targets agitation and hyperactivity, making it suitable for de-escalation. Unlike sedatives, its goal is behavioral control rather than sedation, and it does not immediately equalize mood swings.
Rationale for correct answer
2. Aripiprazole’s primary effect in acute mania is reducing excitability and agitation. Its dopaminergic modulation calms hyperactive behavior without causing oversedation, allowing for safer interaction and stabilization.
Rationale for incorrect answers
1. Sedation is not the therapeutic goal of aripiprazole. While some calming may occur, excessive sedation suggests overmedication or use of a different pharmacologic class like benzodiazepines.
3. Although aripiprazole can reduce psychotic symptoms over time, its immediate IM use in acute mania targets agitation and excitability first. Psychotic symptom relief is not the primary indicator of short-term effectiveness.
4. Mood stabilization is a long-term goal in bipolar management. Acute IM administration does not equalize mood swings immediately; it primarily addresses behavioral dysregulation.
Take Home Points
- Aripiprazole IM is used for rapid control of agitation and excitability in acute manic episodes.
- Sedation is not the intended outcome; behavioral calming without oversedation is preferred.
- Psychotic symptom relief and mood stabilization are longer-term therapeutic goals.
- In acute psychiatric emergencies, medication effectiveness is judged by reduction in dangerous or disruptive behaviors.
Correct Answer is D
Explanation
Disturbed thought process in bipolar I disorder is often linked to biochemical alterations affecting neurotransmitter systems such as dopamine, serotonin, and norepinephrine. During manic episodes, clients may experience delusions, flight of ideas, and impaired reality testing. These cognitive disruptions stem from neurochemical dysregulation and can be severe enough to interfere with judgment, perception, and social functioning. Treatment aims to restore neurochemical balance and improve insight, making reality orientation a central therapeutic goal.
Rationale for correct answer
4. The ability to distinguish reality from delusions directly addresses the disturbed thought process. It reflects improvement in cognitive clarity and insight, aligning with the biochemical basis of the diagnosis and expected therapeutic outcomes.
Rationale for incorrect answers
1. Preventing injury is a safety goal, not a cognitive one. While important, it does not specifically target the disturbed thought process or reflect progress in reality testing.
2. Appropriate interaction is a behavioral goal that may improve with cognitive clarity, but it does not directly measure resolution of delusional thinking or thought disturbance.
3. Medication compliance supports treatment but is a behavioral outcome. It does not confirm cognitive improvement or resolution of disturbed thought processes.
Take Home Points
- Disturbed thought process in bipolar I disorder involves impaired reality testing and delusional thinking.
- Neurochemical dysregulation underlies cognitive symptoms and guides pharmacologic intervention.
- Outcomes should reflect cognitive improvement, such as distinguishing reality from delusions.
- Behavioral goals like safety and compliance are supportive but not primary indicators of thought process resolution.
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