A client diagnosed with bipolar I disorder in the manic phase is yelling at another peer in the milieu. Which nursing intervention takes priority?
Calmly redirect and remove the client from the milieu.
Administer prescribed PRN intramuscular injection for agitation.
Notify the client to lower voice.
Obtain an order for seclusion to help decrease external stimuli.
The Correct Answer is A
Bipolar I disorder in the manic phase presents with elevated mood, agitation, and impaired impulse control, often resulting in disruptive or aggressive behavior. Clients may exhibit poor judgment, pressured speech, and hyperactivity, which can escalate quickly in stimulating environments. Immediate nursing interventions must prioritize safety and de-escalation using the least restrictive measures first.
Rationale for correct answer
1. Calmly redirecting and removing the client from the milieu is the most appropriate initial response. It uses verbal de-escalation and environmental control to reduce stimulation and prevent escalation, aligning with least restrictive intervention principles.
Rationale for incorrect answers
2. Administering a PRN intramuscular injection is a chemical restraint, appropriate only after non-invasive methods fail. It is not the first-line intervention unless the client poses imminent danger.
3. Telling the client to lower their voice may provoke defensiveness or escalate agitation. It lacks therapeutic engagement and does not address the underlying behavioral dysregulation.
4. Seclusion is a restrictive intervention requiring justification and physician order. It is reserved for situations where the client poses a threat and other strategies have failed.
Take Home Points
- Manic episodes in bipolar I disorder often involve agitation, impulsivity, and poor judgment.
- Least restrictive interventions like verbal redirection and environmental modification are prioritized.
- Chemical and physical restraints are used only when safety is compromised and other methods fail.
- Effective nursing care requires rapid assessment and therapeutic communication to prevent escalation.
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Related Questions
Correct Answer is D
Explanation
Psychomotor agitation is a behavioral manifestation of mental tension and internal restlessness, often seen in mood disorders like bipolar I disorder. It involves excessive, purposeless motor activity such as pacing, rapid speech, and exaggerated gestures. These movements are not goal-directed but serve as an outlet for emotional dysregulation. In manic episodes, psychomotor agitation reflects heightened arousal and poor impulse control, and may escalate to aggression if not addressed. It differs from anxiety or anger by its physical intensity and lack of clear emotional focus.
Rationale for correct answer
4. The client’s pacing, loud rapid speech, and elaborate gestures are hallmark signs of psychomotor agitation. These behaviors reflect restlessness and internal tension, commonly seen in manic phases of bipolar disorder.
Rationale for incorrect answers
1. Aggression involves intent to harm or confront others. The client’s behavior lacks hostility or directed threat, making this an inaccurate interpretation.
2. Anger is an emotional state often accompanied by verbal or physical aggression. The client’s actions are more consistent with restlessness than emotional expression.
3. Anxiety may cause restlessness, but psychomotor agitation is more intense and physically expressive. The client’s symptoms exceed typical anxious behavior.
Take Home Points
- Psychomotor agitation involves purposeless, excessive motor activity driven by internal tension.
- It is commonly seen in manic episodes of bipolar disorder and requires early intervention to prevent escalation.
- Differentiating agitation from aggression or anxiety is critical for accurate nursing assessment.
- Behavioral signs like pacing, rapid speech, and exaggerated gestures are key indicators of psychomotor agitation.
Correct Answer is B
Explanation
Delusions are fixed, false beliefs that persist despite evidence to the contrary and are common in manic episodes of bipolar I disorder. These beliefs often reflect the client’s distorted interpretation of reality, driven by heightened dopaminergic activity and impaired insight. Among the various types, persecutory delusions involve the belief that one is being targeted, harmed, or conspired against. These are especially prevalent during manic states when grandiosity and paranoia co-occur, often escalating agitation and mistrust toward others.
Rationale for correct answer
2. Margaret’s belief that her sister-in-law is trying to make her “look insane” reflects a classic persecutory delusion. She perceives intentional harm or sabotage, which is a hallmark of paranoia in manic psychosis.
Rationale for incorrect answers
1. Delusions of grandeur involve inflated self-worth or identity, such as believing one is famous or has special powers. Margaret’s statement does not reflect exaggerated self-importance but rather suspicion of others.
3. Delusions of reference involve interpreting neutral events as having personal meaning, such as believing TV shows are sending messages. Margaret’s accusation is directed at a person, not an external event.
4. Delusions of control involve the belief that one’s thoughts or actions are being manipulated by external forces. Margaret’s statement does not suggest external control over her behavior or thoughts.
Take Home Points
- Persecutory delusions are common in manic episodes and involve beliefs of being targeted or harmed.
- Delusions of grandeur reflect inflated self-concept, not suspicion of others.
- Referential delusions misinterpret neutral events as personally significant.
- Delusions of control involve perceived manipulation of thoughts or actions by external forces.
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