A nurse is providing care to a 28-year-old client diagnosed with bipolar disorder who was admitted in a manic state.
According to Maslow's Hierarchy of Needs theory, the nurse should identify which client symptom as having priority?

Choice A rationale

Granting extra privileges solely based on voluntary admission status contradicts the principle of a therapeutic milieu, which aims for consistent and equitable application of rules and expectations for all patients. Differential treatment can disrupt the communal environment and foster feelings of inequality, potentially hindering the sense of safety and promoting resentment, thereby undermining the goal of promoting psychological healing and emotional security within the unit.

Choice B rationale

A therapeutic milieu is scientifically designed to create a safe, structured, and emotionally supportive environment, utilizing the entire setting—people, structure, and activities—as a treatment modality. This structure provides a predictable and consistent reality, reducing anxiety, fostering a sense of security, and promoting behavioral and emotional regulation, which are critical elements for psychological healing and the development of adaptive coping mechanisms in patients.

Choice C rationale

Rigidly enforcing rules and limits is necessary for a successful therapeutic milieu, as consistency provides a stable external structure that helps patients, especially those with impaired reality testing or impulse control, to feel safe and understand behavioral expectations. Flexibility can introduce ambiguity and instability, which may increase anxiety and undermine the predictability essential for establishing trust and promoting patient responsibility within the unit.

Choice D rationale

Frequent negative feedback is counterproductive to a therapeutic milieu, which emphasizes positive reinforcement and constructive guidance to promote growth and self-esteem. Constant criticism, even if intended to modify behavior, can lead to feelings of shame, defensiveness, and withdrawal, thereby damaging the therapeutic relationship and reducing the patient's willingness to engage in treatment and adopt more adaptive behaviors.

Choice A rationale

Anticholinergic medications primarily block acetylcholine receptors, commonly leading to side effects like dry mouth, blurred vision, constipation, and urinary retention. They do not typically cause hyperprolactinemia-related effects such as gynecomastia (male breast enlargement), amenorrhea (absence of menstruation), or galactorrhea (milky discharge).

Choice B rationale

First-generation (conventional) antipsychotics, like haloperidol, exert a potent Dopamine-2 receptor antagonism in the tuberoinfundibular pathway. This blockade lifts the dopaminergic inhibition on prolactin release from the anterior pituitary, resulting in hyperprolactinemia, which is the direct cause of gynecomastia, amenorrhea, and galactorrhea.

Choice C rationale

Second-generation (atypical) antipsychotics also block D2 receptors but often have a broader receptor profile. While some (like risperidone) can cause hyperprolactinemia, others are prolactin-sparing or cause it less frequently or severely than the first-generation agents.

Choice D rationale

Third-generation antipsychotics, such as aripiprazole, are often dopamine system stabilizers (partial agonists). They are less likely to cause significant D2 blockade and often have a lower risk of inducing hyperprolactinemia and the associated endocrine side effects compared to both first- and some second-generation agents.