Margaret, a 68-year-old widow, is brought to the emergency department by her sister-in-law. Margaret has a history of bipolar disorder and has been maintained on medication for many years. Her sister-in-law reports that Margaret quit taking her medication a few months ago, thinking she did not need it anymore. She is agitated, pacing, demanding, and speaking very loudly. Her sister-in-law reports that Margaret eats very little, is losing weight, and almost never sleeps. “I am afraid she is going to just collapse!” Margaret is admitted to the psychiatric unit. The priority nursing diagnosis for Margaret is:

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.

Acute mania in bipolar disorder can present with extreme agitation, impulsivity, and poor judgment, often escalating to aggressive or dangerous behavior. When admitting a client with recent violent involvement, the priority is to assess current mental status, including mood, behavior, and risk factors such as psychosis, suicidality, or homicidality. This guides immediate safety planning, medication needs, and level of observation. Physical injuries are secondary to psychiatric stabilization in this context, especially when the client is medically cleared.

Rationale for correct answer

4. Determining the client’s current mood and behavioral presentation is essential for psychiatric triage. It informs risk assessment, safety measures, and initial treatment planning, especially in the context of recent violence and bipolar history.

Rationale for incorrect answers

1. While transfer timing is operationally relevant, it does not address clinical urgency. Psychiatric units must first prepare for the client’s behavioral presentation and safety needs.

2. Police presence may be necessary depending on legal status, but asking this first overlooks clinical priorities. Risk assessment should precede logistical or custodial concerns.

3. The client’s physical injuries are minor and medically cleared, making psychiatric admission appropriate. Questioning trauma unit placement diverts focus from psychiatric stabilization.

Take Home Points

• Psychiatric triage prioritizes mental status and behavioral risk over logistical or custodial details.
• Acute mania may involve aggression, requiring immediate assessment of mood and safety risk.
• Physical injuries are managed medically before psychiatric admission; they do not override psychiatric needs.
• Understanding current behavior guides observation level, medication initiation, and staff safety planning.