Recognising the phases
Bipolar I disorder requires at least one manic episode lasting a week or requiring hospitalisation, with or without depressive episodes. Bipolar II involves hypomania — a shorter, less impairing elevation without psychosis — plus major depressive episodes. Cyclothymia describes chronic fluctuating symptoms that do not meet full criteria. The exam expects you to match the description in the stem to the phase before choosing an intervention.
Mania presents with elevated or irritable mood, grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increased goal-directed activity, and risky behaviour such as spending sprees, sexual indiscretion or reckless driving. Dress may be flamboyant and the client may be intrusive, demanding and manipulative on the unit. Psychosis, including grandiose delusions, can occur in severe mania.
Depressive episodes look like major depression: anhedonia, hopelessness, psychomotor slowing, sleep and appetite changes, guilt and suicidal thinking. The highest suicide risk is often as depression begins to lift and energy returns before mood improves, and during mixed episodes when agitation and despair coexist. Ask about suicidal ideation directly — asking never plants the idea.
Nursing priorities during acute mania
Physical safety comes first. A client in acute mania may not have slept or eaten for days and is genuinely at risk of exhaustion, dehydration, cardiovascular strain and injury. Nursing interventions target these needs directly: monitor intake, output and weight, provide fluids, and offer high-calorie, high-protein finger foods such as sandwiches, cheese, milkshakes and protein bars that can be consumed while pacing, since the client will not sit for a meal.
Reduce stimulation. A quiet, structured environment with a private or low-traffic room, dim lighting, limited visitors and a predictable routine reduces escalation. Channel energy into solitary, non-competitive physical outlets like walking rather than group games or competitive sports, which increase arousal and conflict.
Set limits calmly, consistently and as a team. Manic clients test boundaries and may split staff, so consistent expectations communicated in brief, simple statements are essential. Do not argue with or reinforce grandiose statements; acknowledge the feeling and redirect to reality-based activity. Protect the client from consequences of poor judgement where possible, including money, phone and social media access when safety warrants and policy allows.
- •Monitor sleep, hydration, nutrition and weight daily
- •High-calorie finger foods and fluids offered frequently
- •Low-stimulation environment; solitary physical outlets
- •Brief, firm, consistent limits from all staff
- •Redirect rather than debate grandiose or delusional content
- •Assess suicide risk in every phase, including mixed states
Lithium: the most tested medication
Lithium is a first-line mood stabiliser with a narrow therapeutic index. The maintenance range is 0.6 to 1.2 mEq/L, with acute mania treated at the upper end. Levels are drawn twelve hours after the last dose, typically in the morning before the first dose. Because it takes one to three weeks for full effect, an antipsychotic or benzodiazepine may be used short-term for acute agitation.
Toxicity is progressive and testable. Early signs above about 1.5 mEq/L include nausea, vomiting, diarrhoea, coarse hand tremor, drowsiness and muscle weakness. Above 2.0, expect ataxia, confusion, blurred vision, tinnitus and giddiness. Above 2.5, seizures, arrhythmias, coma and death can occur, and haemodialysis may be required. A client reporting persistent vomiting and diarrhoea on lithium is at risk of a rising level because of fluid loss, which makes the situation worse.
Teaching centres on sodium and water. Lithium is handled by the kidney like sodium, so dehydration, low-sodium diets, excessive sweating, vomiting and diarrhoea all raise the level, while a sudden increase in sodium intake lowers it. Clients maintain consistent salt intake, drink two to three litres daily, use caution in heat and with strenuous exercise, and avoid NSAIDs, thiazide diuretics and ACE inhibitors unless the prescriber has adjusted monitoring. Baseline and periodic renal and thyroid function tests are required because lithium can cause hypothyroidism and renal impairment. Lithium is teratogenic, notably cardiac defects, so pregnancy planning is discussed.
| Level (mEq/L) | Meaning | Nursing action |
|---|---|---|
| 0.6–1.2 | Therapeutic maintenance | Continue; routine monitoring and teaching |
| 1.5–2.0 | Early toxicity | Hold dose, notify prescriber, assess hydration and sodium |
| 2.0–2.5 | Moderate toxicity | Hold, urgent evaluation, IV fluids, cardiac monitoring |
| Above 2.5 | Severe toxicity | Emergency; prepare for possible haemodialysis |
Other mood stabilisers and antipsychotics
Valproic acid and divalproex require monitoring of liver function and platelets, with a therapeutic range around 50 to 125 micrograms per millilitre. Clients report abdominal pain, jaundice, unusual bruising or bleeding. It is highly teratogenic, causing neural tube defects, so contraception counselling is essential in clients of childbearing potential.
Carbamazepine carries risk of agranulocytosis and aplastic anaemia, so complete blood counts are monitored and sore throat, fever or infection is reported immediately. It also causes hyponatraemia and many drug interactions through hepatic enzyme induction, including reduced oral contraceptive effectiveness. Lamotrigine is effective for bipolar depression and demands slow dose titration because of the risk of Stevens-Johnson syndrome — any rash is reported at once and the drug typically stopped.
Second-generation antipsychotics such as quetiapine, olanzapine, risperidone and aripiprazole are used for acute mania and maintenance. Monitor for metabolic syndrome with weight, glucose and lipid checks, sedation, orthostatic hypotension and extrapyramidal effects. Antidepressants are used cautiously and generally with a mood stabiliser, because monotherapy can precipitate a manic switch — a favourite exam detail.
Teaching, adherence and exam strategy
Non-adherence is common because clients may miss the energy and productivity of hypomania or feel well and assume medication is unnecessary. Effective teaching links continued medication to preventing relapse, involves the family in recognising early warning signs such as reduced sleep, increased spending or rapid speech, and establishes a plan for what to do when those signs appear. Regular sleep, routine and avoidance of alcohol and stimulants stabilise mood.
For families, education about the illness as a medical condition reduces blame and improves outcomes. Support groups, safety planning around finances during episodes, and knowing when to seek emergency help are practical topics that appear as correct options.
On the exam, if the stem describes a pacing, non-eating, non-sleeping client, choose the physical need. If it describes vomiting, tremor and confusion on lithium, choose toxicity. If it describes a client demanding special treatment and pitting staff against each other, choose consistent team limits. Recognising these three patterns handles most bipolar items.