# A nurse is caring for a 32-year-old patient admitted with an acute manic episode of bipolar I disorder. The patient has been pacing the unit, speaking rapidly with flight of ideas, and has not slept for 2 days. The provider has prescribed lithium carbonate plus olanzapine. Which interventions should the nurse include in the plan of care? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372699&lang=en  
> language: en  
> subject: Crisis Intervention  
> category: PSI

## Question

A nurse is caring for a 32-year-old patient admitted with an acute manic episode of bipolar I disorder. The patient has been pacing the unit, speaking rapidly with flight of ideas, and has not slept for 2 days. The provider has prescribed lithium carbonate plus olanzapine. Which interventions should the nurse include in the plan of care? Select all that apply.

1

Provide finger foods and high-calorie portable beverages because the patient may be unable to sit through full meals

2

Set firm, consistent limits using a calm, matter-of-fact tone, with all staff using the same approach to avoid manipulation and splitting

3

Place the patient in a low-stimulus environment and avoid loud activities, group rooms, or competitive games during the acute phase

4

Encourage participation in unit-wide group therapy and competitive social activities to channel the patient excess energy

5

Hold the lithium dose and notify the provider if the patient develops new coarse tremor, vomiting, ataxia, confusion, or muscle twitching

6

Monitor lithium levels regularly and teach the patient to maintain consistent dietary sodium intake and adequate hydration

## Explanation

Correct: 1, 2, 3, 5, 6. Acute mania requires nutrition support, low-stimulus milieu, lithium safety, consistent limits, and toxicity surveillance. (1) Hyperactivity prevents sitting for meals — finger foods (sandwiches, fruit, cheese, protein bars) and portable high-calorie shakes meet caloric needs while the patient paces. (2) Low-stimulus environment with private or semi-private room, dim lighting, and reduced noise prevents escalation; large groups, competitive games, and loud activities OVERSTIMULATE and worsen mania. (3) Lithium has a narrow therapeutic index (0.6-1.2 mEq/L); LEVELS RISE when sodium is depleted because lithium and sodium compete at the renal tubules — patient teaching emphasizes consistent salt intake, adequate fluids, avoiding NSAIDs/thiazides/ACE inhibitors, and reporting illness with vomiting/diarrhea. (5) Firm, consistent, matter-of-fact limit setting with unified staff approach prevents manipulation and splitting; calm tone de-escalates without triggering. (6) Hold lithium and notify provider for early toxicity signs: coarse tremor (vs fine tremor of normal start), vomiting, ataxia, confusion, fasciculations, or seizures — levels >1.5 mEq/L are toxic. Incorrect: (4) Group therapy and competitive activities overstimulate manic patients — channel energy with solitary, non-competitive physical activity (walking, stationary bike) until acute phase resolves.

## In-depth explanation

Five anchors for acute mania nursing: (1) Nutrition on the move — finger foods and shakes because mania prevents sitting; weigh daily. (2) Stimulus reduction — quiet, private space; one staff member at a time; avoid groups; limit visitors during acute phase. (3) Lithium pharmacology — narrow window (0.6-1.2 mEq/L therapeutic; >1.5 toxic); hold for any GI illness, dehydration, or new tremor; teach consistent sodium and fluids; warn against NSAIDs/thiazides/ACEi which raise lithium. (4) Limit setting — calm, firm, consistent; all staff use the same words; address behaviors not personality; redirect rather than argue. (5) Sleep promotion — pharmacologic + environmental; sleep deprivation perpetuates mania. Adjunctive antipsychotics (olanzapine, risperidone, haloperidol) treat acute mania faster than lithium alone, which takes 7-14 days for therapeutic effect. Watch for early signs of lithium toxicity (coarse tremor, GI upset, ataxia, confusion) and severe toxicity (seizures, cardiovascular collapse, coma).

## Clinical scenario

Inpatient psychiatric unit. Patient: 32-year-old admitted involuntarily for acute mania of bipolar I disorder; has not slept 2 days, pacing constantly, pressured speech with flight of ideas, grandiose statements, agitated when limits set. Lithium carbonate 600 mg PO three times daily and olanzapine 10 mg PO at bedtime initiated today. Roommate complaining about noise.

## Key concepts

- **Acute Mania Milieu** — Therapeutic environment for acute manic patients featuring low stimulus, structured routine, finger foods, individual rather than group activities, and consistent staff limit setting; reduces escalation and supports nutrition and rest
- **Lithium Therapeutic Range** — Lithium serum level 0.6 to 1.2 mEq/L for maintenance, with toxicity occurring above 1.5 mEq/L; sodium depletion or dehydration raises levels because lithium and sodium compete for renal reabsorption; NSAIDs, thiazides, and ACE inhibitors also increase lithium concentration
- **Limit Setting** — Therapeutic communication strategy in which nurses set clear, firm, consistent boundaries on unacceptable behavior using a calm matter-of-fact tone; all staff use unified language to prevent manipulation and splitting common in mania and personality disorders

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