Lithium level above 1.5 mEq/L (toxicity): coarse tremor, ataxia, severe vomiting/diarrhea, confusion, seizures - hold dose and notify provider.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A client with bipolar disorder in a manic phase has not eaten or slept for two days. The priority nursing concern is:
Answer: B. Physical exhaustion, dehydration, and poor nutrition are immediate risks in acute mania — provide rest, finger foods/fluids, and a low-stimulation environment. Insight-oriented therapy is not the priority now.
Question 2 of 5
A client with bipolar disorder on lithium has a level of 1.8 mEq/L with tremor and diarrhea. The nurse should:
Answer: B. A level of 1.8 with symptoms indicates lithium toxicity — hold the dose, notify the provider, and assess hydration/sodium. Giving the next dose worsens toxicity.
Question 3 of 5
A client in an acute manic episode of bipolar disorder is hyperactive, intrusive, and unable to sit still long enough to eat a meal. Which intervention best meets this client's needs?
Answer: B. Manic clients often cannot stop moving long enough to eat, risking exhaustion and poor nutrition. Offering high-calorie finger foods and fluids that can be eaten on the move addresses the immediate nutritional need. A stimulating group setting and large unstructured meals are not appropriate during acute mania.
Question 4 of 5
A client in the manic phase of bipolar disorder is intrusive, hyperverbal, and disrupting the unit. Which intervention is most appropriate?
Answer: B. A manic client benefits from a calm, low-stimulation environment with firm, consistent limits delivered in a matter-of-fact way. Reducing stimuli and redirecting energy to non-competitive activities helps prevent escalation and exhaustion.
Question 5 of 5
A client newly admitted for substance use disorder says, "I can quit any time I want, I just choose not to." Which defense mechanism is the client demonstrating?
Answer: A. Minimizing the problem and insisting one can stop at will reflects denial, a common defense in substance use disorder in which the person refuses to acknowledge the reality or severity of the problem. Projection blames others, rationalization makes excuses with logical-sounding reasons, and regression is reverting to earlier behavior. The therapeutic approach is nonjudgmental and reality-based.
Keep the streak going with more questions like these, each with a full rationale.
What is bipolar disorder?
A manic episode features abnormally elevated, expansive, or irritable mood with increased energy lasting at least one week. Lithium and certain anticonvulsants/antipsychotics are mainstays; mania is a psychiatric emergency due to exhaustion, dehydration, and impaired judgment. Memory aid DIG FAST: Distractibility, Indiscretion/impulsivity, Grandiosity, Flight of ideas, Activity increase, decreased Sleep need, Talkativeness.
Key points to remember
- Mania presents with grandiosity, decreased need for sleep, pressured speech, flight of ideas, and distractibility.
- Manic clients show poor judgment, impulsivity, and high-risk behaviors such as spending sprees and hypersexuality.
- Clients in mania often neglect food, fluids, rest, and hygiene, risking physical exhaustion.
- Depressive phases mirror major depressive disorder including suicide risk.
- Lithium has a narrow therapeutic range and requires routine serum monitoring.
- Antidepressants alone can trigger a switch into mania in bipolar clients.
Signs & symptoms
- Mania: ↑ energy, grandiosity, no sleep
- Pressured speech, flight of ideas
- Risky behavior, poor judgment
Nursing priorities
- Maintain physical safety and reduce environmental stimulation in a calm, structured setting.
- Provide high-calorie finger foods and fluids the client can eat on the move to prevent exhaustion and dehydration.
- Set firm, consistent limits on manipulative or intrusive behavior without arguing.
- Redirect excessive energy into nonstimulating, noncompetitive activities.
- Monitor lithium levels and assess for signs of toxicity.
Labs & values
Patient teaching
- Maintain consistent salt and fluid intake; major changes alter lithium levels.
- Have lithium levels checked regularly and report tremor, vomiting, diarrhea, or confusion.
- Take medication even when feeling well; stopping causes relapse.
Red flags: report now
- Lithium level above 1.5 mEq/L (toxicity): coarse tremor, ataxia, severe vomiting/diarrhea, confusion, seizures - hold dose and notify provider.
- Continuous hyperactivity without rest or intake can progress to fatal exhaustion and requires urgent intervention.
- Escalating aggression or threats to self/others requires immediate safety measures.
References
Clinical references for this topic
