Pass the Shift

Psych / Mental Health · Mood Disorders

Bipolar Disorder

Last reviewed October 15, 2026 by Pending RN review

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On this page
  1. 1. Overview
  2. 2. Signs of Mania — “DIG FAST”
  3. 3. Priority Nursing Actions in Acute Mania
  4. 4. Medications
  5. 5. Emergency: Lithium Toxicity
  6. 6. Patient Education
  7. 7. Memory Aids
  8. 8. NCLEX-Style Practice Questions
  9. References

Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.

If you or someone you know is in crisis: call or text 988 (Suicide & Crisis Lifeline, U.S.) or call 911 for immediate danger. This guide is for exam study, not for diagnosing or treating anyone.

1. Overview

Bipolar disorders are mood disorders with episodes of or , usually alternating with depression.

TypeKey feature
Bipolar IAt least one manic episode (≈ 1 week or any length if hospitalized); may include psychosis
Bipolar IIHypomania + major depression; never full mania
CyclothymicChronic, milder ups and downs for ≥ 2 years (1 year in youth)
Rapid cycling≥ 4 mood episodes in a year

Strong genetic component; triggers include sleep loss, stress, substances, and antidepressant use without a mood stabilizer.

2. Signs of Mania — “DIG FAST”

Distractibility · Impulsivity/indiscretion (spending, sex) · Grandiosity · Flight of ideas · Activity increase · Sleep need decreased · Talkativeness (pressured speech). Also irritability, poor judgment, poor hygiene, inappropriate dress, and possible delusions. Patients often deny illness (poor insight) and stop meds because they miss the “high.”

3. Priority Nursing Actions in Acute Mania

  1. Safety — risk of injury from exhaustion, impulsive acts, or aggression; also screen for suicide (especially in mixed or depressive phases)
  2. Reduce stimulation: private room, low noise, limit group activities, calm and firm approach
  3. Nutrition & fluids: high-calorie, high-protein finger foods and portable drinks (“eat on the go”); monitor weight, I&O — critical with lithium
  4. Rest: schedule rest periods; channel energy into solitary physical activities (walking, folding laundry) — avoid competitive games
  5. Set firm, consistent limits on manipulative or intrusive behavior; all staff consistent
  6. Brief, simple communication; don’t argue with grandiosity; redirect
  7. Protect finances/relationships (e.g., discourage major decisions)

4. Medications

Lithium (mood stabilizer; first-line for classic mania and maintenance; reduces suicide risk)

  • Narrow therapeutic range — common targets: about 0.6–1.2 mEq/L (maintenance often 0.6–1.0; acute mania may be targeted higher per provider). Labs vary — follow your reference
  • Draw level ~12 hours after last dose (trough); check levels frequently when starting or with changes
  • Baseline and periodic: kidney function, thyroid (TSH), electrolytes/sodium, ECG, pregnancy test (teratogenic)
  • Common effects: fine hand tremor, polyuria/thirst, nausea, weight gain, hypothyroidism
  • Sodium and water matter: low sodium or dehydration → the kidneys keep more lithium → toxicity. Keep consistent salt and ~2–3 L fluids/day (unless restricted)
  • Interactions raising levels: NSAIDs, thiazide diuretics, ACE inhibitors/ARBs

Anticonvulsant mood stabilizers

DrugKey nursing points
Valproate (divalproex)Hepatotoxicity, pancreatitis, thrombocytopenia; monitor LFTs, platelets, levels; teratogenic (neural tube defects)
CarbamazepineSJS/TEN risk (HLA-B*1502 screening in some ancestries), agranulocytosis/aplastic anemia, many drug interactions
LamotrigineBipolar depression maintenance; rash → possible SJS — slow titration; report any rash

Second-generation antipsychotics (quetiapine, olanzapine, aripiprazole, etc.) for acute mania or bipolar depression — monitor metabolic effects. Antidepressants alone can trigger mania.

5. Emergency: Lithium Toxicity

(levels above range; severe toxicity often > 2.0 mEq/L):

SeveritySigns
Early/mildNausea, vomiting, diarrhea, coarse tremor, muscle weakness, lethargy
ModerateConfusion, slurred speech, ataxia, muscle twitching, hyperreflexia
SevereSeizures, arrhythmias, coma, acute kidney injury, death

Actions: hold lithium, notify provider, get stat level + BMP/creatinine, ECG; IV fluids (normal saline) per order; hemodialysis for severe toxicity. There is no antidote.

6. Patient Education

  • Take lithium consistently with food; keep regular lab appointments
  • Maintain normal salt intake and fluids; extra fluids with heat, exercise, vomiting, diarrhea, or fever
  • Avoid NSAIDs (use acetaminophen if allowed), check before starting diuretics
  • Learn early warning signs of relapse (sleeping less, racing thoughts) — regular sleep schedule is protective
  • Contraception and pregnancy planning with the provider

7. Memory Aids

  • DIG FAST for mania
  • “Lithium Likes salt” — low salt = high lithium
  • Fine tremor = fine (expected); Coarse tremor = concern

8. NCLEX-Style Practice Questions

1. A patient in acute mania hasn’t eaten in two days and won’t sit for meals. Which intervention is best?

A. Insist the patient sit at the table for 30 minutes
B. Offer high-calorie finger foods and drinks the patient can take while moving
C. Wait until the patient is hungry
D. Place the patient in group dining

Answer: B. Portable, nutrient-dense foods meet needs without requiring the patient to sit still.

2. A patient on lithium reports vomiting, diarrhea, and a coarse hand tremor. What is the nurse’s first action?

A. Give the next dose with food
B. Hold the dose and notify the provider for a lithium level
C. Encourage a low-sodium diet
D. Give an antidiarrheal and reassess in 4 hours

Answer: B. These are signs of toxicity. Low sodium (C) would worsen it.

3. Which statement by a patient taking lithium shows a need for more teaching?

A. “I’ll drink extra fluids when I exercise in hot weather.”
B. “I’ll take ibuprofen for my frequent headaches.”
C. “I need my blood level checked regularly.”
D. “I’ll keep my salt intake about the same each day.”

Answer: B. NSAIDs can increase lithium levels.

4. Which activity is most appropriate for a patient experiencing mania?

A. A competitive volleyball game
B. Walking with a staff member
C. A group board game
D. Watching an action movie in the dayroom

Answer: B. Solitary, noncompetitive physical activity releases energy with low stimulation.

5. Before starting lithium, which baseline tests does the nurse expect? Select all that apply.

A. Serum creatinine
B. Thyroid function
C. Sodium
D. Pregnancy test (if applicable)
E. Pulmonary function test

Answer: A, B, C, D. Lithium affects the kidneys and thyroid, depends on sodium balance, and is teratogenic.

References

Iyer, V., Jain, A., & Mitra, P. (2024). Bipolar disorder. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558998/

Slubicki, M., Avula, A., Schaffer, D. H., & Swoboda, H. D. (2024). Lithium toxicity. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499992/

National Institute of Mental Health. (n.d.). Bipolar disorder. Retrieved October 15, 2026, from https://www.nimh.nih.gov/health/topics/bipolar-disorder

National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page