A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, "I don't know what to do. Everything has been happening so quickly." Which of the following responses by the nurse is therapeutic?

A. 0.9% normal saline: Initial fluid resuscitation in diabetic ketoacidosis (DKA) requires isotonic fluids like 0.9% normal saline to restore intravascular volume, improve perfusion, and correct electrolyte imbalances. This is the first-line intervention before initiating insulin therapy.

B. 0.45% saline: Half-normal saline is hypotonic and may be used later in DKA management if the client is stable and serum sodium is elevated. It is not appropriate as the initial continuous infusion because it does not provide adequate intravascular volume replacement.

C. Glargine insulin: Glargine is a long-acting insulin used for basal glucose control, not for acute management of DKA. Continuous IV insulin is required to rapidly reduce blood glucose and ketone levels.

D. NPH insulin: NPH is an intermediate-acting insulin administered subcutaneously. It is not suitable for continuous IV infusion in DKA, as IV insulin is preferred for rapid and controlled glucose reduction.

Rationale:

• Disorganized thought process: The client exhibits difficulty concentrating, constant movement, and disorganized speech, which can occur in both psychotic and manic episodes. In psychosis, disorganized thinking may result from impaired reality testing, whereas in mania, it can manifest as flight of ideas or tangential thinking. Both conditions share cognitive disorganization.

• Lack of sleep: The client has not slept for 2 days, a classic symptom of mania. Sleep deprivation often accompanies manic episodes, contributing to increased energy, impulsivity, and impaired judgment. This distinguishes mania from psychosis, where sleep patterns may vary but are not necessarily markedly reduced.

• Excessive spending habits: The client demonstrates impulsive financial behaviors, giving away large sums of money and making erratic purchases. This symptom is characteristic of mania, reflecting poor judgment, elevated self-esteem, and risk-taking behavior. Excessive spending is not associated with psychosis unless part of a delusional belief.

• Hallucinations: The client reports seeing and interacting with someone who is not present, which is a core symptom of psychosis. Hallucinations involve sensory perception without external stimulus and indicate a break from reality. These are not inherently features of mania unless comorbid psychotic symptoms are present, making this symptom specific to psychosis.

• Pressured speech: The client’s loud, rapid, and continuous speech reflects pressured speech, a hallmark of manic episodes. It indicates increased thought speed, distractibility, and elevated energy. While speech may be disorganized in psychosis, the rapid, overproductive pattern is more characteristic of mania.