Mental Health and Psychosocial Nursing

Mental Health and Psychosocial Nursing is the body of nursing knowledge concerned with psychiatric illness, emotional distress, and the psychological and social dimensions of all illness. This article is the shared teaching content for both the NCLEX-RN and NCLEX-PN tracks. Track-specific practice questions and flashcards are linked at the end.

Foundations and Frameworks

Mental Health, Mental Illness, and Resilience

Mental health is not the absence of symptoms. It is the capacity to form satisfying relationships, adapt to change, tolerate distress, and function in expected roles. Mental illness is diagnosed when a pattern of thought, mood, or behavior causes clinically significant distress or impairment in social, occupational, or other important functioning, and is not merely an expectable response to a common stressor (American Psychiatric Association, 2022).

Resilience, the ability to recover functioning after adversity, is a protective factor the nurse actively strengthens. Protective factors include social support, employment, stable housing, spiritual or cultural connection, problem-solving skill, and treatment adherence. Risk factors include isolation, substance use, trauma history, chronic pain, recent loss, and access to lethal means.

The Nurse-Client Relationship

The therapeutic relationship is goal-directed, time-limited, and centered entirely on the client's needs. It differs from a social relationship: there is no reciprocal self-disclosure for the nurse's benefit, no gift exchange, no contact outside the professional role.

Peplau's phases:

• Orientation - establish trust, set the contract (purpose, time, place, confidentiality and its limits), begin assessment.
• Working - the bulk of therapeutic work; the client explores problems, tests new behaviors, and experiences both progress and resistance.
• Termination - planned from the beginning; summarize gains, allow expression of feelings about ending, avoid introducing new issues. Regression and anger at termination are common and are addressed, not punished.

Boundary violations to recognize and avoid: accepting or giving gifts, meeting outside the setting, disclosing personal problems, keeping client secrets, treating one client as special, and any romantic or sexual contact. Transference (client redirects feelings about someone else onto the nurse) and countertransference (the nurse's unresolved feelings surface toward the client) are both expected; countertransference is managed through supervision and self-awareness, not denial.

Confidentiality has limits. The nurse must break confidentiality when there is a serious threat of harm to self or to an identifiable other, when child or vulnerable adult abuse is suspected, and when compelled by court order. Tell the client this during orientation, before it becomes relevant.

Erikson's Psychosocial Stages

Useful for framing developmental crises across the lifespan.

• Infant: trust vs mistrust
• Toddler: autonomy vs shame and doubt
• Preschool: initiative vs guilt
• School age: industry vs inferiority
• Adolescent: identity vs role confusion
• Young adult: intimacy vs isolation
• Middle adult: generativity vs stagnation
• Older adult: ego integrity vs despair

Application: an older adult reviewing life events and asking whether their life mattered is doing the work of ego integrity, not exhibiting pathology. The nursing response is life review and validation, not distraction.

Therapeutic Communication

Core Techniques

Technique	Example
Open-ended questioning	"Tell me what has been happening at home."
Broad opening	"Where would you like to begin today?"
Reflecting	"You feel angry when your family visits."
Restating	Client: "I can't sleep." Nurse: "You are having trouble sleeping."
Clarifying	"I'm not sure I follow. Can you give me an example?"
Exploring	"Tell me more about that argument."
Focusing	"You mentioned your son. Let's stay with that."
Silence	Allows the client to organize thoughts; sit attentively and wait.
Offering self	"I will sit with you for a while."
Making observations	"You are pacing and clenching your fists."
Presenting reality	"I do not hear the voices, but I understand they are frightening to you."
Seeking consensual validation	"Tell me what you mean when you say you feel empty."
Voicing doubt	"That is hard for me to imagine. It seems unlikely to me."
Verbalizing the implied	Client: "It's useless to talk." Nurse: "Are you feeling that no one understands?"
Summarizing	"So far we have talked about your sleep and your job. Is that right?"

Nontherapeutic Responses

These block communication and are almost always the wrong NCLEX answer.

• False reassurance: "Everything will be fine." Dismisses feeling and closes the topic.
• Giving advice: "If I were you, I would leave him." Removes autonomy.
• Approval or disapproval: "That was a good decision." Makes the client dependent on the nurse's judgment.
• Asking "why": Demands justification and provokes defensiveness. Use "what" and "how" instead.
• Changing the subject and minimizing: "Let's talk about something happier." "Other people have it worse."
• Defending staff or the institution, challenging a delusion with logic, and requesting explanations the client cannot give.
• Closed-ended questions when exploration is needed, and stereotyped comments such as "Keep your chin up."

Test-Taking Application

On both licensure exams, the best therapeutic response usually:

1. Stays with the client's feeling rather than the content of the story.
2. Is open-ended and invites the client to continue.
3. Does not reassure, advise, judge, or redirect.
4. Is honest, including when the honest statement is "I do not share that experience."

Exception: when the stem contains a physical safety issue, an airway or hemodynamic problem, a suicidal plan with means, or escalating violence, safety outranks exploration. Answer the safety need first.

Communication Across Culture and Ability

Use professional interpreters, not family members, for clients with limited English proficiency. Address the client, not the interpreter. Recognize that eye contact, personal space, expression of pain, and openness about mental illness vary widely by culture; assess rather than assume. For clients who are deaf, provide a qualified sign language interpreter. For clients with aphasia or cognitive impairment, use short sentences, one idea at a time, and allow extra processing time.

Ego Defense Mechanisms

Defense mechanisms are unconscious. They are adaptive when they reduce anxiety enough to allow functioning, and maladaptive when overused or when they prevent problem-solving.

Mechanism	Definition	Clinical example
Denial	Refusal to accept a painful reality	A newly diagnosed client with cancer keeps working and skips appointments
Repression	Involuntary exclusion of a memory or impulse from awareness	A survivor of assault cannot recall the event
Suppression	Voluntary, conscious setting aside of a thought	"I will worry about the biopsy after my daughter's wedding"
Projection	Attributing one's own unacceptable feelings to another	A client who wants to drink accuses the nurse of being judgmental
Displacement	Shifting feeling from a threatening target to a safer one	A client scolded by the provider yells at the nursing assistant
Rationalization	Creating an acceptable explanation for unacceptable behavior	"I only drink because my job is stressful"
Intellectualization	Focusing on facts to avoid emotion	A client recites survival statistics instead of discussing fear
Reaction formation	Acting the opposite of the true feeling	A client who resents a parent is excessively attentive to them
Regression	Returning to an earlier developmental behavior	A hospitalized 5-year-old who was toilet trained begins wetting the bed
Sublimation	Channeling an unacceptable impulse into a socially useful outlet	A client with aggressive urges takes up boxing
Compensation	Emphasizing a strength to offset a deficit	A student with a learning disability excels in athletics
Undoing	Performing an act to cancel out a previous one	A partner brings flowers after an argument
Identification	Adopting the traits of an admired person	A teen dresses like an older sibling
Introjection	Absorbing another's values as one's own	A child adopts a parent's prejudice wholesale
Splitting	Inability to integrate good and bad qualities; people are all good or all bad	A client with borderline personality disorder praises one nurse and condemns another
Conversion	Emotional conflict expressed as a physical symptom without organic cause	Sudden paralysis of an arm after a traumatic event
Dissociation	Detachment from self, surroundings, or memory	A client reports watching the event from outside the body

Nursing application: do not confront a defense mechanism that is currently holding a client together. Denial in the first 48 hours after a catastrophic diagnosis is often protective. Intervene when the defense endangers the client, such as denial that prevents insulin administration.

Anxiety and Anxiety Disorders

Levels of Anxiety

Level	Perceptual field	Learning	Nursing action
Mild	Heightened, alert	Optimal learning	Teach now; use the energy
Moderate	Narrowed, selective attention	Learning possible with direction	Focus the client; short teaching
Severe	Greatly reduced, scattered detail	Learning not possible	Reduce stimuli, stay with client, simple directions
Panic	Distorted, loss of reality	None; risk of injury	Remain with client, calm firm voice, safe low-stimulus area, consider PRN anxiolytic

Never leave a client in panic-level anxiety alone. Use short, simple, repeated sentences. Do not demand decisions.

Specific Disorders

• Generalized anxiety disorder: excessive worry more days than not for at least 6 months with restlessness, fatigue, poor concentration, irritability, muscle tension, or sleep disturbance.
• Panic disorder: recurrent unexpected panic attacks with persistent worry about further attacks or maladaptive behavior change. Attacks peak within minutes with palpitations, dyspnea, chest pain, choking sensation, derealization, and fear of dying. Rule out myocardial infarction, pulmonary embolism, hypoglycemia, thyrotoxicosis, and stimulant intoxication before attributing chest pain to panic.
• Agoraphobia: fear of situations where escape may be difficult; often leads to housebound status.
• Specific phobia and social anxiety disorder: treated with graded exposure and cognitive behavioral therapy; systematic desensitization pairs relaxation with a graded fear hierarchy.
• Obsessive-compulsive disorder (classified separately from anxiety disorders in DSM-5-TR): obsessions are intrusive thoughts; compulsions are repetitive acts that neutralize anxiety. Do not abruptly stop a ritual, which raises anxiety sharply. Allow time for the ritual initially, then collaboratively set limits and gradually reduce it as coping improves. Treat skin breakdown from washing.
• Post-traumatic stress disorder: exposure to actual or threatened death, serious injury, or sexual violence, followed by intrusion (flashbacks, nightmares), avoidance, negative alterations in cognition and mood, and hyperarousal, lasting more than 1 month. Acute stress disorder is the same picture lasting 3 days to 1 month. Trauma-informed care means asking permission before touch, explaining procedures in advance, minimizing restraint use, and giving the client control wherever possible.

Mood Disorders

Major Depressive Disorder

Five or more symptoms for at least 2 weeks, including depressed mood or anhedonia: appetite or weight change, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, worthlessness or excessive guilt, poor concentration, and recurrent thoughts of death.

Nursing priorities:

1. Safety first. Assess suicidal ideation directly at every contact.
2. Meet physical needs the client cannot meet: nutrition, hydration, elimination, sleep, hygiene.
3. Structure the day. Offer simple, achievable activities. Do not offer open-ended choices to a severely depressed client; instead of "What would you like to wear?" say "Here are your blue shirt and your gray shirt."
4. Spend time with the client without demanding conversation. Silence and presence are interventions.
5. Avoid false cheerfulness, which the client experiences as being misunderstood.
6. Expect that mood improves before energy is restored, or that energy returns first. Risk of suicide rises as psychomotor retardation lifts and the client regains the capacity to act.

Related presentations: persistent depressive disorder (2 years of chronic low mood), premenstrual dysphoric disorder, seasonal pattern depression (light therapy), and peripartum-onset depression. Distinguish postpartum blues (self-limited, days 3 to 10, tearfulness, no functional loss) from postpartum depression (persistent, impairing, needs treatment) and postpartum psychosis (a psychiatric emergency with delusions often centered on the infant; do not leave the parent alone with the infant).

Bipolar Disorders

• Bipolar I: at least one manic episode lasting at least 7 days, or any duration requiring hospitalization. Depressive episodes usually occur but are not required.
• Bipolar II: at least one hypomanic episode (4 days, no marked impairment, no psychosis) plus at least one major depressive episode.
• Cyclothymic disorder: 2 years of fluctuating hypomanic and depressive symptoms that do not meet full criteria.

Mania features (mnemonic DIG FAST): Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, Talkativeness with pressured speech.

Nursing care in acute mania:

• Provide a low-stimulation environment: private room away from the nurses' station and dayroom traffic, dim lighting, limited visitors.
• Offer high-calorie, high-protein finger foods and fluids the client can eat while moving. Clients in mania die of exhaustion and dehydration, not of mood.
• Set firm, consistent limits. Manic clients split staff and test boundaries. Communicate limits among the whole team.
• Channel energy into noncompetitive, solitary physical outlets such as walking. Avoid competitive games, group activities, and stimulating crafts.
• Protect the client from consequences of poor judgment such as spending, sexual indiscretion, and giving away possessions.
• Do not argue with grandiosity; redirect.
• Monitor sleep. Restoring sleep is a treatment goal, not a comfort measure.

Psychotic Disorders

Schizophrenia

Two or more of the following for a significant portion of 1 month, with continuous disturbance for at least 6 months, and at least one being delusions, hallucinations, or disorganized speech: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms.

Positive symptoms (added experiences, respond better to antipsychotics): hallucinations (auditory most common), delusions (persecutory, grandiose, somatic, referential, thought broadcasting or insertion), disorganized speech (loose associations, word salad, neologisms, clang associations, echolalia), and bizarre behavior (echopraxia, waxy flexibility).

Negative symptoms (the "five A's", more disabling long term and less drug-responsive): affective flattening, alogia (poverty of speech), avolition, anhedonia, and asociality. Add attention deficit and ambivalence from classic Bleulerian description.

Cognitive symptoms: impaired working memory, executive function, and attention. These drive functional outcome and adherence more than positive symptoms do.

Related diagnoses: schizophreniform disorder (1 to 6 months), brief psychotic disorder (1 day to 1 month with full return to baseline), schizoaffective disorder (psychosis plus a mood episode, with at least 2 weeks of psychosis without prominent mood symptoms), and delusional disorder (nonbizarre delusions with otherwise preserved functioning).

Nursing interventions:

• Hallucinations: ask directly what the voices are saying. Command hallucinations that direct harm to self or others are a safety emergency. Do not argue about whether the voice is real; acknowledge the client's experience and present your reality once: "I do not hear a voice, but I believe you hear one." Reduce stimuli, provide distraction, and use reality-based activities.
• Delusions: do not agree and do not debate. Focus on the underlying feeling: "It must be frightening to believe you are being watched." Avoid whispering or laughing near a paranoid client. For a paranoid client, offer food in sealed containers and let the client open it, and do not touch without warning.
• Milieu: consistent staff, predictable routine, clear brief communication, one topic at a time, avoid abstractions and idioms with concrete thinkers.
• Illness management: adherence, early warning sign identification, family psychoeducation, and substance use treatment substantially reduce relapse.

Personality Disorders

Enduring, inflexible patterns of inner experience and behavior deviating from cultural expectation, beginning by adolescence or early adulthood, causing distress or impairment.

Cluster A (odd, eccentric): paranoid (pervasive distrust), schizoid (detachment, no desire for relationships), schizotypal (odd beliefs, magical thinking, eccentric behavior without frank psychosis).

Cluster B (dramatic, erratic): antisocial (disregard for the rights of others, deceit, impulsivity, lack of remorse; requires age 18 and evidence of conduct disorder before age 15), borderline (instability of relationships, self-image, and affect; splitting; frantic efforts to avoid abandonment; recurrent self-harm and suicidal behavior), histrionic (excessive emotionality and attention seeking), narcissistic (grandiosity, need for admiration, lack of empathy).

Cluster C (anxious, fearful): avoidant (social inhibition from fear of rejection), dependent (excessive need to be cared for, difficulty making decisions), obsessive-compulsive personality disorder (preoccupation with order, perfectionism, and control; ego-syntonic, unlike OCD).

Nursing management principles:

• Consistency across the entire team is the single most important intervention. Document limits and communicate them in report.
• Set clear limits with stated consequences, then enforce them without anger or negotiation.
• Address splitting by staff meeting together and presenting a unified plan; avoid taking flattery personally.
• For self-harm: assess intent, ensure safety, treat wounds matter-of-factly without excessive attention, and explore the feeling that preceded the act. Dialectical behavior therapy is the evidence-based treatment for borderline personality disorder.
• Expect manipulation with antisocial presentations; do not accept gifts or favors, and confront behavior factually.

Substance-Related and Addictive Disorders

General Concepts

Tolerance is the need for more substance for the same effect. Withdrawal is a substance-specific syndrome on cessation. Substance use disorder is diagnosed by impaired control, social impairment, risky use, and pharmacologic criteria, and graded mild, moderate, or severe.

Screening: CAGE (Cut down, Annoyed, Guilty, Eye-opener), AUDIT, CRAFFT for adolescents. Ask about substance use in a nonjudgmental, matter-of-fact way, including exact substances, amounts, routes, and time of last use. Time of last use determines when withdrawal will begin and is the most important assessment datum on admission.

Alcohol

Withdrawal timeline after last drink:

• 6 to 12 hours: tremor, anxiety, nausea, diaphoresis, tachycardia, hypertension
• 12 to 24 hours: alcoholic hallucinosis (usually visual, sensorium otherwise clear)
• 24 to 48 hours: withdrawal seizures (generalized tonic-clonic)
• 48 to 96 hours: delirium tremens - clouded sensorium, disorientation, severe autonomic hyperactivity, hallucinations, fever. This is a medical emergency with meaningful mortality even when treated.

Management: CIWA-Ar symptom-triggered benzodiazepines (lorazepam is preferred in hepatic impairment because it does not require oxidative metabolism), quiet well-lit room, frequent orientation, seizure precautions, fluids and electrolytes, and thiamine before glucose to prevent precipitating Wernicke encephalopathy.

Wernicke encephalopathy is the acute triad of confusion, ataxia, and ophthalmoplegia or nystagmus; it is reversible with thiamine. Korsakoff syndrome is the chronic sequel with anterograde amnesia and confabulation, and it is largely irreversible.

Maintenance pharmacotherapy: disulfiram causes flushing, throbbing headache, vomiting, and hypotension if alcohol is ingested; teach avoidance of hidden alcohol in mouthwash, cough syrup, sauces, aftershave, and hand sanitizer. Naltrexone reduces craving and reward but is contraindicated with current opioid use because it precipitates withdrawal. Acamprosate supports abstinence and is renally cleared.

Opioids

Intoxication: pinpoint pupils, respiratory depression, sedation, hypotension, decreased bowel sounds. Naloxone reverses it; monitor for re-sedation because naloxone has a shorter half-life than many opioids, and expect abrupt withdrawal in dependent clients.

Withdrawal (COWS scale): lacrimation, rhinorrhea, yawning, mydriasis, piloerection, myalgia, abdominal cramping, vomiting, diarrhea. It is intensely uncomfortable but not usually life-threatening in healthy adults, unlike alcohol and sedative withdrawal, which can kill. Neonatal opioid withdrawal, by contrast, is dangerous and requires swaddling, low stimulation, small frequent feedings, and scoring-based pharmacologic treatment.

Treatment: methadone (full agonist, clinic-dispensed), buprenorphine or buprenorphine-naloxone (partial agonist), and naltrexone (antagonist, requires 7 to 10 days opioid-free first).

Sedative-Hypnotics, Stimulants, and Others

• Benzodiazepine withdrawal mirrors alcohol withdrawal and can produce seizures and death. Never stop abruptly; taper. Flumazenil reverses overdose but can precipitate seizures and is used cautiously.
• Stimulants (cocaine, methamphetamine): intoxication causes hypertension, tachycardia, hyperthermia, mydriasis, agitation, paranoia, and risk of seizure, stroke, myocardial infarction, and formication. Withdrawal is a "crash" with hypersomnia, hyperphagia, dysphoria, and significant suicide risk.
• Cannabis: conjunctival injection, increased appetite, impaired time sense; hyperemesis syndrome with chronic heavy use.
• Hallucinogens: perceptual distortion with retained insight in some cases; manage with a quiet environment and "talking down."
• Phencyclidine: violence, nystagmus (including vertical), analgesia, hypertension. Prioritize staff and client safety and minimize stimulation.
• Inhalants: risk of sudden sniffing death from arrhythmia.

Recovery support: 12-step and other mutual-help programs, relapse prevention planning, contingency management, motivational interviewing. Approach relapse as a clinical event to analyze, not a moral failure.

Eating Disorders

• Anorexia nervosa: restriction of intake leading to significantly low body weight, intense fear of weight gain, and disturbed body image. Findings include bradycardia, hypotension, hypothermia, amenorrhea, lanugo, dry skin, and osteopenia.
• Bulimia nervosa: binge eating with compensatory behaviors, usually at or above normal weight. Findings include hypokalemia and metabolic alkalosis from vomiting, dental enamel erosion, parotid enlargement, and Russell's sign (calluses on the knuckles).
• Binge-eating disorder: bingeing without compensatory behavior.
• Avoidant/restrictive food intake disorder: restriction without body image disturbance.

Nursing care: weigh at the same time daily, after voiding, in a gown, with the client's back to the scale; monitor for water loading and hidden weights. Supervise meals and remain with the client for at least 1 hour afterward. Set out a structured contract linking privileges to intake and weight goals. Address the underlying issues of control and perfectionism rather than arguing about food.

Refeeding syndrome is the key safety concern when nutrition is restarted in a severely malnourished client: an insulin surge drives phosphate, potassium, and magnesium intracellularly, producing hypophosphatemia, hypokalemia, hypomagnesemia, fluid overload, arrhythmias, and heart failure. Refeed slowly, monitor electrolytes and cardiac rhythm, and replace phosphorus.

Neurocognitive Disorders: Delirium, Dementia, and Depression

Feature	Delirium	Dementia (major neurocognitive disorder)	Depression
Onset	Acute, hours to days	Insidious, months to years	Weeks
Course	Fluctuates, worse at night (sundowning)	Progressive, stable within a day	Fairly constant, often worse in the morning
Consciousness	Impaired, fluctuating attention	Clear until late stage	Clear
Reversibility	Usually reversible if cause is treated	Usually irreversible	Reversible with treatment
Memory	Immediate and recent impaired	Recent then remote impaired	Inconsistent; "I don't know" answers
Priority	Find and treat the cause	Safety, function, caregiver support	Safety and mood treatment

Delirium is a medical emergency and is commonly caused by infection (especially urinary tract infection in older adults), hypoxia, electrolyte disturbance, hypoglycemia, dehydration, pain, medication effects (anticholinergics, benzodiazepines, opioids), substance withdrawal, and urinary retention or constipation. New confusion in an older adult is delirium until proven otherwise.

Dementia care: consistent caregivers and routine, simple one-step directions, familiar objects, adequate lighting, reduced clutter and noise, validation rather than reality orientation in the later stages, redirection instead of confrontation, and safety measures for wandering (door alarms, identification bracelet, secured exits). Support the caregiver; caregiver burden is a nursing diagnosis in its own right.

Crisis and Crisis Intervention

A crisis occurs when a person's usual coping fails against a perceived threat. It is time-limited, typically resolving within 4 to 6 weeks toward a higher, equal, or lower level of functioning.

Types: maturational (developmental transitions such as retirement or parenthood), situational (job loss, divorce, diagnosis, death), and adventitious (disaster, mass violence, war).

Aguilera's balancing factors determine whether an event becomes a crisis: realistic perception of the event, adequate situational support, and adequate coping mechanisms. Nursing intervention strengthens whichever factor is weakest.

Crisis intervention is:

• Present-focused - address the immediate problem, not childhood history.
• Directive - the nurse takes a more active role than in ongoing therapy, including making concrete plans.
• Time-limited and goal-specific - the goal is return to the precrisis level of functioning, not personality change.
• Safety-anchored - assess suicide and homicide risk first.

Practical steps: ensure safety, assess the precipitating event and the client's perception of it, identify supports and coping strengths, plan concrete actions the client will take before the next contact, and arrange follow-up.

De-escalation and Management of Aggression

Recognize the escalation continuum: anxiety, defensiveness, physical aggression, tension reduction. Intervene early.

Technique: maintain a calm low voice, keep at least two arm-lengths of personal space, position yourself between the client and the exit without blocking either party's escape, avoid sustained direct eye contact and crossed arms, remove the audience, offer choices ("Would you like to walk with me or sit in the quiet room?"), and set a clear limit with a stated consequence. Call for adequate staff before you need them.

Least restrictive intervention first: verbal de-escalation, then voluntary time out and reduced stimuli, then offered PRN medication, then seclusion, then restraint. Restraint is an emergency measure, never a convenience or punishment, and never a substitute for staffing.

Restraint and seclusion requirements for violent or self-destructive behavior (Centers for Medicare and Medicaid Services standards): a provider order is required, an order may never be written PRN, a face-to-face evaluation by a qualified provider must occur within 1 hour of initiation, and orders are time-limited and renewed every 4 hours for adults 18 and older, every 2 hours for ages 9 to 17, and every 1 hour for children under 9. Nursing responsibilities include continuous or every-15-minute observation per policy, circulation and skin checks, range of motion, offering fluids and toileting, documenting behavior and less restrictive measures tried, and discontinuing at the earliest safe moment with a debriefing afterward.

Suicide Risk Assessment and Prevention

Risk Factors

Demographic and historical: prior attempt (the single strongest predictor), family history of suicide, male sex (higher completion; females attempt more often), age extremes with elevated rates in adolescents and young adults and in adults over 65, particularly older white men, LGBTQ identity without family support, veterans, and Indigenous populations.

Clinical: major depression, bipolar disorder, schizophrenia (especially with command hallucinations), substance use disorder, borderline personality disorder, chronic pain, terminal or disfiguring illness, recent psychiatric discharge, hopelessness (a stronger predictor than depression severity itself), insomnia, agitation, and impulsivity.

Situational: recent loss, humiliation or legal trouble, unemployment, isolation, and access to lethal means, especially firearms.

Protective factors: children in the home, pregnancy, religious prohibition, strong social support, engagement in treatment, and future orientation.

Assessment

Ask directly and specifically. Asking about suicide does not plant the idea. Progress from ideation to plan to means to intent to preparatory behavior:

1. "Have you had thoughts of killing yourself?"
2. "Do you have a plan?"
3. "Do you have access to what you would need?"
4. "What has stopped you so far?"
5. "Have you done anything to prepare, such as giving things away, writing a note, or changing a will?"

A specific plan with available and lethal means and a set time is the highest-risk profile and requires immediate one-to-one observation. Screening tools include the Columbia-Suicide Severity Rating Scale and the ASQ; they support but do not replace clinical judgment.

Warning signs of imminent risk include a sudden unexplained calm or improvement in mood in a previously despondent client, which may signal that the decision has been made; giving away prized possessions; saying goodbye; and finalizing affairs.

Interventions

• Institute the ordered observation level, most often continuous one-to-one within arm's reach, including in the bathroom.
• Remove means: belts, shoelaces, cords, glass, sharps, plastic bags, medications, lighters. Search belongings per policy.
• Environmental safety: breakaway shower rods and hooks, tamper-resistant fixtures, no anchor points, shatterproof glass.
• Count and observe medication administration; check the mouth for cheeking.
• Use a collaborative safety plan identifying warning signs, internal coping strategies, supportive contacts, professional and crisis contacts, and specific means-restriction steps. No-suicide contracts are not evidence-based and should not be relied on for safety.
• Recognize the high-risk window in the first days to weeks of antidepressant therapy, when energy and initiative return before mood lifts, and the elevated risk in the weeks after psychiatric discharge.
• Antidepressants carry a boxed warning for increased suicidal thinking and behavior in children, adolescents, and young adults up to age 24; monitor closely and educate families (U.S. Food and Drug Administration, 2018).
• After a suicide death, provide postvention support to survivors and staff.

Legal and Ethical Foundations

• Voluntary admission: the client retains all rights including the right to request discharge, though many jurisdictions allow a short holding period for evaluation.
• Involuntary commitment: generally requires danger to self, danger to others, or grave disability. It is time-limited and subject to judicial review. Involuntary admission does not by itself remove the right to refuse treatment; a separate determination of incompetence or a specific emergency is usually required.
• Retained rights: to be treated with dignity, to communicate and receive visitors, to keep personal belongings, to informed consent, to refuse treatment, to confidentiality, to an individualized treatment plan, and to the least restrictive setting.
• Duty to warn and protect (Tarasoff principle): a serious, credible threat against an identifiable person obligates the treatment team to act, which may include warning the intended victim and notifying law enforcement.
• Emergency treatment may be given over refusal when necessary to prevent imminent serious harm, using the least restrictive effective measure and documenting the emergency.
• Assault is the threat, battery is the unconsented touching, and false imprisonment includes unjustified seclusion or restraint. Document less restrictive measures tried.
• Mandatory reporting applies to suspected abuse or neglect of children and vulnerable adults.

Psychopharmacology Essentials

Antidepressants

• SSRIs (fluoxetine, sertraline, escitalopram, paroxetine, citalopram): first-line. Nausea, headache, insomnia or sedation, and sexual dysfunction are common. Full effect takes 4 to 6 weeks; teach the client not to stop early. Abrupt discontinuation causes a discontinuation syndrome (dizziness, flu-like symptoms, paresthesias), so taper. Risk of hyponatremia in older adults and increased bleeding risk with NSAIDs or anticoagulants.
• SNRIs (venlafaxine, duloxetine): monitor blood pressure with venlafaxine.
• Bupropion: no sexual side effects, aids smoking cessation, but lowers the seizure threshold; contraindicated in seizure disorder, bulimia, and anorexia.
• Mirtazapine: sedation and appetite gain, sometimes used deliberately in older adults with weight loss and insomnia.
• Tricyclics (amitriptyline, nortriptyline, imipramine): anticholinergic effects, orthostatic hypotension, and lethal in overdose from cardiac conduction block; dispense limited quantities to at-risk clients.
• MAOIs (phenelzine, tranylcypromine, isocarboxazid): require a tyramine-restricted diet. Avoid aged cheese, cured and smoked meats, fermented foods, soy sauce, sauerkraut, tap and draft beer, red wine, fava beans, and overripe fruit. Tyramine causes hypertensive crisis with severe occipital headache, stiff neck, palpitations, and marked hypertension. Allow a 2-week washout between MAOIs and most serotonergic agents (5 weeks after fluoxetine). Avoid combining with SSRIs, meperidine, or sympathomimetics.

Serotonin syndrome: onset within hours of a serotonergic increase or combination. Mental status change, autonomic instability, hyperthermia, diaphoresis, diarrhea, and the distinguishing neuromuscular hyperactivity: hyperreflexia, clonus, and tremor, greater in the lower extremities. Stop the agent, provide supportive cooling and benzodiazepines, and consider cyproheptadine.

Mood Stabilizers

• Lithium: therapeutic serum level 0.6 to 1.2 mEq/L for maintenance; acute mania is often managed at 1.0 to 1.5 mEq/L. Toxicity begins above 1.5 mEq/L and is severe above 2.0 mEq/L. Narrow therapeutic index.
  • Early toxicity: nausea, vomiting, diarrhea, coarse hand tremor, drowsiness, muscle weakness.
  • Moderate to severe: ataxia, confusion, blurred vision, giddiness, slurred speech, nystagmus, seizures, arrhythmias, coma.
  • Teaching: maintain consistent sodium intake and 2 to 3 liters of fluid daily. Sodium loss raises lithium levels because lithium is reabsorbed in place of sodium. Caution with vomiting, diarrhea, sweating, fever, exercise in heat, and low-sodium diets. Avoid NSAIDs, thiazide diuretics, and ACE inhibitors, which raise lithium levels. Baseline and periodic renal and thyroid studies. Draw levels 12 hours after the last dose. Contraindicated in pregnancy in most cases because of cardiac malformation risk (Ebstein anomaly).
• Valproate/divalproex: monitor liver function, ammonia, platelets, and pancreatitis symptoms. Highly teratogenic (neural tube defects); confirm contraception.
• Carbamazepine: monitor for agranulocytosis and aplastic anemia, hyponatremia, and Stevens-Johnson syndrome (screen for HLA-B*1502 in clients of Asian ancestry). Strong enzyme inducer that lowers oral contraceptive efficacy.
• Lamotrigine: effective for bipolar depression. Titrate slowly to reduce the risk of serious rash including Stevens-Johnson syndrome. Any rash requires immediate provider notification and usually discontinuation.

Antipsychotics

First generation (haloperidol, fluphenazine, chlorpromazine): strong dopamine blockade, more extrapyramidal symptoms. Second generation (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, paliperidone, lurasidone, clozapine): fewer extrapyramidal symptoms, more metabolic syndrome (weight gain, dyslipidemia, hyperglycemia). Monitor weight, waist circumference, fasting glucose or A1C, and lipids.

Extrapyramidal symptoms:

Type	Typical onset	Features	Management
Acute dystonia	Hours to days	Torticollis, oculogyric crisis, opisthotonos, laryngospasm	Emergency; IM/IV diphenhydramine or benztropine
Akathisia	Days to weeks	Inner restlessness, inability to sit still; often mistaken for agitation and linked to suicide risk	Reduce dose, propranolol, benzodiazepine
Pseudoparkinsonism	Weeks	Shuffling gait, mask facies, pill-rolling tremor, cogwheel rigidity, bradykinesia	Anticholinergic agent, dose reduction
Tardive dyskinesia	Months to years	Involuntary lip smacking, tongue protrusion, choreoathetoid movements; may be irreversible	Screen with AIMS, switch agent, valbenazine or deutetrabenazine

Neuroleptic malignant syndrome: a life-threatening reaction developing over days. Hyperthermia, "lead-pipe" muscular rigidity, autonomic instability, altered consciousness, and markedly elevated creatine kinase with myoglobinuria and risk of acute kidney injury. Stop the antipsychotic immediately, cool aggressively, hydrate, and expect dantrolene or bromocriptine. Contrast with serotonin syndrome, which is faster in onset and features hyperreflexia and clonus rather than lead-pipe rigidity.

Clozapine is reserved for treatment-resistant schizophrenia and reduces suicidality, but requires absolute neutrophil count monitoring for agranulocytosis; report fever, sore throat, or flu-like symptoms immediately. Also causes myocarditis, seizures at higher doses, orthostatic hypotension, sialorrhea, and severe constipation and ileus that can be fatal. Assess bowel function routinely.

Anxiolytics, Hypnotics, and Stimulants

• Benzodiazepines (lorazepam, alprazolam, diazepam, clonazepam): rapid relief, but sedation, fall risk in older adults, tolerance, dependence, and dangerous respiratory depression when combined with opioids or alcohol. Use short-term. Taper; do not stop abruptly.
• Buspirone: nonaddicting anxiolytic with no immediate effect; takes 2 to 4 weeks. Not useful PRN. Avoid grapefruit juice.
• Hydroxyzine: nonaddicting, sedating, useful PRN.
• Stimulants for ADHD (methylphenidate, amphetamine salts): monitor growth, appetite, sleep, blood pressure, and heart rate; give in the morning; controlled substances with diversion risk. Atomoxetine and guanfacine are nonstimulant options.

Electroconvulsive Therapy

Indicated for severe or treatment-resistant depression, depression with psychotic features, acute suicidality where speed matters, and catatonia. Care: informed consent, NPO after midnight, remove dentures and jewelry, void before, an anticholinergic (atropine or glycopyrrolate) to reduce secretions, a short-acting anesthetic (methohexital), and a muscle relaxant (succinylcholine). Afterward, monitor airway and vital signs, position on the side until responsive, reorient frequently, and expect transient confusion and short-term memory loss, most commonly retrograde around the treatment period.

Psychosocial Aspects of Physical Illness and Coping

Stress, Coping, and Adaptation

Lazarus and Folkman described primary appraisal (is this a threat?) and secondary appraisal (can I handle it?), followed by problem-focused coping (change the stressor, useful when the situation is controllable) or emotion-focused coping (change the response, useful when it is not). Selye's general adaptation syndrome describes alarm, resistance, and exhaustion.

Nursing interventions: teach diaphragmatic breathing, progressive muscle relaxation, guided imagery, mindfulness, sleep hygiene, exercise, journaling, and structured problem-solving. Mobilize support systems and address financial, transport, and childcare barriers, which are frequently the real obstacle to coping.

Body Image, Role Change, and Chronic Illness

Amputation, mastectomy, ostomy, burns, stroke, and disfiguring surgery all provoke grief for the lost body and lost role. Assess whether the client looks at, touches, or names the affected part. Do not force viewing; offer opportunities and allow refusal. Involve the client in self-care gradually, use peer visitors from ostomy or amputee programs, and include partners in teaching about sexuality, which nurses commonly omit.

Chronic illness care includes managing uncertainty, regimen fatigue, stigma, and the emotional consequences of dependency. Screen routinely for depression in chronic illness; comorbid depression worsens adherence, function, and mortality.

Grief and Loss

Kübler-Ross's stages (denial, anger, bargaining, depression, acceptance) are not linear and not obligatory. Other useful frames include Worden's four tasks of mourning (accept the reality of the loss, process the pain, adjust to a world without the deceased, and find an enduring connection while moving forward) and Bowlby's phases.

Types: anticipatory grief before the loss, disenfranchised grief that society does not acknowledge (perinatal loss, loss of a same-sex partner in unsupportive settings, loss of a pet, death of an estranged relative), and complicated or prolonged grief with persistent intense yearning, preoccupation, and functional impairment beyond 12 months in adults.

Nursing interventions: be present, use silence, avoid clichés such as "at least" and "everything happens for a reason," use the deceased person's name, permit the full range of feeling including anger and relief, honor cultural and religious rituals, offer memory-making for perinatal and pediatric loss, and refer for bereavement support. Assess your own grief; staff bereavement is real and unaddressed staff grief drives burnout.

Across the Lifespan

• Children: express distress somatically and behaviorally (abdominal pain, headaches, regression, school refusal, irritability rather than sadness). Use play and drawing to assess. Explain procedures in developmentally appropriate terms and permit parental presence. Screen for abuse when the injury does not match the history or the developmental stage.
• Adolescents: identity, autonomy, and peer belonging dominate. Screen for depression, self-harm, disordered eating, substance use, bullying and cyberbullying, and suicidal ideation. Interview privately without the parent for part of the visit. Explain confidentiality and its limits explicitly.
• Adults: role strain, caregiving burden, occupational stress, intimate partner violence. Screen for intimate partner violence privately, never with the partner in the room, and never using a family member as interpreter.
• Older adults: loss accumulation, retirement, sensory decline, functional dependence, relocation stress, elder mistreatment, and polypharmacy. Depression in older adults frequently presents as somatic complaint or cognitive slowing ("pseudodementia") rather than reported sadness. Older adults have high suicide completion rates and often have contact with a primary care provider shortly before death, making routine screening essential. Assess for relocation stress syndrome after a move to long-term care and mitigate it with familiar objects, choice, and orientation.

Prioritization Guide for Exam Items

When a psychiatric item asks what the nurse does first:

1. Physiologic emergency or airway outranks everything (laryngospasm from dystonia, NMS, serotonin syndrome, lithium toxicity, delirium tremens, overdose).
2. Imminent danger to self or others comes next (suicidal plan with means, command hallucinations to harm, imminent violence).
3. Assessment before intervention when no emergency is present. Gather the missing datum.
4. Therapeutic communication that explores feeling when the item is about a relationship or emotional response.
5. Teaching and long-range planning last.

Also remember: stay with the anxious or panicked client, never leave a suicidal client alone, never argue with a delusion, never abruptly interrupt a compulsion, provide finger foods in mania, give thiamine before glucose in alcohol use, and check the time of last substance use on admission.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Centers for Medicare & Medicaid Services. (2020). State operations manual appendix A: Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200). U.S. Department of Health and Human Services.

Halter, M. J. (2022). Varcarolis' foundations of psychiatric-mental health nursing: A clinical approach (9th ed.). Elsevier.

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer.

National Council of State Boards of Nursing. (2026a). 2026 NCLEX-RN test plan (effective April 2026). NCSBN. https://www.ncsbn.org

National Council of State Boards of Nursing. (2026b). 2026 NCLEX-PN test plan (effective April 2026). NCSBN. https://www.ncsbn.org

Townsend, M. C., & Morgan, K. I. (2020). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice (8th ed.). F. A. Davis.

U.S. Food and Drug Administration. (2018). Suicidality in children and adolescents being treated with antidepressant medications. https://www.fda.gov

See Also

• Mental Health and Psychosocial Nursing – RN Practice Questions
• Mental Health and Psychosocial Nursing – LPN Practice Questions
• Mental Health and Psychosocial Nursing – RN Flashcards
• Mental Health and Psychosocial Nursing – LPN Flashcards

This page is independent study material for nursing licensure exam preparation. NCLEX-RN® and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing (NCSBN). This content is not produced, reviewed, or endorsed by NCSBN. Always verify clinical information against current facility policy, drug references, and your nursing program's curriculum before applying it in practice.