Mental Health and Psychosocial Nursing – RN Flashcards

Flashcards for Mental Health and Psychosocial Nursing at NCLEX-RN depth. Cover the answer, recall it, then check.

Therapeutic Relationship and Communication

Four nontherapeutic responses that are almost always the wrong exam answer

False reassurance ("Everything will be fine"), giving advice ("If I were you..."), approval or disapproval, and asking "why," which demands justification. Also avoid changing the subject, minimizing, defending the institution, and challenging a delusion with logic.

When does safety outrank therapeutic exploration on an exam item?

Whenever the stem contains a physiologic emergency, a suicidal plan with available means, command hallucinations directing harm, or escalating violence. Otherwise, choose the open-ended response that stays with the client's feeling.

Three limits to confidentiality the nurse must disclose during orientation

Serious threat of harm to self, serious threat of harm to an identifiable other (duty to warn and protect, the Tarasoff principle), and suspected abuse or neglect of a child or vulnerable adult. Court orders also compel disclosure.

Anxiety, Defenses, and Crisis

What distinguishes severe anxiety from panic-level anxiety, and what does the nurse do?

In severe anxiety the perceptual field is greatly reduced and learning is not possible; in panic the client loses contact with reality and is at risk for injury. In both, stay with the client, lower stimuli, and use short simple repeated sentences. Never leave a panicked client alone and do not demand decisions.

Aguilera's three balancing factors, and the four features of crisis intervention

Balancing factors: realistic perception of the event, adequate situational support, and adequate coping mechanisms; intervention targets whichever is weakest. Crisis intervention is present-focused, directive, time-limited (usually 4 to 6 weeks), and aimed at restoring at least the precrisis level of functioning. Risk of harm to self or others is assessed first.

Mood Disorders

When is suicide risk highest in a client being treated for major depression?

As psychomotor retardation lifts and energy and initiative return before mood fully improves, typically in the first days to weeks of antidepressant therapy, and again in the weeks immediately after psychiatric discharge. A sudden unexplained calm in a previously despondent client is a red flag.

Why do clients in acute mania need finger foods and a low-stimulation environment?

They cannot sit still long enough to eat, and exhaustion and dehydration are the leading physical dangers of untreated mania. Portable high-calorie, high-protein foods and fluids meet nutritional needs without a power struggle, while low stimulation and noncompetitive solitary activity such as walking reduce escalation.

Postpartum blues versus postpartum depression versus postpartum psychosis

Blues are self-limited tearfulness around days 3 to 10 without functional loss. Depression is persistent and impairing and requires treatment. Psychosis is a psychiatric emergency, often with delusions centered on the infant; do not leave the parent alone with the infant.

Psychotic Disorders

Positive versus negative symptoms of schizophrenia, and which respond better to medication

Positive symptoms are added experiences (hallucinations, delusions, disorganized speech, bizarre behavior) and respond well to antipsychotics. Negative symptoms are the five A's (affective flattening, alogia, avolition, anhedonia, asociality), are more disabling long term, and respond poorly.

Nursing response to a hallucination

Ask directly what the voices are saying, because command hallucinations directing harm are a safety emergency. Acknowledge the client's experience while presenting your reality once: "I do not hear a voice, but I believe you hear one." Do not argue, reduce stimuli, and provide reality-based distraction.

Personality, Eating, and Substance Use Disorders

Core nursing strategy for cluster B personality disorders, including splitting

Splitting is the inability to integrate positive and negative qualities, so people are experienced as all good or all bad; the answer is team consistency. Clear, written, consistently enforced limits with stated consequences, communicated across the entire team, delivered without anger or negotiation. Dialectical behavior therapy is the evidence-based treatment for borderline personality disorder.

Refeeding syndrome

mechanism, hallmark lab, and consequence

Reintroduced carbohydrate triggers an insulin surge that drives phosphate, potassium, and magnesium intracellularly. Hypophosphatemia is the hallmark and can cause arrhythmias, cardiac and respiratory failure, and death. Advance nutrition slowly with electrolyte and cardiac monitoring.

Alcohol withdrawal timeline after the last drink

6 to 12 hours tremor, anxiety, autonomic arousal; 12 to 24 hours alcoholic hallucinosis with clear sensorium; 24 to 48 hours withdrawal seizures; 48 to 96 hours delirium tremens, a medical emergency with meaningful mortality.

Why is thiamine given before glucose in a client with alcohol use disorder?

Glucose administration without thiamine can precipitate or worsen Wernicke encephalopathy (confusion, ataxia, ophthalmoplegia or nystagmus), which if untreated progresses to the largely irreversible Korsakoff syndrome with anterograde amnesia and confabulation.

Which withdrawal syndromes can kill, and which is merely miserable?

Alcohol and sedative-hypnotic (benzodiazepine, barbiturate) withdrawal can be fatal from seizures and delirium. Opioid withdrawal is intensely uncomfortable but not usually life-threatening in healthy adults; neonatal opioid withdrawal, however, is dangerous.

Disulfiram versus naltrexone versus acamprosate

Disulfiram causes flushing, throbbing headache, vomiting, and hypotension if alcohol is ingested; teach avoidance of hidden alcohol in mouthwash, cough syrup, sauces, and hand sanitizer. Naltrexone reduces craving but precipitates withdrawal in current opioid users. Acamprosate supports abstinence and is renally cleared.

Psychopharmacology

Lithium

therapeutic range, toxic threshold, and the sodium rule

Maintenance level 0.6 to 1.2 mEq/L; acute mania is often managed at 1.0 to 1.5 mEq/L. Toxicity begins above 1.5 and is severe above 2.0 mEq/L. Sodium loss from vomiting, diarrhea, sweating, fever, or a low-sodium diet raises lithium levels because lithium is reabsorbed in place of sodium. Maintain 2 to 3 liters of fluid and consistent sodium daily. NSAIDs, thiazide diuretics, and ACE inhibitors also raise levels. Draw trough levels 12 hours after the last dose and monitor renal and thyroid function.

Neuroleptic malignant syndrome versus serotonin syndrome

NMS develops over days on a dopamine blocker with hyperthermia, "lead-pipe" rigidity, autonomic instability, altered consciousness, and markedly elevated creatine kinase; treat by stopping the antipsychotic, cooling, hydrating, and giving dantrolene or bromocriptine. Serotonin syndrome develops within hours of a serotonergic increase with hyperthermia, agitation, diarrhea, and neuromuscular hyperactivity, specifically hyperreflexia and clonus greater in the legs; treat by stopping the agent, cooling, giving benzodiazepines, and considering cyproheptadine.

Four extrapyramidal syndromes by onset

Acute dystonia in hours to days (torticollis, oculogyric crisis, laryngospasm) treated with IM diphenhydramine or benztropine; akathisia in days to weeks (inner restlessness, linked to suicide risk) treated with dose reduction, propranolol, or a benzodiazepine; pseudoparkinsonism in weeks (shuffling gait, mask facies, cogwheel rigidity); tardive dyskinesia in months to years (lip smacking, tongue protrusion), screened with the AIMS and treated with valbenazine or deutetrabenazine.

Clozapine monitoring priorities

Absolute neutrophil count for agranulocytosis (report fever, sore throat, or flu-like symptoms immediately), plus myocarditis, seizures at higher doses, orthostatic hypotension, sialorrhea, and severe constipation or ileus that can be fatal. Assess bowel function routinely.

MAOI teaching

the food rule and the washout rule

Avoid tyramine-containing foods (aged cheese, cured and smoked meats, fermented foods, soy sauce, sauerkraut, tap and draft beer, red wine, fava beans, overripe fruit) to prevent hypertensive crisis with severe occipital headache and stiff neck. Allow a 2-week washout between an MAOI and most serotonergic drugs, and 5 weeks after fluoxetine.

Bupropion, lamotrigine, and valproate

one critical caution each

Bupropion lowers the seizure threshold and is contraindicated in seizure disorder, bulimia, and anorexia. Lamotrigine must be titrated slowly because of the risk of serious rash including Stevens-Johnson syndrome; any rash requires immediate provider notification. Valproate is highly teratogenic (neural tube defects) and requires liver, ammonia, and platelet monitoring.

Suicide, Safety, and Legal

Strongest single predictor of suicide, and the strongest symptom predictor

A prior suicide attempt is the strongest historical predictor. Hopelessness predicts suicide more strongly than depression severity itself.

Five-step suicide assessment sequence

Ideation, plan, access to means, intent and deterrents, and preparatory behavior (giving away possessions, writing a note, settling affairs). A specific plan with available lethal means and a set time requires immediate one-to-one observation within arm's reach.

Why are no-suicide contracts not an acceptable safety measure?

They are not evidence-based and do not reduce suicide risk. Use a collaborative safety plan instead: warning signs, internal coping strategies, supportive contacts, professional and crisis contacts, and specific means-restriction steps such as removing firearms from the home.

Least restrictive intervention sequence for escalating behavior

Verbal de-escalation, then voluntary time out with reduced stimuli, then offered PRN medication, then seclusion, then restraint. Restraint is an emergency measure only, never for convenience or punishment and never a substitute for staffing.

Restraint requirements for violent or self-destructive behavior

A provider order is required and may never be written PRN. A face-to-face evaluation must occur within 1 hour of initiation. Orders are 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 duties include frequent observation, circulation and skin checks, range of motion, fluids and toileting, documentation of less restrictive measures tried, and discontinuation at the earliest safe moment with debriefing.

Does involuntary commitment remove the right to refuse treatment?

No. Involuntary admission and incompetence are separate determinations. A committed client generally retains the right to refuse treatment unless adjudicated incompetent or unless emergency treatment is needed to prevent imminent serious harm, using the least restrictive effective measure.

Neurocognitive and Psychosocial

Delirium versus dementia, and the first thought when an older adult becomes newly confused

Delirium is acute in onset, fluctuates, impairs attention and consciousness, and is usually reversible when the cause is treated. Dementia is insidious, progressive, and usually irreversible, with consciousness clear until late. New confusion in a hospitalized older adult is delirium until proven otherwise: look for infection (especially urinary), hypoxia, hypoglycemia, electrolyte disturbance, dehydration, pain, retention or constipation, medications (anticholinergics, benzodiazepines, opioids), and substance withdrawal.

How does depression commonly present in older adults?

As somatic complaints, irritability, or cognitive slowing that mimics dementia ("pseudodementia") rather than reported sadness. Older adults, especially older white men, have high suicide completion rates and often see a primary care provider shortly before death, so routine screening is essential.

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