Module 5 of 9 · Free NCLEX Prep Course · The RN Network
Therapeutic communication, mental health emergencies, substance withdrawal, and abuse recognition. On every communication question, the answer that reflects feelings and keeps the client talking beats the answer that reassures, advises, or asks "why."
Therapeutic Communication
Use: open-ended questions, reflection ("You seem worried about the surgery"), restating, silence, offering self ("I'll sit with you"), and seeking clarification.
Avoid: false reassurance ("Everything will be fine"), "why" questions (interrogating), giving advice ("If I were you…"), changing the subject, approving/disapproving, and defending the hospital or providers.
On the exam, the correct response usually acknowledges the emotion first — even when the client's statement is a factual question.
For delusions: acknowledge the feeling, present reality once, do not argue the delusion's content, and redirect to a concrete activity.
For hallucinations: ask directly what the client hears/sees (command hallucinations are a safety priority), state "I don't hear the voices, but I believe you do," and reduce stimulation.
Cultural care: use professional interpreters (never family, never children), ask rather than assume, and incorporate practices that do not conflict with safety.
Mood Disorders and Psychosis
Major depression: assess suicide risk directly — asking about suicide does not plant the idea. Energy returning before mood improves is a high-risk window, including the first weeks on antidepressants.
SSRIs take 2–6 weeks for effect; watch for serotonin syndrome (agitation, hyperthermia, tremor, diaphoresis) especially with combinations. MAOIs require avoiding tyramine (aged cheese, cured meats, red wine) to prevent hypertensive crisis.
Bipolar mania: decreased need for sleep, pressured speech, grandiosity, poor judgment. Priorities: safety, decreased stimulation, high-calorie finger foods, and firm, consistent limits.
Lithium therapeutic range is narrow (~0.6–1.2 mEq/L): toxicity presents with coarse tremor, vomiting, diarrhea, ataxia, confusion. Maintain steady sodium and fluid intake — dehydration and low sodium raise lithium levels.
Schizophrenia: positive symptoms (hallucinations, delusions) respond best to antipsychotics; negative symptoms (flat affect, avolition, social withdrawal) persist. Monitor antipsychotics for extrapyramidal symptoms, tardive dyskinesia, and the emergency neuroleptic malignant syndrome (rigidity, hyperthermia, autonomic instability — stop the drug, cool, and support).
Suicide assessment: ask directly about ideation, plan, means, and timeline. Specific plan + available lethal means = highest risk; initiate constant observation and remove dangerous items.
Highest risk profiles include: previous attempts, recent discharge from psychiatric care, sudden calm after depression (decision may be made), giving away possessions, and access to firearms.
No-suicide "contracts" are not a substitute for observation and environmental safety.
Escalating agitation: intervene early — calm voice, personal space, simple choices, decrease stimulation; take a position between the client and the door, never cornered.
Restraint and seclusion are last resorts, require orders with strict time limits, face-to-face evaluation, and continuous monitoring — never PRN orders.
After any crisis, debrief the client (and staff): what triggered it, what helped, what to try earlier next time.
Substance Use and Withdrawal
Alcohol withdrawal begins 6–24 hours after the last drink: tremor, anxiety, tachycardia, hypertension, diaphoresis; seizures possible at 12–48 hours. Delirium tremens (48–96 hours) — confusion, hallucinations, autonomic storm — is life-threatening.
CIWA protocol guides benzodiazepine dosing; give thiamine before or with glucose to prevent Wernicke encephalopathy; expect magnesium and folate replacement.
Opioid overdose: pinpoint pupils, respiratory depression, sedation — give naloxone; it wears off faster than many opioids, so keep monitoring and repeat as needed.
Benzodiazepine withdrawal, like alcohol, can cause seizures and requires a managed taper.
Use nonjudgmental language, screen everyone, and treat withdrawal as a medical condition — moralizing answers are always wrong on the NCLEX.
Abuse, Neglect, Grief, and Coping
Abuse red flags: injuries inconsistent with the story, delays in seeking care, injuries in various healing stages, a partner or caregiver who answers every question, wary or overly compliant children.
Interview the person alone, document verbatim statements and objective findings (photograph per policy), and follow mandatory reporting laws for children, older adults, and other protected groups.
Safety planning for intimate partner violence: the most dangerous time is when leaving; provide resources privately and let the client decide — autonomy applies.
Elder abuse includes neglect and financial exploitation; unexplained weight loss, pressure injuries, poor hygiene, and missing funds are cues.
Grief: normal grief may include somatic symptoms and transient hallucinations of the deceased; complicated grief is prolonged, functionally impairing, or involves suicidal thinking. Do not rush stages — presence beats platitudes.
Defense mechanisms to recognize: denial, projection, displacement, rationalization, regression (common in hospitalized children), sublimation (healthy).
Practice Questions
Answer each question, then read the rationale — the rationale is where the learning happens.
1.A client scheduled for a mastectomy says, "I don't know how I'll face myself afterward." Which response by the nurse is BEST?
Rationale: Reflection acknowledges the feeling and invites the client to keep exploring it. False reassurance dismisses the concern, redirecting to survival changes the subject, and "why" questions put clients on the defensive.
2.A client with depression has been withdrawn for two weeks. Today the client is smiling, giving away belongings, and says, "Everything is settled now." What is the nurse's priority action?
Rationale: Sudden calm with giving away possessions after depression suggests the client has decided on suicide and feels relief. Ask directly about ideation and plan, and increase observation immediately — this is a psychiatric emergency, not improvement.
3.A client taking lithium presents with vomiting, diarrhea, coarse hand tremors, and ataxia. What should the nurse do FIRST?
Rationale: Coarse tremor, GI symptoms, and ataxia indicate lithium toxicity. Hold the drug, obtain a stat level, and notify the provider. Giving another dose worsens toxicity; these findings are beyond expected fine tremor and mild GI upset.
4.A client is 36 hours since their last alcoholic drink. Which finding requires the MOST immediate action?
Rationale: Hallucinations with disorientation and autonomic storm signal progression toward delirium tremens — a life-threatening emergency requiring immediate benzodiazepine protocol and provider notification. Tremors, mild vitals elevation, and craving are expected early withdrawal.
5.The nurse suspects a 6-year-old's injuries result from abuse. Which action is required?
Rationale: Nurses are mandatory reporters — reasonable suspicion, not proof, triggers the legal duty to report. Confrontation endangers the child and the investigation; the child should be interviewed separately from caregivers.
6.A client with schizophrenia tells the nurse, "The voices are telling me to hurt my roommate." What is the nurse's priority?
Rationale: Command hallucinations directing harm are a psychiatric emergency. Safety comes first: separate and supervise, then notify the provider. Arguing about the voices' reality is nontherapeutic, and medication timing follows the immediate safety response.