Mental Health & Psychiatric Nursing

✅ Reviewed by NCLEXDeck Clinical Review Board — Updated June 2026

Comprehensive NCLEX-RN Review — Therapeutic Communication, Anxiety, Depression, Bipolar, Schizophrenia, and Crisis Management

1. Therapeutic Communication

Therapeutic communication is foundational and heavily tested on the NCLEX. The correct answer almost always focuses on the client's feelings, uses open-ended and non-judgmental language, and keeps the client talking without shutting down conversation.

Therapeutic Techniques

• Open-ended questions — "Tell me more about…"
• Reflecting — "You seem upset about what happened."
• Restating — "So you're saying the medication makes you feel drowsy?"
• Clarifying — "I'm not sure I understand. Can you explain?"
• Silence — Allows the client to gather thoughts.
• Offering self — "I'll sit with you."
• Focusing — "You mentioned your chest pain — tell me more."
• Exploring — "What happened next?"
• Providing general leads — "Go on…"

Non-Therapeutic Responses (Wrong Answers)

• Giving advice ("You should…")
• False reassurance ("Everything will be fine")
• Asking "why"
• Changing the subject
• Minimizing feelings ("Don't worry about it")
• Approving/disapproving
• Defensive responses

2. Anxiety Disorders

Levels of Anxiety

Nursing Care for Anxiety

• Stay with the client; remain calm; use short, simple sentences
• Decrease stimuli; provide a quiet environment
• Do not touch a highly anxious or panicked client without permission
• For panic: safety first, never leave the client alone

Defense Mechanisms — Know These

Denial, projection, regression, rationalization, displacement, sublimation, reaction formation, undoing, compensation, repression.

Medications

• SSRIs (sertraline, escitalopram) — first-line, 2–6 weeks for onset
• SNRIs (venlafaxine, duloxetine)
• Buspirone — non-addictive; takes weeks
• Benzodiazepines — short-term only; dependence risk

3. Depression & Suicide

Assessment Findings

Depressed mood, anhedonia, sleep/appetite changes, fatigue, worthlessness, poor concentration, psychomotor changes, suicidal ideation.

Suicide Risk — Priority Content

• Direct questioning is safe and required: "Are you thinking about killing yourself?" Asking does not plant the idea.
• Highest risk: a client with a specific plan and means
• Paradoxically high risk as depression begins to lift (energy returns before mood fully improves)
• A client who suddenly becomes calm or gives away possessions may have decided on a plan — increase observation
• Implement suicide precautions: 1:1 observation, remove hazards (belts, cords, sharps, glass), no-harm/safety plan

Antidepressant Medications

4. Bipolar Disorder

Mania — Key Signs

Grandiosity, flight of ideas, pressured speech, decreased need for sleep, impulsivity, poor judgment, hyperactivity, risk of exhaustion/dehydration.

Nursing Care During Mania

• Provide high-calorie finger foods (client won't sit to eat)
• Reduce stimulation; calm, structured environment; consistent limits
• Redirect energy into non-competitive activities
• Ensure rest and hydration

Lithium — High-Yield

Key nursing points:

• Narrow therapeutic index — monitor levels regularly
• Maintain adequate sodium and fluid intake (2–3 L/day)
• Low sodium or dehydration → lithium retention → toxicity
• Other mood stabilizers: valproic acid, carbamazepine, lamotrigine (watch Stevens-Johnson syndrome)

5. Schizophrenia & Psychotic Disorders

Positive vs Negative Symptoms

• Positive symptoms (added): hallucinations, delusions, disorganized speech/behavior
• Negative symptoms (taken away): flat affect, avolition, anhedonia, alogia, social withdrawal

Nursing Care

• Hallucinations: ask what the voices are saying (assess for command hallucinations = safety risk); present reality without arguing
• Delusions: don't argue or agree; focus on underlying feeling; redirect to reality-based activities
• Build trust; be consistent; short frequent contacts

Antipsychotic Medications

Extrapyramidal Symptoms (EPS) — Know All Four

1. Acute dystonia — sudden muscle spasm, torticollis, oculogyric crisis. Emergency — treat with anticholinergic (benztropine, diphenhydramine)
2. Akathisia — motor restlessness, can't sit still
3. Pseudoparkinsonism — tremor, rigidity, shuffling gait, masklike face
4. Tardive dyskinesia — late, often irreversible involuntary movements (lip smacking, tongue). Assess with AIMS

Neuroleptic Malignant Syndrome (NMS) — Life-Threatening Emergency

S/S: Lead-pipe rigidity, hyperthermia (high fever), autonomic instability, altered mental status, elevated CK.

Nursing action: Stop the antipsychotic immediately; supportive care; dantrolene/bromocriptine.

6. Other High-Yield Topics

Eating Disorders

• Anorexia nervosa: priority = cardiac (dysrhythmias from electrolyte loss) and refeeding syndrome (monitor phosphorus). Supervise meals and bathroom for 1 hr after.
• Bulimia: electrolyte imbalance (hypokalemia), dental erosion, Russell's sign (knuckle calluses)

Substance Use Disorders

• Alcohol withdrawal: begins 6–24 hr after last drink; delirium tremens (48–72 hr) is life-threatening. Treat with benzodiazepines; give thiamine to prevent Wernicke's encephalopathy.
• Opioid withdrawal: uncomfortable but not usually life-threatening (yawning, rhinorrhea, cramping, diarrhea)

Restraints

• Least restrictive option; provider order required (time-limited, not PRN)
• Assess/document circulation, ROM, toileting frequently
• Never tie to side rails; quick-release ties to bed frame