Cumulative — all of Exams 1–3, PLUS FINAL ONLY Modules 11 & 12, and the Psychopharm reference (13/14).
Resources row up top: Medications (a card per drug), Mind Maps, PowerPoints, and slide decks.
⚙️ Module → Exam Mapping FROM YOUR KCR
Exam
Modules
Source
Exam 1
1 · 2 · 3
Exam 1 KCR ✓
Exam 2
4 · 5 · 6 · 7
Exam 2 KCR ✓
Exam 3
8 · 9 · 10
✓
Final only
11 · 12 (+ 13/14 psychopharm)
Final KCR ✓
Modules 11 (Somatic Symptom & Neurodevelopmental) and 12 (Disruptive Behaviors & Cognitive Disorders) appear for the first time on the final — per your Final Exam KCR. Both are now loaded.
🔑 Legend
Almost certainly on the exam. Memorize it.
Where the test writer is trying to fool you. Slow down.
A shortcut, mnemonic, or "oh THAT'S why."
Do this and you lose the point automatically.
Exam 1 · Deep Dive · Modules 1–3
Foundations & Neurobiology · Theories, Therapy & Settings · Therapeutic Relationships & Communication. Built from your NUR 175 Exam 1 materials.
Complete physical, mental, and social well-being — not just the absence of disease. Realizing potential, coping with normal stress, working productively, contributing to community.
🔴 Mental Illness
A dysfunction in mood, thinking, or behavior causing distress, impaired functioning, or dissatisfaction with life.
Illness seen as spiritual/demonic; treated with purging & bloodletting.
1790s
Asylums for humane care (Philippe Pinel; Dorothea Dix in the U.S.).
1800s–1900s
Scientific study expands (Freud, Kraepelin, Bleuler).
1950s
First psychotropic drugs (chlorpromazine, lithium).
1963
Community Mental Health Centers Act → deinstitutionalization / community care.
Community care upsides: family connection, independence, psych rehab. Downsides: revolving-door effect (frequent readmissions), psychiatric boarding (waiting in the ER for placement), stigma.
Short-term, goal-focused; return to pre-crisis level.
🌿 Complementary
Meditation, yoga, acupuncture; assess use without judgment.
🌟 Psych Rehab
Symptom mgmt, social skills, employment; recovery ≠ cure.
🏥 Treatment Settings (most → least restrictive)
Setting
Description
Inpatient (Acute)
Acute illness; safety, stabilization, med management.
Partial Hospitalization (PHP)
Structured day program; home at night.
Intensive Outpatient (IOP)
Several sessions/week; step-down from PHP.
Outpatient clinic
Least restrictive; therapy + med management.
Residential
Group homes, assisted living, halfway houses.
ACT
Intensive community team; 24/7; frequent contact for nonadherent clients.
⚠️ Crisis Intervention & the Team
Crisis Type
Example
Maturational
Expected transitions — retirement, marriage, new child.
Situational
Unexpected — job loss, death, divorce.
Adventitious
Disasters, mass violence, accidents.
Crisis nursing priorities:Safety first → attend to immediate needs → assess past coping → teach new coping skills. Goal = return to pre-crisis functioning.
Team: nurses, psychiatrists, psychologists, social workers, pharmacists, OTs, case managers. Nurse roles: advocate, educator, caregiver, coordinator.
Module 3 · Therapeutic Relationships & Communication
🪞 Self-Awareness & Therapeutic Use of Self
Concept
Key Point
Self-awareness
Knowing your values, beliefs, attitudes, prejudices & how they affect care.
Values
Sense of right/wrong guiding conduct.
Beliefs
Ideas held as true — may/may not be evidence-based.
Attitudes
General frame of reference (hopeful, judgmental).
Therapeutic use of self
Intentionally using your personality & awareness to build the relationship.
Self-awareness prevents bias. If your values conflict with a client's care, you must still give nonjudgmental care — or request reassignment.
🤝 Relationship Phases (Peplau)
Orientation trust, roles, contract, confidentiality; discuss termination early
→
Working identification → exploitation; coping & insight, work toward goals
→
Termination goals met; client may grieve; reinforce progress
Peplau = "mother of psychiatric nursing"; pioneered the interpersonal nurse–client relationship.
💛 Core Components
Component
Definition
Trust
Congruence — words & actions match; the foundation.
Empathy (NOT sympathy)
Objectively perceiving & communicating understanding — without taking feelings on.
Acceptance
Non-judgmental; accept the person even while limiting behavior.
Positive regard
Unconditional respect regardless of behavior/background.
Genuine interest
Authentic; selective self-disclosure from the past only.
Empathy ✅
Sympathy ❌
"I can hear how frightening that must be."
"I know exactly how you feel — I went through it too."
Keeps focus on the client; nurse stays objective
Shifts focus to nurse; blurs the boundary
👥 Nursing Roles & Transference
Role
Description
Teacher
Instructs on coping, meds, resources; honest about limits.
Caregiver
Builds & maintains the relationship; psychosocial needs.
Advocate
Informs & supports decisions; acts for the client when needed.
Parent surrogate
Parental functions while keeping adult-to-adult communication.
Transference (client → nurse)
Countertransference (nurse → client)
Attributes feelings for others onto the nurse; demands extra time, idealizes/hates, jealousy
Nurse projects own feelings; over-identifies, excessive anger, competes
More likely when nurse is an authority figure
Manage with self-awareness; discuss with supervisor
Behaviors that diminish the relationship: inappropriate boundaries (over-involvement, gifts, outside friendships), sympathy, and nonacceptance/avoidance.
🏠 Milieu Therapy
Principle
In Practice
Supportive
Acceptance, positive regard, role modeling; groups reduce isolation.
Therapeutic
Nursing station accessible; room/schedule support treatment goals.
Safe
No sharps, secured furniture, locked main entrance (prevent elopement), no alcohol/drugs/sexual activity.
Restraint & seclusion = ALWAYS the last resort. Exhaust every least-restrictive intervention first and document thoroughly.
💬 Verbal / Nonverbal Communication
Verbal
Nonverbal
The explicit words; use concrete, clear language, avoid figures of speech
Facial expression — most visible/complex signal
Congruent = words & behavior match ✅
Body language: open = accepting; crossed arms = defensive
"I've been stressed." → "Tell me more about what's causing your stress."
Focusing
"Can't sleep, anxious, arguing." → "Let's talk about the sleep first."
Making observations
"I'm fine." (crying) → "I notice you are tearful as you say that."
Offering self
"I don't want to be alone." → "I'll stay here with you for a while."
Presenting reality
"The voices say staff will hurt me." → "I don't hear anyone, but I understand it seems real to you."
Restating
"Nobody visits me." → "You feel abandoned by your family."
Reflecting
"Will I get better?" → "What are your thoughts about your recovery?"
Verbalizing the implied
"Friends stopped calling after I lost my job." → "It sounds like you feel rejected and alone."
Silence
Stay quietly present; allow reflection.
Summarizing
"Today we discussed your anxiety, sleep, and social withdrawal."
🚫 Non-Therapeutic — avoid these
Advising ("You should…")Agreeing/disagreeingApproving/disapprovingBelittling feelingsChallengingDefending othersFalse reassurance"Why" questionsChanging the subject
"Why" is almost always the wrong answer. Choose responses that validate feelings, reflect, explore, or open dialogue — never judge, advise, or falsely reassure.
Nondirective
Directive
Client leads; broad openings, reflecting, active listening. Most common approach.
Nurse leads with structure. Used when client is suicidal, in crisis, or out of touch with reality — goal is safety.
🧪 Worked Practice Questions (from your Exam-1 review)
Q1 · Initial mental health assessment — establish which first?
Options: past psychiatric history · current medications · therapeutic rapport · family history.
Answer: therapeutic rapport. Trust/rapport is foundational — it's what makes the rest of the assessment open, honest, and accurate. (Priority "first" question.)
Q2 · Client with auditory hallucinations — best initial response?
Answer: "I do not hear anything, but I understand that you do." Validates the client's experience without reinforcing the hallucination. "Ignore the voices" minimizes; "they're not real" is confrontational; "why…" is accusatory.
Answer: notify the healthcare provider. This is tardive dyskinesia (EPS) and can become permanent. Don't call it "temporary," don't continue the med, and don't tell the client to stop (that's a provider dose decision) — if pre-dose, hold & notify.
🔵 Exam 1 — Drill into a Module
🎯 Exam 1 Quiz — All Loaded Modules
Pulls every question from Modules 1–3 plus your 33-question Exam 1 practice bank (Weeks 1–3).
✍️ Written & Fill-in-the-Blank Practice
From your Weeks 1–3 question bank — tap to reveal the answer.
First American psychiatric nurse
Answer: Linda Richards
Linda Richards was the first professionally trained American nurse and the first psychiatric nurse in the United States.
Advocated for moral treatment of the mentally ill (U.S.)
Answer: Dorothea Dix
Dorothea Dix campaigned for humane treatment and opened 32 state hospitals providing asylum to the mentally ill.
Developed the therapeutic nurse–client relationship framework
Answer: Hildegard Peplau
Peplau published Interpersonal Relations in Nursing (1952) and described the phases and roles of the nurse–client relationship.
Introduced the concept of asylum as a safe refuge (Europe)
Answer: Philippe Pinel (or William Tuke)
Pinel (France) and Tuke (England) championed the concept of asylum as a humane refuge in the 1790s.
First to classify mental disorders according to symptoms
Answer: Emil Kraepelin
Kraepelin (1856–1926) systematically classified mental disorders by symptoms, laying the foundation for modern psychiatric diagnosis.
Identify the drug classification for: Clozapine (Clozaril)
Ends in "-pine"; treats both positive and negative symptoms of schizophrenia; metabolic syndrome risk.
Exam 2 · Deep Dive · Modules 4–7
Built from your NUR 175 Exam 2 study guide & KCRs.
Module 4 · Client's Response to Illness · MSE · Communication · Suicide
😶 The Big Picture — Videbeck Ch 6–8
Module 4 asks how a client responds to illness (individual, interpersonal & cultural factors), how you assess them (the Mental Status Exam), how you talk to them (therapeutic communication) and how you screen for suicide.
On the test the concept usually won't be named — a scenario is described and you pick the right factor/term. Understand it, don't just memorize the list.
Assessment is ONGOINGSubjective + Objective dataPrivate, calm setting
🧠 Individual Factors — What the Client Brings
Protective when strong, risk factors when weak.
Factor
Key Points
Age & Development
Younger onset = poorer outcomes. Erikson's stages — each requires completion of the prior stage. Illness can cause regression to an earlier stage.
Belief that my own effort & abilities can change my life. Built via mastery, modeling, persuasion, managing stress states. Called "very important" for coping.
Hardiness
The 3 C's: Commitment · Control · Challenge. Buffers stress.
Problem-solving to manage daily life; health-seeking behavior; self-monitoring of thoughts.
Spirituality
Meaning/purpose in life — NOT the same as religion. Hope correlates with fewer symptoms. Always build into care.
Spirituality ≠ religion. Spirituality = meaning/purpose; religion is one possible expression of it.
🌱 Erikson's Stages — Ascending Development
Each stage requires completion of the prior stage.
Stage
Age
Task vs. Risk
Virtue
Infant
0–1
Trust vs. Mistrust
Hope
Toddler
1–3
Autonomy vs. Shame
Will
Preschool
3–6
Initiative vs. Guilt
Purpose
School Age
6–12
Industry vs. Inferiority
Competence
Adolescent
12–20
Identity vs. Role Confusion
Fidelity
Young Adult
20–40
Intimacy vs. Isolation
Love
Middle Adult
40–65
Generativity vs. Stagnation
Care
Maturity
65+
Ego Integrity vs. Despair
Wisdom
Items give an age + a behavior and ask if development is on track. A 30-yr-old withdrawing/avoiding others is failing Intimacy → Isolation. A 55-yr-old who can't relinquish full-time parenting of grown children is failing Generativity → Stagnation. A young adult with 3–4 close friends is succeeding (Intimacy achieved).
🌍 Interpersonal & Cultural Factors
Interpersonal: Sense of belonging = Value (feeling needed) + Fit (feeling you mesh in). Social support (emotional sustenance) differs from social contact (small talk). Two keys: the client perceives support as helpful AND it provides what the client wants.
Culture has the PRIMARY influence on health beliefs. Giger & Davidhizar's 6 cultural phenomena:
🗣️ Communication
Touch, eye contact, greetings differ.
↔️ Space
Comfortable distance varies.
👪 Social Organization
Family structure, decision-making.
⏰ Time Orientation
Don't label as "noncompliant."
🎛️ Environmental Control
Affects health-care seeking.
🧬 Biologic Variations
Drug metabolism, disease prevalence.
Cultural Humility (Box 7.1): be open/inquisitive · self-aware · egoless · self-reflect · embrace lifelong learning. ALWAYS ASK — never assume.
PROCESS = HOW they think (flight of ideas, loose associations, clang, word salad). CONTENT = WHAT they think (delusions, SI/HI, ideas of reference, broadcasting). Classic exam swap.
"People can read my mind"
→
"I can see you're concerned about your privacy."
🔬 Objective vs. Subjective + Special Tools
Objective = observed/measured by the data collector: a CIWA score of 10, a recorded 5/10 mood rating, vital signs, observed behavior. Subjective = the client's own perception: "I feel anxious," reported anorexia.
A rating recorded on a scale is objective even though it started as a feeling — SATA items love to sort these.
Literal interpretation (depression & schizophrenia). Be consistent, avoid idioms.
🗣️ Aphasia/Dysarthria
Post-stroke: listen attentively, allow time, don't interrupt.
💬 Therapeutic Communication — Memorize BOTH Tables
Heavily tested on every exam. The model therapeutic response = making an observation (objective, non-judgmental, non-projecting): "I see you have on clean clothes and combed your hair."
✅ THERAPEUTIC
🚫 NON-THERAPEUTIC
Making observations
Giving advice
Open-ended questions
False reassurance ("everything will be fine")
Silence
Asking "WHY" (sounds accusatory)
Reflection · Clarification
Changing the subject
Offering self ("I'll sit with you")
Minimizing feelings
Active listening · eye level
Approving / disapproving
"Why did you stop your meds?"
→
"Tell me what happened with your medication."
Therapeutic communication is also the first-line de-escalation tool — "listen to their concerns." Allow silence; it is therapeutic.
⚠️ Suicide Assessment (Box 8.2) — ASK DIRECTLY
Asking does NOT give someone the idea to die — it is the nurse's professional responsibility. Avoiding it out of discomfort is a form of negligence.
Assess in order — the more specific, the higher the risk:
I · Ideation
"Are you thinking about killing yourself?"
P · Plan
"Do you have a plan?"
M · Method
"How do you plan to do it?"
A · Access
"Do you have access to the means?"
W · Where/When
Specifics raise the risk.
A specific, accessible, lethal plan = highest risk. These IPMAW elements are separate from MSE judgment/insight — a common SATA distractor.
A suddenly CALM client who is giving away possessions may have a finalized plan. This is NOT improvement — it is a red flag.
leave a high-risk client alone. STAY with them, remove means, notify provider, start 1:1 / safety precautions.
🧠 Practice — A 30-year-old avoids all social contact and has no close relationships. Which Erikson conflict is he failing?
Answer: Intimacy vs. Isolation → he is trending toward Isolation. Young adult (20–40) task is Intimacy; failure to form close bonds = isolation.
🧠 Practice — Client says "I feel like a failure," rated mood 4/10, HR 96, states "I can't sleep." Which are OBJECTIVE?
Answer: The recorded mood rating (4/10) and HR 96 are objective (measured/recorded). "I feel like a failure" and "I can't sleep" are subjective (client's perception).
An involuntarily committed client loses ONLY the right to freedom (to leave). ALL other rights remain intact — including the right to refuse treatment.
✅ Rights Retained
Receive AND refuse treatment · least restrictive environment · involved in plan of care · refuse research · unrestricted visitors/mail/phone.
🏥 Commitment
Involuntary only if imminent threat to self/others.
⏱️ Emergency Hold
~48–72 h (facility-specific, NOT a flat 48), then a hearing is required.
🔐 HIPAA
Mental-health/substance records get EXTRA protection.
Mandatory outpatient treatment: court-ordered post-discharge care (47 states + DC).
🔐 Confidentiality — The 3 Legal Breaks of HIPAA
1️⃣ Duty to Warn
Notify a specific, identifiable threatened person (Tarasoff).
2️⃣ Report Abuse
Suspected child or elder abuse (mandated reporter).
3️⃣ Treating Providers
Communicate with others on the care team.
Duty to Warn (Tarasoff) — how it appears: breach confidentiality to warn a specific, identifiable, accessible victim of a credible, serious threat. Notify only the named victim — NOT the police.
"I hate all police" / "I hope everyone dies"
→
No named victim = NO duty to warn
"If I can't have my girlfriend back, no one can"
→
Identifiable victim = WARN her
The item won't say "duty to warn" — it will describe a specific, serious, credible threat to a named person. General hostility is not enough.
📋 Torts & Nursing Liability
Tort
Type
Key Element
Exam Example
Negligence
Unintentional
Fails to act as a prudent nurse
Not monitoring a suicidal client
Malpractice
Unintentional
ALL 4: Duty + Breach + Injury + Causation
Wrong-dose med error that harms & isn't reported
Assault
Intentional
Creating FEAR of harmful contact
"Take this pill or I'll inject you"
Battery
Intentional
Actual harmful/unwanted contact
Nurse pushes a client; injury during forced restraint
False Imprisonment
Intentional
Unjustifiable detention
Secluding a non-threatening loud client "for peace and quiet"
Assault = THREAT (no contact needed). Battery = CONTACT. Both are intentional and can occur simultaneously. Malpractice requires injury — miss one of the 4 elements and it isn't malpractice. Intent is NOT required for malpractice.
🏛️ 6 Ethical Principles (Deontology)
Principle
Meaning
Exam Tip
Autonomy
Right to self-determination
Refusing treatment = autonomy in action
Beneficence
Promote good / benefit client
Positive obligation to act
Nonmaleficence
Do no harm
"First, do no harm"
Justice
Treat all fairly
Equal care regardless of status
Veracity
Be honest/truthful
Report a witnessed med error to instructor + primary nurse + document
Fidelity
Honor commitments
Follow through on care plans
Most common psych dilemma = client AUTONOMY vs. PUBLIC SAFETY. Utilitarianism = greatest good for the greatest number ("the end justifies the means"). Example: a suicidal client refuses hospitalization.
🔒 Seclusion & Restraint
use seclusion/restraint as punishment. Goal = restore self-control & safety. LAST resort only — client imminently dangerous AND all less-restrictive measures failed.
Try first: verbal de-escalation, reduce stimuli, offer choices, give the ordered PRN. "De-escalation = talking, walking, and medication FIRST."
Requirement
Adults
Children/Adolescents
Face-to-face eval
Within 1 h, then every 8 h
Every 4 h
MD order renewal
Every 4 h
Every 2 h
Nurse assessment
Every 1–2 h
Every 1–2 h
Monitoring
1:1 whole restraint; seclusion 1:1 first hour then audio/video
1:1
Debriefing
Within 24 h of release
Within 24 h
4-point restraints fit the client who is hostile & threatening staff/others — NOT the merely intrusive, demanding, noncompliant, or manipulative client. Check circulation, skin, hydration, toileting.
💔 Grief & Loss — Four Theories
Grief = the feelings. Grieving/mourning = the process. Loss isn't only death.
Theory
Phase 1
Phase 2
Phase 3
Phase 4
Phase 5
Kübler-Ross
Denial
Anger
Bargaining
Depression
Acceptance
Bowlby
Numbness
Yearning
Disorganization
Reorganization
—
Engel
Shock
Awareness
Restitution
Resolution
Recovery
Horowitz
Outcry
Denial/Intrusion
Working Through
Completion
—
Grief is NOT linear. Clients move back and forth, skip, or stay in a stage — even after acceptance they can return. There is NO right way to grieve.
🔁 Rando's 6 R's & the 5 Dimensions
Recognize
Experience the loss as real.
React
Feel the emotional response.
Recollect & Reexperience
Review and relive memories.
Relinquish
Accept the world has changed.
Readjust
Return to daily life.
Reinvest
Re-enter the world; new relationships.
Rando = the six R's. "Recover" & "Restitution" belong to Engel, not Rando — classic distractor swap. "Read" is never a real grieving task.
5 Dimensions of grieving:
Cognitive: why? shattered assumptionsEmotional: anger, guilt, numbnessSpiritual: anger at God, lost meaningBehavioral: crying, searching, substance usePhysiological: insomnia, headache, poor appetite
🕊️ Disenfranchised & Complicated Grief + Nursing Care
Disenfranchised grief = loss not openly acknowledged or socially supported: pet death, miscarriage, same-sex partner, incarcerated loved one, ex-spouse. Real grief, no validation.
Complicated grief risk factors: death of spouse/child · sudden/unexpected death · suicide or murder · multiple losses · prior psychiatric disorder · low self-esteem · absent/unhelpful family.
With complicated grief, assess SAFETY first — depression & suicidal thoughts are the priority. Physical signs: impaired immune system, ↑ serum prolactin, ↑ mortality from heart disease.
Aguilera's 3 factors for healthy resolution: adequate Perception + adequate Support + adequate Coping.
DO: allow useful denial early · presence · correct faulty assumptions · review past coping · assess safety
vs
DON'T: "It will get better" · "they're in a better place" · rush a stage · block negative talk
🔬 Go Deeper — The Insanity Defense
Insanity has a legal meaning but no medical definition; state law decides which of four versions applies. When criteria are met a person may be found not guilty by reason of insanity. Public perception says it is used often and succeeds — in reality it is used infrequently and rarely succeeds, but the rare success is widely publicized.
A few states allow "guilty but insane." Four states — Idaho, Kansas, Montana, Utah — abolished the insanity defense (all but Kansas allow "guilty but insane"). Utah is local to you. Competency to stand trial is a separate concept.
⚖️ Practice — A client tells the nurse, "When I get out, I'm going to kill my brother Mark." What must the nurse do?
Answer: Duty to warn (Tarasoff). Breach confidentiality to notify the named, identifiable victim (Mark) — not the police in general. The threat is specific, serious, and credible.
⚖️ Practice — A nurse tells a client, "If you don't take this medication, I'll have you held down and injected." No contact occurs. Which tort?
Answer:Assault — creating fear of harmful/unwanted contact. No touch happened, so it is not battery; both are intentional torts.
Normal emotion — positive when assertive; negative when denied, suppressed, or expressed inappropriately.
Hostility
Verbal aggression: intent to intimidate or cause emotional harm.
Physical Aggression
Attacks, injures, or destroys property.
Assertive Communication
"I feel angry when you interrupt me" — NOT "You make me angry."
Aggression usually escalates predictably through the cycle — that predictability is what lets nurses intervene early.
🥊 Catharsis Myth — Exam Trap
Catharsis (punching a bag/pillow) is WRONG — research shows it may INCREASE anger, not reduce it.
Punching bag / venting
→
Walking or talking
Verbalization of feelings reduces physical aggression — clients who can talk about anger are LESS likely to become physically aggressive.
🔬 Etiology & Related Disorders
Neurobiology: no single cause. Low serotonin (inhibitory) → increased aggression. Increased dopamine & norepinephrine → impulsive violent behavior. Damage to the limbic system and frontal/temporal lobes impairs modulation of aggression.
Directive approach; set clear limits; calm low voice; offer choices; time-out, PRN, show of force
3 · Crisis
Loss of control, physical aggression
Trained team response; restraint/seclusion ONLY if all else fails
4 · Recovery
Decreased tension, lower voice, apologizing
Maintain calm; help regain self-control; do NOT debrief yet
5 · Post-Crisis
Remorse, shame, return to baseline
Debrief within 24 h; review triggers; reinforce positive coping
Intervene EARLY — act in triggering/escalation, BEFORE crisis. Clenched fists + flushed face + yelling + pacing = Escalation (Crisis = actual loss of control + physical aggression).
🏢 Workplace Hostility & Community Care
In 2016 the Joint Commission added workplace bullying (lateral/horizontal violence) to its safety initiative. Bullying = abusive conduct: verbal abuse; threatening/intimidating/humiliating behavior; work interference (sabotage). Ostracism (deliberately excluding someone) is an increasingly common, damaging form.
Less aggression occurs on units with strong leadership, clear roles, and planned activities. Community-based care: anger-management & violence-prevention programs, support groups, follow-up. The nurse models assertive (not aggressive) communication and teaches early recognition of escalation cues.
🚨 Abuse & Violence — Overview
LEAVING the abuser is the MOST dangerous moment — homicide risk skyrockets because the abuser is losing control.
Type
Key Facts
IPV
1 in 5 women, 1 in 7 men. Violence INCREASES during pregnancy. Leaving INCREASES homicide risk. Types: psychological, physical, sexual (often combined).
Child Abuse
Physical, emotional, sexual, neglect. Emotional abuse = hardest to treat. Mandated reporter — do NOT confront parents; consult team.
Elder Abuse / Self-Neglect
Inability to manage finances, poor self-care, unusual injury explanations. Bullying also occurs between senior-living residents.
Rape / Sexual Assault
Allow expression, provide privacy, STAY with client, offer beverages, contact support. Do NOT rush the exam. SANE nurse does the forensic exam.
🔑 Dynamics — Why It Happens & Why Victims Stay
Power & Control
Abuser sees victim as property, not an equal — not "loss of temper."
Intergenerational
Violence learned through role modeling.
Social Isolation
Victims kept silent by threats.
Alcohol/Drugs
Diminish inhibition — NOT the cause.
Why victims stay: fear of increased violence/death · financial & emotional dependence · children/custody · shame, isolation, self-blame.
ask "Why didn't you just leave?" — it is victim-blaming.
🩺 Nursing Priorities & Mandated Reporting
Situation
Nursing Priority
Child abuse
Do NOT confront parents. Consult the team. Report SUSPECTED (not proven). Avoid leading questions.
SANE does forensic exam. Allow expression, offer comfort (coffee/tea), STAY with client, don't rush exam. Offer emergency contraception & STI prophylaxis.
Nurses are mandated reporters for child & elder abuse (specifics vary by state). Report SUSPECTED abuse, not proven. Refer to the client as a "survivor," not "victim" — more empowering.
leave a shocked assault survivor alone (she may be in shock) or rush the examination (adds trauma).
🔥 Practice — A client has clenched fists, a flushed face, and is pacing and yelling. Which aggression phase, and the priority action?
Answer:Escalation (phase 2). Priority: set clear limits with a calm, low voice; offer choices/PRN/time-out — intervene NOW, before crisis. Crisis is actual loss of control + physical aggression.
💔 Practice — A nurse suspects a 4-year-old is being abused. What is the best action?
Answer: Consult with a professional member of the health team about making a report. Report suspected abuse. Do NOT confront the parents (may increase risk) and do NOT ask leading questions.
Meds + CBT combined is more effective than either alone. Stronger cultural identity → LESS PTSD; assimilating quickly (abandoning culture) is LEAST helpful.
🧷 Grounding & PTSD Nursing Care
Grounding during flashbacks/dissociation: "What are you feeling?" · "Do you feel your feet on the floor?" · "Can you see me and the room?" Call by name · reorient to date/place · turn on lights · encourage position change (walking disperses the dissociative state).
grab or force movement. Ask about touch preference BEFOREHAND — unasked touch during a flashback can trigger a defensive/aggressive response.
Assessment Area
Findings in PTSD
Appearance
Hyperalert; startle to small noises; needs more personal space
Insomnia/nightmares; often uses alcohol/drugs to blunt intrusions
Relationships
Problems with authority; difficulty trusting; social avoidance
PRIORITY problems: risk of self-mutilation · risk of suicide. Then ineffective coping, low self-esteem, disturbed sleep, social isolation. Call the client a "survivor," not "victim."
Most helpful for a dissociative client who has difficulty expressing feelings = journaling (feelings list + rate intensity 1–10). Grounding is for active flashbacks/dissociation — don't mix them up.
👓 Related Disorders
Disorder
Key Feature
Notes
Adjustment Disorder
Coping problems after a stressful event
Symptoms within 1 month; resolve within 6 months; triggers = financial, relationship, work
Acute Stress Disorder
PTSD-like 3 days–4 weeks post-trauma
Can precede PTSD; CBT can prevent progression
RAD (child <5)
Minimal social/emotional response to caregivers
From grossly pathogenic care (abuse/neglect); resists social contact
DSED (child <5)
Indiscriminately friendly with anyone
Same cause as RAD; no stranger caution
Dissociative Amnesia
Can't recall important personal info
May include fugue — travel + new identity
DID
2+ distinct identities take control
Strongly linked to childhood abuse; client is NOT psychotic
Don't mislabel a DID client as psychotic — they are not.
Field reduced to one detail; dread; ritualistic; can't problem-solve — still reality-based
STAY with client; lower anxiety FIRST; low calm voice
PANIC
No environmental processing; loss of rational thought; possible delusions/hallucinations — NOT reality-based
SAFETY IS PRIORITY; remain; quiet room; "You are safe"; lasts 5–30 min
SEVERE = still reality-based. PANIC = NOT reality-based. Heavily tested. Anxiety is contagious — remain calm yourself. Teach relaxation ONLY when anxiety is MILD.
📋 Anxiety Disorders & Gain
Disorder
Key Feature
Treatment
Panic Disorder
Recurrent unexpected attacks (15–30 min); chest pain/SOB mimics MI; fear of next attack; often agoraphobia
CBT, deep breathing, benzos, SSRIs
Agoraphobia
Fear of open/public spaces; often homebound; primary & secondary gain
Severe anxiety in social/performance situations; fear of judgment
CBT, positive reframing, assertiveness, SSRIs
GAD
Excessive worry ≥50% of days for 6+ months; 3+ symptoms (uneasiness, irritability, muscle tension, fatigue, poor concentration, sleep changes)
Buspirone, SSRIs/SNRIs, CBT
Primary gain = relief of anxiety by performing the avoidance behavior. Secondary gain = attention/caring from others as a result of it.
🔬 Etiology & CBT Techniques
Neurobiology:GABA is the inhibitory (natural antianxiety) neurotransmitter believed dysfunctional in anxiety. Norepinephrine excites cellular function (excess suspected in panic, GAD, PTSD). Serotonin (5-HT1a) plays a role in anxiety, OCD, panic & GAD. Anxiety disorders show familial incidence.
Positive Reframing
"This is just anxiety — it will pass."
Decatastrophizing
"What's the worst that could happen? Could you survive it?"
Systematic Desensitization
Progressive exposure to the phobic object in a safe setting.
Flooding
Rapid confrontation — ONLY by a trained therapist with client consent.
Thought-Stopping
Splash face with cold water, shout "STOP."
Assertiveness Training
"I" statements — name feelings & needs.
💊 Anxiety Medications — Safety Ranking
SSRIs are first-line for most anxiety disorders — NOT benzodiazepines.
Drug
Class
Used For
Key Notes
Fluoxetine (Prozac)
SSRI
Panic, GAD
First-line; low dependence; takes 2–4 wk
Paroxetine (Paxil)
SSRI
Social phobia, GAD
Can increase anxiety initially
Sertraline (Zoloft)
SSRI
Panic, social phobia, GAD
Low side-effect profile
Venlafaxine (Effexor)
SNRI
PTSD, GAD
First-line for PTSD; monitor BP
Buspirone (BuSpar)
Non-benzo
Chronic anxiety, GAD
NO dependence; takes 3–4 wk (ATI); NOT for acute anxiety; not a controlled substance
Lorazepam (Ativan)
Benzodiazepine
Severe/panic, acute
HIGH dependence; short-term only (4–6 wk)
Alprazolam (Xanax)
Benzodiazepine
Panic, social phobia
HIGH dependence; short-term only
Propranolol (Inderal)
Beta-blocker
Situational/performance anxiety
Bradycardia risk
Benzodiazepines (Ativan): enhance GABA → CNS depression. Assess ALCOHOL use BEFORE starting (benzo + alcohol = respiratory depression). Short-term only; taper, never stop abruptly. Older adults: significant ↑ hip-fracture (fall) risk → fall precautions. Reversal agent = flumazenil.
☀️ Nursing Care for the Anxious Client
DO: STAY at severe/panic (safety) · lower anxiety FIRST · quiet area · short, simple statements ("You are safe") · remain calm
vs
DON'T: teach relaxation during severe/panic · force choices · leave alone · match their energy
🫀 Practice — A client is having a flashback and appears terrified. The nurse wants to help physically. What must she do first?
Answer: Ask about touch preference beforehand and use grounding (call by name, "feel your feet on the floor," reorient, lights on, encourage movement). Never grab or force — unasked touch can trigger a defensive/aggressive response.
💊 Practice — A provider orders lorazepam (Ativan) for a new client. What is the PRIORITY assessment?
Answer: The client's alcohol use. Benzo + alcohol (both CNS depressants) = risk of respiratory depression. Also note high dependence (short-term only) and fall/hip-fracture risk in older adults.
🌡️ Practice — How do you tell SEVERE from PANIC anxiety, and what changes in your care?
Answer: SEVERE = perceptual field reduced to one detail but still reality-based. PANIC = NOT reality-based (loss of rational thought, possible hallucinations, adrenal surge). In both: stay with the client. In panic, safety is the priority; no teaching, no forced choices.
🟣 Exam 2 — Drill into a Module
🎯 Exam 2 Quiz — All Loaded Modules
Pulls every question from every loaded Exam 2 module.
Exam 3 · Deep Dive · Modules 8–10
Built from your NUR 175 Exam 3 deep-dive study guide, KCRs & Quizlet.
📋 Exam 3 KCR — Official Content Review Checklist
Straight from your instructor's Key Content Review doc. If it's on this list, it's fair game.
🧩 Module 8 — OCD & Schizophrenia
OCD + related disorders: etiology, treatment. Schizophrenia: positive (hard) vs negative (soft) symptoms, clinical course, related disorders, etiology, treatment, full nursing process.
Substance types, treatment & prognosis; nursing process for alcohol/opiates; substance use in health professionals; anorexia vs bulimia comparison, etiology, treatment.
Anxiety is a normal alarm. It becomes a disorder when it is out of proportion, persistent, and impairs function.
Fear has a clear external object (a snake). Anxiety is a vague, internal dread with no clear object. Both fire the sympathetic fight-or-flight response.
🎶 The 4 Levels of Anxiety + Interventions
The single most testable anxiety concept. As anxiety rises, the perceptual field narrows and the ability to learn drops. Match the intervention to the level.
Level
What you see
Can they learn?
Nursing intervention
Mild
Alert, motivated, sharper senses, fidgety
✅ Best learning state
Teach now — "teachable moment." Channel energy.
Moderate
Selective attention, ↑HR/RR, tension
✅ With direction
Calm presence, focus attention, teach with guidance.
Severe
Focus on one detail, headache, nausea, confusion
❌ No
Calm, firm short directions. Do NOT teach. Reduce stimuli, stay with them.
Panic
Loss of control, terror, distorted perception, may flee/strike out
❌ No
SAFETY. Stay, low-stimulation room, calm short statements, never leave alone.
At severe and panic levels the client cannot learn — so "teach deep breathing" or "explore the cause" are WRONG. Priority = safety + reducing stimulation.
Order: Mild → Moderate → Severe → Panic. "Learning" lives only in the first two.
🌀 The Anxiety Disorders
Reveal · GAD, Panic, Phobias
Generalized Anxiety Disorder (GAD): excessive, uncontrollable worry about many things, more days than not, for ≥ 6 months. Restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance. First-line = SSRIs/SNRIs; buspirone for chronic anxiety (non-addictive, takes weeks); benzodiazepines only short-term.
Panic Disorder: recurrent, unexpected panic attacks — abrupt surge of intense fear peaking within minutes: palpitations, chest pain, SOB, dizziness, paresthesias, fear of dying, plus worry about the next attack.
Phobias: specific phobia (marked fear of an object/situation, knows it is excessive); agoraphobia (fear of places where escape is hard — crowds, transit, open spaces); social anxiety disorder (fear of scrutiny/embarrassment). Gold standard = exposure-based therapy (systematic desensitization, flooding).
Buspirone is NOT PRN and NOT for acute panic — it takes 3–4 weeks (ATI's number).
Panic attacks MIMIC a heart attack. Always assess/rule out a cardiac or physical cause FIRST.
Agoraphobia = Afraid to be Away from a safe place.
Obsessions = intrusive, unwanted thoughts → cause anxiety. Compulsions = repetitive behaviors/rituals to neutralize that anxiety. Relief is temporary, reinforcing the cycle.
Obsession (thought)
→
Anxiety ↑↑
→
Compulsion (ritual)
→
Brief relief
Nursing care for compulsions: early on, ALLOW time for the ritual — blocking it abruptly causes severe anxiety/panic. Build trust, then gradually set limits. Meds: SSRIs (higher doses) + clomipramine. Therapy: ERP (Exposure & Response Prevention).
🪞 Body Dysmorphic (BDD)
Preoccupation with imagined/slight defect; mirror-checking. High suicide risk.
OCD is ego-dystonic — thoughts feel wrong. OCPD is ego-syntonic — rigid perfectionism feels correct, no true obsessions/compulsions.
🗣️ Therapeutic Communication Cheat Sheet
✅ DO (Therapeutic)
Open-ended ("Tell me more…"), reflecting/restating, offering self ("I'll sit with you"), silence, acknowledge feelings ("That sounds frightening"), focus on the here-and-now.
🚫 DON'T
"Why" questions (accusatory), false reassurance ("Everything will be fine"), giving advice/approval, changing the subject, closed yes/no questions, minimizing.
"Why do you feel that way?" sounds caring but is non-therapeutic — it puts the patient on the defensive. Pick the open-ended option instead.
🧪 Quick Self-Check
Reveal · A client washes their hands until they bleed. Initial plan?
Structure the schedule to ALLOW time for the ritual. Abruptly blocking a compulsion causes severe anxiety; initially allow time, then gradually set limits.
Reveal · At which anxiety level is a client BEST able to learn?
Mild-to-moderate — anxiety sharpens focus enough to learn. Severe and panic block learning.
Reveal · New panic disorder with chest pain, palpitations, SOB — do FIRST?
Assess and rule out a cardiac/physical cause first — panic mimics an MI.
Module 8 · Schizophrenia & Psychotic Disorders
🧠 Schizophrenia — In Depth
A chronic psychotic disorder: a split from reality (NOT "split personality"). Onset usually late teens–mid 20s. Meds manage symptoms; they do not cure. Risk rises with family history (15% with 1 parent, 35% with 2; highest in identical twins).
Dopamine Hypothesis: too much dopamine in the mesolimbic pathway → positive symptoms (antipsychotics block D2). Low dopamine in the mesocortical pathway → negative symptoms. This is WHY 1st-gen agents help positive but barely touch negative symptoms.
➕ Positive vs ➖ Negative Symptoms
Positive = ADDED.Negative = LOST normal functions. Negative symptoms respond best to 2nd-gen antipsychotics and are hardest to treat.
Flat affect, anhedonia, alogia, avolition are NEGATIVE. "Positive" ≠ good; it means added.
👂 Hallucinations — Types + Responses
A hallucination = a false sensory perception without an external stimulus. Auditory is most common.
Type
Sense
Example
Auditory (most common)
Hearing
Voices commenting/commanding
Visual
Sight
Seeing things that aren't there (delirium/substance)
Olfactory
Smell
Smelling odors (think seizure/organic)
Gustatory
Taste
Tasting "poison" — feeds paranoia
Tactile
Touch
Bugs crawling on skin (formication)
Cenesthetic
Body function
Feeling blood pulsing
Kinesthetic
Movement
Feeling movement when still
"Those aren't real, stop it" (denies) — and NEVER "I see them too" (reinforces). Acknowledge feeling → present reality → redirect.
✅ Respond therapeutically: don't argue, don't confirm. "I don't hear that, but I understand it feels real to you." Acknowledge feeling + reality ("That sounds frightening. You are safe here"), assess for command hallucinations ("Are the voices telling you to hurt yourself or anyone?"), then redirect.
COMMAND hallucinations to harm self/others = safety emergency. Ask directly what the voices command and protect everyone.
🧩 Delusions — All Types
A delusion = a fixed, false belief not changed by evidence.
Type
Belief / Example
Persecutory / Paranoid
"The FBI planted cameras to spy on me."
Grandiose
"I am the president and I'm immortal."
Referential (idea of reference)
"The TV anchor sends me secret messages."
Somatic
"My organs are rotting."
Religious
"God speaks only through me."
Erotomanic
"That celebrity secretly loves me."
Nihilistic
"I am dead. The world has ended."
Thought broadcasting / insertion / withdrawal
"Everyone can hear my thoughts / they steal my thoughts."
Control / Influence
"A chip controls my movements."
✅ Responding to delusions: don't argue and don't agree. Acknowledge feeling, voice gentle reality, then redirect. For food paranoia, offer sealed, unopened packaged foods the client opens.
🗨️ Disorganized Speech / Thought Disorder
Term
What it is
Loose associations
Ideas shift with no logical link
Clang association
Words chosen for SOUND/rhyme ("train, brain, rain")
Neologism
Made-up words, private meaning
Word salad
Jumble of unrelated words
Echolalia / Echopraxia
Repeating others' words / imitating movements
Tangentiality
Wanders off, NEVER returns to the point
Circumstantiality
Over-detailed but EVENTUALLY answers
Flight of ideas
Rapid connected jumps (mania)
Thought blocking
Speech stops mid-thought
Clang = rhyme. Word salad = chopped-up, no meaning. Neologism = new word. Tangent = never lands; Circumstantial = circles but lands.
📈 Phases & Related Psychotic Disorders
1. Prodromal
→
2. Acute/Active
→
3. Stabilization
→
4. Maintenance
Nonadherence is the #1 cause of relapse — long-acting injectable antipsychotics help.
Disorder
Key distinguisher
Schizophrenia
Symptoms ≥ 6 months
Schizophreniform
1–6 months
Brief psychotic disorder
< 1 month, often post-stressor, full recovery
Schizoaffective
Schizophrenia + a major mood episode; psychosis also without mood symptoms
Delusional disorder
≥1 month of delusions, otherwise functions normally
Shared psychotic (folie à deux)
Delusion "transferred" within a close relationship
When a client is actively hallucinating mid-conversation, the BEST action is to ask directly — not to ignore it and not to play along.
🧪 Quick Self-Check
Reveal · "The FBI planted cameras in my room to watch me." Type?
Persecutory (paranoid) delusion — a fixed false belief of being watched/harmed.
Reveal · Full schizophrenia symptoms lasting only 2 months = ?
Depersonalization — a sense of detachment from one's own self.
Module 9 · Mood Disorders & Suicide
🌗 Mood Disorders Overview
Two poles: depression (down) and mania (up). Unipolar = depression only. Bipolar = swings between.
⬇️ Major Depressive Disorder (MDD)
≥ 5 symptoms for ≥ 2 weeks, must include depressed mood OR anhedonia, with impairment.
🧠 SIG E CAPS — Sleep ↑/↓ · Interest lost (anhedonia) · Guilt/worthlessness · Energy ↓ · Concentration ↓ · Appetite/weight change · Psychomotor agitation/retardation · Suicidal ideation.
Nursing priorities:safety first — assess suicide risk directly. Meet basic needs (nutrition, hydration, sleep, hygiene). Spend time even if the client doesn't talk; avoid false cheerfulness. Watch the energy-return window (see below).
Treatment: SSRIs/SNRIs first-line; TCAs/MAOIs later; ECT for severe/treatment-resistant; CBT/IPT. Full effect takes 2–6 weeks.
🧠 Vegetative signs = the physical symptoms — SLEEP, EAT, MOVE, POOP, SEX. Insomnia, anorexia/weight loss, psychomotor retardation, fatigue, constipation, ↓libido. ATI uses this exact phrase.
Vegetative-sign care: provide decaffeinated beverages, high-calorie finger foods and frequent snacks, weigh daily or weekly, fluids + fiber for constipation, assist with ADLs. Do NOT schedule daytime naps — they worsen night insomnia. Do NOT limit snacks. Do NOT weigh only monthly.
⬆️ Bipolar Disorders
Type
Defining feature
Bipolar I
At least one full MANIC episode (≥1 week, or any length if hospitalized).
Bipolar II
Hypomania + a major depressive episode. Never full mania.
Search belongings; check med "cheeking"; 1:1 during meals.
Frequent, unpredictable checks if not 1:1; document mood & statements.
Safety plan; never promise to keep suicidal plans "secret."
Reduce precautions just because a client on a new antidepressant suddenly seems "cured/energized" early in treatment.
⚡ Antidepressant Energy-Return Window: early in therapy (first 1–2 weeks) energy & motivation return BEFORE mood lifts — giving a still-hopeless client the energy to act. Suicide risk is HIGHEST here. Black-box warning: increased suicidality in clients < 24.
Antidepressants give energy before joy. Energy + hopelessness = danger.
🧪 Quick Self-Check
Reveal · Depressed inpatient: "My family would be better off without me." Best response?
"You sound very upset — are you thinking of hurting yourself?" This signals possible suicidal ideation and requires a direct assessment.
Reveal · Manic client hasn't eaten or slept for 2 days — best nutrition intervention?
Provide high-calorie finger foods and drinks they can consume while moving. They cannot sit to eat.
Reveal · SIG E CAPS — is "decreased need for sleep with high energy" depression?
No — that is MANIA. SIG E CAPS covers sleep disturbance, anhedonia, guilt, ↓energy, ↓concentration, appetite change, psychomotor change, suicidality.
Modules 9–10 · Personality · Substance Use · Eating
🎭 The 10 Personality Disorders
Enduring, inflexible patterns that deviate from culture, are stable over time, cause impairment, and are ego-syntonic (feel correct) — so insight and change are slow. Three clusters.
A = weird (Odd/Eccentric)B = wild (Dramatic/Erratic)C = worried (Anxious/Fearful)
Cluster A — Odd/Eccentric
Paranoid (distrust, grudges) · Schizoid (detached loner, doesn't desire relationships) · Schizotypal (odd beliefs/magical thinking, not full psychosis).
Cluster B — Dramatic/Erratic
Antisocial (disregard for rights, no remorse, ≥18yo) · Borderline (unstable, fear of abandonment, self-harm, splitting) · Histrionic (attention-seeking, dramatic) · Narcissistic (grandiosity, no empathy).
Cluster C — Anxious/Fearful
Avoidant (wants relationships but fears rejection) · Dependent (excessive need to be cared for) · OCPD (perfectionism/rigidity, ego-syntonic — NOT OCD).
🔀 Borderline & Splitting
Borderline (BPD) hallmarks: fear of abandonment, unstable relationships/identity/affect, impulsivity, self-harm and suicidal behaviors, and splitting.
Splitting = viewing people as all good or all bad. Counter with a consistent, unified team and firm boundaries. Promising secrecy FEEDS splitting.
Rehab referral, AA/12-step, naltrexone · acamprosate · disulfiram, written relapse plan
Exam trap — hallucinosis vs DTs: alcoholic hallucinosis (12–24 h) = hallucinations with intact orientation and near-normal vitals. DTs (48–72 h) = hallucinations PLUS disorientation and autonomic instability. Hallucinosis is not DTs.
🔥 Untreated DTs can kill (up to ~20% mortality; ~1–5% treated). Highest risk: long heavy drinking history, prior DTs or withdrawal seizures, age >30, medical illness, CIWA-Ar >15.
CIWA-Ar under 8 = mild (supportive care) · 8–15 = moderate (medicate) · over 15 = severe (aggressive benzos, watch for DTs).
🧪 Every Substance on Exam 3 — Intoxication · Withdrawal · Treatment
Module 10 / Videbeck Ch 19. Read the Danger tier box first — that is where the test questions live.
Dizzy, slurred speech, ataxia, euphoria then lethargy, perioral rash / "glue sniffer's rash", chemical breath odor, paint on hands/face; "SUDDEN SNIFFING DEATH" — fatal arrhythmia on FIRST use ☠️
Talk down vs shut down: hallucinogens (LSD/MDMA) → TALK DOWN, calm reassurance. PCP → do NOT talk down — minimal stimulation, safety, benzos. Mixing these two up is a guaranteed lost point.
Withdrawal is usually the mirror image of intoxication. Depressant intoxication looks sedated → its withdrawal looks revved up (and can seize). Stimulant intoxication looks revved up → its withdrawal looks crashed and suicidal.
🩺 Substance Use — Assessment, Screening & Nursing Priorities
CAGE (alcohol screen)
Cut down? · Annoyed by criticism? · Guilty about drinking? · Eye-opener in the morning? 2+ yes = further assessment.
"When was your last drink/dose, and how much?" Timing predicts what is coming and when. Ask non-judgmentally, matter-of-factly.
Tolerance vs dependence
Tolerance = needs more for the same effect. Physical dependence = withdrawal when stopped. Neither by itself equals addiction.
Addiction
Compulsive use + loss of control + continued use despite harm + craving. It is the behavior, not just the biology.
Dual diagnosis
SUD + another mental illness. Treat both at the same time — treating one alone predicts relapse.
Codependence
Family's maladaptive coping: enabling, poor boundaries, excessive caretaking, denial, resistance to change. Family needs treatment too (Al-Anon).
Defense mechanisms in SUD
Denial (biggest), rationalization, projection, minimization. Confront the behavior, not the person; use factual, non-argumentative feedback.
Impaired nurse
Signs: frequent absences, mood swings, wasting narcotics, volunteering for med passes, high patient pain-med counts. You are obligated to report to the supervisor / BON — reporting protects patients and gets the nurse into treatment.
Wernicke → Korsakoff
Wernicke = acute, reversible: confusion + ataxia + nystagmus/eye changes. Korsakoff = chronic, permanent: memory loss + confabulation. Thiamine before glucose prevents it.
NURSING PRIORITY ORDER during detox: 1️⃣ Airway/breathing & vital signs · 2️⃣ Seizure & injury precautions · 3️⃣ Fluids/electrolytes/thiamine · 4️⃣ Suicide risk (huge in stimulant crash) · 5️⃣ Orientation & low stimulation · 6️⃣ Rehab & relapse planning. Detox is not treatment — it is the doorway to treatment.
🔥 Therapeutic stance: matter-of-fact, non-judgmental, firm limits, no rescuing and no moralizing. Do not accept excuses; do not argue. Point out discrepancies between what the client says and what the client does.
🔄 Stages of Change & Relapse (Transtheoretical Model)
Stage
Client sounds like
Nurse does
Precontemplation
"I don't have a problem."
Do not confront hard. Give information, plant seeds, build rapport.
Relapse is part of the disease, not failure. The correct response is never shaming — it is "what happened right before?" then revise the plan. Abstinence-violation shame is what turns a slip into a full relapse.
12-step language: powerlessness, sponsor, one day at a time, "people-places-things" (avoid old triggers). AA/NA are the most commonly correct community resource answer.
💊 Addiction Medications & Impaired Nurses
Drug
Use / Teaching
Naloxone (Narcan)
Opioid overdose reversal; short-acting — may need repeat doses; can trigger withdrawal.
Naltrexone
Alcohol & opioid use disorder; must be opioid-free first.
Methadone
Opioid maintenance (agonist); exactly as prescribed; NO alcohol/CNS depressants.
Buprenorphine (Subutex/Suboxone)
Opioid use disorder (partial agonist); ↓ cravings; ceiling effect lowers OD risk.
Disulfiram (Antabuse)
Sobriety med (not withdrawal). Severe reaction with ANY alcohol — avoid mouthwash, aftershave, cough syrup.
Impaired professionals: suspected diversion must be reported through proper channels — not ignored or covered up. Goal = patient safety + getting the colleague into treatment.
⚠️ A commercial study sheet used to sit here. It was removed — it belongs to its publisher, not to this site.
☠️ Hypokalemia
Purging dumps potassium → life-threatening cardiac dysrhythmias. K⁺ of 2.9 → PRIORITY is the heart, not the teeth. Monitor ECG.
☠️ Refeeding Syndrome
Feeding too fast → insulin drives phosphate/K/Mg INTO cells → cardiac/respiratory failure. Watch phosphorus. Refeed LOW & SLOW.
Nursing care: stay with the client during & ~1 hour after meals to prevent hiding food/purging; structured eating plan; weigh per protocol; monitor electrolytes/ECG/vitals. Therapy: CBT (first-line bulimia/binge), family-based (adolescent anorexia). Meds: fluoxetine FDA-approved for bulimia; bupropion CONTRAINDICATED (lowers seizure threshold).
Buspirone: non-addictive; takes 3–4 weeks (ATI's number — not 2–4); NOT a scheduled/controlled substance; no withdrawal and no taper needed when stopping; NOT PRN, NOT for acute panic. Adverse effects — dizziness (most common), xerostomia (dry mouth), headache, nausea, insomnia. Rise slowly; avoid grapefruit juice.
Stimulants (methylphenidate) for ADHD: ↓appetite, insomnia, ↑HR/BP; give early in the day.
Benztropine/diphenhydramine (Benadryl): reverse dystonic reactions/EPS from antipsychotics.
Ibuprofen (NSAID): take with food; avoid alcohol; note it can raise lithium levels.
Benzo = fast, addictive, respiratory depression. Buspirone = slow, non-addictive, NOT for an acute attack.
Per your Final KCR, these appear for the first time on the final.
Everyone reviews what they were already tested on — it feels familiar. Final-only modules are brand-new material. Budget more time here, not less.
📚 Everything on the Final
🔢 High-Yield Numbers — Running List
Number
What it is
0.6–1.2 mEq/L
Lithium — maintenance range
> 1.5 mEq/L
Lithium toxicity begins
> 3.0 mEq/L
Lithium — dialysis territory
2–6 weeks
Antidepressant full therapeutic effect
3–4 weeks
Buspirone onset (ATI)
2 weeks
MAOI washout (5 wks for fluoxetine)
4–6 weeks
Duration of a crisis
3–6 feet
Therapeutic communication distance
1963
Community Mental Health Centers Act → deinstitutionalization
🧠 Final Exam Quiz — Cumulative
Every question from every loaded module.
Quizzes · Mega, Pharmacology & Pathophysiology
Build a custom quiz at the top — pick topics and question count. Below that: everything shuffled, or drill one area (Pharmacology, Pathophysiology, Antidotes).
🎯 My Miss List — auto-tracked
Every question you get wrong anywhere in this guide lands here automatically. Get it right twice in a row and it retires itself. Saved on this device — no account, no login.
0
still missing
0
retired ✓
0
hand-added
Missed something on ATI or in class? Type it here so it shows up on your morning check-in list too.
🎯 Clinical Judgment — your weakest area
The six NCLEX thinking steps with the decoder for spotting which one a question is asking, plus 570 questions tagged by step. It scores you per step, so you find out whether you are losing points on analyze cues, prioritize hypotheses, or evaluate outcomes — not just "clinical judgment."
Pick your topics, pick how many questions, hit Start. No topics selected = everything.
Quick pick
Exams
pick as many as you like · narrows the modules below
Difficulty
none picked = all three
Modules
Extra banks
How many
Options
🧠 Mega Quiz
Every question from every loaded module plus the ATI banks, your Final Exam practice set, and the Medication Teaching Quiz — all shuffled. Reshuffle any time.
💊 Pharmacology Quiz
45 questions — every drug class, plus antidotes & reversal agents, therapeutic levels, and priority actions. Includes SATA.
🧬 Pathophysiology Quiz
30 questions — neuroanatomy, neurotransmitters, the four dopamine pathways, disease mechanisms, and NMS vs serotonin syndrome. Includes SATA.
🚑 Antidote Sprint
Pulled from the pharmacology bank — antidote, reversal-agent, and toxicity items only. Fast reps on your weak spot.
Pharmacology · A Card for Every Drug
One card per drug, grouped by class. Everything from your Videbeck, ATI, and the final review session. Use the filter chips to narrow to one module or one source.
Module
Source
💊 Antipsychotics — 1st Generation (Typical)
Strong D2 blockade · treat positive symptoms only · high EPS risk. Side effects of BOTH generations: anticholinergic, photophobia, photosensitivity, sedation.
🖼️ 1st-Gen Antipsychotics — chart from your folder
The psychiatric-care pharmacology page for schizophrenia — drug classes, monitoring, and teaching.
🖼️ Schizophrenia III — pharmacology
⚠️ A commercial study sheet used to sit here. It was removed — it belongs to its publisher, not to this site.
😔 Antidepressants — SSRIs
1st-line · ↑ serotonin · 2–6 weeks to work · take in the AM. Memory: "E-F-S-P-C = Effective for Sadness, panic & Compulsion." Complications: S-S-S (Stomach upset, Sexual dysfunction, Serotonin syndrome).
🖼️ SSRIs — chart from your folder
SSRI
Fluoxetine
Note: longest half-life → 5-week MAOI washout
Teach: report ↑ suicidal thoughts (esp. <25 yrs)
SSRI
Sertraline
Uses: depression, anxiety, OCD, PTSD, PMDD
Watch: GI upset, sexual dysfunction
SSRI
Paroxetine
Note: most anticholinergic/sedating SSRI; worst discontinuation syndrome
Start here before the individual classes. 1) Suicide risk rises in the first few weeks. 2) Slow onset, slow taper — never stop abruptly. 3) Never mix SSRI + St. John’s Wort, or MAOI + any antidepressant. 4) All psych drugs lower BP and change weight. Bottom third is three SATA questions people miss.
🖼️ Antidepressants — the 4 rules + top 3 missed questions
⚠️ A commercial study sheet used to sit here. It was removed — it belongs to its publisher, not to this site.
The -sertraline/-oxetine/-opram group: onset, side effects, serotonin syndrome teaching.
🖼️ SSRIs
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😔 Antidepressants — SNRIs, TCAs, MAOIs, Atypical
🖼️ SNRIs · TCAs · MAOIs · Atypicals — chart from your folder
SNRI
Venlafaxine
Action: ↑ serotonin + norepinephrine
Watch:↑ BP; don't mix with TCA/MAOI
SNRI
Duloxetine
Bonus: also treats neuropathic pain & fibromyalgia
Watch: dry mouth, constipation, hepatotoxicity
TCA
Amitriptyline
Anticholinergic: "can't see, spit, pee, poop"; orthostatic hypotension
Watch:VERY POTENT — lethal in overdose; limit quantity
Teach: avoid aged cheese, cured/fermented meats, wine, beer; 4 wks to work
Atypical
Bupropion
Bonus:NO sexual side effects; aids smoking cessation; used in ADHD
Watch:lowers seizure threshold — contraindicated in seizure & eating disorders
Atypical
Mirtazapine
Bonus:sedation + weight gain — useful for insomnia/cachexia
Teach: take at bedtime
Atypical
Trazodone
Use: often low-dose for sleep
Watch:priapism — report erection >4 hrs
ALL antidepressants: don't stop abruptly · take time to work · avoid alcohol · report suicidal thoughts · caution with sedation/hazardous activities. St. John's wort + any antidepressant = serotonin syndrome risk.
Direct comparison. TCAs are the ones that kill in overdose — cardiac and anticholinergic.
🖼️ SNRI vs. TCA side by side
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Tyramine-free diet, the 2-week washout, and hypertensive crisis. Antidote for the crisis is phentolamine.
🖼️ MAOIs
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Bupropion, mirtazapine, trazodone — the ones that don’t fit the SSRI/SNRI pattern.
🖼️ Atypical antidepressants
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Teach: take right before bed, with 7–8 hrs available
Benzodiazepines vs. buspirone. Benzo reversal is flumazenil — but airway first, and it can drop the seizure threshold.
🖼️ Anxiolytics
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The whole page is testable. Top block = the bleed-risk six and the stop 2–3 weeks before surgery rule. Bottom right = the psych block: St. John’s Wort + any antidepressant → serotonin syndrome, and valerian for insomnia. Recall table is right below.
🖼️ Herbal supplements
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🌿 Herbal Supplements — what each one is for
Two things get asked: what is it used for and what does it interact with. The interaction is almost always the answer.
The three rules that cover most questions
Assess for interactions with everything else the client takes. Supplements are drugs.
Stop 2–3 weeks before surgery — bleed risk and anesthesia interactions.
Herbals are not FDA-regulated for potency or purity. "Natural" does not mean safe.
Supplement
Used for
Watch for
St. John’s Wort
Mild depression
Serotonin syndrome with SSRIs, SNRIs, TCAs, MAOIs, triptans. Also drops levels of warfarin, digoxin, oral contraceptives, and antiretrovirals. Photosensitivity.
Hepatotoxic — the classic kava answer. Additive sedation with CNS depressants.
Ginkgo biloba
Memory, dementia, circulation
Bleeding — with anticoagulants, antiplatelets, NSAIDs. Lowers seizure threshold.
Ginseng
Energy, stress, immune
Bleeding. Also hypoglycemia with antidiabetics, and insomnia/nervousness.
Garlic · Ginger · Vitamin E · Omega-3
Cholesterol, nausea, heart
Bleeding — all four are in the bleed-risk group.
Black cohosh
Menopause — hot flashes
Black Cohosh = bad CoHOT flash. Hepatotoxicity; avoid in pregnancy.
Saw palmetto
BPH — enlarged prostate
Saw Palmetto = Swollen Prostate. Can mask a rising PSA.
Glucosamine
Osteoarthritis joint pain
Hypoglycemia with antidiabetic meds. Shellfish allergy.
Echinacea
Colds, immune support
Avoid in autoimmune disease and with immunosuppressants.
Melatonin
Sleep, jet lag
Daytime drowsiness. Additive with sedatives.
Hawthorn
Heart failure, BP
Hawthorn = Heart. Potentiates digoxin and antihypertensives.
Evening primrose
Eczema, PMS, skin
Lowers seizure threshold; bleed risk.
Memory hook for the bleed-risk group — the 4 G’s + E + O: Garlic, Ginger, Ginkgo, Ginseng, vitamin E, Omega-3. Any of these with warfarin, aspirin, or an NSAID is a bleeding question.
St. John’s Wort is the #1 herbal on psych exams. If a stem mentions it plus any antidepressant, the answer is serotonin syndrome — not "no concern," not "monitor mood."
Serotonin syndrome, in order of badness: shivering, diarrhea, agitation → hyperthermia, muscle rigidity, hyperreflexia → seizures, death. Treatment is stop the drug, cool, support — antidote is cyproheptadine.
Two herbals are hepatotoxic: kava and black cohosh. Two cause hypoglycemia: ginseng and glucosamine.
"Do you take any vitamins, supplements, or herbal products?" belongs in every medication history. Clients routinely do not report them because they don’t count them as medicine.
Bonus: can combine with a cholinesterase inhibitor
⚡ ECT Medications (procedure)
🖼️ ECT Medications — chart from your folder
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Anticholinergic (pre)
Atropine · Glycopyrrolate
Why: 30 min prior — dries secretions, blocks vagal bradycardia
Anesthetic
Etomidate · Propofol
Why: short-acting IV anesthesia during the procedure
Muscle relaxant
Succinylcholine
Why: paralyzes muscles during seizure
Watch:paralyzes respiratory muscles — client needs airway/O2 support
Also DC benzodiazepines before ECT — they interfere with the seizure.
🧪 Antidotes & Reversal Agents — Infographic
The reversal agents that show up on every pharm exam — naloxone, flumazenil, dantrolene, cyproheptadine, and friends.
🖼️ Antidote Infographic — full chart
Right half is pure antidote drill: naloxone for opioid/heroin overdose, RR below 12 = hold the dose, half-life 1–2 hr so prepare a second dose, and the order is Assess ABCs → Intervene with oxygen → Make HCP aware → Second dose. Airway before antidote.
🖼️ Opioids + naloxone reversal
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Max 4 g/day, hepatotoxicity is the killer. Antidote is acetylcysteine.
🖼️ Acetaminophen (Tylenol)
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📚 Full Drug Cards — Class · MOA · Indications · Contraindications · Adverse Effects
Every core component on every card: Class, MOA, Indications, Contraindications, and Adverse Effects — plus toxicity, nursing care, and client teaching.
MOA (mechanism of action): Selectively blocks reuptake of serotonin in the synapse, raising available serotonin; minimal effect on norepinephrine/dopamine.
Indications: First-line for depression, generalized anxiety, panic, OCD, PTSD, social anxiety, and bulimia.
Contraindications: MAOI within 14 days (5 weeks after stopping fluoxetine) — serotonin syndrome; use with pimozide/thioridazine (QT); caution with NSAIDs/anticoagulants (bleeding) and in clients <25 (early rise in suicidal ideation).
Adverse effects: Early anxiety/insomnia, GI upset, headache, sexual dysfunction, weight change, hyponatremia, ↑ bleeding risk with NSAIDs/anticoagulants.
Toxicity/Emergency: Serotonin syndrome — agitation, hyperreflexia, myoclonus, fever, diaphoresis, ↑ HR/BP; stop drug, supportive care, cyproheptadine. Suicide risk rises early in therapy.
Nursing: Full effect takes 4–6 wk; monitor mood/suicidal ideation, especially first weeks. No MAOI within 14 days (5 wk after fluoxetine). Taper to discontinue.
Teaching: Take daily as prescribed (not PRN), morning dosing if it disrupts sleep, avoid alcohol, do not stop abruptly (discontinuation syndrome), report worsening mood or serotonin-syndrome signs.
Nursing: Monitor BP (esp. at higher doses), mood, and suicide risk; 4–6 wk for full effect; no concurrent MAOI.
Teaching: Report elevated BP/headache, take consistently, do not stop suddenly, avoid alcohol, and rise slowly to limit dizziness.
TRICYCLIC (TCA)
💊 Amitriptyline (tricyclic antidepressant)
Class: TCA (tricyclic antidepressant)
MOA (mechanism of action): Blocks reuptake of norepinephrine and serotonin; also blocks histamine, cholinergic, and alpha-adrenergic receptors (source of side effects).
Indications: Depression (second-line), neuropathic pain, migraine prophylaxis; imipramine for enuresis.
Contraindications: Recent MI, cardiac conduction defects/dysrhythmias; MAOI use; caution in narrow-angle glaucoma, urinary retention/BPH, seizure disorder, and high suicide risk (lethal in overdose — dispense limited amounts).
Toxicity/Emergency: Highly lethal in overdose — cardiac dysrhythmias, seizures, coma. A 1–2 week supply can be fatal.
Nursing: 2–4+ wk for effect; monitor cardiac status/ECG in at-risk clients; assess suicide risk and dispense limited quantities; watch for MAOI interaction.
Teaching: Change positions slowly, increase fluids/fiber for constipation, use sugarless gum for dry mouth, take at bedtime for sedation, avoid alcohol, and do not stop abruptly.
MAOI
💊 Phenelzine (monoamine oxidase inhibitor)
Class: MAOI (monoamine oxidase inhibitor)
MOA (mechanism of action): Inhibits monoamine oxidase, blocking breakdown of serotonin, norepinephrine, and dopamine, so more accumulates.
Indications: Depression unresponsive to other agents; atypical depression.
Contraindications: Concurrent SSRIs/SNRIs/TCAs, meperidine, or sympathomimetics (including OTC decongestants/diet aids); pheochromocytoma; severe cardiovascular disease; tyramine-rich foods.
Adverse effects: Orthostatic hypotension, insomnia, weight gain, sexual dysfunction, dizziness.
Toxicity/Emergency: Hypertensive crisis with tyramine-rich foods (aged cheese, cured/smoked meats, fermented foods, aged red wine, tap beer, overripe fruit, yeast extract) — severe occipital headache, ↑↑ BP, palpitations, neck stiffness; treat with phentolamine/nifedipine. Also serotonin syndrome with serotonergic drugs.
Nursing: Strict dietary teaching; avoid many drugs (SSRIs/SNRIs/TCAs, opioids esp. meperidine, decongestants/sympathomimetics); 14-day washout before/after other antidepressants; monitor BP.
Teaching: Memorize and avoid tyramine foods and OTC cold/diet products, report severe headache immediately, rise slowly, and never combine with other antidepressants.
ATYPICAL ANTIDEPRESSANTS
💊 Bupropion (atypical — with mirtazapine, trazodone)
Class: Atypical antidepressants (NDRI and others)
MOA (mechanism of action): Bupropion inhibits reuptake of norepinephrine and dopamine; mirtazapine enhances norepinephrine/serotonin; trazodone is a serotonin modulator.
Indications: Depression; bupropion also for smoking cessation and has no sexual side effects; trazodone often used off-label for insomnia; mirtazapine helps depression with insomnia/poor appetite.
Contraindications: Bupropion: seizure disorders and anorexia/bulimia (lowers seizure threshold); abrupt alcohol or benzodiazepine withdrawal; MAOI use. Trazodone: caution in cardiac disease.
Toxicity/Emergency: Bupropion lowers the seizure threshold (avoid in seizure/eating disorders); trazodone can cause priapism (a urologic emergency — sustained erection >4 hr).
Nursing: Screen for seizure risk before bupropion; monitor mood/suicide risk; 4–6 wk for effect; no MAOI combination.
Teaching: Bupropion — take doses apart, avoid at bedtime (insomnia), no alcohol; trazodone — report prolonged erection immediately; mirtazapine — expect drowsiness/appetite increase.
BENZODIAZEPINE
💊 Lorazepam (benzodiazepine anxiolytic)
Class: Benzodiazepine anxiolytic
MOA (mechanism of action): Enhances the inhibitory effect of GABA, producing CNS depression, sedation, and anxiety relief.
Contraindications: Acute narrow-angle glaucoma; concurrent alcohol, opioids, or other CNS depressants; severe respiratory insufficiency/sleep apnea; pregnancy; caution with substance use history (dependence risk).
Adverse effects: Sedation, drowsiness, dizziness, ataxia, cognitive impairment; tolerance and physical dependence with prolonged use.
Toxicity/Emergency: Respiratory depression (esp. with alcohol/opioids); overdose reversed with flumazenil. Abrupt withdrawal → rebound anxiety, tremors, and seizures.
Nursing: Use lowest dose for shortest time; assess for dependence/misuse; monitor respirations and sedation; taper to discontinue; institute fall precautions.
Teaching: Short-term use only, no alcohol/CNS depressants, avoid driving until effects known, do not stop abruptly, and use non-drug anxiety techniques alongside.
ANXIOLYTIC (non-benzo)
💊 Buspirone (azapirone anxiolytic)
Class: Non-benzodiazepine anxiolytic (azapirone)
MOA (mechanism of action): Partial serotonin (5-HT1A) agonist; relieves anxiety without CNS depression, sedation, or dependence.
Indications: Long-term management of generalized anxiety disorder.
Contraindications: MAOI within 14 days (hypertensive crisis); caution with grapefruit juice and other serotonergic drugs.
Examples: buspirone.
Adverse effects: Dizziness, headache, nausea, lightheadedness — generally mild; no significant sedation or dependence.
Toxicity/Emergency: Low toxicity; risk of serotonin syndrome if combined with MAOIs or other serotonergic drugs. Not useful for acute/PRN relief.
Nursing: Full effect takes 1–4 weeks; must be taken regularly, not as needed; not a controlled substance; avoid grapefruit juice (raises levels).
Teaching: Take on a fixed schedule, be patient with delayed onset, do not use for acute panic, take consistently with or without food, and avoid grapefruit juice.
MOOD STABILIZER
💊 Lithium carbonate (mood stabilizer)
Class: Mood stabilizer (antimanic)
MOA (mechanism of action): Alters ion transport and neurotransmitter activity to stabilize mood; exact mechanism unclear. Narrow therapeutic index.
Indications: Acute mania and long-term prophylaxis of bipolar mood episodes.
Contraindications: Severe renal disease, dehydration, sodium depletion; concurrent thiazide diuretics or NSAIDs (raise lithium levels); pregnancy (cardiac defects); caution in cardiovascular disease.
Examples: lithium carbonate, lithium citrate.
Adverse effects: Fine tremor, GI upset, polyuria/thirst, weight gain, hypothyroidism, renal impairment, benign leukocytosis.
Toxicity/Emergency: Therapeutic 0.6–1.2 mEq/L. Early toxicity <1.5 (N/V/D, thirst, polyuria, fine tremor); 1.5–2.5 coarse tremor, confusion, ataxia, slurred speech; >2.5 seizures, coma, death. No antidote — hold drug, IV normal saline, hemodialysis for severe/>2.5.
Nursing: Onset 1–3 wk (bridge acute mania with antipsychotic/benzo); draw trough levels ~12 hr post-dose; monitor renal/thyroid function, sodium, and hydration; caution with diuretics, NSAIDs, ACE inhibitors.
Teaching: Maintain steady salt and fluid intake (2–3 L/day), take with food, avoid dehydration (heat, illness, alcohol), keep lab appointments, report early toxicity signs, and avoid during pregnancy (Ebstein anomaly).
Nursing: Baseline and periodic LFTs, platelets, and drug levels; monitor for bruising/bleeding and abdominal pain; assess pregnancy status.
Teaching: Report signs of liver problems (jaundice, dark urine, anorexia, abdominal pain) or unusual bruising, take with food, avoid alcohol, and use reliable contraception.
MOOD STABILIZER (anticonvulsant)
💊 Carbamazepine (anticonvulsant mood stabilizer)
Class: Anticonvulsant mood stabilizer
MOA (mechanism of action): Blocks sodium channels to reduce neuronal excitability; stabilizes mood and controls seizures.
Nursing: Baseline/periodic CBC, LFTs, sodium, and drug levels; watch for infection, bruising, or rash; note it lowers levels of many drugs (including oral contraceptives and warfarin).
Teaching: Report fever, sore throat, bruising, rash, or fatigue; use a backup/non-hormonal contraceptive; take with food; avoid grapefruit juice; and do not stop abruptly.
MOA (mechanism of action): Stabilizes neuronal membranes by inhibiting sodium channels and glutamate release; effective for the depressive phase of bipolar disorder.
Indications: Maintenance treatment of bipolar disorder (particularly bipolar depression); seizures.
Contraindications: Prior serious rash with lamotrigine; caution with valproate (roughly doubles lamotrigine levels — titrate even more slowly).
Toxicity/Emergency: Stevens-Johnson syndrome / toxic epidermal necrolysis — a life-threatening rash. Risk is reduced by slow dose titration.
Nursing: Titrate the dose slowly; inspect for any developing rash and stop the drug/notify provider if one appears; note valproate raises lamotrigine levels (requires lower dosing).
Teaching: Report any rash, blistering, or mucosal sores immediately, do not skip the gradual dose increase, and do not stop abruptly.
FIRST-GEN (TYPICAL) ANTIPSYCHOTIC
💊 Haloperidol (conventional antipsychotic)
Class: First-generation (typical) antipsychotic
MOA (mechanism of action): Blocks CNS D2 dopamine receptors to reduce dopamine-driven psychosis.
Indications: Schizophrenia and acute psychosis; best for positive symptoms (hallucinations, delusions, agitation).
Contraindications: Parkinson's disease; severe CNS depression/coma; dementia-related psychosis in older adults (boxed warning — increased mortality); caution with QT prolongation and seizure history.
Toxicity/Emergency: New-onset diabetes/hyperglycemia; NMS still possible; QT-related dysrhythmia.
Nursing: Baseline and ongoing weight/BMI, waist circumference, fasting glucose or A1c, and lipid panel; monitor ECG when indicated.
Teaching: Diet and exercise to limit weight gain; report increased thirst/urination; change positions slowly; adhere even when feeling better.
ATYPICAL — RESERVED AGENT
💊 Clozapine (special-case atypical)
Class: Atypical antipsychotic — reserved agent
MOA (mechanism of action): Blocks D2 and 5-HT2 receptors; effective where other agents fail.
Indications: Treatment-resistant schizophrenia; reduces suicidality in schizophrenia.
Contraindications: History of clozapine-induced agranulocytosis/severe neutropenia; myeloproliferative disorders; uncontrolled seizures; severe cardiac disease (myocarditis); paralytic ileus.
Examples: Clozapine (class of one for this indication).
Adverse effects: Agranulocytosis, dose-related seizures, myocarditis, severe constipation/ileus, heavy sedation, hypersalivation, metabolic effects.
Toxicity/Emergency: Agranulocytosis (life-threatening neutrophil drop) — fever or sore throat is a red flag; myocarditis; bowel obstruction.
Nursing: Enrolled monitoring program with scheduled ANC/WBC counts (frequent at first); hold the drug and notify provider if ANC falls; monitor bowel function.
Teaching: Keep all blood-draw appointments; report fever, sore throat, flu-like symptoms, chest pain, or constipation immediately.
CNS STIMULANT
💊 Methylphenidate (CNS stimulant)
Class: CNS stimulant
MOA (mechanism of action): Increases CNS norepinephrine and dopamine, improving attention and reducing hyperactivity/impulsivity.
Indications: ADHD in children, adolescents, and adults; narcolepsy.
Contraindications: MAOI within 14 days; glaucoma; severe anxiety/agitation; structural cardiac abnormalities or serious heart disease; caution with tics/Tourette's and substance use history.
MOA (mechanism of action): Blocks aldehyde dehydrogenase, so acetaldehyde accumulates if alcohol is consumed, causing a highly unpleasant reaction.
Indications: Adjunct to maintain abstinence in motivated clients with alcohol use disorder.
Contraindications: Any alcohol within 12 hours (including hidden sources — mouthwash, sanitizer, sauces); metronidazole; psychosis; severe cardiac disease; never give without the client's full knowledge and consent.
Toxicity/Emergency: Disulfiram–alcohol reaction — flushing, throbbing headache, nausea/vomiting, sweating, palpitations, hypotension; can be severe.
Nursing: Confirm the client has been alcohol-free ~12 hours before starting; monitor liver enzymes; ensure informed consent and motivation.
Teaching: Avoid ALL alcohol including mouthwash, cough syrup, aftershave, colognes, sauces, and vinegar; reaction can occur up to 2 weeks after the last dose.
OPIOID/ALCOHOL — ANTAGONIST
💊 Naltrexone (opioid antagonist)
Class: Opioid antagonist (anti-craving)
MOA (mechanism of action): Blocks opioid receptors, reducing craving and the pleasurable/rewarding effects of alcohol and opioids.
Indications: Maintenance of abstinence in alcohol use disorder and opioid use disorder.
Contraindications: Current opioid use or withdrawal (precipitates acute withdrawal — client must be opioid-free 7–10 days); acute hepatitis or liver failure.
Examples: Oral naltrexone (daily); long-acting IM naltrexone (monthly).
Adverse effects: Nausea, headache, dizziness, fatigue; IM injection-site reactions.
Toxicity/Emergency: Precipitated opioid withdrawal if opioids are still on board; hepatotoxicity at high doses; blunts opioid analgesia in emergencies.
Nursing: Verify the client is opioid-free ~7–10 days before the first dose; monitor liver function; confirm no active opioid use.
Teaching: Carry medical identification (opioids won't work for pain relief); report right-upper-quadrant pain or jaundice; keep monthly injection appointments.
ALCOHOL — ANTI-CRAVING
💊 Acamprosate (glutamate/GABA modulator)
Class: Glutamate/GABA modulator (anti-craving)
MOA (mechanism of action): Normalizes glutamate and GABA activity disrupted by chronic alcohol use, easing post-abstinence distress.
Indications: Maintenance of abstinence after the client has already stopped drinking.
Contraindications: Severe renal impairment (CrCl ≤ 30 mL/min).
MOA (mechanism of action): Methadone is a long-acting full opioid agonist; buprenorphine is a partial agonist with a ceiling effect. Both prevent withdrawal and blunt craving.
Indications: Maintenance/substitution therapy and medically supervised withdrawal in opioid use disorder.
Contraindications: Significant respiratory depression; acute or severe asthma; paralytic ileus; methadone — caution with QT prolongation; dispensed only through certified treatment programs.
Examples: Methadone; buprenorphine and buprenorphine/naloxone (sublingual).
Adverse effects: Sedation, constipation, sweating; methadone can prolong the QT interval.
Toxicity/Emergency: Respiratory depression and overdose (higher with methadone); buprenorphine can precipitate withdrawal if given too soon after other opioids.
Nursing: Dispense methadone through regulated programs; monitor respirations, sedation, and ECG (methadone); assess timing before buprenorphine induction.
Teaching: Do not combine with alcohol/sedatives; dissolve buprenorphine sublingually (do not swallow/inject); attend program visits.
TOBACCO — REPLACEMENT/CESSATION
💊 Nicotine replacement therapy (NRT)
Class: Nicotine replacement therapy (NRT)
MOA (mechanism of action): Supplies controlled, tapering nicotine to relieve withdrawal while smoking behaviors are extinguished.
Indications: Smoking cessation / tobacco use disorder.
Contraindications: Recent MI, serious dysrhythmias, unstable angina; do not smoke while using NRT (nicotine toxicity).
Toxicity/Emergency: Nicotine toxicity if smoking continues with the patch; varenicline and bupropion carry neuropsychiatric/mood warnings; bupropion lowers the seizure threshold.
Nursing: Assess readiness to quit; do not overlap doses beyond program limits; monitor mood on bupropion/varenicline.
Teaching: Do not smoke while using the patch; rotate patch sites; take bupropion/varenicline for the full course; report worsening mood.
OPIOID OVERDOSE — ANTAGONIST
💊 Naloxone (opioid antagonist)
Class: Opioid antagonist (overdose reversal)
MOA (mechanism of action): Rapidly displaces opioids from receptors, reversing respiratory depression.
Contraindications: None absolute in a life-threatening overdose; hypersensitivity; expect precipitated acute withdrawal in opioid-dependent clients.
Adverse effects: Precipitated acute opioid withdrawal (agitation, vomiting, pain); it is short-acting — sedation and respiratory depression can return, so repeat dosing is often needed.
Nursing: Support airway/breathing, monitor continuously after reversal, anticipate repeat doses.
MOA (mechanism of action): Zolpidem enhances GABA at the benzodiazepine-1 receptor site; hydroxyzine blocks H1 histamine receptors; propranolol blocks beta-adrenergic receptors, blunting the physical symptoms of anxiety.
Indications: Zolpidem — short-term insomnia. Hydroxyzine — anxiety/agitation when dependence is a concern. Propranolol — performance anxiety and antipsychotic-induced akathisia.
Cholinesterase inhibitors (donepezil, rivastigmine, galantamine): preserve acetylcholine → slow decline; do NOT cure or reverse. Watch GI upset (N/V/diarrhea) and bradycardia; take with food.
Memantine (NMDA antagonist): moderate–severe Alzheimer's; regulates glutamate; can combine with a cholinesterase inhibitor.
Teaching: Set realistic expectations — the goal is slowing decline and preserving function, not recovery.
Contraindications: Cholinesterase inhibitors: caution with bradycardia/conduction disease, GI bleeding/ulcers, asthma/COPD. Memantine: caution in severe renal impairment.
Anticholinergic (atropine/glycopyrrolate), 30 min prior: dries secretions, blocks vagal bradycardia.
Anesthetic (etomidate/propofol): short-acting IV anesthesia during the procedure.
Muscle relaxant (succinylcholine): paralyzes muscles during the seizure — client cannot breathe independently; the nurse's priority is airway and oxygenation support.
Contraindications: Succinylcholine: history of malignant hyperthermia, hyperkalemia, major burns/crush injury; atropine/glycopyrrolate: narrow-angle glaucoma.
🖼️ Antidote Cheat Sheet
From your Final Exam folder — every antidote in one graphic.
🖼️ Antidote Cheat Sheet
🚑 Antidote & Reversal Drill — the ones people miss
You said antidotes are your weak spot. Learn this table cold — then run the Pharmacology quiz, which is loaded with antidote items.
THE BIG SIX for psych: Opioid → NALOXONE · Benzo → FLUMAZENIL · Acetaminophen → ACETYLCYSTEINE · Warfarin → VITAMIN K · Heparin → PROTAMINE · Anticholinergic/atropine → PHYSOSTIGMINE.
Toxicity / overdose
Antidote or first drug
Must-know detail
Opioids (heroin, fentanyl, morphine, oxycodone)
Naloxone (Narcan)
Shorter half-life than most opioids → repeat doses / drip and keep monitoring. Precipitates acute withdrawal (agitation, pain, N/V) — that is expected, not an allergy. Airway first.
Benzodiazepines
Flumazenil (Romazicon)
Can trigger seizures, especially in chronic benzo users or mixed TCA overdose. Often withheld — support airway instead.
Barbiturates
NO antidote
Supportive: airway, ventilation, fluids, alkalinize urine per order. This is why barbiturate OD is deadlier than benzo OD.
Acetaminophen (common in intentional OD)
Acetylcysteine (Mucomyst)
Best within 8–10 hours. Rotten-egg smell/taste — mix in juice/cola. Monitor LFTs; liver failure is the killer.
"Mad as a hatter, red as a beet, dry as a bone, hot as a hare, blind as a bat." TCA OD also → lethal dysrhythmias → sodium bicarbonate + cardiac monitor.
HYPERreflexia, myoclonus/clonus, tremor, diarrhea, agitation, diaphoresis. Onset hours. Cause = two serotonergic drugs (SSRI + MAOI/triptan/tramadol/St. John's wort).
Acute dystonia / EPS from antipsychotics
Diphenhydramine (Benadryl) IM/IV or benztropine (Cogentin)
Torticollis, oculogyric crisis, laryngospasm = airway emergency. Give it now, then notify. TD has no reversal → prevent (AIMS screening); valbenazine/deutetrabenazine may help.
Loss of deep tendon reflexes first → then ↓RR. Shows up on cumulative exams.
Heparin / warfarin
Protamine sulfate / vitamin K (phytonadione)
Classic pharm pairing — memorize both directions.
Iron / digoxin
Deferoxamine / digoxin immune Fab (Digibind)
Rounds out the antidote set most often tested alongside psych meds.
Alcohol withdrawal (not an antidote, but the first drug)
Benzodiazepines (lorazepam, chlordiazepoxide) + thiamine before glucose
Thiamine first prevents Wernicke's. Glucose alone in a thiamine-depleted client can precipitate it.
Two look-alikes, opposite reflexes:NMS = RIGID (lead pipe) and slow to develop; serotonin syndrome = HYPERREFLEXIC/clonic and fast (hours). Rigid → dantrolene. Clonic → cyproheptadine.
Memory hook: Naloxone for Narcotics · Flumazenil for the "Flurazepam family" · Acetylcysteine for Acetaminophen · Dantrolene for the Dangerously rigid (NMS) · Cyproheptadine for Clonus (serotonin syndrome).
🔥 On NCLEX-style items, if a client is hypoxic or apneic, the answer is airway/oxygen before the antidote — unless naloxone is the listed airway intervention. Read whether the stem asks for "first action" or "expected medication."
🎯 Pharmacology Quiz
45 questions across every drug class, plus a heavy dose of antidotes and reversal agents. Includes SATA and priority/first-action items.
Pathophysiology · Why the Symptoms Happen
The biology behind every psych disorder — brain structures, neurotransmitters, and the mechanisms behind the med emergencies. Use the filter chips to narrow to one module or one source.
Module
Source
🧠 Brain Structures — Who Does What
Structure
Job
When it goes wrong
Frontal lobe (prefrontal cortex)
Judgment, impulse control, planning, personality, working memory — "the brakes"
Schizophrenia (negative symptoms, poor executive function), ADHD, TBI → disinhibition, mania-like behavior, apathy. Not fully myelinated until ~25 → teen risk-taking.
Temporal lobe
Hearing, language comprehension, memory
Auditory hallucinations in schizophrenia; seizure focus
Parietal lobe
Sensation, spatial orientation
Neglect, apraxia in dementia
Occipital lobe
Vision
Visual hallucinations (more often delirium/Lewy body than schizophrenia)
Limbic system
Emotion HQ
Mood and anxiety disorders live here
Amygdala
Fear, rage, threat alarm
HYPERactive in PTSD, panic, anxiety → alarm goes off with no fire
Hippocampus
Memory formation (new memories)
Shrinks in Alzheimer's, chronic stress, PTSD, major depression
The two most-swapped answers: thalamus relays sensation, the amygdala creates fear. If the stem says "hyperactive in PTSD" it is the amygdala, never the thalamus.
⚡ Neurotransmitters — Too Much, Too Little
NT
Normal role
TOO LITTLE
TOO MUCH
Dopamine
Reward, movement, motivation, cognition
Parkinson's, EPS, negative symptoms of schizophrenia, anhedonia, ↑prolactin
Positive symptoms of schizophrenia (hallucinations, delusions), mania, stimulant psychosis
Alzheimer's memory loss (why donepezil inhibits its breakdown); anticholinergic delirium
SLUDGE — salivation, lacrimation, urination, defecation, GI upset, emesis
Histamine
Alertness, wakefulness
Blockade → sedation, weight gain (why quetiapine and mirtazapine knock you out)
Allergy symptoms
🔥 Every psych med works by pushing one of these seven up or down. If you know the NT, you can predict both the therapeutic effect and the side effect profile without memorizing lists.
Depression is not "low serotonin" alone — current understanding is a network problem involving monoamines, HPA-axis overdrive, ↓BDNF, ↓hippocampal volume, and inflammation. That is why meds take 2–6 weeks: receptor and neuroplastic changes, not a quick chemical top-up.
🛣️ The Four Dopamine Pathways — the key to every antipsychotic side effect
Pathway
What it normally does
Block dopamine here →
Mesolimbic
Reward, emotion, salience
✅ The therapeutic effect — positive symptoms improve (this is the pathway you WANT to block)
❌ EPS — acute dystonia, akathisia, pseudoparkinsonism, and eventually tardive dyskinesia
Tuberoinfundibular
Inhibits prolactin release
❌ Hyperprolactinemia — galactorrhea, gynecomastia, amenorrhea, ↓libido, erectile dysfunction (risperidone is the worst offender)
This one table explains every antipsychotic side-effect question. 1st-generation drugs block D2 hard and non-selectively → strong on positive symptoms, heavy EPS and prolactin. 2nd-generation drugs block D2 more loosely and also block 5-HT2A → less EPS, but metabolic syndrome (weight gain, ↑glucose, ↑lipids).
EPS timeline: hours–days = acute dystonia (treat with diphenhydramine/benztropine) · days–weeks = akathisia (inner restlessness — often mistaken for anxiety; treat with propranolol/benzos) and pseudoparkinsonism · months–years = tardive dyskinesia (often irreversible — screen with AIMS).
🌀 Schizophrenia — Pathophysiology
Dopamine hypothesis: ↑dopamine in the mesolimbic pathway → positive symptoms; ↓dopamine in the prefrontal/mesocortical pathway → negative and cognitive symptoms.
Glutamate/NMDA hypofunction: PCP and ketamine block NMDA receptors and reproduce positive, negative, and cognitive symptoms — better model than dopamine alone.
Structural findings: enlarged lateral ventricles, ↓total brain and gray-matter volume, ↓hippocampal and temporal lobe volume, hypofrontality on imaging.
Neurodevelopmental: abnormal synaptic pruning in adolescence — which is why onset is late teens–early 20s in men, 20s–30s in women.
Risk factors: genetics (highest single risk — ~50% concordance in identical twins), prenatal infection/malnutrition, obstetric complications, winter birth, cannabis use in adolescence, urban upbringing.
Sensory gating failure (thalamus) → the client cannot filter background stimuli → why a loud, busy unit makes psychosis worse.
Positive symptoms = added experiences (hallucinations, delusions, disorganized speech, bizarre behavior) and respond well to meds. Negative symptoms = subtracted function (flat affect, alogia, avolition, anhedonia, asociality) and respond poorly — they are the biggest driver of long-term disability.
Negative symptoms are the "5 A's." If it starts with A and means "less," it is negative.
😔 Depression & Bipolar — Pathophysiology
Monoamine changes
↓serotonin, ↓norepinephrine, ↓dopamine signaling and receptor sensitivity changes. Explains why SSRIs, SNRIs, and bupropion all work by different routes.
HPA axis overdrive
Chronic stress → ↑CRH → ↑ACTH → ↑cortisol. Sustained cortisol shrinks the hippocampus and impairs memory and mood. Non-suppression on dexamethasone testing is a classic finding.
↓BDNF / neuroplasticity
Brain-derived neurotrophic factor drops in depression; antidepressants and ECT raise it. This lag is why relief takes 2–6 weeks.
Hypothyroidism, anemia, B12 deficiency, and steroids can all present as depression. Always rule out medical causes before diagnosing.
Bipolar — genetics
Most heritable major mental illness. ↑glutamate and dysregulated intracellular signaling; lithium acts on second-messenger systems and is neuroprotective.
Kindling
Each untreated mood episode makes the next one easier to trigger and harder to treat — the argument for staying on maintenance meds even when well.
Suicide biology
Low CSF 5-HIAA (a serotonin metabolite) is associated with impulsive, violent suicide attempts — serotonin governs impulse control, not just mood.
🔥 Antidepressant + bipolar = mania risk. Giving an SSRI to an undiagnosed bipolar client can flip them into mania. Always screen for a manic history before starting an antidepressant.
😰 Anxiety, Panic & Trauma — Pathophysiology
Amygdala hyperactivity + weak prefrontal top-down control = alarm without an off switch. Trauma therapy and SSRIs work partly by restoring prefrontal braking.
↓GABA tone → less inhibition → anxiety and panic. Benzos work by enhancing GABA-A, which is exactly why they are so effective and so addictive.
Locus coeruleus / norepinephrine surge → tachycardia, tremor, sweating, sense of doom. Propranolol blunts the peripheral symptoms.
HPA-axis dysregulation in PTSD: paradoxically low cortisol with high CRH and an oversensitive negative-feedback loop — different pattern from depression.
Fear conditioning & failure of extinction: the traumatic memory never gets filed as "past," so cues re-trigger the full physiologic response — the mechanism behind flashbacks and hypervigilance.
Hippocampal volume loss in chronic PTSD contributes to fragmented, out-of-context memory.
OCD: hyperactive cortico-striatal-thalamo-cortical loop; serotonin dysregulation. Needs higher SSRI doses and longer trials than depression.
Physiologic anxiety symptoms are indistinguishable from a real medical emergency. In an exam item, rule out the physical cause first (MI, PE, hyperthyroidism, hypoglycemia, pheochromocytoma, caffeine/stimulant use) before labeling it panic.
🍺 Addiction — the Reward Pathway
Every drug of abuse ends up raising dopamine in the nucleus accumbens via the mesolimbic reward pathway — that is the common final step.
Repeated surges cause receptor downregulation → tolerance (needs more) and anhedonia (normal pleasures stop working).
Control shifts from the prefrontal cortex to habit circuits in the dorsal striatum → use becomes compulsive rather than chosen. This is the biology behind "loss of control."
Withdrawal = rebound in the opposite direction. Depressants (alcohol, benzos) suppress CNS → withdrawal is CNS hyperexcitability → seizures and DTs. Stimulants flood dopamine → withdrawal is a depleted crash with suicidal depression.
Alcohol specifically: enhances GABA and inhibits NMDA/glutamate. Chronic use → downregulated GABA receptors + upregulated glutamate receptors. Remove the alcohol and you get unopposed glutamate excitation → seizures.
Thiamine (B1) depletion from poor intake and impaired absorption → Wernicke's encephalopathy (acute, reversible) → Korsakoff's psychosis (permanent, confabulation). Give thiamine before glucose.
One sentence that answers most withdrawal questions: withdrawal is the mirror image of intoxication.
🧩 Delirium vs Dementia — Pathophysiology
DELIRIUM
DEMENTIA (Alzheimer's)
Mechanism
Acute global brain dysfunction from a physiologic insult — infection (UTI is #1 in elders), hypoxia, electrolytes, dehydration, drugs (anticholinergics, benzos, opioids), withdrawal, pain, post-op
Progressive neurodegeneration: beta-amyloid plaques + tau neurofibrillary tangles → synapse loss → ↓acetylcholine; hippocampus and cortex atrophy
Onset
Hours to days — sudden
Months to years — insidious
Course
Fluctuates, worse at night (sundowning-like)
Steadily progressive, does not clear
Attention / LOC
Impaired, clouded, fluctuating
Alert until late stages
Hallucinations
Common, often visual
Less common until late
Reversible?
YES — treat the cause
No — slow it, support function
Highest-yield distinction in Module 12. Sudden confusion in an older adult = DELIRIUM until proven otherwise → look for the medical cause (start with infection, meds, oxygen, electrolytes, and pain). Never chart it as "dementia progressing."
Med logic follows the patho: ↓acetylcholine → cholinesterase inhibitors (donepezil, rivastigmine, galantamine). Glutamate excitotoxicity → memantine (NMDA antagonist). Neither reverses the disease.
👶 Neurodevelopmental — Pathophysiology
ADHD
Under-arousal of prefrontal circuits with ↓dopamine and ↓norepinephrine signaling; delayed cortical maturation. Stimulants increase DA/NE in the PFC — that is why a stimulant calms rather than excites.
Autism spectrum
Atypical synaptic pruning and connectivity — local over-connection, long-range under-connection. Strongly genetic. Not caused by vaccines or parenting.
Tourette's
Cortico-striatal-thalamo-cortical loop dysfunction with dopamine hypersensitivity. Treated with antipsychotics or alpha-2 agonists (clonidine, guanfacine).
Intellectual disability
Prenatal (genetic, fetal alcohol, infection), perinatal (hypoxia, prematurity), or postnatal (trauma, lead, meningitis) insults to brain development.
Why onset matters
Neurodevelopmental disorders begin before the brain matures, so the deficits are in acquiring skills — unlike dementia, where established skills are lost.
⚠️ A commercial study sheet used to sit here. It was removed — it belongs to its publisher, not to this site.
🚨 Med-Induced Emergencies — Mechanism Side by Side
Do not mix these up:RIGID and slow = NMS → dantrolene. CLONIC/hyperreflexic and fast = serotonin syndrome → cyproheptadine. Both have fever and altered mental status; the reflexes and the timeline are what separate them.
🧬 Stress-Diathesis, Genetics & Neuroplasticity
Stress-diathesis (diathesis-stress) model: a genetic/biologic vulnerability plus enough environmental stress equals illness. Neither alone is sufficient — this is the framework behind nearly every psych disorder in Videbeck.
Epigenetics: stress, trauma, and substances change gene expression without changing the DNA — a mechanism for how early adversity produces adult illness.
Neuroplasticity: the brain rewires with experience. This is why psychotherapy produces measurable brain change and why therapy plus medication beats either alone.
General adaptation syndrome (Selye): alarm → resistance → exhaustion. Sustained cortisol in the exhaustion phase suppresses immunity and damages the hippocampus.
Heritability rough order: bipolar and schizophrenia are the most heritable, then major depression and anxiety disorders. Genetics load the gun; environment pulls the trigger.
If an exam item asks "what best explains why one twin developed schizophrenia and the other did not," the answer is the stress-diathesis model — shared vulnerability, different stress exposure.
🎯 Pathophysiology Quiz
30 questions on neuroanatomy, neurotransmitters, dopamine pathways, disease mechanisms, and the med emergencies. Includes SATA.
Mind Maps · Visual Connections
Concepts drawn as relationships, not lists. More get added as modules load.
🕸️ Neurotransmitters ↔ Disorders
Too much dopamine → psychosis; too little → Parkinson's. That's why dopamine-blocking antipsychotics cause EPS.
🕸️ The 4 EPS — Timeline
Onset order = severity/permanence order. TD is often permanent — screen with AIMS.
You cannot teach a severe or panicked client. Bring anxiety down first.
🕸️ Therapeutic vs. Nontherapeutic Communication
The therapeutic choice almost always invites the client to expand. Reassuring feels kind — it's the classic trap.
🕸️ Delirium vs. Dementia
New sudden confusion = delirium until proven otherwise → hunt the cause. Slow decline = dementia.
🕸️ Grief — Types & Tasks
Disenfranchised grief = a loss society doesn't recognize (e.g., ex-spouse, pet, pregnancy loss).
More maps arrive as Modules 4–10 load (anxiety disorders, abuse cycle, trauma/PTSD, legal-ethical, defense mechanisms).
PowerPoints · Lecture Decks
Your decks, embedded inline — scroll to view, or open any deck full-screen in Drive. If a preview shows a sign-in prompt, open it in the browser where you're logged into Google.
Exam 1 · Review Decks
📽️ Unit Exam 1 Review
Foundations + a deep run through therapeutic & non-therapeutic communication.
⚠️ An instructor's recording was streaming here. It has been removed — it is not this site's to publish. Your own copy is still in your Drive.
Fri 7/24 → Final on Wed 8/12. One box per day — do the box, close the laptop. Same shape every day: 10 min re-look at yesterday's misses → 35 min the day's topic → 15 min quiz on it. Your Miss List builds itself now — every wrong answer in this guide is saved automatically (card right below). Add ATI/class misses by hand in the same card.
🎯 The 3 Targets
ATI Content Mastery 1
Thu 7/30 — 6 study days
ATI Content Mastery 2
Wed 8/5 — 5 study days
FINAL (cumulative)
Wed 8/12 — 6 study days
A wrong quiz answer isn't a failure — it's a found exam point. Miss it now, not on the 12th.
🎯 My Miss List — auto-tracked
Every question you get wrong anywhere in this guide lands here automatically. Get it right twice in a row and it retires itself. Saved on this device — no account, no login.
0
still missing
0
retired ✓
0
hand-added
Missed something on ATI or in class? Type it here so it shows up on your morning check-in list too.
🚑 Daily Antidote Sprint — 5 min, every single day
You said antidotes are your weak spot. Antidotes are a memorization list, not a concept — one cram day loses to five minutes a day. So this is now bolted onto every box below, including days that have nothing to do with pharm.
The 5-minute protocol: 1. Cover the right column. Read the poison, say the antidote out loud. (2 min) 2. Run the 10-question sprint below, closed book. (3 min) 3. Any miss → Miss List. Same miss twice → write it on a sticky note on your laptop.
Toxicity / crisis
Say it out loud
Opioids (heroin, fentanyl, morphine)
NALOXONE — short half-life, watch for re-sedation, repeat doses
Benzodiazepines
FLUMAZENIL — can trigger seizures in chronic users / TCA co-ingestion
Acetaminophen
ACETYLCYSTEINE — best within 8 hours
Anticholinergic / atropine
PHYSOSTIGMINE
Neuroleptic malignant syndrome (FEVER)
DANTROLENE ± bromocriptine — stop the antipsychotic, cool the client
Serotonin syndrome (SHIVERS)
CYPROHEPTADINE — stop all serotonergic drugs
MAOI + tyramine → hypertensive crisis
PHENTOLAMINE
Warfarin
VITAMIN K (phytonadione)
Heparin
PROTAMINE SULFATE
Magnesium sulfate
CALCIUM GLUCONATE
Iron
DEFEROXAMINE
Digoxin
DIGOXIN IMMUNE FAB (Digibind)
Lithium toxicity
NO antidote — hold drug, IV normal saline, hemodialysis if >2.5
Barbiturates
NO antidote — airway, ventilation, supportive
Alcohol withdrawal (first drug, not an antidote)
BENZODIAZEPINES — lorazepam, chlordiazepoxide
The trap that eats points: on priority items, if the client is hypoxic or apneic, the answer is airway/oxygen BEFORE the antidote — unless naloxone is the listed airway intervention. Read whether they're asking "first action" or "the drug."
Today's sprint — closed book:
More reps: 💊 Medications tab has the Antidote & Reversal Drill table + two antidote infographics. 🧠 Quizzes tab has the full 🚑 Antidote Sprint bank.
Phase 1 · → Content Mastery 1
Fri 7/24 — Cold baseline (closed book!)
Your ATI practice scores don't count — this does. No notes, no book, no lookups.
📗 ATI Content Mastery quiz, ~30 Qs, closed book, exam pace (35 min)
Every miss → Miss List. That list is now your real map (10 min)
Two topics ATI flagged even WITH resources — learn cold: clozapine (agranulocytosis → weekly WBC/ANC, report sore throat/fever) and alcohol withdrawal timeline (tremors 4–12h → hallucinations 12–24h → DTs 48–72h) (15 min)
🚑 Antidote Sprint — 5 min, closed book (card at top of this tab)
🚑 Antidote Sprint — 5 min, closed book (card at top of this tab)
Mon 8/10 — All meds, one hour
Every med chart top to bottom + Antidote sheet (30 min)
Module 13 psychopharm quiz (30 min)
🚑 Antidote Sprint — 5 min, closed book (card at top of this tab)
Tue 8/11 — Dress rehearsal
🏁 Final Exam cumulative quiz, exam pace (45 min)
Final Miss List pass (15 min) — tomorrow you read ONLY this
🚑 Antidote Sprint — 5 min, closed book (card at top of this tab)
⭐ Wed 8/12 — THE FINAL
20 min: Miss List + mnemonics. That's it.
You've touched every module at least twice. Trust the reps.
🧠 ADHD guardrails
Timer on, 60 min, then stop. Stopping on time is what makes tomorrow happen.
Can't focus? Quiz first — questions pull attention better than reading.
Behind a day? Skip it, don't stack it. The quizzes recycle everything anyway.
One Miss List page. It becomes your entire exam-morning review.
⭐ Final Review · Easy Mode
the whole final review — rebuilt in tiny chunks and memory tricks. One idea per box. Skim the bold and the mnemonics; that's the exam.
🧠 How to Use This Tab
Don't read it like a book. Each colored box = one testable idea. If your brain drifts, jump to the next box — they don't depend on each other.
The yellow highlighted words and the ALL-CAPS mnemonics are the answers. Everything else is just there to explain them.
🔀 Confusable Pairs — Start Here
These are not knowledge gaps. They're look-alike gaps. You know the material — you pick the option that's true but not the answer. Every box below is a pair (or trio) that ATI deliberately puts in the same answer set.
Rule for the whole tab: when two options are both true, ask "which one is the question actually asking for?" Not which one is correct — which one is asked.
Schizoid vs Schizotypal vs SchizophreniaAntisocial vs NarcissisticHistrionic vs BorderlineBipolar I vs IICause vs First ActionActive Listening vs SilenceReflecting vs RestatingAkathisia vs AgitationLewy Body vs Alzheimer'sWithdrawal timelines
🧩 The "Schizo" Trio — 3 Different Disorders
Two of these are personality disorders. One is a psychotic disorder. They share a prefix and nothing else.
Disorder
Social life
Thinking
Psychosis?
One-word tag
Schizoid PD Cluster A
Alone — and fine with it. Doesn't want friends, doesn't feel lonely.
Normal. Just detached, flat, indifferent to praise or criticism.
NO
LONER
Schizotypal PD Cluster A
Alone — often because people find them strange. Social anxiety present.
Fast sort: Schizoid = I'd rather be alone. · Schizotypal = typically weird. · Schizophrenia = split from reality.
The trap: a stem describes a withdrawn client with odd beliefs and no hallucinations — and "schizophrenia" is sitting right there in the options. No hallucinations or delusions = not schizophrenia. Odd beliefs = schizotypal. Content solitude = schizoid.
Also: it's flat AFFECT, not "effect." Affect = the emotion you can see (observed). Mood = the emotion they report. ATI writes "client's affect is flat but reports mood as 'fine'" to test that you know the difference.
🎭 Cluster B Look-Alikes — All 4 Are "Dramatic"
Your one-word tags are right. The problem is that on a test, two of these tags fit the same stem. Here's what separates them.
PD
Your tag
What they WANT
Dead giveaway in the stem
Histrionic
Dramatic
Attention. Any attention.
Theatrical, flirtatious/seductive, flamboyant dress, shallow shifting emotions, "life of the party," uncomfortable when not the center.
Borderline
Lability ✓
To not be abandoned.
Self-harm / cutting, suicide threats, splitting ("you're the only one who gets me" → "you're the worst"), unstable identity, chronic emptiness, impulsivity.
Narcissistic
Zero empathy
Admiration. Needs an audience.
Grandiosity, entitlement, "I should have the best doctor here," name-dropping, rage when criticized, envy.
Antisocial
Manipulative
To exploit you. Doesn't care if you like them.
No remorse, unlawful acts, deceit, aggression, exploits others, plays staff against each other, conduct disorder before 15.
Antisocial vs. Narcissistic — both lack empathy, so empathy won't sort them. The split: narcissist wants to be admired · antisocial wants to use you. Narcissist is hurt by criticism; antisocial is indifferent to it.
Histrionic vs. Borderline — both are emotional and attention-getting. The split: histrionic wants the spotlight · borderline fears being left. If there's self-harm, cutting, or splitting → borderline, every time.
Borderline is the #1 tested PD because it carries the highest self-harm and completed-suicide risk of all personality disorders. Any borderline question that offers a safety option — take the safety option.
Staff splitting: if the stem says the team is arguing about the client — half defending, half angry — the splitting has spread to staff. Fix it in report with a consistent plan, not by confronting the client.
🎢 Bipolar I vs. II — "Highs and Lows" Isn't Enough
Bipolar I
Bipolar II
Required
At least one FULL manic episode. Mania is the definer.
Hypomania + at least one major depressive episode.
Full mania?
Yes
Never. If full mania appears, it becomes Bipolar I.
Depression
Common but not required for the diagnosis.
Required.
Hospitalized?
Often — mania impairs function, may include psychosis.
Usually not for the hypomania. Function is changed, not wrecked.
Stem clue
"hospitalized for mania," "grandiose delusions," "hasn't slept in 4 days"
"more productive than usual," "friends noticed she was unusually upbeat," then a depressive crash
Mania vs. hypomania is duration + damage: mania ≥ 7 days (or any length if hospitalization is needed) and impairs function or includes psychosis. Hypomania ≥ 4 days, noticeable to others, but function is intact and no psychosis, ever.
Third one to know: Cyclothymia = at least 2 years of hypomania + depressive symptoms that never reach full episode criteria. The chronic, milder wobble.
🎯 Cause vs. First Action — The Miss That Repeats
On an ATI "first action" or bowtie/cloze item, the etiology is never the answer. Etiology explains the chart. The first action is the greatest immediate physiologic risk.
The real item you missed → manic client, day 2
What the chart showed
Day 1 (2000)
Day 2 (1000)
Blood pressure
158/98
158/98
Heart rate
104/min
134/min
Respirations
20/min
24/min
Temperature
99.4°F
99.9°F
Lithium level
—
0.1 mEq/L (0.8–1.2)
Plus: rapidly pacing, cannot sit or stand still, flushed, diaphoretic, not eating, wearing two sweatshirts + knit cap + boots in 80°F.
❌ Answered: medication noncompliance due to lithium level True. It's why he decompensated. It is not what hurts him first.
↓
✅ Answer: cardiovascular injury due to constant psychomotor activity HR up 30 points overnight, RR climbing, flushed, diaphoretic, no food, no rest, overdressed in heat. This is a body heading toward cardiovascular collapse and exhaustion.
How to catch it in real time: when a cloze says "first action," ignore history and labs on the first pass. Go straight to vitals + the most recent nurses' note. If vitals are trending bad, that's your answer. Restart the lithium after you've kept him alive.
Same error shape shows up as: picking the correct nursing diagnosis when the question wants the safety priority. Order of operations is always ABC → safety → acute physiologic change → psychosocial → teaching. Teaching is never the first action in an acute episode.
💬 Therapeutic Communication Look-Alikes
All of these are correct techniques. That's exactly why they're in the same answer set. The question names one.
The split that unlocks it:active listening is what you TAKE IN. The others are what you PUT OUT. Only one option will describe the nurse receiving information.
Technique
What the nurse does
Words in the option that give it away
Active listening
Receives both verbal AND nonverbal communication.
attention to body language, observing posture / eye contact / facial expression / tone
Use of silence
Waits. Says nothing, gives the client room to answer.
"sits quietly," "waits for the client to respond"
Offering self
Gives presence, with no agenda.
"I'll stay with you," "I'll walk with you," "I'll sit here"
Reflecting
Gives back the feeling.
"You sound frightened," "That seems to make you angry"
Restating
Gives back the content — near-repeats the words.
Client: "I can't sleep." Nurse: "You're having trouble sleeping."
Clarifying
Asks for the missing piece.
"I'm not sure I follow — can you explain what you mean by that?"
Making observations
States the visible fact out loud, neutrally.
"I notice you're trembling," "You haven't eaten today"
Presenting reality
Kindly states what IS, without arguing.
"I don't hear a voice, but I understand you do"
Reflecting vs. Restating is the next place this gets you. Reflect = feeling. Restate = content. If the nurse names an emotion the client didn't name, that's reflecting.
ATI's exact wording for the win: "Active listening involves identifying verbal AND nonverbal communication by the client." The word nonverbal is the tell — nothing else in the answer set will mention it.
🍺 Withdrawal Timelines — Only Two Can Kill
Alcohol and benzodiazepines are the two withdrawals that can kill you. (Barbiturates too — same CNS-depressant family.) Opioid withdrawal is miserable but not lethal in a healthy adult. ATI tests this distinction directly.
SEIZURE window — tonic-clonic. Seizure precautions on.
24–48 hours
Peak of the minor symptoms. Autonomic signs loudest.
48–72+ hours up to 96 hrs
DELIRIUM TREMENS — this is the part that kills. Confusion, disorientation, visual and tactile hallucinations, severe autonomic instability, fever, ↑↑HR/BP. Medical emergency.
Fix in your notes: withdrawal does not start at 24 hours — it starts at 4–12. And the deadly phase is DT at 48–72+ hours, not the 24–48 hr peak. A client who is calm on day 1 and 2 and then suddenly confused and seeing bugs on day 3 = DT, not "getting worse anxiety."
Treatment:benzodiazepines (lorazepam, chlordiazepoxide) to substitute and taper · thiamine BEFORE glucose (prevents Wernicke's) · folate, multivitamin, fluids · CIWA-Ar to score severity and dose · quiet, well-lit room · seizure precautions.
Skip "hyperglycemia" — it isn't a discriminator and it clutters recall. Lock in tremors → seizures → DT and the hours attached to each.
Benzo withdrawal looks like alcohol withdrawal but on a longer, delayed clock (can start days later with long-acting agents, and seizures can appear up to 1–2 weeks out). Never stop a benzo abruptly — always taper.
🧠 Lewy Body Dementia — The Med You Cannot Give
🚫 ANTIPSYCHOTICS — especially first-generation/typical ones like haloperidol. Lewy body dementia causes severe neuroleptic sensitivity: irreversible parkinsonism, sharp cognitive decline, NMS, and death. Also avoid anticholinergics (diphenhydramine, benztropine) — they worsen confusion.
The trap ATI builds: Lewy body presents with vivid visual hallucinations. Hallucinations make you reach for haloperidol. That reflex is the entire question. If an antipsychotic is truly unavoidable, quetiapine is preferred (lowest dopamine blockade).
Lewy body's 4-part picture
👁️ Visual hallucinations
Vivid, detailed, recurrent — often people or animals. Present early, unlike Alzheimer's.
🌊 Fluctuating cognition
Good days and bad days, sometimes good hours. Alert and clear, then confused. Family says "she comes and goes."
🚶 Parkinsonism
Shuffling gait, rigidity, bradykinesia, tremor, falls. Fall precautions are a real answer here.
😴 REM sleep behavior disorder
Acts out dreams — punching, kicking, yelling while asleep. Often shows up years before anything else.
Gradual, steady memory loss first. Recent memory goes before remote. No early hallucinations.
Avoid if possible (black box: ↑mortality in older adults with dementia)
Vascular
Stepwise decline tied to strokes/TIAs. Focal neuro findings. Abrupt drops, then plateaus.
Avoid if possible
Frontotemporal Pick's
Personality and behavior change FIRST — disinhibition, socially inappropriate, apathy. Memory relatively spared early. Younger onset.
Avoid if possible
Every dementia carries the black box warning: antipsychotics increase mortality in older adults with dementia-related psychosis. Lewy body is the one where it's not just a warning — it's an outright contraindication.
🔁 OCD, Phobia, and the Anxiety Look-Alikes
Your note — "OCD = uses rituals to ease anxiety" — is correct. Here's what gets tested around it.
Disorder
Core
Split from its look-alike
OCD
Obsessions (intrusive thoughts) → compulsions (rituals) that temporarily relieve anxiety.
Client knows it's irrational and is distressed by it. Ego-dystonic.
No obsessions, no rituals. Client thinks they're right, not sick. Ego-syntonic.
Specific phobia
Intense fear of a specific object/situation → avoidance.
Fear has an external object. No rituals.
Panic disorder
Recurrent unexpected panic attacks + fear of the next one.
Comes out of nowhere. Peaks in ~10 min. Feels like dying/MI.
GAD
Excessive worry most days, ≥ 6 months, about many things.
Diffuse — no specific object, no attacks, no rituals.
Never abruptly stop or forbid an OCD client's ritual. It will spike anxiety, sometimes to panic. Allow time for the ritual, set limits gradually as anxiety improves, and build in the schedule so it doesn't block meals or treatment.
First-line for OCD: SSRIs (often higher doses than for depression) + ERP — exposure and response prevention. Clomipramine is the classic TCA option.
🧠 Quiz yourself — 22 look-alike questions
🗣️ Mental Status Exam
Memory trick: "A Beautiful Mental State Always Pleases Customers, Provided Of course It's Justified"
1. Tension building minor anger, walking on eggshells
→
2. Acute battering serious abuse — shortest phase
→
3. Honeymoon "I'm sorry, I'll change" → repeats
Leave a suspected-abuse client's safety unassessed. Ask about a safety plan. Reporting rules vary by state/population.
⚰️ Grief — 5 Stages
Denial
→
Anger
→
Bargaining
→
Depression
→
Acceptance
Stages aren't a straight line. Anticipatory grief = grieving before the loss. With an unconscious dying client, hearing is the last sense to go — watch what you say.
😴 Sleep Hygiene (quick list)
Same sleep/wake timeBedroom = sleep onlyNo clock-watchingNo caffeine at nightNo heavy meals lateNo daytime napsExercise daily (not right before bed)
⚡ ECT — 30-Second Version
What: tiny controlled seizure under anesthesia. Best for: severe/treatment-resistant depression.
Full drug cards are in the Medications tab; the emergencies are drawn out in Mind Maps.
Study sheets
This tab held commercial study sheets from another publisher. They have been removed — they were not this site's to hand out. Your own copies are still in your Drive.
ATI Content Mastery
Full RN Mental Health review — study guide, medications, and a 370+ question NCLEX-style quiz. Covers all 6 units / 33 chapters.Built from standard ATI/NCLEX Mental Health curriculum (Ed. 11.0 chapter map).
📋 Your Filled ATI Active Learning Templates
15 templates filled out from your Practice Test A (73.3%, closed book) report and your two Dynamic Quizzing screenshots — 7 Basic Concept, 5 System Disorder, 3 Medication. Each one starts with what you actually missed and why the keyed answer won.
Biggest single lesson on that page: 5 of your 9 Clinical Judgment misses were ONE case study (the acute mania ED client). Every time, you picked the psychological finding and the key wanted the physiological or safety finding.
🧠 the Mnemonic Vault — from your Content Mastery Final Review
Every memory trick from the 28-page the final review session, in one place. If a question stem matches one of these, run the letters.
🧾 MSE
"ABeautiful Mental State Always Pleases Customers, Provided Of Course It's Justified" — Appearance · Behavior · Motor · Speech · Affect/mood · Thought Process · Thought Content · Perception · Orientation · Cognition · Insight · Judgment
😟 GAD = MISERAble
Muscle tension · Irritability · Sleep disturbance · Energy loss · Restlessness · Attention difficulty (6 months of uncontrolled worry)
Underweight · Nervous to gain · Distorted perception · Exercise/purging · Restricting intake (BMI <18, bradycardia, lanugo, cardiac risk)
🥣 BOWL-emia
Binging · Offsetting (purging) · Weekly for >3 months · Linked to self-esteem (normal BMI, hypokalemia with purging)
🩺 Somatic = SOME ATTIC
Symptoms · One or more (PHQ-15) · Medically unexplained · Excessive · Anxiety · Thinking about · Time-consuming · Impairing · Chronic
🦵 Conversion = CAN'T-Version
Clinically unexplained · Abnormality · Nervous system · Trigger (sometimes). And: MALingering Always Leaves; FACtitious always comes back.
⚡ ADHD = FIDGETY
Functionally impairing · Inattention · Disinhibition · Greater than normal · Exclude other disorders · Two+ settings · Young onset (<12)
🧩 Autism = ASD
Alone · Sameness · Developmental. Tics = TIC (Transient, Irresistible, Contraction); TWO-rette = two forms of tics (motor + vocal)
🌀 Delirium = "Where The F AM I?"
Where (disorientation) · Transient · Fluctuating · Acute · Medical causes · Intoxicants — a medical emergency, worse at night
🧓 Dementia = DIRE
Decline in cognition · Impairment · Rule out delirium · Exclude psychiatric causes (depression). Continuous, irreversible, months–years.
🎭 PD Clusters — the party trick
"How does each cluster act when invited to a party?" A = weird (paranoid, schizoid, schizotypal), B = wired (borderline, antisocial, histrionic, narcissistic), C = worried (dependent, avoidant, OCPD). Borderline = I DESPAIR.
🧩 the review session Extras — Topics Covered Nowhere Else
These appear in your Content Mastery review but not in the module lectures — easy points if they show up.
🤝 Codependence
Maladaptive coping in family members after a prolonged relationship with a person who uses substances: poor relationship skills, excessive worry, compulsive behaviors, resistance to change.
CBT-I and nonpharm measures are first-line for primary insomnia (long-term meds NOT indicated): fixed sleep-wake schedule, presleep routine, bedroom for sleep only, no clock-watching, limit caffeine/alcohol, no naps, exercise daily but not before bed.
⚡ ECT Contraindications
Cardiovascular and cerebrovascular disorders. Indications include delusional depression, failed med trials, catatonia, severe malnutrition/dehydration from lengthy depression. 2–3×/week × 6–12 treatments; stop benzos first.
🛡️ Defense Mechanisms — rapid-fire
Displacement = taking it out on the wrong target · Projection = my feelings, your fault · Reaction formation = acting the opposite · Regression = acting younger · Repression = unconscious forgetting vs Suppression = chosen forgetting · Splitting = all good/all bad (borderline) · Sublimation = channeling urges into something acceptable · Undoing = canceling it out · Conversion = stress becomes a physical symptom.
🚻 Sexual & Gender Topics
Sexual dysfunction = disturbance in desire/excitement/orgasm phases or pain (often medication-related). Gender identity forms ~age 3; gender dysphoria = persistent cross-gender identification with distress. Paraphilic disorders: pedophilic is most common; exhibitionistic, voyeuristic, frotteuristic, fetishistic, sadism/masochism, transvestic.
Discuss ways to keep control · assess the milieu for triggers · encourage the client to talk about the incident · debrief staff · document everything (what preceded it, less-restrictive methods tried, outcomes).
📗 How ATI Tests — The 5 Active Learning Templates
ATI tests in templates. Fill these five from memory for any topic and you're ready.
🧬 Basic Concept
Related content · underlying principles · nursing interventions
Every template on that page maps to something you actually missed. Red boxes = the exact spot you lost the point. There's a 🏠 Home button on it to come back here.
Unit 1 · Foundations for Mental Health Nursing
🧠 Ch 1 — Basic Mental Health Nursing Concepts
Mental health is not merely the absence of illness; it is the capacity to cope with everyday stress, maintain satisfying relationships, adapt to change, and function productively. Mental illness is a clinically significant disturbance in thinking, mood, or behavior that causes distress and impaired functioning. The two exist on a fluid continuum that shifts with circumstances.
📗 DSM-5-TR
The standardized manual used to classify and diagnose mental disorders with agreed criteria.
🔁 Resilience
Ability to recover and adapt after adversity — a protective factor against illness.
🧩 Coping
Conscious efforts to manage stress; can be adaptive (problem-solving) or maladaptive (avoidance).
👥 Peplau
Founder of psychiatric nursing; described the nurse–client relationship as the therapeutic tool.
Nursing process (ADPIE) applies fully in psych: Assess → Diagnose → Plan → Implement → Evaluate. Assessment includes a mental status exam, risk assessment (suicide/violence), and biopsychosocial history.
The therapeutic use of self — the nurse's personality, insight, and communication — is the primary instrument of psychiatric care.
⚖️ Ch 2 — Legal and Ethical Issues
Admission Type
Key Point
Voluntary
Client consents; retains all rights, may request discharge.
Involuntary (commitment)
Court/provider ordered; client did NOT consent — requires danger to self/others or grave disability.
Emergency
Short-term hold for imminent danger; time-limited pending evaluation.
Involuntary commitment criteria: danger to self, danger to others, or gravely disabled (unable to meet basic needs). A person can be committed and STILL refuse specific treatments unless separately adjudicated incompetent.
Client rights: informed consent, confidentiality (HIPAA), the least restrictive environment, the right to treatment, and the right to refuse treatment. Involuntary status does not automatically strip the right to refuse medication.
Negligence (failure to act reasonably), Malpractice (professional negligence causing harm)
Threatening to medicate a client against their will = assault; actually giving it = battery. Confining a competent client or using unnecessary restraints = false imprisonment.
Duty to warn (Tarasoff): when a client makes a serious, specific threat against an identifiable person, confidentiality yields — the nurse/provider must warn and protect the intended victim.
Never apply restraints or seclusion without a current provider order (except a brief emergency), never for staff convenience or punishment, and never leave a restrained client unmonitored. Orders are time-limited and require frequent reassessment and renewal.
💬 Ch 3 — Effective Communication
Communication has a sender, message, receiver, and feedback (the receiver's verbal/nonverbal response). Nonverbal cues (tone, posture, eye contact, facial expression) carry most of the emotional message; when verbal and nonverbal conflict, believe the nonverbal.
Steer responses toward the client's feelings (left); avoid shutting exploration down (right).
🔎 Clarifying
"I'm not sure I follow — can you give an example?"
🪞 Reflecting
Return feelings to the client: "You sound frightened."
🤝 Offering self
"I'll sit with you for a while." Presence without demand.
🔇 Silence
Gives the client time to gather and lead the conversation.
"Why did you do that?" sounds accusatory and pressures the client to justify — replace with an open observation: "Tell me what was happening before that." "Don't worry, everything will be fine" is false reassurance and blocks feelings.
Client: "I can't do anything right."
→
Nurse: "You feel like you're failing. Tell me more."
Active-listening posture — SOLER: Sit squarely, Open posture, Lean in, Eye contact, Relax.
🌪️ Ch 4 — Stress and Defense Mechanisms
Selye's General Adaptation Syndrome (GAS) describes the body's response to a stressor in three stages:
1. Alarm (fight-or-flight, SNS surge)
→
2. Resistance (adapt / cope)
→
3. Exhaustion (reserves depleted, illness)
Anxiety Level
Perception & Nursing Focus
Mild
Heightened alertness; learning is enhanced.
Moderate
Narrowed perception; can redirect with help.
Severe
Greatly reduced focus; needs direction & calm.
Panic
Disorganized, loss of control — ensure SAFETY first, stay with client.
Defense mechanisms are unconscious. They are adaptive when used briefly to reduce anxiety, but maladaptive when overused or reality-distorting. Sublimation is generally the most mature; denial is among the most primitive.
🚫 Denial
Refuses to accept reality ("I don't have a drinking problem").
🎯 Projection
Attributes own feelings to others ("You hate me" when he is angry).
↩️ Displacement
Redirects emotion to a safer target (yells at spouse after boss scolds).
🎨 Sublimation
Channels urges into acceptable outlets (anger → kickboxing).
🧠 Rationalization
Logical-sounding excuses ("I failed because the test was unfair").
👶 Regression
Reverts to earlier behavior (hospitalized child wets bed).
🔄 Reaction formation
Acts opposite to true feelings (overly kind to someone disliked).
📚 Intellectualization
Focuses on facts to avoid emotion (recites diagnosis stats).
Repression = unconscious forgetting; Suppression = conscious "I'll deal with it later." Undoing = trying to cancel out an act (gift after an insult).
🏥 Ch 5 — Therapeutic & Safe Environment (Milieu)
Milieu therapy uses the whole treatment environment — people, structure, and daily activities — as a deliberate therapeutic tool. The therapeutic community is safe, structured, and predictable, with clear roles and consistent limits.
SafetyStructureSupportInvolvementValidation
Safety is the top milieu priority. Perform environmental rounds: remove sharps, cords, belts, glass, and medications; know client locations; maintain therapeutic staffing and observation levels (e.g., 1:1 for high suicide risk).
🧱 Structure
Predictable schedule and rules lower anxiety and testing behavior.
🚧 Limit-setting
Consistent, firm, non-punitive boundaries applied by all staff.
🧯 De-escalation
Calm tone, personal space, offer choices before restraint.
🤝 Involvement
Clients share in decisions and community meetings.
Restraint and seclusion are last resorts after less-restrictive measures fail. Continuous monitoring, documentation, and time-limited renewed orders are required — never routine or punitive.
Never ignore a suicidal statement or promise of secrecy about self-harm — safety overrides confidentiality; place the client on appropriate precautions and notify the team immediately.
🌍 Ch 6 — Diverse Practice Settings
Care spans a continuum from most to least restrictive, matched to the client's acuity and ability to stay safe. The goal is the least restrictive setting that still meets needs.
Inpatient acute (24-hr, crisis/danger)
→
Partial hospitalization / IOP
→
Community / outpatient / home
Setting
Best For
Inpatient (acute)
Imminent danger, stabilization, close monitoring.
Partial hospitalization (PHP)
Structured day program; client goes home at night.
Intensive outpatient (IOP)
Several sessions/week while living at home.
Community mental health center
Ongoing outpatient care, meds, therapy, follow-up.
Assertive Community Treatment (ACT)
Mobile team for severe, persistent illness in the community.
Residential / crisis stabilization
Supervised housing or short-term crisis beds.
Deinstitutionalization shifted care from long-stay hospitals to community settings — improving autonomy but raising risks of gaps in follow-up, homelessness, and readmission without strong case management.
The interdisciplinary team (nurse, provider, social worker, psychologist, OT, case manager) coordinates care; the nurse often ensures continuity and transitions between levels of care.
Unit 2 · Traditional Nonpharmacological Therapies
🧠 Ch 7 · Developmental & Personality Theories
High-yield frameworks that anchor psychoanalytic and psychotherapeutic practice. On NCLEX, match the age to the correct stage and remember which stage is failing when behavior regresses.
Peplau's nurse–client relationship = Orientation → Working (identification + exploitation) → Termination. Build trust first; do not push interventions before the working phase.
Erikson stages are sequential: unresolved earlier crises resurface under stress. A hospitalized toddler acting out is often a regression, not new pathology.
🧠 Ch 7 · Psychotherapy & Cognitive Approaches
Psychotherapy = talk-based treatment to change thoughts, feelings, and behavior. Know the signature technique of each modality.
🛋️ Psychoanalysis
Long-term; uncovers unconscious conflicts via free association & dream analysis.
Yalom's curative factors include instillation of hope, universality, altruism, catharsis, and group cohesiveness. Redirect a monopolizing member to protect the group process.
👥 Ch 8 · Family Therapy
Treats the family as the unit of care — the identified patient's symptoms often reflect dysfunction in the whole system.
🌳 Bowen (systems)
Differentiation of self, triangulation, multigenerational transmission, the genogram.
Reappraise the stressor to change the emotional response.
Match teaching to acuity: for acute anxiety at the bedside, start with slow deep breathing — simple, immediate, no equipment.
⚡ Ch 10 · Electroconvulsive Therapy (ECT)
ECT applies a brief electrical current to induce a generalized seizure. Reserved for severe, treatment-resistant depression, especially with psychosis or active suicidality, and for mania/catatonia.
🎯 Indications
Major depression unresponsive to meds; need for rapid response; med contraindication (e.g., pregnancy).
Memory loss & confusion (usually temporary), headache, muscle soreness, nausea.
Most common side effects = transient confusion and short-term memory loss (retrograde/anterograde amnesia). Reassure clients it typically resolves within weeks.
ECT is not a first-line treatment and is not just for "hopeless" cases — it is highly effective and specifically preferred when a fast antidepressant response is needed.
⚡ Ch 10 · ECT Nursing Care — Pre / During / Post
Nursing priority across the whole procedure = airway, aspiration prevention, and safety.
ECT care flows Pre → During → Post; every phase guards the airway and orients the client.
Never send a client to ECT who is not NPO — aspiration under anesthesia is a life threat. Verify NPO status and signed consent before transport.
Post-ECT, place the client in a side-lying (recovery) position, stay until awake and oriented, and reorient frequently — confusion is expected and temporary.
⚡ Ch 10 · TMS · VNS · DBS Compared
Newer brain-stimulation options for treatment-resistant depression — know the invasiveness and the signature side effect of each.
Left → right = least to most invasive: TMS (external) · VNS (implanted lead) · DBS (intracranial electrodes).
Therapy
What it is
Key teaching / side effects
TMS
Noninvasive magnetic pulses to prefrontal cortex; outpatient, daily × 4–6 wks; no anesthesia/NPO
Mild headache, scalp tingling; rare seizure. Contraindicated with metal/implants in head
VNS
Surgically implanted device stimulates the left vagus nerve; also treats epilepsy
Unit 3 · Psychobiologic Disorders (Anxiety → Psychotic)
😰 Anxiety Disorders — The Big Picture
Anxiety is a vague, diffuse apprehension to an unknown threat (unlike fear, which has a known object). A little anxiety fuels learning; too much paralyzes it. High-yield disorders: generalized anxiety disorder (GAD), panic disorder, specific phobia / agoraphobia / social anxiety, and separation anxiety.
🌀 GAD
Excessive, uncontrollable worry most days ≥ 6 months + restlessness, fatigue, irritability, muscle tension, sleep disturbance.
💥 Panic Disorder
Recurrent, unexpected panic attacks (peak ~10 min) + ≥1 month of worry about the next attack or avoidance.
🕷️ Specific Phobia
Marked fear of an object/situation, out of proportion, leading to avoidance.
🚪 Agoraphobia
Fear of places where escape is hard (crowds, transit, lines) → housebound.
Panic attack quick recall — PANICS: Palpitations, Abdominal distress, Numbness, Intense fear of dying, Choking/Chest pain, Sweating/Shaking.
😰 Levels of Anxiety — Assessment Ladder
The single most testable anxiety concept: as anxiety rises, the perceptual field narrows and the ability to learn/problem-solve collapses. Match your intervention to the level.
As anxiety climbs the pyramid, focus narrows and learning drops toward zero at panic.
Level
Perception / Learning
Nursing focus
Mild
Field sharpened; alert, motivated, learns well
Teachable moment — reinforce coping
Moderate
Field narrows; selective attention; can redirect
Calm presence, redirect focus
Severe
Field greatly reduced; detail-focused, poor problem-solving
Reduce stimuli, simple/short directions
Panic
Field distorted; loss of control, misperceptions, possible unsafe behavior
Stay with client — do NOT leave; ensure safety
😰 Anxiety — Nursing Care & Meds
During a panic attack: stay with the client, remain calm, use a quiet low-stimulation area, speak in short simple sentences, and do not demand problem-solving. Teaching happens only after anxiety drops to mild/moderate.
SSRIs — first-lineSNRIs (venlafaxine)Buspirone (GAD)Benzodiazepines — short-term only
💊 Buspirone
No dependence, non-sedating, but takes 1–2 weeks (full 3–6) — not for acute panic.
💊 Benzodiazepines
Lorazepam/diazepam — fast relief; risk of dependence, sedation, tolerance. Avoid alcohol; taper to stop.
💊 Beta-blockers
Propranolol blunts physical symptoms of performance anxiety.
🧠 Therapy
CBT, relaxation/deep breathing, and graded exposure/desensitization for phobias.
Buspirone is not a rescue drug — a client expecting instant relief needs re-teaching. Don't give a benzodiazepine PRN for GAD long-term.
🌪️ Trauma- & Stressor-Related Disorders
All require exposure to a stressor/trauma. Key distinction is timing after the event.
Intrusion: flashbacks, nightmaresAvoidance of remindersNegative mood/cognitionHyperarousal, ↑ startle
Therapeutic communication: use a calm, nonjudgmental, unhurried approach; let the client control pacing of trauma disclosure; validate feelings; never force reliving the event. Reassure that flashbacks and numbing are expected trauma responses.
Alpha-blocker that reduces trauma nightmares; watch for orthostatic hypotension.
🧠 Trauma therapy
CBT, prolonged exposure, EMDR, group therapy.
🛟 Grounding
Teach grounding/5-senses techniques for flashbacks; ensure safety first.
Never dismiss or minimize the trauma ("that was long ago"), and never push the client to describe details before they're ready.
🌧️ Depressive Disorders — Diagnosis
Major depressive disorder (MDD): ≥5 symptoms during the same 2-week period, and at least one is depressed mood or anhedonia (loss of interest/pleasure).
SIG-E-CAPS — Sleep change · Interest loss (anhedonia) · Guilt/worthlessness · Energy loss · Concentration ↓ · Appetite/weight change · Psychomotor agitation or retardation · Suicidal ideation. (+ depressed mood = MDD)
📆 Persistent Depressive (Dysthymia)
Depressed mood most days ≥ 2 years (milder, chronic).
🌗 PMDD
Mood symptoms in the luteal phase, resolving after menses.
🌦️ Disruptive Mood Dysregulation
Chronic irritability + severe outbursts in children.
👶 Postpartum
MDD with peripartum onset; screen new parents.
🌧️ Depression — Safety Is the #1 Priority
Suicide risk assessment comes first. Ask directly: "Are you thinking of killing yourself? Do you have a plan?" Asking does NOT plant the idea. A specific plan + available means + prior attempts = high risk.
Watch the sudden lift in mood or a client giving away possessions — a newly energized depressed client may now have the energy to act on a suicide plan. Risk can rise as energy returns, before mood fully recovers.
Ask directly about ideation/plan/meansEnsure a safe environment (remove means)1:1 / close observation per riskNo-harm/safety contract & support
🗣️ Communication
Sit with silence, offer self, use open-ended prompts; avoid false reassurance ("cheer up") and avoid "why" questions.
🍽️ Care
Monitor nutrition/hydration, sleep, hygiene; structure simple activities; set small achievable goals.
🌧️ Depression — Medications
SSRIs — first-lineSNRIsMAOIs — tyramine riskTCAs — lethal in overdose
💊 SSRIs
Fluoxetine, sertraline. 2–4 weeks for effect. Watch serotonin syndrome & early activation of suicide risk in young clients.
💊 SNRIs
Venlafaxine, duloxetine — monitor BP.
💊 Bupropion
No sexual side effects, aids smoking cessation; lowers seizure threshold — avoid in eating disorders/seizures.
Never combine an MAOI with an SSRI/SNRI/triptan → serotonin syndrome (fever, hyperreflexia, agitation, autonomic instability). Never stop antidepressants abruptly.
ECT: for severe/refractory depression or acute suicidality; short-term memory loss is the main expected effect. NPO before, monitor airway/vitals after.
🎢 Bipolar Disorders — Spectrum
🔺 Bipolar I
≥1 manic episode (≥1 week or hospitalization); depression common but not required.
🔻 Bipolar II
Hypomania (≥4 days, no marked impairment/psychosis) + major depression.
〰️ Cyclothymic
Hypomanic + depressive symptoms ≥ 2 years, not meeting full criteria.
⚠️ Mania w/ psychosis
Grandiose/paranoid delusions possible in Bipolar I.
During acute mania, safety = preventing exhaustion & injury: reduce stimuli, calm firm limits, high-calorie finger foods the client can eat on the move, redirect energy, and monitor for physical collapse and dehydration.
🧩 Schizophrenia — Therapeutic Communication & Safety
Hallucinations/delusions: do not argue or agree. Acknowledge the feeling, then present reality gently: "I don't hear the voices, but I can see you're frightened." Focus on the underlying emotion, not the content.
🔊 Command hallucinations
Top safety priority — ask directly what the voices say; risk of harm to self/others.
Unit 3 · Psychobiologic Disorders (Personality → Somatic)
📊 All 10 Personality Disorders — Side by Side
Looking for borderline? It's row 4 and it has its own box at the bottom of this card. Every PD is ego-syntonic — the client thinks the problem is everyone else — so engagement is the hard part, and the whole team must give the same answer.
Three clusters, three moods: A = weird (odd/eccentric) · B = wild (dramatic/erratic) · C = worried (anxious/fearful).
🔍 The one-line tell for each
← swipe the table sideways to see the third column →
Disorder
Cluster
The one-line tell
Paranoid
A — weird
“Everyone is out to get me.” Distrust, grudges, reads malice into neutral acts — but no hallucinations.
Schizoid
A — weird
“I don't want people.” Genuine loner, emotionally cold, indifferent to praise or criticism.
Schizotypal
A — weird
“The TV is sending me signs.” Magical thinking, ideas of reference, odd speech/dress — reality testing still intact.
“I'm special, get me the real doctor.” Grandiose, entitled, no empathy, rages when criticized.
Avoidant
C — worried
“I want friends but they'll reject me.” Feels inadequate, hypersensitive to criticism.
Dependent
C — worried
“You decide for me.” Clingy, submissive, helpless alone, replaces a lost partner fast.
Obsessive-Compulsive (OCPD)
C — worried
“It has to be done my way, perfectly.” Rigid, controlling, workaholic — no rituals, and they see nothing wrong with it.
🔬 Hallmark · discriminator · what the nurse does
⭐ Borderline (B)
Hallmark: instability in relationships, self-image, and mood + impulsivity + fear of abandonment + recurrent self-harm. Discriminator: histrionic wants attention and antisocial wants gain — borderline is driven by terror of being abandoned. Only PD with splitting and repeated self-injury. Nursing:consistent limits, identical from every staff member, written in the care plan. Name the splitting out loud. Safety checks. No self-disclosure, no favors, no rescuing. DBT is first-line.
Paranoid (A)
Hallmark: pervasive suspicion, questions loyalty, holds grudges. Discriminator: suspicious without psychosis — no hallucinations, no fixed bizarre delusion. Nursing: neutral, honest, matter-of-fact. Do not be overly warm or friendly — it reads as a trick. Never whisper near the client. Keep every promise. Give simple written explanations.
Schizoid (A)
Hallmark: detached, solitary, flat, no interest in relationships or sex. Discriminator:doesn't want closeness (avoidant wants it and is scared). Nursing: respect the need for solitude. Do not force group activities. Low-demand, one-on-one, gradual.
Schizotypal (A)
Hallmark: magical thinking, ideas of reference, eccentric dress and speech. Discriminator:not schizophrenia — no sustained hallucinations/delusions; brief transient psychosis only under heavy stress. Nursing: respectful, don't argue with or reinforce the magical thinking; social skills training.
Antisocial (B)
Hallmark: violates others' rights, deceitful, aggressive, zero remorse; history of conduct disorder before 15. Discriminator: exploits for gain or thrill; borderline acts out from fear; narcissist acts out for admiration. Nursing: firm limits + stated consequences. Don't be charmed or flattered. Protect the other clients. Highest risk of violence toward others.
Histrionic (B)
Hallmark: attention-seeking, theatrical, seductive, shallow emotions that switch fast. Discriminator:no self-harm, no identity instability — that's what separates it from borderline. Nursing: hold professional boundaries, redirect flirtatious/seductive behavior calmly, reward genuine emotion, don't reward drama.
Narcissistic (B)
Hallmark: grandiosity, entitlement, needs admiration, exploits others, lacks empathy; fragile self-esteem underneath. Discriminator: wants admiration, not gain (antisocial) and not rescue (borderline). Nursing: matter-of-fact. Don't argue about their superiority and don't feed it. Set limits on demands. Avoid power struggles. Expect rage after criticism.
Avoidant (C)
Hallmark: socially inhibited, feels inadequate, terrified of criticism and rejection — but wants connection. Discriminator: desire for closeness = avoidant; indifference = schizoid. Nursing: assertiveness and social skills training, role-play, small graded successes, build self-esteem. Don't push too fast.
Dependent (C)
Hallmark: can't make decisions, submissive, clinging, needs others to take responsibility, urgently replaces a lost relationship. Discriminator:submits to keep you; borderline rages or self-harms to keep you. Nursing: require the client to make her own decisions. Do not do what she can do herself. Assertiveness training. Set limits on clinging — don't become the caretaker.
Obsessive-Compulsive PD (C)
Hallmark: perfectionism, order, control; rigid, stingy, workaholic, can't delegate. Discriminator:OCPD ≠ OCD. OCPD has no obsessions and no rituals and the client thinks it's correct (ego-syntonic). OCD has intrusive thoughts + rituals and the client hates them (ego-dystonic). Nursing: give control where it's safe, use written schedules, don't rush her, coach tolerating “good enough.”
⚔️ The pairs the exam makes you separate
Confused pair
What decides it
Schizoid vs Avoidant
Do they want relationships? Schizoid no. Avoidant yes, but fears rejection.
Schizotypal vs Schizophrenia
Is reality testing intact? Schizotypal yes (odd, magical). Schizophrenia no (hallucinations, delusions).
Paranoid PD vs Delusional disorder
A fixed delusion? Paranoid PD = generalized suspicion. Delusional disorder = one specific fixed false belief.
Borderline vs Histrionic
Self-harm and splitting. Borderline has both. Histrionic just wants the spotlight.
Borderline vs Antisocial
Motive. Borderline = don't abandon me. Antisocial = what can I get, and no guilt.
Narcissistic vs Antisocial
Admiration vs exploitation. Narcissist needs to be admired. Antisocial doesn't care what you think.
Dependent vs Borderline
Reaction to losing you. Dependent clings and submits. Borderline rages, threatens, self-harms.
OCPD vs OCD
Rituals + insight. OCPD: no rituals, sees no problem. OCD: rituals, distressed by them.
Never on a PD question: never negotiate a limit you already set · never give one client a rule the others don't have · never share personal information or take a gift · never argue with grandiosity or magical thinking · never tell a client with borderline PD you're the one who “understands” her — that is the splitting.
⭐ Borderline PD — the deep dive you were looking for
Definition: pervasive instability of interpersonal relationships, self-image, and affect plus marked impulsivity, beginning by early adulthood. The 9 criteria (I DESPAIRR):Identity disturbance · Disturbed/unstable relationships · Emotional instability (mood swings in hours, not weeks) · Suicidal or self-mutilating behavior · Paranoid or dissociative episodes under stress · Abandonment fear (frantic efforts to avoid it) · Impulsivity (spending, sex, substances, driving, binge eating) · Rage (inappropriate, intense anger) · Real emptiness (chronic feelings of emptiness). Splitting: can't hold good and bad in the same person, so people are all-good or all-bad and flip without warning. On the unit it shows up as “you're the only nurse who cares, the day shift is horrible” — that is not a compliment, it is a symptom.
The trap: when the client with borderline PD praises you and criticizes another nurse, the answer is not to reassure her about the other nurse and not to accept the praise. Take it to the team, keep the plan identical across all staff, and address the behavior with the client directly and without judgment.
Priority: safety
Ask directly about suicide and self-harm every shift. Borderline PD carries the highest completed-suicide rate of any PD (~8–10%). Self-injury is usually to relieve emptiness or numbness, not always to die — assess intent, never dismiss it. Remove means; observation per policy.
Limit setting
State the limit once, calmly, with the consequence. Then do not renegotiate. Same limits from every staff member, documented so nobody gets played. Focus on the feeling behind the behavior, not the drama.
Manipulation
Don't argue, defend, or explain twice. No special privileges, no personal phone numbers, no gifts either direction. Point out the behavior matter-of-factly and redirect to a coping skill.
No drug is FDA-approved for a personality disorder. Meds treat symptoms only: SSRIs for mood/impulsivity, mood stabilizers for lability, low-dose atypical antipsychotic for transient stress-related paranoia or dissociation.
Staff splitting
If the team starts arguing about the client — half defending her, half angry — the splitting has moved into the staff. Fix it in report and on the care plan, not with the client.
One-sentence answer key: consistency, limits, safety, and DBT. If an option offers extra attention, an exception, or a personal connection, it's wrong.
A personality disorder (PD) is an enduring, inflexible pattern of inner experience and behavior that deviates markedly from cultural expectations, begins by adolescence/early adulthood, and causes distress or functional impairment. Clients are usually ego-syntonic — they see the problem as the world, not themselves — which makes engagement and follow-through difficult.
"Anxious / fearful." Avoidant, Dependent, Obsessive-Compulsive PD. Driven by fear and clinginess.
Mnemonic: A = Alone/odd, B = Bad/wild, C = Cowardly/clingy.
💔 Borderline PD — Splitting & Self-Harm
Borderline personality disorder (BPD) is the Cluster B disorder tested most heavily. Core features: unstable relationships, unstable self-image, unstable affect, chronic emptiness, fear of abandonment, and impulsivity.
Splitting = the inability to see people as having both good and bad qualities; staff and others are viewed as all-good or all-bad, and those views flip quickly. Clients play staff against one another.
Counter splitting with consistency: the whole team enforces the same limits and communicates in report so the client cannot pit one nurse against another.
Self-injury (cutting) in BPD is usually a way to relieve tension / feel something, not always a lethal attempt — but always assess and take every self-harm behavior seriously. Ensure safety and a no-self-harm contract.
😈 Antisocial PD — Manipulation & Limit-Setting
Antisocial PD: a pervasive pattern of disregard for and violation of the rights of others since age 15 (client must be ≥18 for the diagnosis; earlier this is conduct disorder). Features: deceit, exploitation, impulsivity, aggression, reckless disregard for safety, and lack of remorse.
🎣 Manipulation
Charming, glib; uses others for personal gain.
🚫 No remorse
Rationalizes harm; blames the victim.
⚡ Impulsive
Aggressive, reckless, poor planning.
Never argue, bargain, or make exceptions "just this once." Any inconsistency is read as a crack to exploit.
The client may flatter you or claim a personal bond to gain privileges. Stay matter-of-fact and neutral; enforce unit rules identically for everyone.
🧰 PD Nursing Care — Limits, Milieu, Safety
Across Cluster B disorders the therapeutic backbone is clear limits + consistency + safety.
Set limits calmly and state the expected behavior and the consequence before a problem arises; apply consequences without anger.
Use a matter-of-fact, non-punitive tone — limits protect the client, they are not punishment.
Team communication is essential; document behaviors and share the plan so all staff respond the same way.
Reinforce independent, appropriate behavior; avoid rescuing or over-helping (feeds dependency/manipulation).
Prioritize safety: assess for suicidal/self-harm risk, remove means, use written safety agreements.
Encourage journaling and skills training (dialectical behavior therapy / DBT is first-line for BPD).
On an NCLEX item, the "best" nursing response to boundary-testing is almost always the one that is calm, consistent, and restates the limit — not one that reasons, argues, or grants an exception.
🧠 Delirium vs. Dementia — The Money Table
The single most tested neurocognitive concept: delirium is acute and reversible; dementia is gradual and progressive.
In an older adult, a sudden change in mentation is delirium until proven otherwise — look first for a UTI, new medication, dehydration, or hypoxia.
⚡ Delirium — Acute & Reversible
Delirium is a medical emergency of acute confusion with fluctuating consciousness and inattention. Because it is reversible, the priority is identifying and correcting the underlying cause.
Delirium spikes then returns to baseline once the cause is treated; dementia steadily declines.
Care: correct the cause (treat infection, fix electrolytes/oxygen, stop offending drugs), provide a calm, well-lit, low-stimulation room, reorient frequently, keep glasses/hearing aids on, and keep family present.
🌇 Alzheimer's / Dementia Care
Alzheimer's disease is the most common dementia — progressive loss of memory (recent first), language, judgment, and ADLs. Nursing care centers on safety, routine, and dignity.
Consistent routine and a familiar environment reduce anxiety and agitation.
Communicate with simple, one-step directions; allow time; do not argue with confusion — redirect and validate feelings.
Sundowning = worsening confusion/agitation in the late afternoon/evening; increase light, reduce noise, avoid naps late in the day.
Do not quiz or reality-orient a client with advanced dementia ("Don't you remember?"). It increases distress. Use redirection and reassurance instead.
🍺 Alcohol — Withdrawal, CIWA & Timeline
Alcohol is a CNS depressant. Withdrawal is potentially lethal. Use the CIWA-Ar scale (Clinical Institute Withdrawal Assessment) to score severity and drive symptom-triggered benzodiazepine dosing.
DTs are the deadliest alcohol-withdrawal complication (fever, tachycardia, HTN, delirium). Priority = prevent with scheduled/symptom-triggered benzodiazepines and monitor vitals closely.
🧠 Wernicke-Korsakoff & Thiamine
Chronic alcohol use depletes thiamine (vitamin B1), causing Wernicke-Korsakoff syndrome.
👁️ Wernicke's
Acute & reversible. Triad: confusion, ataxia, ophthalmoplegia/nystagmus. Treat FAST with thiamine.
🕳️ Korsakoff's
Chronic & often permanent. Profound memory loss with confabulation (fills gaps with invented stories).
Give thiamine before glucose (or with IV dextrose) — a glucose load in a thiamine-deficient client can precipitate or worsen Wernicke encephalopathy.
Untreated Wernicke's can progress to irreversible Korsakoff psychosis. Early thiamine can prevent permanent damage.
Supportive; benzodiazepines for agitation/seizures; monitor cardiac/suicide risk
Naloxone → opioid antidoteFlumazenil → benzodiazepine antidoteWatch for re-sedation
Opioid overdose = respiratory depression + pinpoint pupils → give naloxone. Because naloxone is short-acting, watch for recurrent respiratory depression and repeat doses as needed.
⚖️ Antidotes & Flumazenil Caution
Two reversal agents to memorize together:
Naloxone (Narcan) — reverses opioid overdose. May precipitate acute withdrawal in dependent clients (agitation, pain, N/V).
Never give flumazenil routinely to a benzo-dependent client or a mixed overdose — it can trigger refractory seizures and severe withdrawal. Use with extreme caution.
Disulfiram (Antabuse) supports alcohol abstinence: drinking alcohol on it causes flushing, nausea, vomiting, headache. Teach the client to avoid all hidden alcohol (mouthwash, sauces, aftershave).
⚠️ A commercial study sheet used to sit here. It was removed — it belongs to its publisher, not to this site.
⚠️ Complications & Refeeding Syndrome
The most dangerous complication of nutritional rehabilitation in a severely malnourished client is refeeding syndrome.
When feeding restarts, an insulin surge drives electrolytes into cells, causing sudden, dangerous drops in serum levels:
Prevent it: refeed slowly ("start low, go slow"), monitor phosphate/potassium/magnesium closely, watch for edema and cardiac changes, and weigh the client at the same time daily.
Hypophosphatemia is the classic marker of refeeding syndrome. A falling phosphate after feeds begin is a red flag.
🤝 Eating Disorder Nursing Care
Medical stabilization first — cardiac status and electrolytes take priority over psychotherapy in acute severe cases.
Set a structured, consistent mealtime routine; a nurse observes during and for ~1 hour after meals (prevents purging/hiding food).
Weigh same time, same scale, gown only, back to the scale; watch for water-loading to falsify weight.
Be matter-of-fact and non-controlling about food; avoid power struggles and excessive focus on weight/appearance.
Address distorted body image and perfectionism/control issues; involve family; CBT is first-line therapy.
Assess for self-harm and suicide risk, especially in bulimia.
Don't praise the client for "looking healthier" or comment on appearance — clients often interpret it as "getting fat." Reinforce healthy behaviors and coping instead.
🩺 Somatic & Related Disorders — The Five
These disorders share physical symptoms or health preoccupation with no adequate medical explanation. The key is who produces the symptom and why.
Disorder
Hallmark
Symptom intentional?
Motive
Somatic Symptom Disorder
Real, distressing physical symptoms + excessive thoughts/anxiety about them
No — unconscious
None (genuine distress)
Illness Anxiety Disorder
Preoccupation with having/getting a serious illness; few or no actual symptoms
No — unconscious
None (fear-driven)
Conversion Disorder (FND)
Sudden neurologic deficit (paralysis, blindness, pseudoseizure); may show la belle indifférence
No — unconscious
Resolves an inner conflict
Factitious Disorder
Deliberately fakes/induces illness (self or another — "by proxy")
Yes — conscious
To assume the sick role / attention
Malingering
Fakes symptoms (not a mental disorder)
Yes — conscious
External gain (money, drugs, avoid work/jail)
Discriminator: Factitious vs Malingering are both conscious/faked — the difference is the motive. Factitious = internal (be the patient); Malingering = external reward.
💬 Somatic Disorders — Nursing Care
The symptoms feel very real to the client (except in factitious/malingering). Confrontation and dismissiveness backfire.
Rule out real medical causes first, then provide care with one consistent provider to limit "doctor shopping" and repeat testing.
Acknowledge the client's distress as real — don't tell them "it's all in your head."
Schedule brief, regular visits so attention is not tied to new symptoms; limit reinforcement of the sick role.
Redirect from symptoms to coping, stressors, and feelings; teach relaxation and stress management.
Encourage normal ADLs and gradual return to function; avoid unnecessary reassurance-seeking loops.
For conversion disorder, don't focus on or reinforce the physical deficit; matter-of-factly encourage function and explore the underlying stressor — the deficit typically resolves as the conflict is addressed.
Never angrily confront or accuse a somatic-symptom client of faking — it destroys the therapeutic relationship and increases symptom focus.
Unit 4 · Psychopharmacology (Anxiety · Depression · Bipolar)
😰 Ch 21 · Medications for Anxiety & Trauma/Stressor Disorders
Anxiety and PTSD are treated first-line with antidepressants that raise serotonin, reserving fast-acting agents for short-term relief. The goal is long-term symptom control without dependence.
🌿
SSRIs / SNRIs — first-line; take 4–6 wk for full effect
Benzodiazepines are for situational, short-term anxiety (panic, acute crisis). Because tolerance and dependence develop, they are bridge therapy while an SSRI/SNRI takes effect.
A client says buspirone "isn't working" after 3 days. This is expected — it needs 1–4 weeks. Do not use it PRN; it must be taken on a regular schedule.
Never stop an SSRI/SNRI or a benzodiazepine abruptly. Abrupt SSRI/SNRI stop → discontinuation syndrome (flu-like, dizziness, "brain zaps"); abrupt benzo stop → rebound anxiety, tremors, seizures.
Benzodiazepine overdose reversal = flumazenil IV. Give oxygen/airway support first; flumazenil can precipitate seizures in dependent clients.
Client teaching: avoid alcohol/other CNS depressants, no driving until effects known, take SSRIs in the morning if they cause insomnia, and report worsening mood or suicidal thoughts early in therapy.
🌧️ Ch 22 · Medications for Depressive Disorders
All antidepressants take 4–6 weeks for full therapeutic effect, though sleep/appetite/energy improve first — a window when suicide risk rises because energy returns before mood lifts.
Class
Prototype
Signature side effects
SSRI
fluoxetine
Sexual dysfunction, GI upset, insomnia, wt change
SNRI
venlafaxine, duloxetine
↑ BP, nausea, sweating; also treats neuropathic pain
TCA
amitriptyline
Anticholinergic + orthostatic hypotension; lethal in overdose (cardiac)
Both are hyperthermic emergencies — differentiate by onset speed and muscle sign (hyperreflexia vs rigidity).
Serotonin syndrome — onset within 2–72 hr of starting/increasing a serotonergic drug or combining agents. Signs: agitation, confusion, hallucinations, hyperreflexia, myoclonus, tremor, diaphoresis, fever, tachycardia, hypertension, GI upset. Stop all serotonergic drugs, cool, supportive care, cyproheptadine.
Combining an SSRI/SNRI with an MAOI, or switching between them without a washout, is a classic serotonin-syndrome trigger. Allow at least 14 days between an MAOI and another antidepressant (5 weeks after fluoxetine due to long half-life).
Never give a TCA to an impulsive/high-risk client with a large supply — a week's worth can be fatal by cardiac dysrhythmia in overdose. Dispense limited quantities.
MAOI + tyramine = hypertensive crisis. Avoid aged cheese, cured/smoked/aged meats, fermented foods (sauerkraut, soy sauce, tofu, miso), aged red wine, tap/draft beer, overripe fruit (avocado, banana peel), and yeast extracts. Crisis = severe occipital headache, ↑↑ BP, palpitations, neck stiffness, sweating → treat with phentolamine or nifedipine.
Nursing/teaching: monitor mood and suicidal ideation closely for the first weeks, take as prescribed daily (not PRN), do not stop abruptly, avoid alcohol, and report serotonin-syndrome or bleeding signs (SSRIs ↑ bleeding risk with NSAIDs/anticoagulants).
🌊 Ch 23 · Medications for Bipolar Disorders (Mood Stabilizers)
Mood stabilizers control mania and prevent mood swings. Lithium is the prototype but has a narrow therapeutic range, so blood levels drive safe dosing.
Therapeutic window is narrow (0.6–1.2). Draw trough levels ~12 hr after a dose; check q few days when starting, then every 1–3 months.
Lithium & sodium travel together. Low sodium or dehydration → kidneys retain lithium → toxicity. Keep salt and fluid intake steady (2–3 L/day); caution with diuretics, NSAIDs, and ACE inhibitors, which all raise lithium levels.
A manic client on lithium starts a new low-sodium diet and a thiazide diuretic before a summer heat wave. This is a toxicity setup — sweating + Na⁺ loss + diuretic all drive lithium up.
Never assume lamotrigine rash is minor. Any spreading rash, blistering, or mucosal involvement → stop the drug and notify the provider (Stevens-Johnson/toxic epidermal necrolysis risk). Slow dose titration lowers this risk.
There is no antidote for lithium toxicity — management is hold the drug, IV fluids/normal saline, and hemodialysis for severe levels (>2.5 mEq/L or symptomatic).
🧪
Lithium onset — 1–3 wk; use a benzo/antipsychotic short-term for acute mania
🤰
Pregnancy — lithium (Ebstein anomaly), valproate & carbamazepine all teratogenic
🩸
Valproate — baseline & periodic LFTs and platelets
🧬
Carbamazepine — induces liver enzymes → lowers levels of many drugs (incl. oral contraceptives)
Client teaching: take lithium with food, maintain consistent salt/fluid intake, avoid dehydration (illness, heat, alcohol), keep lab appointments, report early toxicity signs (tremor, diarrhea, confusion), and never adjust the dose independently.
Unit 4 · Psychopharmacology (Antipsychotics · Peds · Substance)
Prototype:haloperidol (high potency) and chlorpromazine (low potency). Action: block D2 dopamine receptors in the CNS, which quiets the dopamine excess thought to drive psychosis.
Best at:positive symptoms — hallucinations, delusions, agitation, disorganized thinking. They do little for negative symptoms (flat affect, apathy, social withdrawal).
High potency (haloperidol, fluphenazine): more EPS, fewer anticholinergic/sedative effects.
Low potency (chlorpromazine): more sedation, anticholinergic effects, orthostatic hypotension; less EPS.
Common effects: anticholinergic (dry mouth, constipation, urinary retention, blurred vision), orthostatic hypotension, sedation, lowered seizure threshold, photosensitivity, sexual dysfunction, and neuroendocrine effects from raised prolactin (gynecomastia, galactorrhea, menstrual changes).
A depot IM form (e.g., haloperidol decanoate) is given every few weeks to support adherence in clients who struggle with daily oral dosing.
A high-potency drug looks "cleaner" (less sedation) but carries the highest EPS risk — don't equate fewer sedative effects with fewer complications.
Advantage: improve both positive AND negative symptoms, with a lower risk of EPS and tardive dyskinesia than first-gen drugs. First-line for most clients.
Feature
First-gen (typical)
Second-gen (atypical)
Receptors
D2 only
D2 + 5-HT2
Symptom coverage
Positive mainly
Positive + negative
EPS / TD risk
High
Lower
Signature danger
EPS, NMS
Metabolic syndrome
Signature concern:metabolic syndrome — weight gain, elevated blood glucose (can trigger new diabetes), and dyslipidemia. Olanzapine and quetiapine carry the most metabolic risk; risperidone still raises prolactin; ziprasidone can prolong the QT interval; aripiprazole is a partial agonist and relatively weight-neutral.
Baseline + ongoing monitoring: weight/BMI, waist circumference, fasting glucose or A1c, and a lipid panel. Catching metabolic drift early is a core nursing role.
🚨 Ch 24 · The Antipsychotic Emergencies
Four families of complications separate a safe med pass from a rapid-response call. Know the onset timeline and the antidote for each.
EPS type
Onset
Signs
Management
Acute dystonia
Hours–days
Spasms of tongue/face/neck, oculogyric crisis, torticollis; laryngospasm = airway emergency
Lip-smacking, tongue writhing, facial grimacing, choreoathetoid moves — may be permanent
Prevent; screen with AIMS; switch drug; VMAT2 inhibitor (valbenazine)
NMS (neuroleptic malignant syndrome) is life-threatening: sudden high fever, "lead-pipe" muscle rigidity, autonomic instability (labile BP, tachycardia, diaphoresis), altered mental status, and sharply elevated CK. STOP the antipsychotic, cool the client, hydrate, and give dantrolene ± bromocriptine.
Agranulocytosis (classically clozapine): a dangerous drop in neutrophils. Fever or sore throat is a red flag — check the ANC before assuming it's a simple cold.
Extrapyramidal symptoms roughly follow a time course: the earlier ones respond to anticholinergics; late tardive dyskinesia is the one to prevent.
⚡ Ch 25 · CNS Stimulants for ADHD
Prototype:methylphenidate; also amphetamine mixtures (dextroamphetamine/amphetamine) and lisdexamfetamine (a prodrug). Action: raise CNS norepinephrine and dopamine, which paradoxically improves focus and reduces hyperactivity/impulsivity in ADHD.
Use: attention-deficit/hyperactivity disorder in children, adolescents, and adults; also narcolepsy.
Appetite ↓ / weight loss: give with or after meals; monitor weight.
Growth suppression: plot height and weight on a chart over time.
Insomnia: dose in the morning; last dose by mid-afternoon.
Cardiac: ↑ HR and BP; screen for heart disease before starting.
Abuse and dependence potential — stimulants are Schedule II controlled substances. Teach safe, locked storage and watch for diversion. Do not combine with an MAOI (hypertensive crisis risk).
Some prescribers use "drug holidays" (weekends/summers) to gauge continued need and give growth a chance to catch up — an individualized decision.
🎯 Ch 25 · Atomoxetine & Nonstimulant Options
Atomoxetine is a selective norepinephrine reuptake inhibitor — a nonstimulant, not a controlled substance, with essentially no abuse potential. It's an option when stimulants can't be used or misuse is a concern.
Onset: effect builds over 1–3 weeks, unlike the same-day response of stimulants. Side effects: appetite suppression, weight loss, GI upset, and rarely hepatotoxicity.
Atomoxetine carries a boxed warning for increased suicidal ideation in children and adolescents. Monitor mood and behavior, especially early in therapy, and teach families to report worsening mood at once.
Alpha-2 agonists guanfacine and clonidine (extended-release) are also nonstimulant ADHD options. Watch for sedation and hypotension, and never stop abruptly — taper to avoid rebound hypertension.
Disulfiram = aversion therapy. It blocks aldehyde dehydrogenase, so if the client drinks, toxic acetaldehyde builds up and triggers the disulfiram–alcohol reaction: flushing, throbbing headache, nausea/vomiting, sweating, palpitations, and hypotension — occasionally severe.
On disulfiram, any alcohol is off-limits — including hidden sources like mouthwash, cough syrup, aftershave, colognes, sauces, and vinegars. The reaction can still occur up to 2 weeks after the last dose.
Naltrexone: an opioid antagonist that cuts craving and the "reward" of alcohol; also used for opioid use disorder. Oral daily or monthly IM (long-acting). Monitor liver.
Acamprosate: stabilizes glutamate/GABA balance to ease post-abstinence discomfort. Started after the client stops drinking; main effect is diarrhea; kind to the liver, dosed by kidney function.
Because naltrexone blocks opioid receptors, giving it to someone still using opioids precipitates withdrawal — the client must be opioid-free ~7–10 days first. It also blunts opioid analgesia in an emergency.
💉 Ch 26 · Opioid, Nicotine & Withdrawal Meds
Methadone — a long-acting full opioid agonist used for maintenance/substitution: it prevents withdrawal and blunts craving without the highs and lows of illicit use. Dispensed through regulated programs. Watch for respiratory depression, QT prolongation, and constipation.
Buprenorphine — a partial opioid agonist (often combined with naloxone to deter injection). Its ceiling effect lowers overdose/respiratory-depression risk. Given sublingually; giving it too soon precipitates withdrawal.
Nicotine replacement (patch, gum, lozenge, spray, inhaler): supplies tapering nicotine to soften withdrawal while behaviors change.
Bupropionvarenicline: non-nicotine aids that cut craving; varenicline is a partial nicotinic agonist — monitor mood/neuropsychiatric effects.
Alcohol/sedative withdrawal: benzodiazepines (chlordiazepoxide, diazepam, lorazepam) are the mainstay — they prevent withdrawal seizures and delirium tremens and are tapered down. Clonidine eases the autonomic surge of opioid withdrawal.
A partial agonist (buprenorphine) is safer in overdose than a full agonist (methadone) because its opioid effect plateaus even as the dose climbs — a favorite exam contrast.
Unit 5 · Specific Populations
💀 Ch 27 · Grief, Loss & the Kübler-Ross Stages
Grief is the emotional response to a loss; bereavement is the state of having experienced a loss; mourning is the outward, culturally shaped expression of that grief. All three are normal and expected — the nurse's role is to support, not to rush, the process.
⏳ Anticipatory
Grieving that begins before the actual loss, during a terminal illness. Lets the client and family begin adjusting early; not a sign of giving up.
✅ Normal (uncomplicated)
Expected feelings (sadness, anger, guilt, somatic aches) that gradually ease over time and allow return to function.
⚠ Complicated
Intense, prolonged grief (>12 months) that impairs daily functioning. Subtypes: chronic, delayed, exaggerated, masked. High risk for major depression.
🚫 Disenfranchised
A loss that cannot be openly acknowledged or socially supported — e.g., miscarriage, death of an ex-partner or a pet, loss in a stigmatized relationship. Lacks public validation.
Disenfranchised grief is defined by the lack of social recognition, not by the size of the loss. Screen these clients carefully — hidden grief raises the risk of a complicated course.
Know all four grief types by their one-line trigger: anticipatory = before the loss, complicated = prolonged/impairing, disenfranchised = unacknowledged.
🌊 Ch 27 · Kübler-Ross: The Five Stages (DABDA)
Elisabeth Kübler-Ross described five common responses to dying and loss. They are not strictly linear — a client may skip stages, revisit them, or feel several at once.
✋ Denial — "This can't be happening to me."😡 Anger — "Why me?" resentment, may target staff/family🤝 Bargaining — "If I get better, I'll…" deals, often with a higher power😕 Depression — sadness, withdrawal, mourning what is lost😌 Acceptance — calm, at peace, may quietly withdraw
Stages ebb and flow; the acronym DABDA fixes the order for exams.
On a test, "Why is God doing this to me?" = Anger; "I just need to live until my daughter's wedding" = Bargaining. Match the quote to the stage.
🩺 Ch 27 · End-of-Life & Hospice/Palliative Care
Never tell a dying client "everything will be fine" or change the subject when they raise death. Use therapeutic presence, silence, and open-ended listening instead.
👂 Hearing is thought to be the last sense lost. Keep speaking calmly to an unresponsive dying client, explain care before you do it, and coach the family to say what they need to say — assume the client can still hear.
Palliative care
Hospice care
Comfort/symptom relief at any stage of serious illness
Comfort care when prognosis is roughly ≤6 months
Can run alongside curative treatment
Curative treatment is stopped; focus is quality of remaining life
Interdisciplinary symptom management
Interdisciplinary + family bereavement support
💉 Pain
Give scheduled (around-the-clock) opioids for comfort. Do not withhold out of fear of addiction or respiratory depression — comfort is the priority.
💨 "Death rattle"
Noisy secretions — reposition, give anticholinergics (scopolamine, glycopyrrolate). Avoid deep suctioning.
💨 Dyspnea
Elevate HOB, low-dose opioid, oxygen, a fan/cool air, calm presence.
📜 Directives
Living will, durable POA for health care (proxy), DNR. Honor cultural & spiritual wishes in postmortem care.
Signs of imminent death above are high-yield — recognize the mottling + Cheyne-Stokes + falling BP cluster.
🧠 Ch 28 · ADHD & Autism Spectrum
⚡ ADHD findings
Symptoms before age 12 in ≥2 settings (home + school). Inattention (careless errors, loses things, doesn't listen), hyperactivity (fidgets, can't stay seated), impulsivity (blurts, interrupts, can't wait a turn).
🧊 Autism (ASD) findings
Onset in early childhood. Two cores: social-communication deficits (poor eye contact, doesn't respond to name, delayed/absent language, echolalia) + restricted/repetitive behavior (hand-flapping, rocking, insistence on sameness, sensory over/under-reactivity).
Both disorders thrive on consistent routine, structure, and reduced environmental stimuli. For ASD, use the child's own rituals to lower anxiety and introduce change gradually.
Give morning/early, last dose before ~1800 to protect sleep; give after meals; monitor appetite, height & weight (growth suppression) and heart rate.
Nonstimulant
atomoxetine
Takes weeks; monitor for suicidal ideation and liver injury.
Alpha-2 agonists
clonidine, guanfacine
Adjuncts; watch for sedation and hypotension.
Stimulant appetite suppression stunts growth — dose after meals and track the growth chart. A common distractor is "give a stimulant at bedtime" — that causes insomnia.
For ASD with self-injurious behavior (head-banging), safety comes first — never leave the child unprotected; provide a low-stimulation, safe environment.
😡 Ch 28 · ODD vs Conduct Disorder
Both are disruptive behavior disorders, but the severity and target differ — this contrast is a favorite test point.
ODD attacks authority; Conduct Disorder attacks the rights of others.
👊 ODD
Angry/irritable mood, argues with adults, defies rules, deliberately annoys, blames others, is vindictive — but does not seriously violate others' basic rights.
💥 Conduct Disorder
Persistent aggression to people/animals, property destruction, deceit/theft, serious rule-breaking (truancy, running away). Can progress to antisocial personality disorder in adulthood.
Nursing care for both: firm, consistent limits with clear consequences, behavior contracts, positive reinforcement, and protecting others from harm.
😮 Ch 28 · Tourette's & Developmental Nursing Care
Tourette's disorder: onset before age 18 (often 6–7). Requires multiple motor tics AND at least one vocal tic, present >1 year (they wax and wane).
Antipsychotics (haloperidol, pimozide, risperidone, aripiprazole) and alpha-agonists (clonidine, guanfacine) for disabling tics.
🤝 Comorbidity
Frequently co-occurs with ADHD and OCD — screen for both.
💛 Care
Tics are involuntary — never punish them. Reduce stress (it worsens tics), educate the family/school, and support self-esteem.
🧩 Assess kids
Use play, drawing, and the child's developmental level to communicate; involve caregivers; watch for adolescent suicide risk.
Never discipline a child for tics, echolalia, or coprolalia — these are neurologic, not willful. Punishment increases anxiety and worsens symptoms.
Coprolalia (involuntary obscene speech) is the famous but least common Tourette's feature — most tics are simple (blinking, throat clearing).
Unit 6 · Psychiatric Emergencies
🌀 Ch 29 · Crisis Management
A crisis is an acute, time-limited state of disequilibrium that occurs when a person's usual coping mechanisms and problem-solving methods fail to resolve a stressor. It is not a mental illness — it is a normal reaction to an overwhelming event. Crises are self-limiting and typically resolve within 4–6 weeks as the client either adapts or decompensates.
Crisis is defined by the person's perception of the event and their available support/coping — not by the size of the event itself. The same stressor may be a crisis for one client and routine for another.
Aguilera/Caplan phases of crisis escalate as coping fails:
1 · Exposure to stressor ↑ anxiety
→
2 · Usual coping fails
→
3 · New coping tried, resources sought
→
4 · Severe anxiety / panic, disorganization
Anxiety climbs as coping fails; the goal of intervention is to restore the client to at least their pre-crisis level of functioning.
Crisis intervention is reality-oriented, short-term (weeks), directive, and focused on the here-and-now problem — not on personality change or insight.
Assess safety FIRSTDirective/active roleFocus on immediate problemUse existing/new coping + supportsDo NOT explore deep-seated issues
The goal is to return the client to their pre-crisis level of functioning (baseline) — NOT to a higher level or a "cure." Insight-oriented psychotherapy is inappropriate during acute crisis.
☠️ Ch 30 · Suicide — Risk & Warning Signs
Suicide risk assessment is a top nursing priority in mental health. Always ask directly about suicidal ideation, plan, and means.
Asking a client directly "Are you thinking about killing yourself?" does NOT plant the idea or increase risk. It communicates concern and opens the door to help. NEVER avoid the question.
SAD PERSONS risk scale — Sex (male completes more), Age (<19 or >45), Depression · Previous attempt, Ethanol/substance use, Rational thinking loss (psychosis), Social supports lacking, Organized plan, No spouse/single, Sickness (chronic illness).
Higher-risk factors
Warning signs
Prior attempt (strongest predictor)
Giving away prized possessions
Specific, lethal, available plan
Making a will / saying goodbye
Male, older, single, socially isolated
Withdrawal, hopelessness statements
Substance use, chronic/terminal illness
Sudden calm/improvement after depression
A sudden, unexplained sense of calm, peace, or improved mood in a previously severely depressed client is a RED FLAG — it often means the client has finalized a plan and feels relief. Increase observation; do NOT relax precautions.
🛟 Ch 30 · Suicide — Priority = SAFETY
When suicide risk is identified, client safety is the #1 priority. Act in this order:
Ask directly: ideation / plan / means
→
Institute 1:1 continuous observation
→
Remove / secure all means
→
Safe environment + support
👁️ 1:1 Observation
Constant one-to-one, arm's length, including bathroom. Highest-risk clients are never left alone.
Dispense limited amounts; watch "cheeking." Energy may return before mood lifts on antidepressants → ↑ early risk.
A "no-suicide / no-harm contract" is NOT evidence-based and must never substitute for observation or clinical judgment. A promise not to self-harm does not guarantee safety.
Priority-setting: even when other needs exist (sleep, nutrition, grief), physical safety from self-harm always comes first (risk to life).
💢 Ch 31 · Anger & Aggression Management
The assault (aggression) cycle is predictable; early recognition allows early de-escalation.
1 · Triggering
→
2 · Escalation
→
3 · Crisis (violence)
→
4 · Recovery
→
5 · Post-crisis (remorse)
Intervene EARLY — at triggering/escalation, verbal de-escalation is most effective. Once in the crisis phase, safety/physical intervention dominates.
Stay calm, low voiceMaintain personal space (arm's length +)Non-threatening stance, hands visibleOffer PRN medicationSet clear, simple limitsNever corner/touch or turn your back
Restraint and seclusion are the LAST RESORT, used only to prevent imminent harm to self or others when less-restrictive measures have failed. Never for staff convenience, punishment, or discipline.
Always exhaust less-restrictive options before restraint/seclusion.
Legal / safety requirement
Standard
Provider order required
Yes — emergency start allowed but order + face-to-face eval within 1 hr
Order duration limits
Adult ≤4 hr · ages 9–17 ≤2 hr · <9 yr ≤1 hr; renew per policy
PRN / standing orders
NEVER allowed
Monitoring
Continuous observation; circulation, vitals, hydration, toileting, ROM at set intervals
Release
As soon as client meets behavioral criteria (calm, safe) — not delayed to order max
NEVER use restraint/seclusion as punishment, for staff convenience, or as a PRN/standing order. Release when behavior is controlled, not at the order's max time.
🏚️ Ch 32 · Family & Community Violence
Abuse crosses all ages: child, elder, and intimate-partner (IPV). Types include physical, emotional/psychological, sexual, financial (esp. elder), and neglect.
🧒 Child abuse
Injuries inconsistent with story or developmental stage; multiple healing fractures; spiral/patterned burns; fear of caregiver; regression.
Injuries in various healing stages, hidden by clothing, controlling partner answers for victim, ↑ risk in pregnancy.
Mandatory reporting: Nurses are legally mandated reporters for suspected abuse of CHILDREN and vulnerable/dependent ELDERS. Report on reasonable suspicion — proof is not required. A competent adult IPV victim's disclosure is generally not reported against their wishes (varies by state); respect autonomy.
🔁 Ch 32 · Cycle of Violence & Safe Assessment
The cycle of violence (Walker) tends to repeat and escalate over time:
Tension building
→
Acute battering
→
Honeymoon (calm/remorse)
↺
Honeymoon phase (promises, gifts, remorse) explains why victims stay; over time it shortens or disappears.
Assess the suspected victim ALONE — separate them from the accompanying person. Do NOT interview with the suspected abuser present.
NEVER tell a victim to "just leave." Leaving is the most dangerous time (highest lethality risk). Give a nonjudgmental ear, hotline resources, and help build a safety/escape plan — but respect the client's autonomy and timing.
Interview alone & nonjudgmentallyDocument objectively (quotes, body map, photos w/ consent)Provide safety plan & resourcesDon't pressure to leave or confront abuser
🕊️ Ch 33 · Sexual Assault — Survivor-Centered Care
Care is survivor-centered: nonjudgmental, empowering, and driven by the survivor's choices. Sexual assault is a crime of violence and power; consent cannot be given if a person is coerced, unconscious, intoxicated, or otherwise unable to agree freely.
Nurse's role: ensure safety and medical stability first (treat injuries), provide emotional support, obtain informed consent before any exam or evidence collection, and let the survivor make the decisions (whether to report, to have a forensic exam, etc.).
👩⚕️ SANE
Sexual Assault Nurse Examiner — trained to collect forensic evidence and provide trauma-informed care.
🧪 Evidence
Maintain chain of custody; don't let client bathe, shower, douche, brush teeth, change clothes, eat, or void before exam. Paper bags, not plastic.
✅ Consent
Written informed consent required for exam, photos, and evidence release. Survivor may decline any part.
💊 Prophylaxis
Offer STI prophylaxis, emergency contraception, HIV PEP counseling, and follow-up.
NEVER force decisions, pressure the survivor to report to police, or judge/question their account ("Why were you there?"). Restoring a sense of control is central to care.
🌗 Ch 33 · Rape-Trauma Syndrome
Rape-trauma syndrome is a form of PTSD with recognizable phases:
Acute (disorganization)
→
Outward adjustment (denial)
→
Reorganization (integration)
Phase
Presentation
Acute
Hours–days: shock, disbelief, crying OR calm/controlled/flat affect; fear, guilt, somatic complaints. Both reactions are normal.
Outward adjustment
Weeks–months: appears "back to normal," uses denial/suppression to cope; may minimize.
Reorganization
Months–years: works through feelings, may relocate/change routines, gradual resolution and recovery.
A survivor who is calm, quiet, or emotionally flat is NOT lying or "unaffected" — a controlled/blunted response is a recognized acute reaction. Do not judge credibility by emotional display.
Support = "LISTEN": Let them lead, Informed consent, Safety first, Trauma-informed & nonjudgmental, Evidence w/ permission, Never pressure decisions.
📚 Detailed Reference — straight from the ATI Book (Ed. 13.0)
ℹ️ How to use this section
The cards above are the quick high-yield version. This section fills in the specific testable details — the numbers, criteria and lists that mental-health exams keep coming back to. Written from my own notes and organised by unit.
If a fact here has a number in it (a level, a time limit, a lab value), assume it's fair game for a "select all" or drop-down item.
Unit 1 · Foundations — the details
🩺 Mental Status Exam (MSE) — Level of Consciousness
Term
What you see
Alert
Opens eyes, responds fully to normal voice, answers spontaneously and appropriately.
Lethargic
Opens eyes and responds but is drowsy, falls asleep readily.
Stuporous
Requires vigorous or painful stimuli (sternal rub) for a brief response; may not respond verbally.
Comatose
Unconscious, no response to painful stimuli.
🧍 Decorticate
Flexion & internal rotation of arms toward the core. Legs extended.
🧍 Decerebrate
Neck & elbow extension, wrist/finger flexion. Worse than decorticate.
Mood = what the client REPORTS.Affect = what you OBSERVE (flat, blunted, labile). Don't mix them up.
🧠 MSE — Memory & Cognition testing
Domain
How to test it
Immediate memory
Repeat a series of numbers or a list of objects.
Recent memory
Recall events from today (visitors, why they were admitted).
Remote memory
State a verifiable fact from the past (birth date, mother's maiden name).
Calculation/attention
Count backward from 100 by 7s ("serial sevens").
Abstract thinking
Explain a similarity or proverb ("How are a car and a train alike?"). Be culture-sensitive.
Judgment
Answer a hypothetical ("What would you do if there were a fire in your room?").
Repeating a list of objects tests immediate memory — NOT remote memory. This is a classic distractor.
📋 Standardized Screening Tools (know which fits whom)
🧩 MMSE / MoCA / Mini-Cog / SLUMS
Cognition & dementia. MoCA is more sensitive than MMSE.
Cultural Formulation Interview — guides cultural assessment; awareness prevents stereotyping.
Serious mental illness (SMI) = severe, persistent, lifelong with remissions/exacerbations; difficulty with ADLs and role expectations.
⚖️ Types of Admission
Type
Key points
Voluntary
Client/guardian chooses admission. Considered competent → can refuse meds & treatment.
Temporary/Emergency
Admitted because unable to make care decisions; court hearing required within a set time (varies by state).
Involuntary
Against client's will. Criteria: danger to self/others, severe disability/can't meet basic needs, needs treatment but can't seek it. Still competent → can refuse treatment unless court-ordered.
Involuntary/committed clients are still considered competent and keep the right to refuse medication unless a court says otherwise.
🔒 Seclusion & Restraint — the rules ATI loves
Last resort only, after less-restrictive measures fail. Provider must prescribe in writing (nurse may start in an emergency, then get the order within 15–30 min). Never for staff convenience or punishment.
Never leave a secluded/restrained client alone, in a locked room unsupervised, or prone/supine unattended. New order needed each time restraints restart.
⚖️ Ethics & Torts
Principle
Meaning
Beneficence
Doing good / charity.
Autonomy
Client's right to decide (and accept consequences).
Justice
Fair, equal treatment for all.
Fidelity
Loyalty, keeping commitments.
Veracity
Truthfulness/honesty.
😡 Assault
A threat (approaching with a syringe threateningly).
✋ Battery
Harmful/offensive touch without consent (giving the injection against will).
🚪 False imprisonment
Confining/secluding without justification (for staff convenience).
📷 Invasion of privacy
Breaking confidences, photos without permission.
Malpractice = the 4 D's:Duty, Dereliction (breach), Damages, Direct (proximate) cause. It's professional negligence and needs expert testimony.
Restating repeats the main idea. Reflecting turns focus back to the client's feelings. Paraphrasing restates feelings for confirmation. Presenting reality counters hallucinations/delusions without arguing.
Barriers (nontherapeutic): giving advice, false reassurance, minimizing feelings, changing the topic, "why" questions, approval/disapproval, excessive or rapid questioning.
Intonation (tone of voice) = VERBAL communication. Posture, eye contact, personal space, silence = nonverbal. Believe the nonverbal when they conflict.
Working problem-solve, examine feelings, new coping
→
Termination address loss, use new behaviors
↩️ Transference
Client projects feelings about someone from their past onto the nurse.
↪️ Countertransference
Nurse projects their own past feelings onto the client. Consult a supervisor.
Developing goals & boundaries = orientation. Practicing problem-solving = working. Discussing how to use new behaviors after discharge = termination.
📶 Levels of Anxiety (+ what the nurse does)
As anxiety rises, the ability to function and learn falls.
🟢 Mild–Moderate
Active listening, open-ended questions, explore coping, offer PRN. Teaching is OK at mild.
🔴 Severe–Panic
Stay with client, calm quiet low-stimulation environment, short simple firm statements, meds/restraint only if needed. No teaching.
Moderate anxiety client = "shaky, nervous, hard to comprehend," VS mildly up → still can learn with simple/clear directions. Severe = can't problem-solve at all.
🛡️ Defense Mechanisms (adaptive ↔ maladaptive)
Mechanism
Definition / example
Denial
Refusing reality ("I cough from a cold" — smoker w/ lung cancer).
Displacement
Shifting feelings to a safer target (angry at boss → yells at kids).
Projection
Attributing own unacceptable feelings to another (accuses partner of the affair they want).
Rationalization
Making excuses for behavior.
Reaction formation
Acting opposite to true feelings.
Regression
Reverting to an earlier stage (bedwetting under stress).
Splitting
All-good or all-bad; hallmark of borderline PD.
Sublimation
Channeling impulses into acceptable outlets (anger → hard workout). Always healthy.
Altruism
Managing anxiety by helping others. Always healthy.
Altruism & sublimation are always adaptive. Others are adaptive or maladaptive depending on frequency, intensity, and whether they impair function.
🏥 Milieu Therapy & Levels of Prevention
Milieu therapy = a safe, structured, therapeutic environment. Orient the client, set rules/boundaries, ensure safety, guide appropriate activities, hold community meetings.
Primary prevent — community stress class, education
→
Secondary early detection — screening for depression
→
Tertiary rehab — support group after a SUD program
Ask this first: has the problem already happened? No → PRIMARY (prevent) · Maybe, we're looking for it → SECONDARY (screen, detect early) · Yes, already happened → TERTIARY (rehab, prevent recurrence)
The same intervention changes level based on timing. Stress-management class for a parent who has not abused = primary. The identical class for a parent who already abused their children = tertiary. Read the stem for whether harm has occurred.
1–2–3 = Before · Beginning · Been. Screening is almost always secondary. Education to a well population is almost always primary.
🏨 Partial hospitalization
Day treatment, home at night with a responsible person present.
🚗 ACT
Assertive Community Treatment — for clients nonadherent to traditional care ("forgets" the monthly injection).
🏘️ Community MH center
Education groups, med dispensing, individual/family counseling. (Detox = PHP.)
Unit 2 · Nonpharmacological Therapies — the details
🛋️ Psychoanalysis & Psychotherapies
💭 Free association
Say the first thing that comes to mind, uncensored.
🌙 Dream analysis
Freud — dreams reveal the unconscious.
🔁 Transference
Feelings toward the therapist mirror past significant people.
🧠 Cognitive therapy
Thoughts come before feelings/actions; change thoughts.
Classical psychoanalysis focuses on PAST relationships to uncover unconscious conflict — over months to years.
🎯 Behavioral Therapies — tell them apart
Technique
What it is
Modeling
Therapist demonstrates; client imitates.
Operant conditioning
Positive rewards for positive behavior (token economy).
Systematic desensitization
Gradual exposure + relaxation. Best for phobias.
Flooding
Exposure to a large amount of the stimulus at once.
Aversion therapy
Pair bad behavior with unpleasant stimulus (disulfiram + alcohol).
Response prevention
Block the compulsive act so anxiety fades.
Thought stopping
Say "stop" to interrupt negative thoughts.
Cognitive reframing tools: priority restructuring, monitoring thoughts, journaling. (Breathing & meditation are behavioral/relaxation, not cognitive.)
👥 Group & Family Therapy
🗳️ Democratic
Supports group input & decision-making.
👑 Autocratic
Leader controls everything.
🍃 Laissez-faire
Leader observes, doesn't direct.
Subgroup = a few members functioning separately/excluding others. Individual roles (e.g., the recognition-seeker who brags) block group progress.
Dysfunctional family patterns: blaming, manipulating, placating, distracting, generalizing; scapegoating (blame the powerless one), triangulation (pull in a 3rd party), enmeshed (blurred) vs rigid (inflexible) boundaries.
⚡ ECT — the procedure details
Electrical current induces a brief seizure under anesthesia. For MDD unresponsive to meds, suicidal clients needing rapid response, catatonia, and bipolar with rapid cycling. Course = 2–3×/week for 6–12 treatments. No absolute contraindications (caution with recent MI, ↑ICP, stroke).
≥4 symptoms (palpitations, SOB, chest pain, doom); stay with client, quiet, no teaching mid-attack.
OCD
Compulsions reduce anxiety from obsessions.
Body dysmorphic
Assess self-harm risk first.
First-line meds for anxiety & OCD = SSRIs. Benzodiazepines only short-term (dependence). Buspirone takes 1–4 wks, no dependence, not PRN, contraindicated with MAOIs.
💥 Trauma & Dissociative disorders
Disorder
Timeline / hallmark
Acute stress disorder
Symptoms 3 days–1 month after trauma; sense of unreality/dissociation.
The world feels unreal ("furniture looks small/far away").
Dissociative fugue
Travel + can't recall identity. Use grounding techniques.
Trauma therapies: EMDR, prolonged exposure, cognitive processing therapy (CPT), TF-CBT. EMDR contraindicated with active suicidal ideation/psychosis/detached retina.
🌧️ Depressive disorders & antidepressant safety
MDD
≥5 findings, ≥2 weeks, most of the day. Suicide risk highest early in the acute phase (and as energy returns).
Persistent depressive
Milder, ≥2 years (1 yr children).
SAD
Light therapy first-line.
PMDD
Luteal-phase mood symptoms.
Serotonin syndrome (2–72 hr): confusion, agitation, hyperreflexia, fever, diaphoresis, tremor. Stop drug; can be lethal. Watch when combining serotonergics or St. John's wort.
MAOIs + tyramine = hypertensive crisis. Avoid aged cheese, cured/smoked meats, liver, fermented foods, red wine, tap beer. Wash-out: MAOI→SSRI 14 days; fluoxetine→MAOI 5 weeks. Take SSRIs in the morning; taper — don't stop abruptly.
🎢 Bipolar & Lithium
Bipolar I = ≥1 manic episode. Bipolar II = hypomania + major depression. Rapid cycling = ≥4 episodes/year. Mania care: safety, decrease stimulation, high-calorie finger foods, rest periods, protect from impulsivity, no long/detailed tasks.
Narrow therapeutic range — monitor levels, sodium, and hydration.
Lithium level 1.2 during acute mania is acceptable — give the dose. Low sodium or low fluid → ↑lithium → toxicity. NSAIDs & diuretics raise it; use acetaminophen & report vomiting/diarrhea/sweating. Early toxicity: coarse tremor, GI upset, confusion, polyuria, muscle weakness, tinnitus.
Command hallucinations to harm = psychiatric emergency. Ask directly about hallucinations; don't argue delusions, address feelings; use music to compete with voices.
EPS (with 1st-gen)
Onset / treat
Acute dystonia
1–5 days; severe spasm tongue/neck/face/back → benztropine or diphenhydramine IM, stay & monitor airway.
Limit-setting & consistency counter manipulation (borderline/antisocial). Borderline → highest risk to self; antisocial → highest risk to others. Do self-assessment before care (countertransference).
🧠 Neurocognitive — Delirium vs Dementia
Delirium
Dementia
Onset
Rapid (hours–days)
Gradual (months–years)
LOC
Altered, fluctuates
Usually unchanged
Reversible?
Yes — find the cause (UTI, meds, dehydration)
No — progressive
Delirium is a medical emergency. Alzheimer's care: consistent routine, memory aids, safe environment (mattress on floor, locks up high, cover mirrors), reorient calmly, "I'm your nurse — let's walk to your room."
Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild–moderate AD; donepezil once daily at bedtime, long half-life; GI upset & bradycardia; avoid NSAIDs. Memantine for moderate–severe. The 4 A's: amnesia, aphasia, apraxia, agnosia.
🍷 Substance use — withdrawal & antidotes
🍺 Alcohol
Withdrawal 4–12 hr; tremors, ↑VS, N/V, seizures. Withdrawal delirium 2–3 days = emergency. Treat with benzodiazepines (CIWA-Ar). Life-threatening.
💊 Opioids
Miserable but not life-threatening. Antidote naloxone.
😴 Benzodiazepines
Withdrawal can seize → seizure precautions priority. Antidote flumazenil.
❄️ Stimulants/cocaine
Withdrawal: crash, depression, suicide risk — not life-threatening.
Care: structured meals, one-to-one observation during & after meals (prevent purging), behavioral contracts, weight 1–2 lb/wk outpatient (2–3 inpatient), limit high-fat/gassy foods early, no caffeine.
Refeeding syndrome — potentially fatal when nutrition restarts in the severely malnourished. Watch electrolytes (↓phosphate, ↓K, ↓Mg); "start low, go slow" in a hospital setting.
🩹 Somatic Symptom & Related Disorders
Disorder
Hallmark
Somatic symptom disorder
Real distressing physical symptoms + excessive thoughts/anxiety. Unconscious — not faking.
Illness anxiety disorder
Preoccupied with having a serious illness; few/no symptoms.
Functional neuro (conversion)
Neuro symptom (paralysis, blindness) with no medical cause; may show la belle indifférence.
Factitious disorder
Consciously produces symptoms for the sick role (self or imposed on another).
Malingering
Consciously fakes for external gain (not a mental illness).
Care: accept symptoms as real, assess self-harm risk, limit time discussing symptoms, teach coping/assertiveness, scheduled brief regular provider visits.
Units 4–6 · Populations & Emergencies — the details
Accept reality → process pain → adjust → find enduring connection & move on.
Anticipatory
Grieving before the loss (terminal illness).
Disenfranchised
Loss not socially acknowledged (suicide, pet, pregnancy loss).
Complicated/prolonged
Stuck; loss of self-esteem, suicidal thoughts — beyond normal grief.
Normal grief includes resentment, withdrawal, sleep changes — and reaches some acceptance by ~6 months. Suicidal thoughts & loss of self-esteem = maladaptive.Hearing is the last sense to go — watch what's said at the bedside.
🧒 Child & Adolescent disorders
ADHD
Inattention/hyperactivity/impulsivity before age 12, >1 setting; ↑injury risk.
Asking about suicide does NOT plant the idea. Assess plan: does it exist, how lethal, how detailed, access to means? A sudden calm/mood lift can signal a decision. Priority assessment = lethality + availability of means.
Overt
"My family is better off if I'm dead."
Covert
"Everything looks pretty grim."
Precautions: 1:1 constant observation, document location/mood/behavior every 15 min, remove hazards (belts, laces, glass, razors, perfume), no private room, door open, ensure meds are swallowed. Prevention = primary; acute crisis = secondary; survivor support = tertiary.
🌊 Crisis & Anger management
A crisis is acute, time-limited (4–6 weeks) — normal coping fails. Assess suicidal/homicidal ideation first; take an active, directive role; set realistic short-term goals.
Maturational
Expected life transition (marriage, retirement).
Situational
Unanticipated event (job loss, illness).
Adventitious
Disaster/crime (hurricane, assault).
Escalating client: respond quickly, stay calm, allow personal space (never corner), eye contact at their level, offer PRN, reduce stimulation, set clear limits. Crisis meds: SSRIs & benzodiazepines (not mood stabilizers/antipsychotics for the anxiety itself).
🔄 Family & Community Violence
Tension building minor anger, victim blames self
→
Acute battering shortest & most dangerous
→
Honeymoon apologetic — why victims stay
👶 Abusive head trauma
Respiratory distress, retinal hemorrhage, ↓LOC, ↑head circumference, bulging fontanels. Any bruising <6 mo is suspicious.
🚸 Suspicious injury
Round cigarette burns, ecchymosis on torso/back/buttocks, spiral fractures, belt-buckle marks, injuries not matching the story.
Child & vulnerable-adult abuse = mandatory report. Assess the victim alone (not with the partner). Priority for IPV = safety plan / safe houses & shelters. Risk is highest when the victim tries to leave; pregnancy increases risk.
🛑 Sexual Assault & Rape-Trauma Syndrome
Rape is a crime of violence, power, and anger — not passion. Most perpetrators are known to the survivor. Alcohol/GHB/flunitrazepam/ketamine are common in drug-assisted assault.
Phase
Findings
Acute/impact
Expressed (crying, anger) OR controlled (calm, blunted, numb) — both normal.
May progress to ASD (3 days–1 mo) then PTSD (>1 mo).
Care: safety, nonjudgmental support, informed consent for exam/evidence (SANE nurse, chain of custody), treat injuries, STI & pregnancy prophylaxis, assess suicide risk. Use restating, avoid "why" questions, never imply blame, don't force decisions.
Prototype drug cards by class — Class · MOA · Indications · Contraindications · Adverse Effects, plus toxicity/emergency, nursing, and client teaching.
MOA (mechanism of action): Selectively blocks reuptake of serotonin in the synapse, raising available serotonin; minimal effect on norepinephrine/dopamine.
Indications: First-line for depression, generalized anxiety, panic, OCD, PTSD, social anxiety, and bulimia.
Contraindications: MAOI within 14 days (5 weeks after stopping fluoxetine) — serotonin syndrome; use with pimozide/thioridazine (QT); caution with NSAIDs/anticoagulants (bleeding) and in clients <25 (early rise in suicidal ideation).
Adverse effects: Early anxiety/insomnia, GI upset, headache, sexual dysfunction, weight change, hyponatremia, ↑ bleeding risk with NSAIDs/anticoagulants.
Toxicity/Emergency: Serotonin syndrome — agitation, hyperreflexia, myoclonus, fever, diaphoresis, ↑ HR/BP; stop drug, supportive care, cyproheptadine. Suicide risk rises early in therapy.
Nursing: Full effect takes 4–6 wk; monitor mood/suicidal ideation, especially first weeks. No MAOI within 14 days (5 wk after fluoxetine). Taper to discontinue.
Teaching: Take daily as prescribed (not PRN), morning dosing if it disrupts sleep, avoid alcohol, do not stop abruptly (discontinuation syndrome), report worsening mood or serotonin-syndrome signs.
Nursing: Monitor BP (esp. at higher doses), mood, and suicide risk; 4–6 wk for full effect; no concurrent MAOI.
Teaching: Report elevated BP/headache, take consistently, do not stop suddenly, avoid alcohol, and rise slowly to limit dizziness.
TRICYCLIC (TCA)
💊 Amitriptyline (tricyclic antidepressant)
Class: TCA (tricyclic antidepressant)
MOA (mechanism of action): Blocks reuptake of norepinephrine and serotonin; also blocks histamine, cholinergic, and alpha-adrenergic receptors (source of side effects).
Indications: Depression (second-line), neuropathic pain, migraine prophylaxis; imipramine for enuresis.
Contraindications: Recent MI, cardiac conduction defects/dysrhythmias; MAOI use; caution in narrow-angle glaucoma, urinary retention/BPH, seizure disorder, and high suicide risk (lethal in overdose — dispense limited amounts).
Toxicity/Emergency: Highly lethal in overdose — cardiac dysrhythmias, seizures, coma. A 1–2 week supply can be fatal.
Nursing: 2–4+ wk for effect; monitor cardiac status/ECG in at-risk clients; assess suicide risk and dispense limited quantities; watch for MAOI interaction.
Teaching: Change positions slowly, increase fluids/fiber for constipation, use sugarless gum for dry mouth, take at bedtime for sedation, avoid alcohol, and do not stop abruptly.
MAOI
💊 Phenelzine (monoamine oxidase inhibitor)
Class: MAOI (monoamine oxidase inhibitor)
MOA (mechanism of action): Inhibits monoamine oxidase, blocking breakdown of serotonin, norepinephrine, and dopamine, so more accumulates.
Indications: Depression unresponsive to other agents; atypical depression.
Contraindications: Concurrent SSRIs/SNRIs/TCAs, meperidine, or sympathomimetics (including OTC decongestants/diet aids); pheochromocytoma; severe cardiovascular disease; tyramine-rich foods.
Adverse effects: Orthostatic hypotension, insomnia, weight gain, sexual dysfunction, dizziness.
Toxicity/Emergency: Hypertensive crisis with tyramine-rich foods (aged cheese, cured/smoked meats, fermented foods, aged red wine, tap beer, overripe fruit, yeast extract) — severe occipital headache, ↑↑ BP, palpitations, neck stiffness; treat with phentolamine/nifedipine. Also serotonin syndrome with serotonergic drugs.
Nursing: Strict dietary teaching; avoid many drugs (SSRIs/SNRIs/TCAs, opioids esp. meperidine, decongestants/sympathomimetics); 14-day washout before/after other antidepressants; monitor BP.
Teaching: Memorize and avoid tyramine foods and OTC cold/diet products, report severe headache immediately, rise slowly, and never combine with other antidepressants.
ATYPICAL ANTIDEPRESSANTS
💊 Bupropion (atypical — with mirtazapine, trazodone)
Class: Atypical antidepressants (NDRI and others)
MOA (mechanism of action): Bupropion inhibits reuptake of norepinephrine and dopamine; mirtazapine enhances norepinephrine/serotonin; trazodone is a serotonin modulator.
Indications: Depression; bupropion also for smoking cessation and has no sexual side effects; trazodone often used off-label for insomnia; mirtazapine helps depression with insomnia/poor appetite.
Contraindications: Bupropion: seizure disorders and anorexia/bulimia (lowers seizure threshold); abrupt alcohol or benzodiazepine withdrawal; MAOI use. Trazodone: caution in cardiac disease.
Toxicity/Emergency: Bupropion lowers the seizure threshold (avoid in seizure/eating disorders); trazodone can cause priapism (a urologic emergency — sustained erection >4 hr).
Nursing: Screen for seizure risk before bupropion; monitor mood/suicide risk; 4–6 wk for effect; no MAOI combination.
Teaching: Bupropion — take doses apart, avoid at bedtime (insomnia), no alcohol; trazodone — report prolonged erection immediately; mirtazapine — expect drowsiness/appetite increase.
BENZODIAZEPINE
💊 Lorazepam (benzodiazepine anxiolytic)
Class: Benzodiazepine anxiolytic
MOA (mechanism of action): Enhances the inhibitory effect of GABA, producing CNS depression, sedation, and anxiety relief.
Contraindications: Acute narrow-angle glaucoma; concurrent alcohol, opioids, or other CNS depressants; severe respiratory insufficiency/sleep apnea; pregnancy; caution with substance use history (dependence risk).
Adverse effects: Sedation, drowsiness, dizziness, ataxia, cognitive impairment; tolerance and physical dependence with prolonged use.
Toxicity/Emergency: Respiratory depression (esp. with alcohol/opioids); overdose reversed with flumazenil. Abrupt withdrawal → rebound anxiety, tremors, and seizures.
Nursing: Use lowest dose for shortest time; assess for dependence/misuse; monitor respirations and sedation; taper to discontinue; institute fall precautions.
Teaching: Short-term use only, no alcohol/CNS depressants, avoid driving until effects known, do not stop abruptly, and use non-drug anxiety techniques alongside.
ANXIOLYTIC (non-benzo)
💊 Buspirone (azapirone anxiolytic)
Class: Non-benzodiazepine anxiolytic (azapirone)
MOA (mechanism of action): Partial serotonin (5-HT1A) agonist; relieves anxiety without CNS depression, sedation, or dependence.
Indications: Long-term management of generalized anxiety disorder.
Contraindications: MAOI within 14 days (hypertensive crisis); caution with grapefruit juice and other serotonergic drugs.
Examples: buspirone.
Adverse effects: Dizziness, headache, nausea, lightheadedness — generally mild; no significant sedation or dependence.
Toxicity/Emergency: Low toxicity; risk of serotonin syndrome if combined with MAOIs or other serotonergic drugs. Not useful for acute/PRN relief.
Nursing: Full effect takes 1–4 weeks; must be taken regularly, not as needed; not a controlled substance; avoid grapefruit juice (raises levels).
Teaching: Take on a fixed schedule, be patient with delayed onset, do not use for acute panic, take consistently with or without food, and avoid grapefruit juice.
MOOD STABILIZER
💊 Lithium carbonate (mood stabilizer)
Class: Mood stabilizer (antimanic)
MOA (mechanism of action): Alters ion transport and neurotransmitter activity to stabilize mood; exact mechanism unclear. Narrow therapeutic index.
Indications: Acute mania and long-term prophylaxis of bipolar mood episodes.
Contraindications: Severe renal disease, dehydration, sodium depletion; concurrent thiazide diuretics or NSAIDs (raise lithium levels); pregnancy (cardiac defects); caution in cardiovascular disease.
Examples: lithium carbonate, lithium citrate.
Adverse effects: Fine tremor, GI upset, polyuria/thirst, weight gain, hypothyroidism, renal impairment, benign leukocytosis.
Toxicity/Emergency: Therapeutic 0.6–1.2 mEq/L. Early toxicity <1.5 (N/V/D, thirst, polyuria, fine tremor); 1.5–2.5 coarse tremor, confusion, ataxia, slurred speech; >2.5 seizures, coma, death. No antidote — hold drug, IV normal saline, hemodialysis for severe/>2.5.
Nursing: Onset 1–3 wk (bridge acute mania with antipsychotic/benzo); draw trough levels ~12 hr post-dose; monitor renal/thyroid function, sodium, and hydration; caution with diuretics, NSAIDs, ACE inhibitors.
Teaching: Maintain steady salt and fluid intake (2–3 L/day), take with food, avoid dehydration (heat, illness, alcohol), keep lab appointments, report early toxicity signs, and avoid during pregnancy (Ebstein anomaly).
Nursing: Baseline and periodic LFTs, platelets, and drug levels; monitor for bruising/bleeding and abdominal pain; assess pregnancy status.
Teaching: Report signs of liver problems (jaundice, dark urine, anorexia, abdominal pain) or unusual bruising, take with food, avoid alcohol, and use reliable contraception.
MOOD STABILIZER (anticonvulsant)
💊 Carbamazepine (anticonvulsant mood stabilizer)
Class: Anticonvulsant mood stabilizer
MOA (mechanism of action): Blocks sodium channels to reduce neuronal excitability; stabilizes mood and controls seizures.
Nursing: Baseline/periodic CBC, LFTs, sodium, and drug levels; watch for infection, bruising, or rash; note it lowers levels of many drugs (including oral contraceptives and warfarin).
Teaching: Report fever, sore throat, bruising, rash, or fatigue; use a backup/non-hormonal contraceptive; take with food; avoid grapefruit juice; and do not stop abruptly.
MOA (mechanism of action): Stabilizes neuronal membranes by inhibiting sodium channels and glutamate release; effective for the depressive phase of bipolar disorder.
Indications: Maintenance treatment of bipolar disorder (particularly bipolar depression); seizures.
Contraindications: Prior serious rash with lamotrigine; caution with valproate (roughly doubles lamotrigine levels — titrate even more slowly).
Toxicity/Emergency: Stevens-Johnson syndrome / toxic epidermal necrolysis — a life-threatening rash. Risk is reduced by slow dose titration.
Nursing: Titrate the dose slowly; inspect for any developing rash and stop the drug/notify provider if one appears; note valproate raises lamotrigine levels (requires lower dosing).
Teaching: Report any rash, blistering, or mucosal sores immediately, do not skip the gradual dose increase, and do not stop abruptly.
FIRST-GEN (TYPICAL) ANTIPSYCHOTIC
💊 Haloperidol (conventional antipsychotic)
Class: First-generation (typical) antipsychotic
MOA (mechanism of action): Blocks CNS D2 dopamine receptors to reduce dopamine-driven psychosis.
Indications: Schizophrenia and acute psychosis; best for positive symptoms (hallucinations, delusions, agitation).
Contraindications: Parkinson's disease; severe CNS depression/coma; dementia-related psychosis in older adults (boxed warning — increased mortality); caution with QT prolongation and seizure history.
Toxicity/Emergency: New-onset diabetes/hyperglycemia; NMS still possible; QT-related dysrhythmia.
Nursing: Baseline and ongoing weight/BMI, waist circumference, fasting glucose or A1c, and lipid panel; monitor ECG when indicated.
Teaching: Diet and exercise to limit weight gain; report increased thirst/urination; change positions slowly; adhere even when feeling better.
ATYPICAL — RESERVED AGENT
💊 Clozapine (special-case atypical)
Class: Atypical antipsychotic — reserved agent
MOA (mechanism of action): Blocks D2 and 5-HT2 receptors; effective where other agents fail.
Indications: Treatment-resistant schizophrenia; reduces suicidality in schizophrenia.
Contraindications: History of clozapine-induced agranulocytosis/severe neutropenia; myeloproliferative disorders; uncontrolled seizures; severe cardiac disease (myocarditis); paralytic ileus.
Examples: Clozapine (class of one for this indication).
Adverse effects: Agranulocytosis, dose-related seizures, myocarditis, severe constipation/ileus, heavy sedation, hypersalivation, metabolic effects.
Toxicity/Emergency: Agranulocytosis (life-threatening neutrophil drop) — fever or sore throat is a red flag; myocarditis; bowel obstruction.
Nursing: Enrolled monitoring program with scheduled ANC/WBC counts (frequent at first); hold the drug and notify provider if ANC falls; monitor bowel function.
Teaching: Keep all blood-draw appointments; report fever, sore throat, flu-like symptoms, chest pain, or constipation immediately.
CNS STIMULANT
💊 Methylphenidate (CNS stimulant)
Class: CNS stimulant
MOA (mechanism of action): Increases CNS norepinephrine and dopamine, improving attention and reducing hyperactivity/impulsivity.
Indications: ADHD in children, adolescents, and adults; narcolepsy.
Contraindications: MAOI within 14 days; glaucoma; severe anxiety/agitation; structural cardiac abnormalities or serious heart disease; caution with tics/Tourette's and substance use history.
MOA (mechanism of action): Blocks aldehyde dehydrogenase, so acetaldehyde accumulates if alcohol is consumed, causing a highly unpleasant reaction.
Indications: Adjunct to maintain abstinence in motivated clients with alcohol use disorder.
Contraindications: Any alcohol within 12 hours (including hidden sources — mouthwash, sanitizer, sauces); metronidazole; psychosis; severe cardiac disease; never give without the client's full knowledge and consent.
Toxicity/Emergency: Disulfiram–alcohol reaction — flushing, throbbing headache, nausea/vomiting, sweating, palpitations, hypotension; can be severe.
Nursing: Confirm the client has been alcohol-free ~12 hours before starting; monitor liver enzymes; ensure informed consent and motivation.
Teaching: Avoid ALL alcohol including mouthwash, cough syrup, aftershave, colognes, sauces, and vinegar; reaction can occur up to 2 weeks after the last dose.
OPIOID/ALCOHOL — ANTAGONIST
💊 Naltrexone (opioid antagonist)
Class: Opioid antagonist (anti-craving)
MOA (mechanism of action): Blocks opioid receptors, reducing craving and the pleasurable/rewarding effects of alcohol and opioids.
Indications: Maintenance of abstinence in alcohol use disorder and opioid use disorder.
Contraindications: Current opioid use or withdrawal (precipitates acute withdrawal — client must be opioid-free 7–10 days); acute hepatitis or liver failure.
Examples: Oral naltrexone (daily); long-acting IM naltrexone (monthly).
Adverse effects: Nausea, headache, dizziness, fatigue; IM injection-site reactions.
Toxicity/Emergency: Precipitated opioid withdrawal if opioids are still on board; hepatotoxicity at high doses; blunts opioid analgesia in emergencies.
Nursing: Verify the client is opioid-free ~7–10 days before the first dose; monitor liver function; confirm no active opioid use.
Teaching: Carry medical identification (opioids won't work for pain relief); report right-upper-quadrant pain or jaundice; keep monthly injection appointments.
ALCOHOL — ANTI-CRAVING
💊 Acamprosate (glutamate/GABA modulator)
Class: Glutamate/GABA modulator (anti-craving)
MOA (mechanism of action): Normalizes glutamate and GABA activity disrupted by chronic alcohol use, easing post-abstinence distress.
Indications: Maintenance of abstinence after the client has already stopped drinking.
Contraindications: Severe renal impairment (CrCl ≤ 30 mL/min).
MOA (mechanism of action): Methadone is a long-acting full opioid agonist; buprenorphine is a partial agonist with a ceiling effect. Both prevent withdrawal and blunt craving.
Indications: Maintenance/substitution therapy and medically supervised withdrawal in opioid use disorder.
Contraindications: Significant respiratory depression; acute or severe asthma; paralytic ileus; methadone — caution with QT prolongation; dispensed only through certified treatment programs.
Examples: Methadone; buprenorphine and buprenorphine/naloxone (sublingual).
Adverse effects: Sedation, constipation, sweating; methadone can prolong the QT interval.
Toxicity/Emergency: Respiratory depression and overdose (higher with methadone); buprenorphine can precipitate withdrawal if given too soon after other opioids.
Nursing: Dispense methadone through regulated programs; monitor respirations, sedation, and ECG (methadone); assess timing before buprenorphine induction.
Teaching: Do not combine with alcohol/sedatives; dissolve buprenorphine sublingually (do not swallow/inject); attend program visits.
TOBACCO — REPLACEMENT/CESSATION
💊 Nicotine replacement therapy (NRT)
Class: Nicotine replacement therapy (NRT)
MOA (mechanism of action): Supplies controlled, tapering nicotine to relieve withdrawal while smoking behaviors are extinguished.
Indications: Smoking cessation / tobacco use disorder.
Contraindications: Recent MI, serious dysrhythmias, unstable angina; do not smoke while using NRT (nicotine toxicity).
Toxicity/Emergency: Nicotine toxicity if smoking continues with the patch; varenicline and bupropion carry neuropsychiatric/mood warnings; bupropion lowers the seizure threshold.
Nursing: Assess readiness to quit; do not overlap doses beyond program limits; monitor mood on bupropion/varenicline.
Teaching: Do not smoke while using the patch; rotate patch sites; take bupropion/varenicline for the full course; report worsening mood.
OPIOID OVERDOSE — ANTAGONIST
💊 Naloxone (opioid antagonist)
Class: Opioid antagonist (overdose reversal)
MOA (mechanism of action): Rapidly displaces opioids from receptors, reversing respiratory depression.
Contraindications: None absolute in a life-threatening overdose; hypersensitivity; expect precipitated acute withdrawal in opioid-dependent clients.
Adverse effects: Precipitated acute opioid withdrawal (agitation, vomiting, pain); it is short-acting — sedation and respiratory depression can return, so repeat dosing is often needed.
Nursing: Support airway/breathing, monitor continuously after reversal, anticipate repeat doses.
MOA (mechanism of action): Zolpidem enhances GABA at the benzodiazepine-1 receptor site; hydroxyzine blocks H1 histamine receptors; propranolol blocks beta-adrenergic receptors, blunting the physical symptoms of anxiety.
Indications: Zolpidem — short-term insomnia. Hydroxyzine — anxiety/agitation when dependence is a concern. Propranolol — performance anxiety and antipsychotic-induced akathisia.
Cholinesterase inhibitors (donepezil, rivastigmine, galantamine): preserve acetylcholine → slow decline; do NOT cure or reverse. Watch GI upset (N/V/diarrhea) and bradycardia; take with food.
Memantine (NMDA antagonist): moderate–severe Alzheimer's; regulates glutamate; can combine with a cholinesterase inhibitor.
Teaching: Set realistic expectations — the goal is slowing decline and preserving function, not recovery.
Contraindications: Cholinesterase inhibitors: caution with bradycardia/conduction disease, GI bleeding/ulcers, asthma/COPD. Memantine: caution in severe renal impairment.
Anticholinergic (atropine/glycopyrrolate), 30 min prior: dries secretions, blocks vagal bradycardia.
Anesthetic (etomidate/propofol): short-acting IV anesthesia during the procedure.
Muscle relaxant (succinylcholine): paralyzes muscles during the seizure — client cannot breathe independently; the nurse's priority is airway and oxygenation support.
Contraindications: Succinylcholine: history of malignant hyperthermia, hyperkalemia, major burns/crush injury; atropine/glycopyrrolate: narrow-angle glaucoma.
🎓 Medication Teaching Quiz — from your cheat sheet
Built from your psych-med reference chart. Every rationale re-teaches the fact with the memory hook, so wrong answers still move you forward.
🧠 ATI Priority Framework
1. SAFETY suicide · violence · airway
→
2. ABCs / physiologic
→
3. Assess before intervene
→
4. Acute before chronic
→
5. Psychosocial
ATI is a priority test disguised as a content test. When two answers are both "correct," pick the one that is safest, soonest, or assessment first.
🚩 Dynamic Quizzing Rescue — the 5 things that got you
Built from your 7/26 ATI Dynamic Quizzing session. Six misses, and they clustered into five patterns. Each block below is the exact discriminator ATI used, not the general topic.
1️⃣ Buspirone side effects
Missed twice. You know the onset facts — you don't know the adverse-effect list.
2️⃣ EPS → which drug
Tremor + drooling + rigidity → benztropine, not a benzo.
3️⃣ Vegetative signs
The body symptoms of depression, and what the nurse actually does about them.
4️⃣ Intellectualization
Facts and theory instead of feelings. Not the same as rationalization.
5️⃣ Prevention levels
Ask "did the problem already happen?" before you pick.
1 · Buspirone — the adverse effects, ranked
Onset facts, corrected to ATI's wording: 3 to 4 weeks, non-addictive, not a scheduled medication, no withdrawal / no taper needed, not PRN, not for acute panic. What ATI asked twice was side effects.
Effect
Rank
Dizziness / lightheadedness
Most common — this is the answer when the stem says "common" or "expected"
Xerostomia (dry mouth)
Very common — also anticholinergic-flavored
Headache
Common
Nausea
Common
Insomnia / nervousness
Reported, but lower yield
Drowsiness, restlessness, excitement
Possible
The exact trap that got you. Insomnia is on buspirone's adverse-effect list — ATI's own rationale even says so. But when the question asks for the common or most likely effect, the answer is dizziness. Insomnia is the plausible-but-not-best distractor. If both are options, dizziness wins.
Memory hook: BUSpirone → you get dizzy on the BUS and your mouth goes dry waiting 3–4 weeks for it.
Teaching: take with food to reduce nausea, rise slowly (dizziness = fall risk), sip water / sugarless gum for dry mouth, avoid grapefruit juice, take it every day — not when anxious.
2 · Extrapyramidal symptoms → the drug you reach for
Stem was thioridazine (a 1st-gen antipsychotic) with hand tremors, drooling, and rigid extremities. That is pseudoparkinsonism. You picked diazepam; the answer was benztropine.
Lip smacking, tongue rolling, facial grimacing — often irreversible
No anticholinergic. Stop/switch the drug; valbenazine
A benzodiazepine is the distractor for pseudoparkinsonism and dystonia. Benzos help akathisia (restlessness) as a second-line agent — they do nothing for tremor, drooling, or rigidity. If the findings are motor-slow and stiff, the answer is anticholinergic.
Benztropine is anticholinergic, so it brings the whole dry package: dry mouth, blurred vision, constipation, urinary retention. Contraindicated in narrow-angle glaucoma and BPH.
Do not confuse EPS with NMS. Add fever + very high CK + altered mental status + autonomic instability and it is neuroleptic malignant syndrome — stop the antipsychotic, cool, and give dantrolene or bromocriptine. Rigidity alone with a normal temp is EPS.
3 · Vegetative signs of depression — and what the nurse does
Vegetative signs are the physical / somatic symptoms of depression — the body shutting down. This is the exact phrase ATI uses, so know it.
Vegetative sign
Nursing action
Insomnia or early-morning waking
Provide decaffeinated beverages. Sleep-hygiene measures, quiet routine, get the client out of bed and dressed during the day
Anorexia, weight loss
Small frequent meals, high-calorie finger foods and snacks, sit with the client while eating, record intake, weigh daily or weekly
Constipation
Fluids, fiber, activity, track bowel movements
Psychomotor retardation, fatigue
Assist with ADLs and hygiene, allow extra time, one simple task at a time, gradually increase activity
Decreased libido, amenorrhea
Acknowledge; reassure it improves with treatment
The exact trap that got you. "Schedule regular naptimes" looks caring, but daytime naps worsen night insomnia. Do not schedule naps. Keep the client up and active during the day and remove caffeine instead — that is why decaffeinated beverages is the answer.
Two more distractors in this family: limiting snacks (wrong — you encourage intake in depression) and weighing monthly (too infrequent — daily or weekly).
Vegetative = SLEEP, EAT, MOVE, POOP, SEX. If a depression option is about one of those five and it supports the function, it is probably right.
Safety still outranks everything. If suicide risk is an option, it wins. Vegetative-sign questions only become the answer once safety is not on the table.
4 · Intellectualization vs. its neighbors
Intellectualization = using facts, theory, research, and clinical language to stay away from the feeling. The client sounds like a textbook about their own problem.
Defense
Sounds like
Intellectualization
"I've read that problems with substances can have a variety of predisposing factors."
Denial
"I don't have a problem. I could stop whenever I want."
Rationalization
"I only drink because my job is stressful." (an excuse, a reason)
Minimization
"It's just a couple of beers, no big deal."
Projection
"You're the one with the drinking problem, not me."
Displacement
Yelled at by the boss → goes home and yells at the kids.
Reaction formation
The recovering user who becomes the loudest anti-drug crusader.
Undoing
Buys a gift after an argument to cancel it out.
Sublimation
Channels rage into boxing. Always adaptive.
The exact trap that got you. "I was just using the medication… I can stop whenever I want" is denial, not intellectualization. The tell for intellectualization is academic vocabulary — "predisposing factors," "studies show," "statistically," "the literature says." No feeling words anywhere.
5 · Levels of prevention — the one question that decides it
Stem: a parent who has already verbally abused their children is taught stress-management techniques. You said primary. The answer is tertiary. Only 57% of students got this one — ATI rates it Hard.
Ask this first, every time: has the problem already happened? No, and nobody is at risk yet → PRIMARY It may be starting — we are looking for it or catching it early → SECONDARY Yes, it already happened — we are limiting the damage and preventing recurrence → TERTIARY
Level
Goal
Examples
Primary
Prevent it from ever happening — healthy population
Parenting classes for expectant parents · stress-management class at a community center · school mental-health education · immunizations · anti-bullying programs
Secondary
Early detection + prompt treatment — shorten the illness
Depression or suicide screening · crisis hotline · crisis intervention · ED triage of an acute episode · home visits to a family flagged as at-risk
Tertiary
Rehabilitation — reduce lasting disability, prevent it happening again
Teaching stress management to a parent who already abused · support groups · day treatment / partial hospitalization · halfway house · vocational rehab · AA after detox · med management after discharge
The exact trap that got you. The same intervention changes level depending on when it happens. Stress management for a parent who has not abused = primary. The identical class for a parent who has abused = tertiary, because now you are preventing recurrence in someone already affected. Read the stem for whether harm has occurred — that word is the whole question.
1–2–3 = Before · Beginning · Been. Primary = before it starts. Secondary = it's beginning, catch it. Tertiary = it's already been, rehab.
Screening is almost always secondary — the disease may already be there, you are just finding it. Education to a well population is almost always primary.
Two you got right — keep them. Risperidone → watch for elevated blood glucose (metabolic syndrome: glucose, lipids, weight; check A1C and a fasting lipid panel). TCAs → up to 6 weeks for full therapeutic effect, same as the rest of the antidepressants.
📊 Practice Test A Rescue — your real 73.3%
Built from your ATI Practice Test A report (73.3%, closed book — this is your real number, not the 98% you got with the guide open) plus the two Dynamic Quizzing screenshots. 37 questions below, every one of them aimed at something you actually missed.
The single biggest finding.5 of your 9 Clinical Judgment misses were ONE case study — the acute mania client brought in by law enforcement, tested across five of the six clinical judgment steps. The pattern is identical every time: you picked the psychological finding and the key wanted the physiological or safety finding. Fix that one habit and you move several points at once.
1️⃣ Recognize cues
Keyed: sleep, hydration/nutrition, wrist cuts. Not appearance, not affect. Maslow first.
2️⃣ Analyze cues
You missed decreased intake. Skipping meals from hyperactivity is a manic manifestation.
3️⃣ Prioritize hypotheses
You chose insufficient nutrition; keyed was risk for violence (wrist lacerations + non-consensual touching). Actual harm beats potential deficiency.
4️⃣ Take actions
Rest is an anticipated outcome. Disulfiram is not — that is alcohol use disorder, not mania.
5️⃣ Evaluate outcomes
Missed impaired judgment / anosognosia, and read lithium 0.2 mEq/L as progress. 0.2 is subtherapeutic.
6️⃣ Delegation
You gave the PN an AP task (recording I&O). Read the verb before the client.
Verb-first delegation rule.Assess · plan · teach something new · evaluate → RN only.Reinforce · monitor · give meds · sterile procedure → PN.Measure · move · wash · feed · record I&O → AP. The Five Rights: right task, right circumstance, right person, right direction, right supervision. You may delegate the task — never the accountability.
Weak area
The exact discriminator ATI used
Discontinuing restraints
Release on behavioral criteria (calm, cooperative, can contract for safety) — the order is a ceiling, not a duration. Sleep is not release criteria; that may be sedation, not restored control.
Client advocate
Advocacy protects autonomy — it never means deciding for the client. Support a decision you disagree with. Informed consent is the provider's duty; the nurse stops the process when consent is not informed.
Older adult maltreatment
Risk = dependence + cognitive impairment + isolation + caregiver strain. When the caregiver answers for the client, separate them first, then report. Nurses are mandatory reporters — suspicion is enough, no proof and no permission needed.
Types of psychotherapy
Split the list: cognitive/behavioral = change the thought or behavior now, short-term (CBT, DBT, exposure, aversion, token economy). Insight/interpersonal = understand the why or fix the relationship (psychodynamic, IPT, group, family). The nurse refers and reinforces; she does not conduct therapy.
Dementia home safety
Keep the environment the same — rearranging furniture was the distractor. Locks high/low, alarms, wandering-response program, current photo, lowered water heater, removed stove knobs, locked meds. Teach the caregiver, before discharge, in writing.
Alcohol withdrawal priority
Benzodiazepine + seizure precautions first — untreated withdrawal can kill. Score with CIWA-Ar. Thiamine before glucose or you risk Wernicke's. Seizures 12–48 hr; DT 48–72 hr.
Anorexia nervosa
Absent insight is the hallmark. Daily weight same time/after voiding/same clothing, stay 1 hr after meals, 1–2 lb per week, and watch refeeding syndrome — phosphorus, potassium, magnesium crash → arrhythmias, heart failure, seizures.
Narcissistic PD
Idealization and splitting. Answer = consistent team message + firm matter-of-fact limits. Do not accept the flattery and do not agree the other nurses are unfair. Grandiosity here is lifelong; in mania it is episodic.
Buspirone (Q45)
ATI says 3 to 4 weeks — not 2–4. Also: not a scheduled/controlled medication, no withdrawal, no taper needed, not PRN, not for acute panic. Avoid grapefruit juice (CYP3A4 → level rises).
Sertraline (Q60)
The keyed set is two clusters: serotonin syndrome (agitation, confusion, hyperreflexia, rigidity, tremor, diaphoresis, fever) and SIADH / hyponatremia (Na <135, headache, lethargy, confusion). You added heart rate — 88/min is normal. That was over-reach, not under-knowledge.
Food–medication interactions
Three pairings, memorize as a set. MAOI + tyramine → hypertensive crisis.Grapefruit + CYP3A4 drug → level rises.Lithium + sodium/fluid change → level swings.
Do not trust your 98% and 97.9%. Those were taken with this guide open. Your closed-book numbers are 85% baseline and 73.3% on Practice Test A. Study to the 73.3.
🎯 ATI Comprehensive Quiz — 370+ NCLEX-style questions
Multiple choice · select all that apply · drop-down · matching — including 110 real ATI-style items + your 61-question Final Exam practice set. Covers all 6 units. Use Reshuffle on the results screen for a fresh order.
Key Terms Glossary
📖 Glossary
Agnosia
Inability to recognize familiar objects. A dementia "A."
Agranulocytosis
Dangerous drop in neutrophils. Clozapine & carbamazepine. Sign: sore throat + fever. Monitor ANC.
Akathisia
Inner restlessness; pacing. An EPS. Misread as anxiety.
Amnesia
Loss of memory for past events. A dementia "A."
Aphasia
Deterioration of language function. A dementia "A."
Apraxia
Inability to execute motor tasks despite intact motor ability. A dementia "A."
Deinstitutionalization
Post-1963 shift from state hospitals to community. Underfunded → homelessness, criminalization, revolving door.
Delirium
Acute, sudden, fluctuating confusion. Reversible — find the cause. A medical emergency.
Disenfranchised grief
Grief over a loss society doesn't openly acknowledge (ex-spouse, pet, pregnancy loss).
Empathy vs. Sympathy
Empathy = understanding + communicating it (therapeutic). Sympathy = pity, projects the nurse's feelings (nontherapeutic).
Family, support system, relationships, sense of belonging.
🏙️ Cultural
Beliefs about health/illness, stigma, spirituality, language.
📊 Social Determinants
Income, housing, education, access to care, safety, food security.
Culture shapes how illness is expressed AND treated. Use the Cultural Formulation Interview (CFI). Awareness of culture prevents stereotyping and stigma.
Assume your own cultural norms apply. Assess the client's beliefs about diet, health practices, and who makes health decisions in the family.
Affect = what you observe (flat, blunted, labile). Mood = what the client reports feeling. Thought process = HOW they think (flight of ideas, tangential). Thought content = WHAT they think (delusions, SI).
🎯 Module 4 — Interactive Quiz
Module 5 · Legal & Ethical Issues; Grief & Loss
📘 From your Exam 2 KCR + the final review session · Exam 2
📋 Module 5 — Deliverables (from your KCR)
Describe the rights of the client in a psychiatric setting.
Identify the types of losses and the grieving process.
⚖️ The 6 Ethical Principles
Autonomy
Respect their right to decide.
Beneficence
Act to benefit the client (do good).
Non-maleficence
Do no harm.
Justice
Distribute care fairly, regardless of who they are.
Fidelity
Loyalty; keep your commitments.
Veracity
Tell the truth; don't mislead.
📜 Patient Rights & the Law
Right to treatmentRight to refuseInformed consentConfidentiality
Torts (civil wrongs)
Tort
Plain English
Assault
Threatening — makes them fear harm
Battery
Actually touching without consent
False imprisonment
Confining without justification (improper restraint/seclusion)
Invasion of privacy
Sharing private info
Defamation
Damaging someone's reputation
Negligence = failure to give ordinary care. Malpractice (needs expert testimony) = the 4 D's: Duty, Dereliction (breach), Direct cause, Damages.
Voluntary admission = client can request discharge. Involuntary = danger to self/others or can't meet basic needs; client keeps rights but not free-to-leave. Least restrictive environment always wins.
⚰️ Grief & Loss
Kübler-Ross — 5 Stages
Denial
→
Anger
→
Bargaining
→
Depression
→
Acceptance
Not a straight line — people move back and forth.
Anticipatory
Grieving before the loss (client or family).
Disenfranchised
A loss society doesn't openly recognize (ex-spouse, pet, pregnancy loss).
Complicated
Prolonged, impairing grief that doesn't ease.
With a dying client who is unconscious, hearing is the last sense to go — be careful what you say in the room.
🖼️ Infographics
Tap each to expand.
🖼️ Death & Dying
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
Allow personal space; non-threatening eye contact at the client's level.
Offer PRN meds, decrease stimulation, close observation.
Use seclusion/restraints as anything but a LAST resort. Try least-restrictive first. Document what happened before, what you tried, and outcomes. Never leave the client unwatched. Remove ASAP.
🔁 Cycle of Violence
1. Tension building minor anger; victim placates
→
2. Acute battering serious abuse — shortest phase
→
3. Honeymoon "I'm sorry, I'll change" → repeats
The vulnerable person often has low self-esteem, guilt, shame, protects the abuser, and denies severity. The honeymoon phase is why people stay.
🚨 Types of Abuse
Intimate partner (IPV)
Assess privately, without the partner present. Ask directly. Provide a safety plan; respect the client's choice to leave or stay.
Child abuse
Mandatory report. Physical, sexual, emotional, neglect. Note injuries inconsistent with the story.
Elder abuse
Mandatory report. Physical, financial, neglect. Watch for a caregiver who answers for the elder.
PTSD = TRAUMA: Traumatic event · Re-experiencing · Arousal · Unable to function · Month or more · Avoidance.
Acute stress disorder: 3 days–1 month. PTSD: 1 month → years. Adjustment disorder: milder mood/function change after a stressor.
Dissociative disorders
Depersonalization
Watching yourself from outside your body.
Derealization
The world feels unreal/dreamlike.
Dissociative amnesia / fugue
Can't recall a time period (amnesia) or whole identity + travel (fugue).
Dissociative identity
Two+ distinct personalities.
PTSD treatment: EMDR (eye movement) — NOT for suicidal, psychotic, severe dissociation, detached retina/glaucoma, or unstable substance use. Meds = SSRIs. Give dissociative clients a safe, routine environment; don't overload with info.
🖼️ Infographics
Tap each to expand.
🖼️ Anxiety Disorders
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
🖼️ Panic Attack
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🖼️ Phobias
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🖼️ OCD — Obsessive-Compulsive Disorder
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🖼️ PTSD & Acute Stress Disorder
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🖼️ Dissociative Identity Disorder
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
📘 From the final review session + Videbeck · Exam 3
📋 Module 8 — Deliverables (from your KCR)
Compare and contrast the characteristics of major depressive disorder and the bipolar spectrum.
Identify the risk factors, warning signs, and protective factors for suicide, and implement appropriate precautions.
Describe the nursing care of a client receiving electroconvulsive therapy (ECT) and other somatic treatments.
Apply therapeutic communication to clients experiencing depression and mania.
Explain the pharmacologic management of mood disorders, including the mood stabilizer safety windows.
👉 This module is the single biggest chunk of ATI Content Mastery. Mood + suicide questions show up in every practice form you've taken. Suicide safety is always a priority question.
Communication with a depressed client: short sentences, allow time to respond, make observations instead of asking lots of questions. ECT = most effective for severe/treatment-resistant.
🎢 Bipolar & Mania
Bipolar I = full mania (≥1 week). Bipolar II = hypomania + depression. Cyclothymia = 2 yrs of milder ups/downs.
Mania care: safe environment, decrease stimulation without isolating, rest periods, finger foods (too busy to sit & eat), physical outlets, protect from impulsive/poor-judgment decisions.
Meds: lithium (long-term), valproate/carbamazepine (acute mania), lamotrigine (maintenance) — full cards in the Medications tab.
🛟 Suicide Precautions
1:1 supervision; document location, mood, quoted statements, behavior q15 min.
Remove anything usable as a weapon; plastic utensils only.
Check for hazards (windows, pipes, non-breakaway rods).
Keep hands visible; no private room, door stays open (safety > privacy).
Watch swallowing meds (hoarding to overdose); screen visitors' items.
Ask directly: "Are you thinking of killing yourself? Do you have a plan?" A specific plan + means = highest risk. Asking does NOT plant the idea.
Promise to keep a suicidal statement secret. Safety overrides confidentiality here.
🧪 Depression — The Deep Dive
DSM criteria: 5+ symptoms for at least 2 weeks, and at least one of them must be depressed mood or anhedonia (loss of pleasure). It has to be a change from baseline and it has to impair function.
🔬 What's going on underneath
Depression is low serotonin, low norepinephrine, and low dopamine — plus a stress-driven drop in BDNF (the protein that keeps neurons growing). That BDNF piece is why antidepressants block reuptake in hours but the mood doesn't lift for 2–4 weeks: the receptors and neurons have to physically remodel. Memorize the lag; ATI loves it.
📊 The depression family — one line each
Diagnosis
The tell
Key point
Major depressive disorder
5+ SIDECAPS symptoms, ≥2 weeks
Episodic; can fully remit between episodes
Persistent depressive (dysthymia)
Milder but ≥2 years, most days
Chronic low grade; can stack an MDD episode on top ("double depression")
Premenstrual dysphoric (PMDD)
Severe mood symptoms in the luteal phase, gone after menses
SSRIs work, sometimes dosed only during the luteal phase
Disruptive mood dysregulation (DMDD)
Child 6–18: severe temper outbursts + persistently irritable mood between them
Created so irritable kids stop being labeled bipolar
Seasonal pattern (SAD)
Onset with the short days, remits in spring
Light therapy 10,000 lux, ~30 min, in the morning
Peripartum onset
During pregnancy or within 4 weeks postpartum
Screen with the Edinburgh; separate from baby blues (self-limiting, ~2 weeks) and postpartum psychosis (emergency — infant is at risk)
Highest suicide risk subtype — ECT is often the answer
Atypical features
Mood lifts with good news; ↑sleep, ↑appetite, leaden limbs
Historically the MAOI-responsive group
👁️ What you actually see at the bedside
Vegetative signs
Sleep, appetite, weight, energy, libido, bowel function — all down (or up in atypical). These are the objective data you chart.
Psychomotor retardation
Slowed speech and movement, long latency before answering, poor grooming. Give them time.
Psychomotor agitation
Pacing, wringing hands, can't sit. More common in older adults — and it raises risk, because agitation supplies the energy to act.
Anhedonia · anergia · avolition
No pleasure · no energy · no drive to start anything. These predict who won't attend group without a personal invitation.
Cognitive distortion
Worthlessness, guilt, hopelessness. Hopelessness is the single strongest predictor of suicide — stronger than sadness.
Pseudodementia
In older adults depression mimics dementia. Tell: the depressed client says "I don't know" and is distressed by the deficit; the dementia client confabulates and isn't bothered.
🗣️ Talking to a depressed client
Do
Don't
Short, simple sentences
Long open-ended paragraphs they can't track
Sit in silence; allow long pauses
Fill every gap with more questions
Make observations — "I notice you haven't eaten today."
Fire a string of questions
Offer a specific, structured activity — "Walk with me to the dayroom."
"What would you like to do today?" (avolition = no answer)
Spend time with them expecting nothing
False reassurance: "Cheer up, you have so much to live for."
Accept the feeling, then ask about safety
Change the subject when they mention death
The classic ATI trap: the client who has been on an antidepressant for about 1–2 weeks and suddenly has more energy is at higher suicide risk, not lower. Energy and psychomotor activity return before mood and hopelessness resolve — now they have the drive to carry out the plan. Same logic for the client who abruptly seems calm and at peace. Increase observation; never relax it.
Care planning order: safety → physical needs (nutrition, hydration, sleep, elimination) → activity and self-care → self-esteem and cognition. If a question offers "explore childhood feelings" while the client hasn't eaten in three days, it's wrong.
🎢 Bipolar Spectrum — The Deep Dive
The whole diagnosis hangs on one question: has there ever been a manic episode? One manic episode = Bipolar I, forever, even if the client has never had a depressive episode.
⚖️ Mania vs hypomania — the four discriminators
Mania
Hypomania
Duration
≥ 1 week (or any length if hospitalized)
≥ 4 days
Function
Marked impairment — job, relationships, finances blow up
Noticeable change, but function is preserved
Hospitalization
Often required
By definition, not required
Psychosis
May have delusions/hallucinations
Never — psychosis makes it mania
Disorder
Requires
Also has
Bipolar I
≥1 manic episode
Depression usual but not required
Bipolar II
≥1 hypomanic + ≥1 major depressive episode
Never a full manic episode — that would make it I
Cyclothymia
2 years of hypomanic and depressive symptoms
Never meets full criteria for either pole
Rapid cycling
≥4 mood episodes in 12 months
A specifier, not a diagnosis. Antidepressants can trigger it.
💥 Acute mania — priorities in order
1. Safety & exhaustion
A manic client can literally die of exhaustion and dehydration. Watch VS, I&O, weight. Physical status is the priority, not the behavior.
2. Nutrition
High-calorie finger foods and shakes they can carry — they will not sit for a plated meal.
3. Sleep
Decreased need for sleep is both a symptom and a driver. Quiet, dim, low-stim room; scheduled rest periods.
4. Decrease stimulation
Low light, no TV, few people — but do not seclude unless there's an imminent safety threat. Seclusion is a last resort with an order.
5. Channel the energy
Solitary, non-competitive, gross-motor outlets: walking, stationary bike, punching bag, tearing paper. No ping-pong tournaments, no card games, no leading group.
6. Protect from consequences
Impaired judgment = spending sprees, sexual indiscretion, giving away money, business schemes. Involve family about finances and phone/card access.
🗣️ Talking to a manic client
Do
Don't
Calm, firm, matter-of-fact; short directions
Match their energy or joke along — it escalates them
Redirect flight of ideas back to one topic
Argue with grandiosity or try to reason them out of it
Set consistent limits the whole team enforces
Bargain, or let one nurse be the exception
Address one behavior at a time, in private
Confront in front of the milieu — that's an audience
Ignore minor provocation; step away and return
Take the insults personally or engage in a power struggle
Traps: (1) Antidepressants alone can flip a bipolar client into mania — a mood stabilizer must be on board. (2) Manic clients are hypersexual and intrusive; that's illness, and the intervention is a private limit plus redirection, not a lecture. (3) The manic client who suddenly becomes quiet may be crashing into depression — reassess suicide risk immediately.
Discharge teaching: take the mood stabilizer even when feeling fine, keep labs, keep a regular sleep schedule (sleep loss is the #1 relapse trigger), avoid alcohol and stimulants, and know the personal early warning signs — usually decreased sleep and increased spending or talking.
🔺 Suicide — Risk, Precautions, and Aftercare
Rule that answers most questions: when suicide is anywhere in the stem, the answer is the option that assesses directly or keeps the client physically safe right now. Everything else is later.
🧠 SAD PERSONS — the risk scale
Letter
Risk factor
S
Sex — women attempt more; men complete more (more lethal means)
A
Age — highest risk at the extremes: adolescents/young adults and adults over 65 (white men over 75 highest of all)
D
Depression — especially hopelessness
P
Previous attempt — the strongest single predictor
E
Ethanol / substance use — lowers inhibition, raises impulsivity
R
Rational thinking loss — psychosis, command hallucinations
S
Social supports lacking — isolation, recent loss
O
Organized plan — the more specific and lethal, the higher the risk
"I'm going to kill myself." "I want to die." Treat as an emergency, every time.
Indirect cues
"Everyone would be better off without me." "I won't be a problem much longer." "This is the last time I'll see you." These count. Ask directly.
Behavioral
Giving away prized possessions, writing a will, sudden goodbyes, putting affairs in order, buying a weapon, stockpiling meds.
The sudden-calm trap
A previously agitated, hopeless client who becomes peaceful, calm, or energized may have made the decision. This is a red flag, not improvement.
Protective factors
Children in the home, pregnancy, religious belief against suicide, strong social ties, engagement in treatment, future-oriented goals, no access to lethal means.
Highest-risk windows
1–2 weeks after starting an antidepressant, the first days after admission, and the first weeks after discharge or transfer to a less restrictive setting.
📋 How to ask — in this order
1. "Are you thinking about killing yourself?" — use the word. Asking does not plant the idea.
2. "Do you have a plan?" — specific plan = higher risk.
3. "Do you have the means?" — access to the gun, the pills, the rope.
4. "Have you set a time?" — a date or a window raises it again.
5. "Have you tried before?" — previous attempt is the strongest predictor.
6. "What has kept you from acting on it?" — this surfaces protective factors and starts the safety plan.
🛟 Precautions — what you actually do
Level
Nursing action
1:1 constant observation
Staff within arm's reach at all times, including the bathroom and shower. Used for active ideation with plan and means.
q15-minute checks
Document location, behavior, mood, and quoted statements — vary the timing so it isn't predictable.
No private room, close to the nurses' station, door stays open. Safety outranks privacy here.
Medications
Watch them swallow; check the mouth (cheeking and hoarding for a later overdose).
Visitors & belongings
Search packages and personal items on admission and after every visit.
Shift changes & meals
Known high-risk times — staff are distracted and the unit is loose. Assign coverage deliberately.
Never promise to keep a suicidal statement secret. Never leave a client with active ideation alone. Never argue with the client about whether life is worth living. Never rely on a "no-suicide contract" as your safety plan — it is not evidence-based and it does not replace observation.
After an attempt: treat the physical injury first, then reassess ideation — an attempt does not mean the risk is over. Debrief the milieu (other clients are affected), and complete a collaborative safety plan before discharge: warning signs, coping strategies, people to call, crisis line 988, and means restriction (gun locked and stored elsewhere, meds dispensed by a family member). Means restriction saves more lives than contracts.
Documentation trap: "Client denies SI" alone is not enough. Chart what you asked, what they said verbatim, what you observed, and what you did. On q15 checks, "resting quietly in bed" without eyes-on the client's face and chest is the finding that shows up in every lawsuit.
⚡ ECT and the Other Somatic Treatments — All in One Place
You asked where ECT lived in this guide — here it is, consolidated. ECT is the most effective treatment for severe, treatment-resistant depression, and it works faster than medication (days, not weeks), which is why it's chosen when someone is actively suicidal, catatonic, or not eating.
✅ When ECT is the answer
Treatment-resistant MDD
Two or more adequate medication trials have failed.
Depression with psychotic features
Highest-risk subtype; ECT often beats meds.
Active suicidality
When you cannot wait 2–4 weeks for an antidepressant to work.
Catatonia
Response rates are the highest of any indication.
Acute mania
Severe, unresponsive to mood stabilizers.
Pregnancy & older adults
Often safer than medication. There is no absolute contraindication — relative risk is highest with raised intracranial pressure or recent MI.
💉 The three drugs given every treatment
Drug
Why
Atropine or glycopyrrolate
Anticholinergic — dries secretions and blocks the vagal bradycardia from the stimulus. Given ~30 min before.
Methohexital (short-acting anesthetic)
The client is asleep. This is why "ECT is painful" is a myth.
Succinylcholine (paralytic)
Prevents the convulsion so nothing fractures. The seizure still happens in the brain — the body barely twitches. Requires bag-valve-mask ventilation, because it paralyzes the diaphragm too.
🔄 Nursing care, in order
Before: verify informed consent (the client can withdraw it at any time, including between treatments) · NPO after midnight · remove dentures, glasses, hairpins, jewelry · have the client void · baseline VS and a memory/cognition baseline · hold benzodiazepines and anticonvulsants (they raise the seizure threshold and blunt the treatment).
Immediately after:position on the side and maintain the airway — the top priority is patent airway and adequate ventilation until the paralytic wears off. Suction available.
Recovery: expect confusion and disorientation on waking — reorient frequently and calmly, stay with the client, and reassess before ambulating (fall risk). Headache, muscle aches, and nausea are common and treatable.
Ongoing: usually 2–3 treatments per week for a total of 6–12. Maintenance ECT may continue to prevent relapse. Antidepressants are usually continued afterward — ECT is not a cure.
Memory: the real side effect. Expect retrograde amnesia for events around the treatment period and some short-term memory gaps that improve over weeks to months after the course ends. Teach this before consent. Do not tell the client memory loss is permanent, and do not tell them there is none. And ECT does not cause brain damage — if an option says it does, it's wrong.
⚖️ ECT vs the other somatic options
Treatment
How it's done
Key nursing point
ECT
Anesthesia + induced seizure, 2–3×/wk × 6–12
Fastest and most effective; airway after; memory effects
rTMS (transcranial magnetic stim)
Magnetic coil, awake, no anesthesia, ~5 days/wk × 4–6 wks
No memory loss, no seizure, no sedation — client drives home. Screen for metal implants; rare seizure risk.
VNS (vagus nerve stim)
Implanted device, chronic stimulation
For long-term treatment-resistant depression; hoarseness and voice change are common.
Light therapy
10,000 lux, ~30 min, in the morning
First-line for seasonal pattern. Eye strain and headache; can trigger mania in bipolar.
🖼️ ECT — Full Infographic (what it is, how it works, the procedure step by step, effectiveness, side effects, myths vs facts)
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
Heads up: the effectiveness panel in this infographic has a typo — the first row reads "Secatonia," which should be depression (70–90% respond). Catatonia is the 80–100% row.
😢 Grief vs Depression — How to Tell Them Apart
Grief is a normal response to loss. Depression is a disorder. The exam wants you to know when grief has crossed the line.
Normal grief
Major depression
Mood
Comes in waves; the client can still laugh and be comforted
Persistent and unrelenting; little relief
Self-esteem
Intact — "I miss him"
Worthlessness — "I'm worthless and I deserve this"
Thoughts of death
Wanting to join or be with the deceased
Wanting to die because life has no value; plan and means
Focus
On the loss
On the self
Course
Gradually improves; function returns
Stays or worsens without treatment
Response to support
Accepts comfort and connection
Withdraws from it
Kübler-Ross stages
Denial · Anger · Bargaining · Depression · Acceptance. Not linear — people move back and forth and skip stages. Never tell a client which stage they should be in.
Anticipatory grief
Grieving before the loss (terminal diagnosis). Normal; it does not shorten grief afterward.
Prolonged/complicated grief
Intense yearning and preoccupation lasting >12 months in adults with impaired function. This one gets referred.
Disenfranchised grief
A loss society won't validate — miscarriage, a pet, an ex-spouse, a stigmatized death. Acknowledging it is the intervention.
What the nurse does for grief: be present, use silence, encourage the client to tell the story of the loss in their own words, normalize the range of feelings including anger and relief, and assess for suicide anyway. Do not say "I know how you feel," "at least he isn't suffering," or "it was God's plan" — those are all false reassurance and they close the conversation.
First-line. 2–4 weeks for effect. Sexual dysfunction, GI upset, weight change, insomnia. Serotonin syndrome. Do not stop abruptly (discontinuation syndrome). Black-box: suicidality in clients under 25.
SNRI
venlafaxine, duloxetine
Same as SSRI plus monitor blood pressure (venlafaxine raises it). Duloxetine also treats neuropathic pain.
Atypical
bupropion, mirtazapine, trazodone
Bupropion: no sexual side effects, helps smoking cessation, lowers the seizure threshold — contraindicated in seizure disorder, bulimia, and anorexia. Mirtazapine: sedation + appetite/weight gain (useful in an underweight, insomniac client). Trazodone: sedating, used for sleep; teach about priapism — an erection over 4 hours is an emergency.
TCA
amitriptyline, nortriptyline, imipramine
Anticholinergic (dry mouth, constipation, urinary retention, blurred vision), orthostatic hypotension, and lethal in overdose — cardiac dysrhythmia. Dispense limited quantities to a suicidal client.
MAOI
phenelzine, tranylcypromine, selegiline
Tyramine-free diet or hypertensive crisis: avoid aged cheese, cured/smoked meats, soy sauce, sauerkraut, tap/draft beer, red wine, overripe fruit, fava beans. Wash out 2 weeks between an MAOI and an SSRI (5 weeks for fluoxetine). Report severe occipital headache, stiff neck, palpitations — that's the crisis.
Serotonin syndrome — too much serotonin, often from combining agents (SSRI + MAOI, + triptan, + tramadol, + St. John's wort, + linezolid). Look for agitation and confusion, hyperthermia, diaphoresis, tachycardia, hypertension, tremor, muscle rigidity, hyperreflexia, and clonus. Stop the drug and get help. Onset is hours; that speed is what separates it from neuroleptic malignant syndrome, which builds over days and comes with lead-pipe rigidity and antipsychotics.
Mood stabilizers
Drug
Level / labs
The thing they ask
Lithium
Maintenance 0.6–1.2 mEq/L; acute mania up to 1.5; toxic >1.5, life-threatening >2.0. Narrow window. Check lithium level, renal function, and TSH.
Keep sodium and fluid steady — 2–3 L/day and a consistent salt intake. Low sodium, dehydration, sweating, vomiting, diarrhea, and NSAIDs or thiazides all raise the level. Early toxicity: N/V/D, fine tremor, thirst, polyuria. Advancing: coarse tremor, confusion, ataxia, slurred speech, seizure. Takes 1–2 weeks to work — an antipsychotic or benzo covers the acute mania meanwhile. Pregnancy: Ebstein anomaly.
First-line for acute mania and rapid cycling. Watch for hepatotoxicity and pancreatitis — report abdominal pain, nausea, vomiting. Highly teratogenic (neural tube defects) — contraception counseling.
Carbamazepine
Level 4–12 mcg/mL; monitor CBC and sodium
Agranulocytosis and aplastic anemia — report fever and sore throat. Hyponatremia (SIADH). Strong enzyme inducer — it lowers oral contraceptive levels.
Lamotrigine
No routine level
Best for the depressive pole and maintenance. Stevens-Johnson syndrome — any rash, stop the drug and call the provider. This is why it is titrated up slowly; never rush the dose.
Atypical antipsychotics
Metabolic panel, weight, A1C, lipids
quetiapine, olanzapine, risperidone, aripiprazole, lurasidone — used for acute mania and for bipolar depression. Monitor for metabolic syndrome and EPS.
The four numbers to have cold on exam day: antidepressant lag 2–4 weeks · lithium therapeutic 0.6–1.2, toxic >1.5 · valproate 50–125 · ECT 2–3×/week for 6–12 treatments.
🖼️ Infographics
Tap each to expand.
🖼️ Depression — Signs & Symptoms
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🖼️ Depression — Nursing Care
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🖼️ Depression — Procedures (ECT & more)
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🖼️ Bipolar Disorder — Part 1
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🖼️ Bipolar Disorder — Part 2
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🎯 Module 8 — Interactive Quiz
Module 9 · Schizophrenia & Psychotic Disorders
📘 From the final review session + Videbeck · Exam 3
📋 Module 9 — Deliverables (from your KCR)
Describe the diagnostic criteria and course of schizophrenia and differentiate it from the other disorders on the psychotic spectrum.
Differentiate positive, negative, cognitive, and affective symptoms and explain why negative symptoms drive long-term disability.
Define and recognize the altered thought, perception, speech, and behavior terms (delusion types, hallucination types, word salad, waxy flexibility, echolalia, and the rest).
Apply therapeutic communication to a client experiencing hallucinations, delusions, and paranoia — including the response to a command hallucination.
Explain antipsychotic pharmacology: first- vs second-generation, the four EPS in order of onset, tardive dyskinesia, NMS, clozapine monitoring, and metabolic effects.
Maintain safety — de-escalation, milieu management, and the legal rules for restraint and seclusion.
👉 Where the points actually are: ATI asks far fewer "what is schizophrenia" questions than what do you say and what do you do about the medication. Budget your study time accordingly — the communication card and the pharm card below are the money cards.
Flat affect, alogia (poverty of speech), avolition (no motivation), anhedonia, social withdrawal
1st-gen antipsychotics treat positive symptoms only. 2nd-gen treat positive AND negative. Negative symptoms are harder to treat and cause the most long-term disability.
🗣️ Hallucinations & Nursing Care
Argue with, or pretend to share, a hallucination or delusion. Don't reinforce it.
Assess for COMMAND hallucinations — "voices telling you to hurt yourself or others?" → safety priority.
Acknowledge the feeling, present reality calmly: "I don't hear the voices, but I can see you're frightened."
Build trust, encourage med adherence, promote self-care and group activities.
Watch for the medication emergencies with antipsychotics: EPS, tardive dyskinesia, NMS. (Full detail in Medications + Mind Maps.)
🧠 Schizophrenia — The Deep Dive
DSM-5 criteria:2 or more of the following, present a significant portion of 1 month — and at least one must be from the first three: ① delusions ② hallucinations ③ disorganized speech | ④ grossly disorganized or catatonic behavior ⑤ negative symptoms. Plus total disturbance ≥ 6 months (including prodrome/residual) and a decline in function — work, relationships, or self-care.
Two numbers, two different jobs.1 month = how long the active symptoms must last. 6 months = how long the whole disturbance must last. Swap them and you'll pick schizophreniform when the answer is schizophrenia.
🔬 What's going on underneath
Dopamine is not simply "too high" — it's mis-distributed. Too much dopamine in the mesolimbic pathway produces the positive symptoms (hallucinations, delusions). Too little dopamine in the mesocortical / prefrontal pathway produces the negative and cognitive symptoms. That single fact explains the whole drug story: first-generation drugs block D2 everywhere, so they crush positive symptoms and leave (or worsen) negative symptoms, and they wreck the nigrostriatal pathway on the way through — which is EPS — and the tuberoinfundibular pathway, which is why prolactin goes up.
Add two more pieces: glutamate/NMDA hypofunction (this is why ketamine and PCP produce a state that looks like schizophrenia, negative symptoms included), and serotonin — 5-HT2A blockade is what second-generation drugs add, and it's why they touch negative symptoms and cause less EPS.
📊 The psychotic spectrum — how to tell them apart
Diagnosis
The discriminator
Key point
Brief psychotic disorder
≥ 1 day but < 1 month, then full return to baseline
Often follows a severe stressor (including postpartum). Best prognosis on the spectrum.
Schizophreniform disorder
Schizophrenia symptoms lasting 1 to 6 months
A placeholder diagnosis. About a third recover; the rest convert to schizophrenia.
Schizophrenia
≥ 6 months total, ≥ 1 month active
Functional decline is required. Lifelong, relapsing.
Schizoaffective disorder
Mood episode plus psychosis — but psychosis persists ≥ 2 weeks with NO mood symptoms
That 2-week psychosis-alone window is the whole test question. If psychosis only ever happens during the mood episode, it's a mood disorder with psychotic features, not schizoaffective.
Delusional disorder
≥ 1 month of delusions, function otherwise largely intact, no prominent hallucinations or disorganization
These clients often keep working and hide it well. Subtypes: persecutory, jealous, erotomanic, somatic, grandiose.
Substance/medication-induced
Onset tied to intoxication or withdrawal; resolves as the substance clears
Always your first rule-out. Get a drug screen. Stimulants, cannabis, hallucinogens, steroids, alcohol withdrawal.
Visual hallucinations and an acute, fluctuating course point away from schizophrenia and toward a medical cause.
Schizotypal personality disorder
Odd beliefs, magical thinking, social oddity — but no frank psychosis
Lives in the personality-disorder chapter; listed on the spectrum because it is genetically related.
🌀 The course — and what makes it go well or badly
Premorbid
Function is normal or near-normal. Sometimes a quiet, socially awkward childhood in hindsight.
Prodromal
Months to years of withdrawal, declining grades or work, odd beliefs, neglected hygiene. This is where early intervention pays off most — and where families first say "something changed."
Acute / active
Positive symptoms are obvious. This is the hospitalization phase. Goal: safety first, then symptom reduction.
Stabilization
Symptoms are settling on medication. Goal: adherence, teaching, discharge planning.
Maintenance / residual
Between episodes. Positive symptoms are quiet; negative symptoms remain — and they are what keeps the client unemployed and isolated.
⚠️ Relapse
Almost always preceded by stopping medication. Other triggers: substance use, sleep loss, high-conflict family environment, major stressor.
✅ Better prognosis
❌ Worse prognosis
Later onset · abrupt onset with a clear trigger
Early onset (teens) · gradual, insidious onset
Good premorbid function and work history
Poor premorbid function, childhood social problems
Female
Male (earlier onset, more negative symptoms)
Positive symptoms predominate
Negative symptoms predominate
Strong support system, treated early
Long duration of untreated psychosis, isolation, substance use, family history
🧠 Two facts that quietly show up everywhere. First, anosognosia — genuine inability to recognize you are ill — is the number one reason clients stop medication. It is a symptom, not stubbornness, and you don't argue a client out of it. Second, people with schizophrenia die roughly 15–20 years earlier than average, and it is mostly cardiometabolic, not suicide. That's why you monitor weight, glucose, and lipids like it matters — because it does.
🗣️ The Vocabulary — Thought, Perception, Speech, Behavior, Affect
These are pure definition points. ATI gives you the behavior and asks you to name it, or gives you the name and asks what you'd see. Read down the tables until each one clicks in one pass.
💭 Altered thought — the delusions
A delusion is a fixed false belief that will not budge for evidence. Compare: an illusion is misinterpreting a real stimulus (the coat on the door looks like a person). A hallucination is a sensory experience with no stimulus at all. A delusion is a belief, not a perception.
Type
What the client says
Persecutory (paranoid) — most common
"The staff are putting something in my food." "The FBI follows my car."
Grandiose
"I invented the internet." "God chose me to heal people."
Somatic
"My intestines are rotting." "There are insects under my skin."
Erotomanic
"The doctor is secretly in love with me."
Jealous
"My wife is unfaithful" — with no evidence and no persuading otherwise.
Nihilistic
"I'm already dead." "The world has ended."
Ideas of reference
"The news anchor was talking directly about me."
Thought broadcasting
"Everyone can hear what I'm thinking."
Thought insertion / withdrawal
"Those aren't my thoughts, they were put there." / "Someone is taking my thoughts out."
Delusion of control / influence
"The satellite makes my arms move."
👂 Altered perception — the hallucinations
Type
What to know
Auditory
Most common in schizophrenia. Voices — commenting, criticizing, or conversing.
Command
A voice ordering an action. Always assess for this directly and always assess safety. "Are the voices telling you to do something? Are they telling you to hurt yourself or anyone else?"
Visual
Second most common overall — but more suggestive of a medical or substance cause (delirium, withdrawal, dementia) than of schizophrenia.
Tactile
Bugs crawling on or under the skin (formication) — classic in stimulant use and alcohol withdrawal.
Olfactory / gustatory
Burning, rotting, or metallic smells and tastes — think temporal lobe seizure or tumor first.
Behavioral cues that a client is hallucinating right now, even before they tell you: eyes tracking something you can't see, tilting the head as if listening, talking or muttering to no one, sudden laughing at nothing, distractibility mid-sentence, hands over the ears.
💬 Altered speech and thought process
Term
Definition
Example
Neologism
An invented word with private meaning
"I need my splorkinator."
Word salad
Words strung together with no grammar or meaning at all — the most severe disorganization
"Purple table run of the sky yes button."
Clang association
Chosen for rhyme or sound, not meaning
"I'll take a cake, a rake, a lake, awake."
Echolalia
Parroting back what was just said
Nurse: "Time for lunch." Client: "Time for lunch, time for lunch."
Loose associations
Ideas shift with no logical link
"My mom called. Dogs shed in April. The pipes are loud."
Tangentiality
Wanders off and never returns to the point
Asked about pain, ends up describing a road trip.
Circumstantiality
Endless detail but eventually gets there
Ten minutes of backstory, then answers the question.
Thought blocking
Speech stops mid-sentence; the thought is simply gone
"I was going to say — " long silence " — I don't know what it was."
Perseveration
Same word or idea repeated regardless of the new question
Every answer is "my back hurts."
Alogia
Poverty of speech — brief, empty replies. This one is a negative symptom.
"Fine." "No." "I guess."
Flight of ideas
Rapid but connected topic jumps
Belongs to mania, not schizophrenia — know the contrast.
🚶 Altered behavior
Catatonia
Extreme psychomotor disturbance — either immobile and mute (stupor) or wildly excited and purposeless. Treat with a benzodiazepine (lorazepam) or ECT. Nursing priority: nutrition, hydration, skin, DVT prevention, elimination.
Waxy flexibility
You place a limb in a position and the client holds it — sometimes for hours. Reposition them yourself to prevent injury and pressure ulcers.
Echopraxia
Mimicking your movements. The motor twin of echolalia.
Stereotypy · Automatism
Repetitive, purposeless movement (rocking, rubbing) · automatic acts the client can't explain.
Negativism · Posturing
Doing the opposite of, or resisting, every instruction · holding a bizarre stance for long periods.
Ambivalence · Boundary impairment
Holding two opposing feelings at once and being unable to act · not knowing where self ends and others begin (depersonalization, feeling unreal; derealization, the world feeling unreal).
😐 Altered affect — and the negative symptoms
Term
What you chart
Flat affect
No visible emotional expression — face, voice, and gestures all still.
Blunted affect
Markedly reduced expression. Less severe than flat.
Restricted affect
Narrow range — mildly reduced.
Labile affect
Rapid, abrupt shifts — laughing then sobbing.
Inappropriate affect
Emotion doesn't match content — giggling while describing a death.
📝 Memorize the negative symptoms as the A's:Affect (flat), Alogia (poverty of speech), Avolition (no motivation or goal-directed behavior), Anhedonia (no pleasure), Asociality (withdrawal), plus Attention deficit and Anergia. Everything on that list is something lost. Positive symptoms are things added. Positive respond well to medication; negative barely do — which is exactly why negative symptoms cause the most disability and why "the medication is working, why isn't he working?" is a real family question you will have to answer.
Two traps that catch people. ① Avolition is not laziness and not depression. A client who won't shower isn't being defiant — break the task into single steps and cue each one. ② Flat affect means the face is blank, not that the client feels nothing. Never document "client denies distress" based on affect alone — ask.
💬 Therapeutic Communication — Hallucinations, Delusions, Paranoia
If you only have twenty minutes before the exam, spend them here. This is where the largest share of the module's questions live, and the wrong answers are all very tempting.
Argue with a delusion or hallucination. Agree with it or pretend to share it. Laugh, whisper, or talk quietly with another staff member within sight of a paranoid client. Touch a client who is frightened or suspicious without asking first. Ask "why" questions. Say "there's nothing there" and walk away.
🔊 When a client is hallucinating
① Assess "Are you hearing something right now? What are the voices saying?"
→
② Screen for command "Are they telling you to hurt yourself or anyone else?" — safety first if yes
→
③ Present reality, don't argue "I don't hear any voices, but I can see this is frightening for you."
→
④ Focus on the feeling Respond to the fear, not the content
→
⑤ Redirect to reality Simple, concrete, one-on-one activity — cards, a walk, music
The magic sentence structure: "I don't hear/see it, but I can see you do, and I'm here with you." It's honest, it doesn't argue, and it doesn't abandon them. Every good answer choice on this topic is some version of that sentence.
Coping strategies you actually teach: talk back to the voices firmly ("go away"), hum or sing, listen to music with headphones, call a support person, do something with the hands, tell staff. Reducing isolation reduces hallucinations — they get louder alone in a quiet room.
🧷 When a client is delusional
✅ Do
❌ Don't
Respond to the underlying feeling: "It must feel terrifying to believe people are watching you."
"Nobody is watching you. That's not real." (arguing → they lose trust in you, not the delusion)
Voice doubt once, calmly: "I understand you believe that. I find it hard to believe myself."
Debate it repeatedly, or demand evidence. You will not win, and the belief hardens.
Redirect to concrete reality and to the here-and-now.
Play along — "yes, I'll help you hide from them." That reinforces it and destroys credibility.
Be consistent and matter-of-fact; same staff, same routine, brief clear sentences.
Long explanations or reasoning. Disorganized thinking can't follow them.
Assess whether the delusion puts anyone at risk — persecutory delusions can lead to preemptive violence.
Assume a delusion is harmless because it sounds odd rather than threatening.
🕵️ When a client is paranoid
Food and fluids
Offer sealed, unopened items — canned drinks, packaged food — and let the client choose and open them. This is the single most-tested paranoia intervention.
Medication
Explain each one plainly every time, allow the client to see the package or unit-dose wrapper, and never insist. Offer, don't force.
Your body language
Stay in the client's line of sight, keep hands visible, no whispering or laughing nearby, announce yourself before approaching, don't touch.
Space
Give extra personal space — 4 to 6 feet. Crowding a paranoid client is how you get hit.
Activities
Start one-on-one and with non-competitive, solitary-friendly tasks. Group therapy and competitive games come later, once trust exists.
Trust
Do exactly what you said you'd do, when you said you'd do it. With paranoia, reliability is the intervention.
💡 How to pick the right answer under pressure. Rank the options: safety beats everything (command hallucinations, plans to harm), then assessment ("tell me what you're hearing"), then the feeling ("you look frightened"), then reality presentation ("I don't hear it"), then redirection. Any option that argues, agrees, dismisses, or asks "why" is wrong before you finish reading it.
💊 Antipsychotics — The Whole Picture
Expect a 1–2 week wait for the positive symptoms to quiet and up to 6 weeks for full effect. Agitation and sleep often improve in days, which is exactly when clients decide they're better and stop taking it.
Sudden sustained muscle spasm — torticollis (neck twists), oculogyric crisis (eyes roll up), jaw locking, opisthotonos (arched back), and worst case laryngospasm
EMERGENCY — airway. Give IM/IV diphenhydramine or benztropine immediately. Relief in minutes. Stay with the client.
Akathisia
Days to weeks
Inner restlessness — pacing, rocking, cannot sit still, "I feel like I'm going to jump out of my skin"
Propranolol (first choice), a benzodiazepine, or lower the dose. Do not mistake it for psychotic agitation and increase the antipsychotic — that's the classic error, and untreated akathisia raises suicide risk.
Benztropine, trihexyphenidyl, or amantadine; reduce dose or switch to a 2nd-gen drug. Fall precautions.
Tardive dyskinesia
Months to years (latest)
Lip smacking, tongue protrusion and writhing, chewing, facial grimacing, blinking, choreiform movements of the hands and trunk
Often permanent — prevention is the whole game. Screen with the AIMS tool at baseline and at least every 3–6 months. Report it immediately; the drug is stopped or switched (often to clozapine). Valbenazine or deutetrabenazine may be added. Anticholinergics do not help and can make it worse.
The discrimination question they love: a client is pacing the hall two days after a haloperidol dose increase. Is that anxiety, psychotic agitation, or akathisia? It's akathisia — it started after the dose change, and the client describes a physical restlessness, not fear or voices. The wrong answer is a PRN antipsychotic. The right answer is to hold, notify, and expect propranolol.
🔥 Neuroleptic malignant syndrome — the one that kills
NMS = FEVER.Fever (often >103°F / 40°C) · Encephalopathy (confusion, ↓LOC) · Vitals unstable (labile BP, tachycardia, tachypnea, diaphoresis) · Elevated CK and WBC · Rigidity — lead-pipe, whole-body. Add myoglobinuria (dark urine) and the risk of acute kidney injury. Onset is usually within the first 2 weeks of starting or increasing a drug, or after a rapid dose escalation. Mortality around 10%.
Nursing actions, in order: ① Stop the antipsychotic ② call the provider / transfer to ICU ③ cool the client actively ④ IV fluids to protect the kidneys ⑤ expect dantrolene (muscle relaxant) and bromocriptine (dopamine agonist) ⑥ monitor CK, renal function, cardiac rhythm.
Fastest way to separate them:clonus and hyperreflexia = serotonin. Lead-pipe rigidity = NMS. Both are hyperthermic emergencies; both start with stopping the drug.
🩸 Clozapine — the special case
Issue
What you monitor / teach
Agranulocytosis
ANC at baseline, then weekly for 6 months, every 2 weeks for months 6–12, then monthly. Baseline ANC must be ≥1500. Interrupt below 1000; severe neutropenia is <500. Teach the client to report fever, sore throat, flu-like symptoms immediately — the drug is dispensed through a REMS program, so no labs means no refill.
Seizures
Dose-related. Highest risk at higher doses and with rapid titration.
Myocarditis
Usually within the first 2 months. Report chest pain, dyspnea, tachycardia, unexplained fatigue.
Severe constipation / ileus
Genuinely dangerous with this drug — bowel regimen, fluids, fiber, monitor bowel movements.
Sialorrhea
Paradoxical drooling, worst at night. Towel on the pillow; it's benign but distressing.
Orthostatic hypotension · weight gain
Rise slowly; the metabolic burden is the heaviest of any antipsychotic.
Why use it at all
It's the drug for treatment-resistant schizophrenia (after 2 adequate trials fail), it has the lowest EPS/TD risk, and it's the only antipsychotic shown to reduce suicidality.
🍔 Metabolic and drug-specific pearls
Metabolic syndrome
Olanzapine and clozapine are the worst offenders. Monitor weight/BMI and waist circumference, fasting glucose or A1c, lipids, and BP at baseline and periodically. Teach diet, activity, and to report increased thirst, urination, and hunger.
Risperidone
Highest prolactin elevation of the 2nd-gens → galactorrhea, gynecomastia, amenorrhea, sexual dysfunction. Also EPS at higher doses. Available as a long-acting injection.
Ziprasidone · thioridazine
QT prolongation — get a baseline ECG and potassium. Ziprasidone must be taken with food (~500 kcal) or absorption drops by half.
Quetiapine
Very sedating, very low EPS — which is why it's the choice in Parkinson's and Lewy body dementia. Cataract monitoring on long-term use.
Aripiprazole · lurasidone
Aripiprazole is a partial agonist — more activating, less metabolic. Lurasidone must be taken with food (~350 kcal).
Anticholinergic load
Dry mouth, blurred vision, constipation, urinary retention, photophobia. Sugarless gum or candy, fluids and fiber, sunglasses, report inability to void.
Long-acting injections (LAI)
Haloperidol and fluphenazine decanoate, risperidone, paliperidone, aripiprazole, olanzapine pamoate. Given every 2–4 weeks — the answer for a client who keeps stopping oral medication. Olanzapine pamoate needs 3 hours of observation for post-injection delirium/sedation syndrome.
⚠️ Black box — older adults
Increased mortality when antipsychotics are used for behavioral symptoms of dementia. Not approved for that use. Expect a question where the right answer is a non-pharmacologic intervention.
Water intoxication
Psychogenic polydipsia is common in schizophrenia. Monitor daily weights and sodium; watch for confusion, nausea, and seizures from hyponatremia.
Never do this
Do not abruptly stop an antipsychotic — cholinergic rebound and relapse. Do not add alcohol or CNS depressants. Do not treat TD with an anticholinergic.
🔢 The numbers to have cold on exam day. Antipsychotic effect: positive symptoms 1–2 weeks, full effect up to 6 weeks. Acute dystonia: hours to days. Akathisia: days to weeks. Pseudoparkinsonism: weeks to months. Tardive dyskinesia: months to years, AIMS every 3–6 months. NMS: usually the first 2 weeks, fever >103°F, mortality ~10%. Clozapine ANC: baseline ≥1500, weekly ×6 months, hold under 1000, severe under 500. LAI dosing: every 2–4 weeks.
🛟 Safety, Milieu, De-escalation, and the Restraint Rules
🚨 De-escalation — the order you actually do it in
① Environment Reduce stimulation, clear other clients, remove hazards
→
② Position yourself 4–6 ft, at an angle, hands visible, keep your own exit clear, never let them block the door
→
③ Talk One speaker only, calm low voice, short simple sentences, use their name
→
④ Offer choices "Would you rather go to your room or walk with me?" Autonomy de-escalates.
→
⑤ Offer medication PRN, offered — not threatened
→
⑥ Show of support / seclusion Team present; seclusion before restraint
→
⑦ Restraint Absolute last resort
Warning signs that violence is building, in escalating order: pacing and restlessness → clenched fists and jaw → loud, rapid, or profane speech → invading others' space → direct threats → refusing to follow direction. Intervene at pacing, not at threats.
⛓️ Restraint and seclusion — the legal points
Rule
Detail
Least restrictive first
You must be able to document that verbal de-escalation, environment change, and offered medication were tried or clearly unsafe.
Indication
Only for imminent danger to self or others. Never for punishment, staff convenience, or short staffing.
Order
Requires a provider order. In a true emergency the nurse may initiate and obtain the order within 1 hour. PRN or standing restraint orders are never permitted.
Face-to-face evaluation
By the provider (or trained LIP) within 1 hour of initiation.
Time limits per order
4 hours adults · 2 hours ages 9–17 · 1 hour under 9. Must be renewed, not assumed.
Monitoring
Continuous observation for violent restraint (1:1 or continuous video/audio with staff in the area). Document at least every 15 minutes.
Care during
Circulation and skin checks, ROM to one limb at a time, fluids, toileting, nutrition, vital signs. Restrain in a position that protects the airway — never prone or face-down.
Release
At the earliest possible moment the client is no longer a danger — not when the order expires. Debrief with the client afterward.
Documentation
Behavior that justified it, alternatives tried, time on and off, monitoring, care given, client response, notifications.
Rights that survive involuntary admission: being committed does not automatically mean the client loses the right to refuse medication, to send and receive mail, to legal counsel, to privacy, or to informed consent. Forced medication requires a separate legal process or a true emergency. An exam item where the "helpful" nurse overrides a right is almost always the wrong answer.
🏠 Milieu, discharge, and relapse prevention
Structure the day
Predictable routine, short concrete activities, low stimulation. Disorganized thinking cannot handle an unstructured afternoon.
Start simple with groups
One-on-one → parallel activity → small group → group therapy. Non-competitive first. Pushing a paranoid or actively psychotic client into group is a wrong answer.
Self-care
Avolition means you cue each step — "put toothpaste on the brush" — rather than saying "go get ready." Use checklists. Praise the specific action.
Adherence is the whole ballgame
Address anosognosia, side effects, cost, and complexity. Offer LAI injections, pill boxes, and a single daily dose. Ask what they don't like about the medicine — the honest answer is usually sedation, weight gain, or sexual side effects.
Family teaching
Reduce criticism and over-involvement (high expressed emotion predicts relapse). Teach the client's specific early warning signs and who to call. Refer to NAMI and family psychoeducation.
Comorbidity
Substance use is very common and makes everything worse. Smoking rates are high — and smoking lowers clozapine and olanzapine levels, so quitting can push levels up. Suicide risk is real: about 5% die by suicide, highest early in the illness and after discharge.
🎯 Priority logic for this module. When a question gives you a psychotic client and four reasonable-sounding actions, the order is: airway/physical emergency (laryngospasm from dystonia, NMS) → danger to self or others (command hallucinations, threats, plan) → assessment of the symptom → therapeutic communication → teaching and long-term planning. Teaching is never the answer to an acutely psychotic client — they can't take it in yet.
🖼️ Infographics
Tap each to expand.
🖼️ Schizophrenia — Signs & Symptoms
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
🖼️ Schizophrenia — Communication
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
🖼️ Schizophrenia — Pharmacology
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
🎯 Module 9 — Interactive Quiz
Module 10 · Personality, Eating & Substance Use Disorders
📘 From the final review session + Videbeck · Exam 3
📊 All 10 Personality Disorders — Side by Side
Looking for borderline? It's row 4 and it has its own box at the bottom of this card. Every PD is ego-syntonic — the client thinks the problem is everyone else — so engagement is the hard part, and the whole team must give the same answer.
Three clusters, three moods: A = weird (odd/eccentric) · B = wild (dramatic/erratic) · C = worried (anxious/fearful).
🔍 The one-line tell for each
← swipe the table sideways to see the third column →
Disorder
Cluster
The one-line tell
Paranoid
A — weird
“Everyone is out to get me.” Distrust, grudges, reads malice into neutral acts — but no hallucinations.
Schizoid
A — weird
“I don't want people.” Genuine loner, emotionally cold, indifferent to praise or criticism.
Schizotypal
A — weird
“The TV is sending me signs.” Magical thinking, ideas of reference, odd speech/dress — reality testing still intact.
“I'm special, get me the real doctor.” Grandiose, entitled, no empathy, rages when criticized.
Avoidant
C — worried
“I want friends but they'll reject me.” Feels inadequate, hypersensitive to criticism.
Dependent
C — worried
“You decide for me.” Clingy, submissive, helpless alone, replaces a lost partner fast.
Obsessive-Compulsive (OCPD)
C — worried
“It has to be done my way, perfectly.” Rigid, controlling, workaholic — no rituals, and they see nothing wrong with it.
🔬 Hallmark · discriminator · what the nurse does
⭐ Borderline (B)
Hallmark: instability in relationships, self-image, and mood + impulsivity + fear of abandonment + recurrent self-harm. Discriminator: histrionic wants attention and antisocial wants gain — borderline is driven by terror of being abandoned. Only PD with splitting and repeated self-injury. Nursing:consistent limits, identical from every staff member, written in the care plan. Name the splitting out loud. Safety checks. No self-disclosure, no favors, no rescuing. DBT is first-line.
Paranoid (A)
Hallmark: pervasive suspicion, questions loyalty, holds grudges. Discriminator: suspicious without psychosis — no hallucinations, no fixed bizarre delusion. Nursing: neutral, honest, matter-of-fact. Do not be overly warm or friendly — it reads as a trick. Never whisper near the client. Keep every promise. Give simple written explanations.
Schizoid (A)
Hallmark: detached, solitary, flat, no interest in relationships or sex. Discriminator:doesn't want closeness (avoidant wants it and is scared). Nursing: respect the need for solitude. Do not force group activities. Low-demand, one-on-one, gradual.
Schizotypal (A)
Hallmark: magical thinking, ideas of reference, eccentric dress and speech. Discriminator:not schizophrenia — no sustained hallucinations/delusions; brief transient psychosis only under heavy stress. Nursing: respectful, don't argue with or reinforce the magical thinking; social skills training.
Antisocial (B)
Hallmark: violates others' rights, deceitful, aggressive, zero remorse; history of conduct disorder before 15. Discriminator: exploits for gain or thrill; borderline acts out from fear; narcissist acts out for admiration. Nursing: firm limits + stated consequences. Don't be charmed or flattered. Protect the other clients. Highest risk of violence toward others.
Histrionic (B)
Hallmark: attention-seeking, theatrical, seductive, shallow emotions that switch fast. Discriminator:no self-harm, no identity instability — that's what separates it from borderline. Nursing: hold professional boundaries, redirect flirtatious/seductive behavior calmly, reward genuine emotion, don't reward drama.
Narcissistic (B)
Hallmark: grandiosity, entitlement, needs admiration, exploits others, lacks empathy; fragile self-esteem underneath. Discriminator: wants admiration, not gain (antisocial) and not rescue (borderline). Nursing: matter-of-fact. Don't argue about their superiority and don't feed it. Set limits on demands. Avoid power struggles. Expect rage after criticism.
Avoidant (C)
Hallmark: socially inhibited, feels inadequate, terrified of criticism and rejection — but wants connection. Discriminator: desire for closeness = avoidant; indifference = schizoid. Nursing: assertiveness and social skills training, role-play, small graded successes, build self-esteem. Don't push too fast.
Dependent (C)
Hallmark: can't make decisions, submissive, clinging, needs others to take responsibility, urgently replaces a lost relationship. Discriminator:submits to keep you; borderline rages or self-harms to keep you. Nursing: require the client to make her own decisions. Do not do what she can do herself. Assertiveness training. Set limits on clinging — don't become the caretaker.
Obsessive-Compulsive PD (C)
Hallmark: perfectionism, order, control; rigid, stingy, workaholic, can't delegate. Discriminator:OCPD ≠ OCD. OCPD has no obsessions and no rituals and the client thinks it's correct (ego-syntonic). OCD has intrusive thoughts + rituals and the client hates them (ego-dystonic). Nursing: give control where it's safe, use written schedules, don't rush her, coach tolerating “good enough.”
⚔️ The pairs the exam makes you separate
Confused pair
What decides it
Schizoid vs Avoidant
Do they want relationships? Schizoid no. Avoidant yes, but fears rejection.
Schizotypal vs Schizophrenia
Is reality testing intact? Schizotypal yes (odd, magical). Schizophrenia no (hallucinations, delusions).
Paranoid PD vs Delusional disorder
A fixed delusion? Paranoid PD = generalized suspicion. Delusional disorder = one specific fixed false belief.
Borderline vs Histrionic
Self-harm and splitting. Borderline has both. Histrionic just wants the spotlight.
Borderline vs Antisocial
Motive. Borderline = don't abandon me. Antisocial = what can I get, and no guilt.
Narcissistic vs Antisocial
Admiration vs exploitation. Narcissist needs to be admired. Antisocial doesn't care what you think.
Dependent vs Borderline
Reaction to losing you. Dependent clings and submits. Borderline rages, threatens, self-harms.
OCPD vs OCD
Rituals + insight. OCPD: no rituals, sees no problem. OCD: rituals, distressed by them.
Never on a PD question: never negotiate a limit you already set · never give one client a rule the others don't have · never share personal information or take a gift · never argue with grandiosity or magical thinking · never tell a client with borderline PD you're the one who “understands” her — that is the splitting.
⭐ Borderline PD — the deep dive you were looking for
Definition: pervasive instability of interpersonal relationships, self-image, and affect plus marked impulsivity, beginning by early adulthood. The 9 criteria (I DESPAIRR):Identity disturbance · Disturbed/unstable relationships · Emotional instability (mood swings in hours, not weeks) · Suicidal or self-mutilating behavior · Paranoid or dissociative episodes under stress · Abandonment fear (frantic efforts to avoid it) · Impulsivity (spending, sex, substances, driving, binge eating) · Rage (inappropriate, intense anger) · Real emptiness (chronic feelings of emptiness). Splitting: can't hold good and bad in the same person, so people are all-good or all-bad and flip without warning. On the unit it shows up as “you're the only nurse who cares, the day shift is horrible” — that is not a compliment, it is a symptom.
The trap: when the client with borderline PD praises you and criticizes another nurse, the answer is not to reassure her about the other nurse and not to accept the praise. Take it to the team, keep the plan identical across all staff, and address the behavior with the client directly and without judgment.
Priority: safety
Ask directly about suicide and self-harm every shift. Borderline PD carries the highest completed-suicide rate of any PD (~8–10%). Self-injury is usually to relieve emptiness or numbness, not always to die — assess intent, never dismiss it. Remove means; observation per policy.
Limit setting
State the limit once, calmly, with the consequence. Then do not renegotiate. Same limits from every staff member, documented so nobody gets played. Focus on the feeling behind the behavior, not the drama.
Manipulation
Don't argue, defend, or explain twice. No special privileges, no personal phone numbers, no gifts either direction. Point out the behavior matter-of-factly and redirect to a coping skill.
No drug is FDA-approved for a personality disorder. Meds treat symptoms only: SSRIs for mood/impulsivity, mood stabilizers for lability, low-dose atypical antipsychotic for transient stress-related paranoia or dissociation.
Staff splitting
If the team starts arguing about the client — half defending her, half angry — the splitting has moved into the staff. Fix it in report and on the care plan, not with the client.
One-sentence answer key: consistency, limits, safety, and DBT. If an option offers extra attention, an exception, or a personal connection, it's wrong.
Borderline = I DESPAIR: Identity disturbance · Dysphoria/emptiness · Emotional instability · Suicide/self-harm · Psychotic/dissociative · Anger · Impulsivity · Relationships. Uses splitting (all-good/all-bad). Set consistent limits; DBT is first-line.
Antisocial = no remorse, violates rights, manipulative. Set firm limits; don't get pulled into manipulation.
⚠️ 2 study pictures from other publishers were here. They have been removed — they were not this site's to host.
What it actually is
Restriction of intake leading to significantly low body weight for age, sex and health.
Intense fear of gaining weight — or persistent behaviour that prevents gain, even when the client will not say they are afraid.
Disturbance in how body weight is experienced — they see themselves as overweight at 35 kg — plus absent insight into how serious the low weight is.
Your course material and the infographic use less than 75% of expected body weight ("25% below normal") and BMI under 18. Use those numbers on your exam. For context only: DSM-5-TR no longer sets a single cutoff — it grades severity by BMI (mild 17+, moderate 16–16.99, severe 15–15.99, extreme under 15). If a question gives you a percentage, it wants the 75% rule.
Two subtypes — and why it matters
Subtype
How they get there
What you watch
Restricting
Dieting, fasting, excessive exercise. No bingeing or purging in the last 3 months
Starvation physiology: bradycardia, hypothermia, hypotension. Exercise is a symptom, not fitness
Binge-eating / purging
Recurrent bingeing or purging — vomiting, laxatives, diuretics, enemas
Starvation plus purging damage: hypokalemia, alkalosis, enamel erosion. Higher impulsivity and suicide risk
A client can have anorexia and purge. The subtype is decided by the behaviour; the diagnosis is decided by the weight. That is the single most common mix-up on this topic.
Risk factors
Adolescent and young adult femalesOnset in the teensPerfectionism, rigidity, high achievementSports and roles judged on weightFamily history of eating or mood disordersAnxiety, OCD, depressionTrauma, bullying, weight teasing
It is most common in adolescent females, but males are underdiagnosed, and it occurs at every body size — a client who was previously overweight and has lost dangerous amounts of weight has "atypical anorexia" and is just as medically at risk.
The heart is muscle, and the body catabolises muscle. This is what kills them
Skin and hair
Lanugo (fine downy hair), dry brittle skin, hair loss on the head, yellow-tinged palms, cold mottled hands and feet
Lanugo is the body insulating itself. The yellow is carotenemia
Endocrine
Amenorrhea — common, but DSM-5 REMOVED it as a diagnostic criterion, so a client can have anorexia and still menstruate, and males count — plus low T3, cold intolerance, low body temperature
The body shuts down reproduction and slows metabolism to survive
Bone
Osteopenia and osteoporosis, stress fractures — often permanent
Low estrogen plus low intake. Peak bone mass is built in the teens and cannot be fully regained
GI
Constipation, bloating, delayed gastric emptying, early fullness. Also superior mesenteric artery syndrome — the fat pad that cushions the duodenum is gone, so the artery compresses it: postprandial pain, nausea, vomiting
Gut motility slows. Their fullness is real, not resistance — and SMA syndrome gets mistaken for refusing to eat
Neuro / psych
Poor concentration, rigid thinking, irritability, depression, social withdrawal
A starved brain cannot think flexibly — some "personality" resolves with weight restoration
Heme
Leukopenia, anemia, thrombocytopenia
Bone marrow suppression from starvation
The classic SATA answer set: lanugo · amenorrhea · bradycardia / pulse 48 · hypotension · low body temperature · cold intolerance · potassium 2.6 · irregular heart rate · dry skin. If a finding is slow, cold, low or hairy, it belongs.
🧪 Labs and what they mean
Lab
Expect
Why you care
Potassium
Low — especially with purging. Under 3.5 is hypokalemia; a 2.6 is an emergency
Cardiac dysrhythmias. This is the number that gets someone admitted
Phosphorus
May look normal on admission — then crashes once feeding starts
The refeeding marker. See the next card
Magnesium, calcium
Low
Also drive dysrhythmias and worsen hypokalemia that will not correct
Sodium
Low if water-loading before weights; low with laxative use
Water-loading to fake a weight is common — and dangerous
ABG
Metabolic alkalosis with vomiting; metabolic acidosis with laxative abuse
A poor prognostic sign — it means the liver has run out. Report it
LFTs, cholesterol
Transaminases up; cholesterol paradoxically high
Starvation liver injury early, fatty liver on refeeding. The high cholesterol surprises people — it is not diet
ECG
Bradycardia, prolonged QTc, ST changes, U waves with hypokalemia
Continuous monitoring in the severely malnourished
🏥 When does she get admitted?
Treatment is usually outpatient. Hospitalisation is for medical instability — the exam wants you to recognise the unstable one:
Body weight below 75% of ideal (your course's number), or rapid ongoing loss
Heart rate under 40–50 (SAHM: under 50 awake, under 45 asleep; APA adult: under 40), systolic BP under 80–90 (SAHM under 90/45), or orthostasis — HR rise over 20–30 bpm (over 40 in adolescents) or a systolic drop over 20 mmHg
Potassium under 3, or any dangerous electrolyte derangement
Prolonged QTc or any dysrhythmia
Temperature under 35.6°C / 96°F (SAHM; APA uses under 36.1°C / 97°F), severe dehydration
Suicidal ideation, or failure of outpatient treatment
"Which client does the nurse see first?" On this topic the answer is almost always the one with a cardiac or potassium finding — not the one who is most distressed, most underweight, or refusing to eat. Physiology outranks behaviour.
🤝 Nursing care that actually gets tested
Stay with the client during every meal and for 1 hour after. The hour is when purging happens — bathroom door supervised or delayed.
Weigh the same way every time:same time each morning, after voiding, before intake, same scale, gown only, back to the scale. Check for water-loading and weights hidden in clothing.
Strict intake and output, and a strict record of calories and protein.
Goal weight gain 1–2 lb per week — your course's number, and the APA 2023 figure for outpatient. Know the setting: the published inpatient target is 2–3 lb per week. Faster is not safer — but what actually causes refeeding syndrome is the calorie load in the first days, not the rate of tissue gain.
No exercise during the acute phase, and supervise for hidden exercise — pacing, standing, isometrics in bed.
Matter-of-fact, non-controlling tone. Eating is not negotiable, but you do not argue, bribe or comment on appearance. A written behavioural contract does the arguing for you.
Reinforce progress toward a healthy weight, not looks. Never comment on appearance — "you look better" is heard as "you look bigger."
Limit high-fat and gas-forming foods early; no caffeine; small frequent meals.
Assess suicide risk directly and repeatedly.
Help her identify triggers and examine the dysfunctional thoughts driving it — that is the cognitive-behavioural piece.
Praise how the client looks, argue about food, let her eat unobserved, or leave her alone in the hour after a meal. And never let a behaviour question outrank a potassium of 2.6.
💊 Treatment
Priority in the acute phase is weight restoration and medical stability. Insight work comes after — a starved brain cannot do therapy.
CBT for the distorted thoughts; family-based treatment (Maudsley) is first-line for adolescents still at home.
No medication is FDA-approved for anorexia nervosa. Olanzapine is sometimes used off-label as an adjunct for weight and rumination. SSRIs do not work while the client is starved.
Fluoxetine is the FDA-approved drug for BULIMIA — 60 mg daily in the morning, adults, moderate to severe. That is the one they ask.
Bupropion is contraindicated with a current or prior diagnosis of bulimia or anorexia nervosa — the label's stated reason is a higher observed seizure incidence, and purging clients are already electrolyte-depleted. The contraindication does not lift in remission.
Vitamin D and calcium for bone; DEXA after 6 or more months of amenorrhea. Oral contraceptives do NOT restore bone density and they mask the return of menses — weight restoration is the bone treatment.
Therapeutic response to "I'm going to be huge." Do not argue with the distortion and do not reassure her that she is thin — both feed it. Reflect the feeling and stay with it: "It sounds frightening to feel like you are losing control. Let's talk about what that is like."
☠️ Refeeding Syndrome — The Treatment That Can Kill
The dangerous moment in anorexia is not admission. It is day 1 to day 5, once you start feeding her — which is why this is a nursing problem, not a dietitian problem.
Starved — body burns fat and protein
→
Carbohydrate given
→
Insulin surges
→
PO₄, K⁺, Mg²⁺ driven INTO cells
→
Serum levels crash
→
Cardiac & respiratory failure, seizures
Why phosphate is the one they ask about
Total body phosphate is already depleted from starvation even when the serum level looks normal on admission. The moment glucose arrives, insulin pushes what is left into the cells to build ATP — and the serum number falls off a cliff. Without ATP the heart cannot contract and the diaphragm cannot pull. That is the whole syndrome in one sentence.
HYPOPHOSPHATEMIA is the hallmark. A falling phosphate after feeds begin is the earliest and most specific warning — even while the value is still inside the normal range. Potassium and magnesium fall with it, and thiamine is consumed too. ASPEN grades it by how far any one of phosphate, potassium or magnesium drops within 5 days of restarting calories: a 10–20% fall is mild, 20–30% moderate, over 30% or any organ dysfunction is severe.
Who is at risk — before you feed anyone
High risk if ONE of these
Or TWO of these
BMI under 16 · unintentional loss of more than 15% in 3–6 months · little or no intake for more than 10 days · low phosphate, potassium or magnesium before feeding starts
BMI under 18.5 · loss of more than 10% in 3–6 months · little or no intake for more than 5 days · history of alcohol use, insulin, chemotherapy, diuretics or antacids
🛡 Preventing it
Start low, go slow. NICE: begin at a maximum of 10 kcal/kg/day — 5 kcal/kg/day if BMI is under 14 or intake has been negligible for more than 15 days — and build to full requirements over 4 to 7 days, guided by labs, not by how hungry or cooperative she is.
Correct low electrolytes BEFORE and DURING feeding — you do not wait for them to normalise before starting, but you do replace as you go.
Thiamine BEFORE the first feed — 100 mg at least 30 minutes before calories (ASPEN), or 200–300 mg orally daily through the first 10 days (NICE) — and daily after. Refeeding burns thiamine, and giving carbohydrate to a thiamine-depleted client can precipitate Wernicke's encephalopathy — confusion, ataxia, eye movement changes. Give the vitamin first.
Phosphate, potassium and magnesium at least daily — often every 12 hours through the first few days. The danger window is days 1–5; keep monitoring for about a week.
Continuous cardiac monitoring in the severely malnourished.
Daily weights and strict I&O — and watch fluid, because too much too fast causes overload in a heart with no reserve.
Restrict sodium early; watch for edema, which is expected but must not be ignored.
A sudden weight gain in the first days of refeeding is usually fluid, not tissue — and paired with edema or crackles it is a warning sign, not progress. Real tissue restoration is 1–2 lb per week outpatient, 2–3 lb per week inpatient.
🚨 What you report immediately
Falling phosphateNew dysrhythmia or tachycardiaShortness of breathEdema, crackles, JVDSudden weight jumpConfusion, weaknessSeizure activityMuscle pain or weakness
Advance calories fast because the client is finally eating, skip the phosphate check because admission labs were normal, or start carbohydrate before thiamine. "She ate the whole tray" is not a reason to speed up.
Two-second recall. Refeed a starved body → insulin → phosphate, potassium and magnesium go INTO the cells → serum crashes → heart and lungs fail. Hallmark = hypophosphatemia. Thiamine first, start low, go slow, labs daily, cardiac monitor, 1–2 lb a week.
Reveal · A client with anorexia is on day 3 of nutritional support. Which finding does the nurse report first?
A serum phosphorus that has dropped since admission — even if it is still within the normal range. The trend is the warning, and phosphate is the earliest marker. Cardiac and respiratory changes follow it.
Reveal · Why is thiamine given before the first feeding?
Refeeding consumes thiamine, and giving carbohydrate to a thiamine-depleted client can trigger Wernicke's encephalopathy. Vitamin first, then calories.
⚖️ Anorexia vs Bulimia — The Full Comparison
The one-line version is in the quick card above. This is the version that survives a hard question.
Anorexia Nervosa
Bulimia Nervosa
Body weight
Significantly LOW — under 75% of expected, BMI under 18 (your course's numbers; DSM-5-TR grades severity by BMI instead). This is the #1 distinguisher
Normal or slightly above. You cannot tell by looking — which is why it is missed
Core behaviour
Restriction, fasting, excessive exercise (± purging in the binge-purge subtype)
Binge, then compensate — vomiting, laxatives, diuretics, fasting, over-exercise
Frequency criterion
Not applicable — defined by weight
At least once a week for 3 months. Severity by episodes per week: mild 1–3, moderate 4–7, severe 8–13, extreme 14+
Severity graded by
BMI — mild 17+, moderate 16–16.99, severe 15–15.99, extreme under 15
Compensatory episodes per week (above)
How they see it
Ego-syntonic — the control feels good. Denies there is a problem. Absent insight is the hallmark
Ego-dystonic — feels shame and guilt, hides it, and is more likely to seek help
When a bulimic client stops purging, aldosterone is still running high, so she retains fluid — edema and an alarming jump on the scale in the first week or two ("pseudo-Bartter" rebound). It is fluid, not fat, and it settles. Warn her before it happens, because this is the moment clients relapse.
Both of them: hypokalemia → life-threatening dysrhythmias · supervise meals and the hour after · do not comment on appearance · bupropion is contraindicated · assess suicide risk.
Binge-eating disorder is the third one, and the discriminator is simple: bingeing with NO compensatory behaviour. Usually overweight or obese, marked distress and guilt afterwards, at least once a week for 3 months. A binge is a large amount in a discrete period of about 2 hoursplus a sense of loss of control — both halves are required, in bulimia too. First-line is CBT; lisdexamfetamine (Vyvanse) is the FDA-approved drug, for moderate to severe BED in adults only, and the label states it is not indicated or recommended for weight loss.
SUD + mental illness → treat both simultaneously or relapse is near-certain.
Impaired nurse
Absences, mood swings, wasting narcotics, volunteering for med passes → you must report to supervisor/BON.
Relapse
Part of the disease, not failure. Ask what happened before it; revise the plan. Never shame.
Nurse stance
Matter-of-fact, non-judgmental, firm limits. No rescuing, no moralizing, no arguing with denial.
🖼️ Infographics
Tap each to expand.
🖼️ Personality Disorders
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🖼️ Bulimia
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🖼️ Drug Abuse
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🖼️ Alcohol Abuse
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🎯 Module 10 — Interactive Quiz
Module 11 · Somatic Symptom Illness; Neurodevelopmental Disorders FINAL ONLY
📘 From my final exam key concepts review · First tested on the final
📋 Module 11 — Deliverables (from your KCR)
Discuss the characteristics and dynamics of specific somatic symptom illnesses.
Discuss the characteristics, risk factors, and family dynamics of autism spectrum disorder (ASD) and ADHD.
Describe etiology and treatment of somatic symptom and related disorders.
Describe treatments for ASD and ADHD.
🩹 Somatic Symptom Illnesses
Physical symptoms that are real to the client and cause excessive thoughts, feelings, and anxiety — with no adequate medical explanation, or out of proportion to a known condition.
Call it "faking." Somatic symptom illness is unconscious — the distress and symptoms are genuine. (That's what separates it from malingering.)
Disorder
Hallmark
Somatic symptom disorder
One+ distressing physical symptoms + disproportionate thoughts/anxiety about them
Illness anxiety disorder
Preoccupation with having a serious illness; few/no actual symptoms
Conversion disorder (FND)
Neurologic symptom (paralysis, blindness) with no medical cause; classic la belle indifférence
Factitious disorder
Consciously producing symptoms for the sick role (not external reward)
Treatment & nursing
One consistent provider (limits doctor-shopping)Journaling — link symptoms to stressEmotion-focused coping (deep breathing, relaxation)Don't reinforce the sick role
Goal: help the client see the mind–body connection. A symptom journal that notes what was happening (alone? conflict?) reveals the stress trigger.
🧩 Autism Spectrum Disorder (ASD)
Core features
Deficits in social communication & interaction + restricted, repetitive behaviors/interests. Onset in early childhood.
Signs
Poor eye contact, delayed/absent language, need for sameness & routine, stereotyped movements (rocking, hand-flapping), sensory sensitivities.
Predictability is therapeutic in ASD. Sudden change in routine → distress and behavioral escalation. Keep the environment and schedule consistent.
⚡ ADHD
Three presentations
Inattentive · Hyperactive-impulsive · Combined. Symptoms before age 12, in 2+ settings.
Treatment
Stimulants (methylphenidate, amphetamines) + behavioral therapy + parent training + school support.
Meds teaching
Give after breakfast; last dose before 4 PM; monitor height, weight, appetite; watch for insomnia.
Medication alone is not a cure. Kids also need behavior strategies, self-esteem rebuilding, and school programs (they DO qualify under IDEA). Parent support groups help.
New, sudden confusion = DELIRIUM until proven otherwise → hunt the cause. In older adults, a UTI is a classic trigger. Young children with high fever are also high-risk.
The 4 A's of dementia
Amnesia — memory lossAphasia — language lossApraxia — can't do motor tasksAgnosia — can't recognize objects
Commonly tested: a client who can't recognize a pen or notebook = agnosia (not amnesia/aphasia/apraxia).
Dementia nursing: consistent routine, orientation cues, safety (wandering, falls), simple choices, validation therapy — meet them in their reality rather than correcting.
🎯 Module 12 — Interactive Quiz
Module 13 · Psychopharmacology Reference FINAL ONLY
The high-density drug module. Full drug cards live in the Medications tab.
One-page visual for the six theorists NUR 175 keeps asking about. Tap to collapse; the recall table underneath is what you should be able to say out loud without looking.
🖼️ Theorist infographic (tap to collapse)
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
8 stages, each a crisis to resolve, birth → death. Trust vs Mistrust · Autonomy vs Shame · Initiative vs Guilt · Industry vs Inferiority · Identity vs Role Confusion · Intimacy vs Isolation · Generativity vs Stagnation · Integrity vs Despair
Lower needs must be met before higher ones motivate. This is your priority-question tool. Physiologic → Safety → Love/Belonging → Esteem → Self-actualization
💬 Rogers — CLIENT-centered
The client is the expert on their own life. Unconditional positive regard · empathy · congruence (genuineness). Non-directive — reflect feelings, don't advise.
🎟️ Skinner — CONSEQUENCES
Behavior is shaped by what follows it. Positive reinforcement = add a reward. Negative reinforcement = remove something unpleasant (still increases behavior). Punishment decreases behavior. Token economy on inpatient units.
Age
Freud
Erikson
0–1
Oral
Trust vs Mistrust
1–3
Anal
Autonomy vs Shame
3–6
Phallic
Initiative vs Guilt
6–12
Latency
Industry vs Inferiority
12–18
Genital
Identity vs Role Confusion
19–40
Genital
Intimacy vs Isolation
40–65
—
Generativity vs Stagnation
65+
—
Integrity vs Despair
Negative reinforcement is not punishment. It increases the behavior by taking away something aversive. This is a favorite distractor.
Count the stages: Freud 5, Piaget 4, Erikson 8, Maslow 5 levels. If a question hands you a wrong count, that's the wrong answer.
Age → stage is the highest-yield version of this content. If a stem gives you an age, name Freud's stage, Erikson's crisis, and Piaget's stage before you read the options.
Transference = the patient. Countertransference = the nurse (behind the counter).
🎧 Mnemonics Podcast + Visual Cheat Sheet
Two companions to the Mnemonic Vault above. Play the podcast while you drive or fold laundry; use the cheat sheet the night before.
🎧 Podcast — Medical Mnemonics for Psychiatric Diagnosis Streams from your Google Drive. If the player below doesn't load on your phone, use the button.
🖼️ Psychiatric Mnemonics — The Ultimate Clinical Cheat Sheet Every mnemonic in the vault, drawn out: MSE · MISERABLE · I-MURDER · TRAUMA · SIDECAPS · DIG FAST · SOME ATTIC · UNDER-rexia / BOWL-emia · CAN’T-Version · FIDGETY · ASD & TWO-rette · Where The F AM I? · DIRE · Cluster A/B/C · I DESPAIR.
🖼️ Cheat sheet (tap to collapse)
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The picture is the index, not the content. Look at it, then close it and say the letters out loud. If you can't produce them from memory, that mnemonic isn't learned yet.
🧠 Picmonic — Anxiety Assessment (filled in)
Your blank Picmonic workbook page, completed. Cover the right column and say each one out loud from the picture.
🖼️ Picmonic image — Anxiety Assessment (tap to open)
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
🔥 Topic character: "Anxiety-bag Assess-man." Anxiety is one of several psychological responses to stress. The two defining features are apprehension and uncertainty. It becomes a disorder when it interferes with the ability to meet basic needs — and you pick your intervention based on the level.
#
Level
Key fact · Picmonic cue
What it actually means
1
MILD
Increased Alertness Up-arrow Alerting-alarm
The fight-or-flight response fires. The HPA axis (hypothalamic-pituitary-adrenal) activates → cortisol + catecholamines ("adrenaline") released → senses heighten. This level is useful — it's how you study for an exam.
As anxiety climbs the body starts getting overwhelmed by the HPA system. The client notices more of the environment. Some show the "flight" response → restlessness: shifting in bed, trying to climb out of bed, pacing.
Perceptual field narrows — tunnel vision. Problem-solving diminishes. The client needs assistance to complete tasks and stay focused.
4
Short Attention Span Shorts with Attention Span
Easily distracted, yet starts fixating on specific details. Give short, simple, repeated directions.
5
Shaking Shaking
Restlessness advances to shaking and muscle tension. The body cannot relax and the client may begin to look disoriented.
6
SEVERE
Ineffective Problem Solving Inability to Solve Problem-cube
Problem-solving stops. Even the simplest task is too much. Attention locks onto one detail or scatters across many — either way, nothing productive happens.
7
Automatic Behavior Automatic-robot
Behavior and thoughts run on autopilot, aimed only at relieving the anxiety. Irrational thoughts "flash": "I can't cope with this," "I'm not going to make it."
8
Hyperventilation Hiker-vent
Catecholamine overproduction → rapid breathing → CO₂ blown off → respiratory alkalosis. Early signs: numbness & tingling in the extremities, lightheadedness, dizziness, possible carpopedal spasm.
9
PANIC
Hallucinations Halloween-hallucination
Hallucinations or delusions can occur. Approach with caution — their reaction to any intervention is unpredictable. Care is supportive and protective.
10
Inability to Function or Communicate Inability to Communicate on Malfunctioning-telephone
Highest level: withdrawn, behavior can be "wild," a feeling of terror, and often the thought that they are "going crazy." Cannot follow directions.
MATCH THE INTERVENTION TO THE LEVEL — this is the test question. MILD/MODERATE: the client can still learn → teach coping skills, deep breathing, problem-solve with them, use short simple sentences. SEVERE/PANIC: the client cannot learn and cannot problem-solve → do NOT teach and do NOT ask them to make decisions. Stay with them, remain calm, speak in short firm simple statements, reduce stimuli (quiet dim room), keep them safe, and medicate (benzodiazepine) if ordered. Teaching comes later, after anxiety drops.
Level
Perception
Learning ability
Nurse's #1 job
Mild
Widened — sees more
Learning is enhanced
Support and teach — this level is productive
Moderate
Narrowed — selective inattention
Learning still possible with help
Refocus, simple directions, teach coping
Severe
Greatly reduced — one detail only
No learning
Stay with them, reduce stimuli, do not teach
Panic
Distorted / lost
None
SAFETY — protect from harm, calm presence, medicate
Classic wrong answer: teaching relaxation techniques or asking a client to "describe what happened" during severe or panic level anxiety. They physically cannot process it. Reduce stimuli and stay with them first.
Hyperventilation is a severe-level finding, not panic. Numbness and tingling in the fingers plus dizziness = blowing off CO₂ = respiratory alkalosis → have them breathe slowly, not into a paper bag by reflex.
🔥 Anxiety differs from fear: fear has an identifiable external object; anxiety is a vague, objectless sense of apprehension and uncertainty. ATI tests that distinction.
🧠 Picmonic — Social Anxiety Disorder (filled in)
Your blank Picmonic workbook page, completed. Cover the right column and say each one out loud from the picture.
🖼️ Picmonic image — Social Anxiety Disorder (tap to open)
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
🔥 Topic character: "Anxiety-bag with social people around." Social anxiety disorder = intense anxiety and fear of being negatively evaluated in a social situation. Plain version: an exaggerated fear of embarrassment in social settings that interferes with normal function. The "performance only" specifier = the fear is limited to public speaking.
#
Key fact · Picmonic cue
What it actually means
1
Classification: Phobia Phone-bee
A phobia is an anxiety disorder defined by a persistent fear of a specific object or situation. The person usually recognizes the fear is excessive — insight is intact. Social anxiety disorder sits inside this broad phobia group.
The single most effective treatment for social anxiety disorder. CBT analyzes and reshapes the maladaptive thoughts driving the emotional and behavioral distress. Often paired with graded exposure and social skills training.
3
SSRIs Selective Silver-tonic Reuptake tube with Inhibiting-chains
First-line medication. Selectively block serotonin reuptake into the presynaptic cell → more serotonin in the synaptic cleft. Takes 2–6 weeks for full effect — teach the client not to quit early.
4
Venlafaxine Vanilla-fax
An SNRI — works on serotonergic and noradrenergic receptors at moderate doses. Used for social anxiety and panic disorder. Monitor blood pressure (norepinephrine effect at higher doses).
5
Beta-Blockers Nonselective Beta-fish with LOL Blocks
For the "performance only" type — public speaking. Given acutely, before the event. They blunt the physical symptoms: tremor, tachycardia, sweating, shaky voice. Example: propranolol.
6
Benzodiazepines Benz-dice
Also for acute, performance-related anxiety only. Short-term use only — dependence, sedation, and tolerance make them a poor long-term choice.
The two-bucket rule for social anxiety meds: Ongoing / generalized social anxiety → SSRI (or venlafaxine) + CBT. This is the long game. Performance-only, one-off event → beta blocker or benzodiazepine, taken before the event. Neither is a daily maintenance drug.
Classic wrong answer: picking a benzodiazepine or a beta blocker as the long-term treatment for social anxiety disorder. Those are acute, situational tools. Long-term = SSRI + CBT.
Insight is the discriminator. In a phobia, the client knows the fear is excessive and still can't stop it. In a delusion, they don't. ATI uses that to separate anxiety disorders from psychotic ones.
🔥 Don't confuse it with agoraphobia (fear of places where escape is difficult or help unavailable) or avoidant personality disorder (a pervasive lifelong pattern of feeling inadequate and hypersensitive to criticism, not situation-bound).
Second Picmonic page, completed. Assessment findings first, then interventions.
🖼️ Picmonic image — OCD (tap to open)
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
🔥 Topic character: "OCD-tiles." OCD is a severe, debilitating, often chronic disorder of repetitive, distressing thoughts outside the client's control that interfere with daily functioning. The anxiety shows up as an obsession — a rigid application of rules — and can only be relieved by compulsions that chase a sense of "completeness."
#
Group
Key fact · Picmonic cue
What it actually means
1
ASSESSMENT
Repetitive and Intrusive Thoughts Repetitive and Intrusive Thought-bubble
This is the obsession — the thought. Common themes: cleaning (contamination fear), symmetry (orderliness, repeating, counting), forbidden/taboo (sexual, religious, aggressive), and harm (fear of harm to self or others → checking).
2
Suppressed by Thought or Action Suppressed by Thought-bubble with Action
This is the compulsion — the behavior that temporarily relieves the obsession. Worried about germs → washes hands excessively. Relief is short-lived, which is why the cycle repeats.
3
Interferes with Daily Functioning Broken Daily Functions
The diagnostic threshold. Clients can spend more than one hour a day on compulsions. Rituals aren't a disorder until they cost time, function, or relationships.
4
May or May Not Be Aware Aware or Unaware
Insight varies. Compulsions may be obvious to everyone else while the client is only partly aware they're doing it repeatedly. Never assume insight is intact.
Analyzes and reshapes the maladaptive thoughts driving the distress. Evidence supports CBT + a serotonergic agent over either one alone. Related approaches: limiting the time allowed for the compulsion, systematic desensitization, and flooding. The gold standard behavioral piece is exposure and response prevention (ERP).
6
SSRIs Selective Silver-tonic Reuptake Tube with Inhibiting-Chains
Drug of CHOICE for OCD. All SSRIs are FDA-approved for OCD except citalopram and escitalopram. OCD needs higher doses and longer trials (up to 8–12 weeks) than depression.
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Clomipramine Clam-map-ramen
Tricyclic that blocks serotonin and norepinephrine reuptake. Efficacy comparable to SSRIs but poorly tolerated (anticholinergic effects, sedation, cardiac risk) → second-line.
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Venlafaxine Vanilla-fax
SNRI. Despite a similar mechanism, it has NOT shown benefit over placebo for OCD and is not FDA-approved for it. Minimal research; used only sparingly. This is the distractor answer.
OBSESSION vs COMPULSION — get this right every time. Obsession = thought. Intrusive, unwanted, recurrent, distressing, ego-dystonic (feels foreign, "not me"). Compulsion = action. The ritual performed to neutralize the obsession and reduce anxiety. the mnemonic: I-MURDER — Intrusive · Mind-based · Unwanted · Resistant · Distressing · Ego-dystonic · Recurrent.
Never interrupt or forbid the ritual outright — that spikes anxiety and can trigger panic. Allow time for the ritual at first, set limits gradually, and build in structure. Also: do not argue about whether the fear is rational.
OCD vs OCPD:OCD = ego-dystonic obsessions + compulsions, the client is distressed by them. OCPD (Cluster C personality disorder) = ego-syntonic perfectionism and rigidity, the client thinks their way is simply correct. OCD has rituals; OCPD has standards.
Nursing care essentials: allow time for rituals, keep a predictable routine, don't shame, help identify triggers and feelings, teach relaxation when anxiety is low enough to learn, and set collaborative limits as therapy progresses. Watch skin breakdown from washing rituals.
🔥 Related OCD-spectrum disorders ATI groups here: body dysmorphic disorder (Fix ME DOC), hoarding, trichotillomania (hair pulling), and excoriation (skin picking).
🧠 Picmonic — PTSD (filled in)
Your blank Picmonic workbook page, completed. Cover the right column and say each one out loud from the picture.
🖼️ Picmonic image — PTSD (tap to open)
⚠️ A study picture from another publisher was here. It has been removed — it was not this site's to host.
🔥 Topic character: "Post Trauma-spike." PTSD follows exposure to a traumatic event and produces re-experiencing, avoidance, negative mood/cognition, and hyperarousal. Symptoms must last > 1 month. Under 1 month with the same picture = acute stress disorder. Symptoms can be delayed — starting 6 months or more after the event.
The client mentally re-lives the event through flashbacks and nightmares. Produces irrational behavior and severe anxiety. This is the core of the disorder — the trauma keeps happening in the present tense.
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Flashbacks Flash-back
A sudden, vivid memory with intense sensory detail and the original emotions attached. Usually triggered by an unrelated cue — a smell, a sound, a date. The client may lose track of where they are.
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Nightmares Night-mare
Very common, especially in children. They disrupt sleep and create anxiety around going to sleep — so the client becomes sleep-deprived on top of everything else. Pairs with hypervigilance and an exaggerated startle response.
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Avoidance Avoid-sign
Emotional detachment from family, friends, and people generally. Actively avoids people, places, and situations that trigger memories — e.g. driving a different route to skip the intersection. Loses interest in activities they used to enjoy.
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Self-destructive Behaviors Destroying Self
Suicidal thoughts and substance abuse. A hallmark cognitive sign is the inability to foresee a sustainable future — no marriage, no career, no normal life span. This is a safety finding, not just a mood finding.
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Assess Suicide Risk Assess-man with Risk of Suicide-jumper
Priority nursing action. Use a screening tool, ask directly, and assess grief, depression, and support systems. Survivor guilt is common. Never assume a quiet client is a safe client.
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Actively Listen to Their Story Listening to Story
Acknowledge guilt and self-blame without arguing them out of it. Provide a calm, non-threatening, private environment and let them tell it at their own pace. Do not push for details or set a timeline for recovery.
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Anxiety Medications Anxiety-bag Med-bottles
First-line: SSRIs — especially sertraline (Zoloft) — plus venlafaxine and prazosin.Prazosin is the one for nightmares (alpha-1 blocker; watch orthostatic hypotension, give at bedtime). Adjuncts: beta blockers, carbamazepine, valproic acid, lithium.
Drug pick, straight up: nightmares → prazosin. Everything else first-line → sertraline or paroxetine (the two FDA-approved SSRIs for PTSD), or venlafaxine. Benzodiazepines are NOT first-line for PTSD — high abuse potential in a population already at risk for substance abuse, and they interfere with trauma processing. If an ATI option offers a benzo for long-term PTSD management, it is the wrong answer.
Timeline
Diagnosis
Symptoms 3 days to 1 month after the trauma
Acute stress disorder
Symptoms lasting more than 1 month
PTSD
Onset 6+ months after the event
PTSD with delayed expression
Classic wrong answer: "Tell me everything that happened, start to finish." Forcing a detailed retelling before the client is ready re-traumatizes them. The correct action is to stay present, listen at their pace, and assess safety.
Therapies that show up on ATI: CBT, prolonged exposure, cognitive processing therapy, EMDR (eye movement desensitization and reprocessing), and group therapy with other survivors.
