Foundations of Psychiatric Nursing Assessment — NCLEX Lesson A&P · Health Assessment · Foundations of Psychiatric Nursing Assessment Lesson · NCLEX-PN / NCLEX-RN · Psychosocial Integrity

Psych assessment is safety assessment. What you see, hear, and ask determines risk for suicide, homicide, self-harm, and loss of rights. Your words are your assessment tools. Therapeutic communication uncovers cues that vital signs cannot.

In this lesson

Learning Objectives
Why Assessment Matters
Health History
Inspection
Palpation / Physical Cues
Percussion / Projective Techniques
Auscultation / Listening
Focused Assessment
Assessment Tools
Red Flag Findings
Documentation
Clinical Judgment
NCLEX High-Yield
Memory Aids
Case Study — Click to Reveal
Practice Questions
Key Takeaways
References

Learning Objectives

Perform a complete psychiatric nursing assessment including chief complaint, HPI using OLDCARTS for psychosocial stressors, past psych and medical history, medications including over-the-counter and substance use, family, social, cultural, and risk assessment.
Differentiate expected mental health continuum vs abnormal findings in appearance, behavior, cognition, thought, perception, mood, affect, speech, coping, and judgment using Mental Status Examination.
Identify defense mechanisms adaptive vs maladaptive and explain WHY they are assessed for coping.
Apply legal and ethical principles autonomy beneficence nonmaleficence justice fidelity veracity confidentiality duty to warn Tarasoff duty to protect informed consent voluntary involuntary holds least restrictive.
Assess therapeutic milieu safety, cultural considerations cultural humility, and stress coping using Selye General Adaptation Syndrome and Lazarus transactional model.
Prioritize immediate actions for suicide homicide self-harm psychosis mania severe anxiety.

Why Assessment Matters

Patient safety: Suicide is 12th leading cause death US, 1.6 million attempts yearly, every 11 minutes one death. 50% of mental health clients seen in primary care month before suicide. Missed assessment = death. Homicide duty to warn Tarasoff — if client threatens identifiable victim you must warn protect. Seclusion restraint last resort requires assessment q15min. Elopement, falls from psychotropics, NMS, serotonin syndrome, agranulocytosis clozapine are safety events.

Early recognition: Prodromal signs pacing clenched fists loud pressured speech → violence within hours. Flat affect anhedonia withdrawal → depression suicide risk. ↑ anxiety → coping failure → defense mechanisms overuse → decompensation. Cultural expressions of distress may mimic psychosis — misdiagnosis if not assessed culturally.

Prevention of complications: Assessing stress coping early prevents maladaptive coping substance use self-harm. Assessing medication adherence prevents relapse readmission. Assessing legal status voluntary vs involuntary 5150 5250 prevents false imprisonment claims. Assessing milieu prevents violence contraband.

Clinical judgment: NCLEX Psychosocial Integrity 6-12% of exam tests therapeutic communication, coping, crisis, legal ethical, culture. Priority is always safety over therapeutic relationship.

Health History

Component	What to ask & WHY it matters	Expected vs Abnormal
Chief complaint	"What brings you here today? In your own words." WHY: client perception of problem reveals insight and priority. Use open-ended therapeutic communication.	Expected: clear statement. Abnormal: "I'm here because FBI put chip" → paranoia, thought content abnormal.
History of present illness HPI — OLDCARTS adapted for psych	Onset when did symptoms start, Location where stress occurs, Duration how long, Characteristics what does anxiety depression look like, Aggravating what worsens, Relieving what helps coping, Timing constant vs episodic, Severity 0-10 scale anxiety depression. WHY: timeline shows stressor coping link.	Expected: identifiable stressor 2 weeks ago divorce job loss coping with exercise support. Abnormal: 6 months anhedonia anergia SI plan.
Past psychiatric history	Prior diagnoses, hospitalizations, suicide attempts lethality, self-harm, outpatient therapy, what helped, trauma ACEs. WHY: prior attempt is #1 predictor future attempt.	Expected: no prior. Abnormal: 3 hospitalizations, attempt hanging 1 year ago high lethality.
Past medical history & ROS	Medical conditions mimicking psych: thyroid hyper/hypo anxiety depression, neuro tumor, infection, pain, sleep, appetite, libido, substance withdrawal. WHY: rule out organic cause before psych diagnosis.	Expected: no medical. Abnormal: hyperthyroid → anxiety tachy weight loss.
Medications & Substance	Prescribed psychotropics adherence side effects, OTC, herbals St. John's wort, caffeine, alcohol, nicotine, cannabis, illicit stimulants depressants, last use withdrawal risk. WHY: many drugs cause psych symptoms, nonadherence → relapse, substance → psychosis anxiety. Ask in nonjudgmental way: "Many people use... tell me about your use."	Expected: takes sertraline daily adherent. Abnormal: stopped lithium 2 weeks ago, binge alcohol daily, positive methamphetamine psychosis.
Family history	First-degree mental illness suicide substance bipolar schizophrenia, family support, family coping. WHY: genetic vulnerability + learned coping + support. Use genogram.	Expected: supportive family no mental illness. Abnormal: mother bipolar, father suicide, no support.
Social history	Age, gender identity, pronouns, occupation, school, housing, finances, legal issues, relationships, support system, stressors, coping strategies adaptive vs maladaptive, spirituality, strengths. ACEs adverse childhood experiences. WHY: social determinants affect mental health and discharge planning.	Expected: employed housed supportive friends uses walking journaling adaptive. Abnormal: homeless unemployed isolated uses alcohol maladaptive.
Cultural history	Language preferred interpreter, race ethnicity, immigration, beliefs about mental illness, healers, decision maker, eye contact personal space touch norms, stigma, discrimination. WHY: cultural humility prevents misdiagnosis, builds trust. Use LEARN model. Ask: "What do you call your problem? What do you think caused it?"	Expected: open about beliefs uses both traditional and Western. Abnormal: cultural distress dhat susto interpreted as psychosis if not assessed.
Risk assessment — Safety always	Suicide: ideation intent plan means lethality access protective factors. Ask directly: "Are you thinking about killing yourself?" Does NOT plant idea. Homicide: ideation intent plan target access. Self-harm cutting. Violence history. Vulnerability exploitation. WHY: safety overrides confidentiality. Duty to warn Tarasoff if identifiable victim. Document.	Expected: denies SI/HI, no plan, protective family faith. Abnormal: "I have pills, plan tonight" + hopelessness + access + no protective → immediate 1:1 observation.

Inspection — What the Nurse Observes

In psych, inspection is Mental Status Exam observation before you speak.

Domain	Normal / Expected	Abnormal & Clinical Significance
Appearance	Well-groomed age appropriate hygiene intact.	Poor hygiene disheveled odor → depression schizophrenia self-neglect mania hyperactive poor self-care. Overly meticulous → OCD anxiety.
Behavior / Psychomotor	Calm cooperative eye contact culturally appropriate no abnormal movements.	Psychomotor agitation pacing restless → anxiety mania withdrawal. Retardation slow → depression. Catatonia posturing waxy flexibility → schizophrenia. Tremor EPS → medication side effect. Aggression clenched fists pacing loud → violence imminent.
Speech	Normal rate rhythm volume coherent.	Pressured loud rapid → mania. Slow soft → depression. Slurred → substance intoxication neuro. Circumstantial tangential loose associations word salad → psychosis.
Mood & Affect	Mood subjective "how do you feel?" euthymic. Affect objective observed congruent appropriate range.	Mood dysphoric euphoric irritable anxious. Affect flat blunted incongruent labile constricted → depression schizophrenia mania. WHY assess: mood affect incongruence → thought disorder.
Thought Process / Content	Logical linear goal-directed, no SI/HI delusions obsessions phobias.	Process: circumstantial tangential flight of ideas loose associations → mania psychosis. Content: delusions persecutory grandiose somatic, paranoia, SI/HI with plan means, obsessions. Abnormal requires immediate safety action.
Perception	No hallucinations illusions intact reality testing.	Auditory visual tactile olfactory hallucinations → psychosis substance withdrawal medical. Command hallucinations telling to harm self others = emergency.
Cognition MMSE elements	Alert oriented x4, attention intact, memory immediate recent remote, abstract proverbs, judgment insight good.	Disoriented poor concentration → delirium dementia depression pseudodementia. Impaired judgment insight → psychosis mania. Concrete thinking.
Milieu inspection	Unit calm safe no contraband ligatures sharp objects, exits secured, noise low, structure.	Overstimulating loud crowded → ↑ agitation anxiety. Contraband belts strings lighters drugs → safety risk.

Palpation / Physical Cues — Technique and Findings

Psych assessment includes physical touch with consent and trauma-informed care.

Technique	Normal	Abnormal / Nursing Implications
Handshake with consent, observe diaphoresis cold clammy, assess skin turgor hydration nutrition, check for track marks self-harm scars hidden inner arms thighs, EPS palpation muscle rigidity.	Warm dry handshake no scars, no EPS.	Diaphoretic clammy → anxiety withdrawal. Track marks → IV substance use infection risk. Self-harm scars linear healed → borderline self-harm assess SI intent. Muscle rigidity + fever + AMS + autonomic instability → NMS from antipsychotics emergency stop drug cooling. Tremor akathisia restlessness EPS → benztropine diphenhydramine per order.

Percussion — Purpose in Psych (Metaphorical)

Not routine chest percussion. In psych, percussion means tapping into underlying defenses and stress response.

Purpose	Technique	Expected vs Abnormal
Tap to reveal defense mechanisms and coping resonance.	Ask "What was that like for you?" "How do you handle stress?" Projective gentle probing. Use silence therapeutic.	Expected: adaptive defenses humor sublimation suppression. Abnormal: overuse maladaptive denial projection displacement regression acting out → assess impairment. Selye GAS alarm resistance exhaustion → chronic stress exhaustion.

Auscultation / Therapeutic Listening — Technique

Technique	Normal Sounds	Abnormal Sounds & Clinical Significance
Active listening therapeutic communication SOLER sit square open lean eye contact relaxed, open-ended questions, reflection, clarification, silence. Auscultate for themes hopelessness worthlessness guilt anhedonia anxiety fear.	Coherent story congruent affect reports adaptive coping support.	Hops: hopelessness worthlessness helplessness → suicide risk. Anhedonia anergia guilt → depression. Pressured speech flight ideas → mania. Suspiciousness → paranoia. Command hallucinations. Incongruent affect. Silence may indicate severe depression psychosis trauma — do not fill silence too quickly.

Focused Assessment — Complete Psychiatric Assessment Procedure

Prepare: Review chart legal status voluntary 5150 5250 conservatorship, ensure safety private quiet no ligature risk, introduce self explain purpose confidentiality limits harm to self others abuse, obtain interpreter not family for accuracy, trauma-informed consent, no touch without permission, ensure 2 exits.
General survey inspection: Appearance hygiene behavior psychomotor eye contact culturally appropriate, speech rate volume, mood subjective affect objective.
Safety screen first: Suicide "Are you thinking about killing yourself? Do you have a plan? Means? Intent? When? What stops you?" Homicide "Are you thinking about hurting someone else? Who? Plan? Access?" Self-harm cutting. Vulnerability. If yes → immediate action 1:1 maintain safety.
Mental Status Exam MSE systematic: Appearance, Behavior, Speech, Mood, Affect, Thought process, Thought content SI/HI delusions obsessions, Perception hallucinations, Cognition orientation memory attention concentration abstract judgment insight, Insight judgment.
Stress & coping: Stressor recent, appraisal primary secondary Lazarus, coping adaptive exercise support therapy journaling vs maladaptive substance avoidance aggression, defense mechanisms observed, support system, spirituality, resilience strengths, ACEs.
Substance & meds: Last use withdrawal CIWA COWS, adherence, side effects EPS NMS serotonin syndrome.
Cultural assessment: LEARN Listen Explain Acknowledge Recommend Negotiate, explanatory model, decision maker, healers, stigma, discrimination, language, eye contact touch norms.
Milieu & legal: Unit safety contraband check, rights informed consent, least restrictive, involuntary criteria danger to self others gravely disabled, confidentiality HIPAA limits, documentation objective quotes.
Wrap up: Summarize validate, ask "Anything else you want me to know?", plan next steps, ensure safety, document.

Domain	Normal Findings	Abnormal / Priority
Mental Status	Alert oriented x4, speech coherent, mood euthymic affect congruent full range, thought logical no SI/HI, no hallucinations, insight good.	Disoriented tangential delusional SI plan means command hallucinations flat affect pressured speech = priority safety psychosis mania depression.
Coping / Defenses	Adaptive humor sublimation suppression exercise support.	Maladaptive denial projection displacement regression acting out overuse → decompensation, Selye exhaustion stage chronic stress illness.
Legal ethical	Voluntary informed consent understands risks benefits alternatives, confidentiality maintained, rights respected.	Involuntary hold criteria met danger self others gravely disabled, Tarasoff identifiable victim threatened must warn protect, seclusion restraint last resort requires assessment.

Assessment Tools

Tool	Purpose	Interpretation / Clinical Significance
Mini-Mental State Exam MMSE / MoCA Montreal Cognitive Assessment	Cognitive screening orientation memory attention language visuospatial.	MMSE 24-30 normal 18-23 mild 0-17 severe impairment. MoCA ≥26 normal. Abnormal → delirium dementia depression pseudodementia needs medical workup.
PHQ-9 Patient Health Questionnaire-9 depression	Depression severity over 2 weeks.	0-4 minimal 5-9 mild 10-14 moderate 15-19 moderately severe 20-27 severe. Question 9 suicide ideation → immediate safety assessment if positive. NCLEX expects PHQ-9.
GAD-7 anxiety	Anxiety severity.	0-4 minimal 5-9 mild 10-14 moderate 15-21 severe. High → coping assessment.
Columbia Suicide Severity Rating Scale C-SSRS	Suicide ideation behavior lifetime and recent.	Ideation intent plan behavior → determines level of intervention. Gold standard NCLEX expects direct ask.
CIWA-Ar Alcohol Withdrawal, COWS Opiate Withdrawal, CRAFFT adolescent substance	Withdrawal severity substance use.	CIWA >20 severe DT risk, COWS >25 severe. Abnormal → medical emergency.
Abnormal Involuntary Movement Scale AIMS for tardive dyskinesia	EPS TD from antipsychotics.	Score ≥2 in 2 areas TD → notify provider stop antipsychotic may be irreversible.
Cultural Formulation Interview DSM-5-TR	Cultural identity concept of distress, vulnerability.	Prevents misdiagnosis culturally normative distress vs psychosis, guides culturally responsive care.
Braden? Actually in psych: Braden for self-care deficit, Elopement Risk Assessment	Safety milieu.	High elopement → 1:1 checks.

Red Flag Findings — Immediate Action Table

Finding	Possible Cause	Immediate Nursing Action
SI with plan means intent + hopelessness + access + no protective factors	Major depression psychosis	Never leave alone 1:1 observation remove ligatures sharps, notify provider STAT, safety contract NOT sufficient alone, place on suicide precautions, search belongings per policy, document verbatim quotes plan lethality.
Command hallucinations "kill yourself" "kill them"	Psychosis schizophrenia mania	Assess content obeys? Safety 1:1, do not argue with voices, ask "What are voices saying?" assess reality testing, notify provider STAT, maintain safety.
Threat to identifiable victim "I will kill my wife tonight"	Homicide ideation	Tarasoff duty to warn protect — notify provider supervisor security, warn intended victim per state law, document, maintain safety seclusion if imminent, do NOT promise confidentiality.
Pacing clenched fists loud yelling threatening eye contact	Escalating violence agitation	De-escalation calm voice low stimuli offer PRN per order, remove others, no touching cornering, call assistance, least restrictive seclusion restraint last resort q15min assessment.
Fever + muscle rigidity + AMS + autonomic instability tachy labile BP diaphoresis after antipsychotic	Neuroleptic Malignant Syndrome NMS emergency	Stop antipsychotic per order notify provider STAT rapid response, vitals q15min cooling, I&O, labs CK WBC, dantrolene bromocriptine per order ICU.
Hyperthermia + agitation + tremor + clonus + diaphoresis + confusion after SSRI + MAOI	Serotonin Syndrome emergency	Stop serotonergic agent notify STAT, cooling, benzodiazepines per order, cyproheptadine per order.
New periorbital edema tea/cola urine HTN after Strep? Not psych but in psych: no.	Anaphylaxis after latex hives wheeze angioedema hypo	Epi IM O2 rapid response.
Elopement attempt confused, or gravely disabled not eating not bathing	Psychosis mania depression	Prevent elopement checks, ensure basic needs ADLs, involuntary hold criteria grave disability notify provider.

Documentation — How to Document Accurately

Principles: Objective quotes not judgments, behavior observed, verbatim client statements in quotes, MSE language, risk assessment, interventions, response, milieu, legal status, rights given, cultural considerations, defense mechanisms observed not labeled as insult, confidentiality limits documented.

Poor (subjective, judgmental)	Good (objective, clinical judgment)
Client is manipulative and crazy, refusing meds.	0930: 28yo female admitted voluntary, appearance disheveled hair uncombed, psychomotor agitation pacing, speech pressured loud rapid, mood reports "on top of world" affect labile euphoric congruent, thought process flight of ideas, thought content grandiose delusions "I'm president" denies SI "No" HI "No" denies AH/VH, insight impaired. MSE: alert oriented x3 person place time, attention distractible. Risk: denies SI/HI, no plan means, protective mother. C-SSRS negative ideation. Coping reports no sleep 3 days using alcohol to cope maladaptive. Meds lithium nonadherent 1 week. Cultural identifies Latina decision maker family. Legal voluntary informed consent given rights reviewed. Plan: safety maintained, de-escalation, notified provider.

Poor (subjective, judgmental)

Good (objective, clinical judgment)

Client is manipulative and crazy, refusing meds.

0930: 28yo female admitted voluntary, appearance disheveled hair uncombed, psychomotor agitation pacing, speech pressured loud rapid, mood reports "on top of world" affect labile euphoric congruent, thought process flight of ideas, thought content grandiose delusions "I'm president" denies SI "No" HI "No" denies AH/VH, insight impaired. MSE: alert oriented x3 person place time, attention distractible. Risk: denies SI/HI, no plan means, protective mother. C-SSRS negative ideation. Coping reports no sleep 3 days using alcohol to cope maladaptive. Meds lithium nonadherent 1 week. Cultural identifies Latina decision maker family. Legal voluntary informed consent given rights reviewed. Plan: safety maintained, de-escalation, notified provider.

Documentation examples for key areas

SI: Client states "I want to die, I have pills at home, plan tonight" Q: "What stops you?" A: "Nothing." Intent high lethality high protective none → 1:1 initiated provider notified STAT.
Defense: Client states "My wife left because of my boss, not because I drink" — projection observed. Will explore coping.
Cultural: Client states problem is "susto" after fright, uses curandero and prayer, prefers Spanish interpreter, eye contact avoidance culturally normative not avoidance.

Clinical Judgment — Using Assessment to Recognize Cues to Evaluate

Recognize Cues: Gather MSE, safety, stress coping defenses cultural legal. Look for change from baseline.
Analyze Cues: Cluster cues: anhedonia anergia worthlessness hopelessness guilt sleep appetite change → depression. Pressured speech ↓ need sleep grandiose flight ideas → mania. Paranoia auditory hallucinations flat affect → schizophrenia. Maladaptive defenses denial projection → coping failure. Cultural normative vs pathologic.
Prioritize Problems: Maslow safety first SI/HI command hallucinations violence NMS serotonin syndrome. Then psychosocial coping impaired, anxiety, self-care deficit. Legal ethical least restrictive.
Determine Next Steps: 1:1 safety, de-escalation, notify provider, least restrictive, therapeutic communication, coping skills, milieu safety, cultural humility, teach, involve family with consent.

NCLEX High-Yield Review — What the NCLEX Wants You to Know

Safety first: SI/HI with plan means intent + access + no protective = immediate 1:1 remove ligatures notify provider STAT — safety contract alone insufficient
Ask directly about suicide does NOT plant idea — C-SSRS PHQ-9 Q9 positive → safety assessment — Tarasoff duty to warn identifiable victim
Therapeutic communication: open-ended, reflection, clarification, silence, SOLER, no false reassurance "you'll be fine", no advice giving, no probing "why", no nontherapeutic "calm down"
Defense mechanisms: adaptive humor sublimation suppression altruism — maladaptive denial projection displacement reaction formation regression rationalization intellectualization — immature acting out passive aggressive
Legal: voluntary can leave with AMA if not danger, involuntary 5150 72h hold danger self others gravely disabled needs MD eval, 5250 14-day, patient rights can refuse meds except emergency danger, informed consent risks benefits alternatives voluntary, confidentiality HIPAA limits SI/HI abuse Tarasoff
Stress: Selye GAS alarm fight-flight cortisol ↑ resistance exhaustion illness — Lazarus transactional appraisal coping adaptive vs maladaptive — crisis 4-6 weeks intervention opportunity
Milieu: least restrictive, structure consistency, no contraband, de-escalation calm low stimuli offer choices PRN, seclusion restraint last resort requires order q15min assessment documentation
Culture: cultural humility not competence, LEARN model, interpreter not family, eye contact touch norms vary, cultural syndromes susto dhat, do NOT stereotype, ask explanatory model

Common NCLEX traps: Choosing therapeutic communication that is false reassurance "Don't worry" vs silence reflection. Thinking safety contract replaces 1:1 — no. Not assessing SI directly — must ask directly. Forgetting Tarasoff must warn identifiable victim not just document. Confusing voluntary can refuse vs involuntary still has rights can refuse meds except emergency. Mixing defense mechanisms projection vs displacement vs reaction formation. Prioritizing coping over safety.

Memory Aids

MSE: A B S M A T P C I — Appearance Behavior Speech Mood Affect Thought Perception Cognition Insight Judgment
SI risk: S A D P E R S O N S — Sex male, Age elderly young, Depression, Previous attempt, Ethanol abuse, Rational thought loss, Sickness medical, Organized plan, No spouse, Social support lacks, Stated future intent
Defense mechanisms: D D R R P D — Denial Projection Displacement Reaction formation Rationalization Regression, mature: S H A S — Suppression Humor Altruism Sublimation
Legal: V I C — Voluntary can leave, Involuntary danger self others gravely disabled, Confidentiality limits SI/HI abuse Tarasoff
Stress: A R E — Alarm Resistance Exhaustion Selye — Lazarus: Primary appraisal is this threatening? Secondary can I cope?
Tarasoff: Threat to identifiable victim = warn protect — Tarasoff = Target identifiable

Case Study

Patient: Maria, 24F, Latina, college student, brought by roommate for 2 weeks withdrawal anhedonia not eating bathing, reports "I'm worthless, everyone better off without me." History MDD one prior attempt overdose 1 year ago. Stopped sertraline 3 weeks ago. Uses alcohol to cope. Recent breakup job loss. Says "I have pills at home, plan tonight." Denies HI. Hearing whisper "you're no good" occasionally. Appearance disheveled poor hygiene, psychomotor retardation slow speech soft, mood dysphoric affect constricted tearful incongruent? Actually congruent, thought process linear but ruminative, SI with plan means intent high, AH non-command? Whisper critical. Insight fair but impaired judgment. Support mother supportive but distant, cultural uses prayer curandera. Legal voluntary currently. VS stable.

Step 1: Recognize Cues ▼

Subjective: worthlessness anhedonia anergia 2 weeks not eating bathing, SI "better off without me" pills at home plan tonight, prior attempt overdose high lethality, stopped sertraline 3w nonadherence, alcohol maladaptive coping, breakup job loss stressors, AH whisper "you're no good", mother support, cultural prayer curandera, voluntary.
Objective: disheveled poor hygiene, psychomotor retardation slow speech soft, dysphoric mood constricted tearful affect congruent, linear ruminative thought, SI plan means intent high, no HI, non-command AH critical, oriented x4 memory intact attention poor due depression, insight fair judgment impaired, PHQ-9 likely 22 severe Q9 positive, C-SSRS positive intent plan, no aggression but withdrawal, no contraband.

Step 2: Analyze Cues ▼

Cluster depression: anhedonia anergia worthlessness guilt withdrawal poor hygiene not eating bathing sleep? anorexia, prior attempt #1 predictor, nonadherence sertraline, alcohol maladaptive coping increases risk, stressors breakup job loss Lazarus secondary appraisal poor coping, defense denial? regression, AH critical may worsen worthlessness but non-command not immediate command, cultural distress prayer curandera protective factor but also may delay care, voluntary status may change if danger persists, Selye exhaustion stage chronic stress illness. Differential: MDD severe with psychotic features vs MDD vs adjustment — PHQ-9 severe.

Step 3: Prioritize Problems ▼

#1 Safety: Suicide high risk — prior attempt + plan pills + intent tonight + means access + hopelessness + worthlessness + no protective immediate + AH critical + alcohol + nonadherence.
#2 Self-care deficit bathing eating related to depression psychomotor retardation.
#3 Ineffective coping related to stressors breakup job loss maladaptive alcohol denial.
#4 Risk for psychosis exacerbation AH critical.
#5 Cultural spiritual distress vs support.

Step 4: Plan ▼

Safety: observation never leave alone remove ligatures sharps belts search belongings per policy, notify provider STAT psychiatry, place on suicide precautions, no safety contract alone, C-SSRS document verbatim quotes lethality, obtain collateral roommate mother with consent.
Medical workup rule out organic: vitals labs TSH BMP, substance screen, medication reconciliation, assess withdrawal.
Therapeutic communication open-ended reflection silence: "Tell me more about feeling worthless" "What stops you?" Explore protective factors mother faith, involve mother with consent, cultural LEARN ask about curandera prayer integrate, interpreter not needed Spanish? Actually Latina may prefer Spanish assess.
Milieu low stimuli structure, encourage ADLs small steps, nutrition hydration, sleep hygiene.
Legal ethical: voluntary currently but if danger persists may need 5150 involuntary hold danger self criteria, informed consent for treatment, confidentiality limits explained, least restrictive, rights reviewed.
Coping skills adaptive deep breathing journaling exercise, substance counseling, adherence teaching sertraline takes 4-6 weeks no alcohol, teach defense mechanisms.

Step 5: Take Action ▼

Action: Initiated removed ligatures, notified provider STAT psychiatrist evaluated high risk placed on 5150 72h hold danger self voluntary to involuntary, admitted psych unit, searched belongings per policy, safety checks q15min, C-SSRS PHQ-9 documented verbatim "I have pills at home plan tonight" "everyone better off without me", notified supervisor, mother contacted with consent provides support, curandera prayer allowed, low stimuli room, encouraged shower with staff assist ADL, small meals offered, sertraline restarted per order after assessment no NMS, PRN anxiety per order, no restraints, therapeutic communication 30 min, coping list created.

Step 6: Evaluate & Discharge Planning ▼

Evaluate: After 3 days SI "no plan now" ideation decreased PHQ-9 22→12, sleep appetite improved, hygiene improved, AH whisper decreased, no self-harm, 1:1 → q15min checks, coping using journaling prayer walking adaptive, alcohol craving coping plan, mother involved.
Discharge planning: Follow-up outpatient therapy psychiatry 1 week, crisis hotline 988, safety plan means restriction remove pills, coping card, support mother curandera prayer integrated, medication teaching sertraline adherence 4-6 weeks side effects no alcohol, cultural humility continue, relapse signs anhedonia withdrawal SI plan → return ED, legal 5150 lifted to voluntary discharge with follow-up, rights reviewed, documentation objective, case management housing job resources, no driving if sedated, teach NMS serotonin signs fever rigidity.

NCLEX Practice Questions — Randomized Answers

1. A client says "I'm worthless, everyone better off without me, I have pills at home, plan tonight." What is priority nursing action?

Document and reassure "You'll be fine, don't worry" and leave client alone to rest
Make a safety contract and have client promise not to harm self, then check hourly
Explore coping and ask about defense mechanisms without safety measures
Never leave alone, initiate 1:1 observation, remove ligatures sharps, notify provider STAT, search belongings per policy, document verbatim quotes plan lethality, place on suicide precautions

Rationale

Answer: 4. Why 4 correct: SI with plan means intent tonight + prior attempt predictor + hopelessness worthlessness + access = high risk immediate safety 1:1 never leave alone remove ligatures sharps notify STAT suicide precautions C-SSRS verbatim documentation. Safety contract alone insufficient. Why others wrong: 1. False reassurance nontherapeutic and leaving alone unsafe — never leave high risk alone. 2. Safety contract alone does NOT replace 1:1 — must maintain safety. 3. Coping exploration important but safety first — Maslow safety overrides.

2. A client threatens "I will kill my wife tonight, I have a gun at home." Wife is identifiable. What is priority legal ethical action?

Maintain confidentiality and document only, do not warn because of HIPAA
Promise confidentiality to maintain therapeutic relationship and explore defense mechanisms
Ignore because client may be using projection defense
Tarasoff duty to warn protect — notify provider supervisor security immediately, warn identifiable victim per state law, notify law enforcement per policy, maintain safety, document, do NOT promise confidentiality

Rationale

Answer: 4. Why 4 correct: Threat to identifiable victim with plan means = Tarasoff duty to warn protect overrides confidentiality — must notify provider supervisor security warn victim per law law enforcement per policy safety measures. Why others wrong: 1. Confidentiality does NOT apply when identifiable victim threatened — duty to warn protects. 2. Promising confidentiality nontherapeutic and illegal when danger. 3. Projection defense assessment but safety overrides — cannot ignore threat.

3. A client says "My boss made me drink, my wife left because of my job, not my drinking." Which defense mechanism is this?

Sublimation — channeling unacceptable impulse into acceptable activity
Humor — adaptive coping with humor
Projection — attributing own unacceptable feelings motives to others, blaming others
Suppression — consciously delaying attention

Rationale

Answer: 3. Why 3 correct: Projection attributes own unacceptable behavior drinking to others boss wife — blaming others. Why others wrong: 1. Sublimation adaptive running painting after anger not blaming. 2. Humor adaptive joking to cope not blaming. 4. Suppression conscious "I'll worry later" not blaming.

4. A client on haloperidol develops fever 101.8F, muscle rigidity, AMS confusion, tachy 118, labile BP, diaphoresis. What should the nurse suspect and do first?

Serotonin syndrome — give cyproheptadine and continue antipsychotic
Extrapyramidal symptoms EPS — give benztropine and continue drug
Neuroleptic Malignant Syndrome NMS emergency — stop antipsychotic per order notify provider STAT rapid response vitals q15min cooling I&O labs CK WBC dantrolene bromocriptine per order ICU
Anxiety — give PRN lorazepam and reassure

Rationale

Answer: 3. Why 3 correct: NMS triad fever muscle rigidity AMS autonomic instability tachy labile BP diaphoresis after antipsychotic haloperidol emergency stop drug notify STAT rapid response cooling I&O labs CK ↑ WBC dantrolene bromocriptine ICU. Why others wrong: 1. Serotonin syndrome hyperthermia clonus tremor hyperreflexia after SSRI + MAOI not rigidity AMS after antipsychotic alone. 2. EPS rigidity tremor akathisia but no fever AMS autonomic instability. 4. Anxiety no fever rigidity AMS.

5. A client is on involuntary hold 5150 for danger to self. Which statement about rights is correct?

Client loses all rights and can be forced medication without emergency
Involuntary hold means cannot refuse any treatment including meds always
Confidentiality can be breached to family without limits
Involuntary hold criteria danger to self others gravely disabled needs MD evaluation, client still has rights can refuse meds except emergency danger, retains right to attorney, least restrictive, rights reviewed

Rationale

Answer: 4. Why 4 correct: Involuntary 5150 72h hold for danger self others gravely disabled requires MD eval, client retains rights attorney refuse meds except emergency imminent danger, least restrictive, rights given. Why others wrong: 1. Loses all rights false — retains rights except safety. 2. Cannot refuse any treatment false — can refuse meds except emergency danger per law. 3. Confidentiality breached without limits false — HIPAA still applies except SI/HI abuse Tarasoff.

6. SATA. Which are adaptive coping strategies? Select all that apply.

Drinking alcohol daily to forget stress
Exercising walking 30 min daily, journaling, deep breathing, talking to supportive friend, using humor appropriately, problem solving
Punching wall when angry
Using sublimation channeling anger into running, suppression "I'll deal later" consciously, seeking therapy support group
Avoiding all stressors and isolating in room for weeks

Rationale

Answers: 2, 4. Why these: Adaptive coping exercise journaling deep breathing support humor problem solving sublimation suppression therapy. Why others maladaptive: 1. Alcohol maladaptive substance avoidance. 3. Aggression acting out maladaptive. 5. Avoidance isolation maladaptive leads to decompensation.

7. SATA. Which statements reflect therapeutic communication? Select all that apply.

"Don't worry, you'll be fine, everything will be okay"
"Why did you do that? You should know better"
"Tell me more about feeling worthless" open-ended, "What you are saying is you feel hopeless" reflection, silence therapeutic, SOLER
"I hear you are feeling hopeless, it sounds difficult" empathy, "What does that mean to you?" clarification
"You need to calm down and stop crying"

Rationale

Answers: 3, 4. Why these: Therapeutic open-ended reflection clarification empathy silence SOLER sit square open lean eye contact relaxed. Why others nontherapeutic: 1. False reassurance "you'll be fine" nontherapeutic. 2. Why probing judgmental "you should". 5. Ordering "calm down" nontherapeutic dismissive.

8. Priority. Four clients in milieu: Client 1 pacing clenched fists yelling threatening others, Client 2 crying quietly anhedonia SI no plan, Client 3 sleeping, Client 4 asking for PRN anxiety. Who should the nurse see first?

crying quietly anhedonia SI no plan
asking for PRN anxiety
sleeping
pacing clenched fists yelling threatening others — imminent violence

Rationale

Answer: 4. Why 4 first: Imminent violence pacing clenched fists yelling threatening others = safety risk to milieu self others — de-escalation calm low stimuli offer choices PRN per order remove others call assistance least restrictive first. Why others later: 1. SI no plan needs assessment second after violence controlled. 2. PRN anxiety needs assessment third. 3. Sleeping stable routine last.

Key Takeaways

Assessment is safety assessment — SI/HI with plan means intent access + no protective + prior attempt = 1:1 never leave alone remove ligatures notify STAT — safety contract alone insufficient.
Ask directly about suicide does NOT plant idea — C-SSRS PHQ-9 Q9 positive → safety — Tarasoff identifiable victim threatened = warn protect overrides confidentiality.
MSE systematic: Appearance Behavior Speech Mood Affect Thought process Content SI/HI delusions Perception hallucinations Cognition orientation memory Insight Judgment — objective quotes not judgments.
Defense mechanisms: adaptive sublimation suppression humor altruism vs maladaptive denial projection displacement reaction formation regression rationalization — assess coping Selye alarm resistance exhaustion Lazarus appraisal.
Legal: voluntary can leave AMA if not danger, involuntary 5150 72h danger self others gravely disabled, 5250 14-day, rights retained can refuse meds except emergency, informed consent risks benefits alternatives, confidentiality limits SI/HI abuse Tarasoff.
Milieu least restrictive structure consistency no contraband de-escalation calm low stimuli offer choices PRN seclusion restraint last resort q15min — cultural humility LEARN interpreter not family eye contact touch norms vary.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.
Townsend, M. C., & Morgan, K. I. (2023). Psychiatric mental health nursing: Concepts of care in evidence-based practice (11th ed.). F. A. Davis.
Videbeck, S. L. (2020). Psychiatric-mental health nursing (8th ed.). Wolters Kluwer.
Varcarolis, E. M. (2021). Essentials of psychiatric mental health nursing (4th ed.). Elsevier.
National Institute of Mental Health. (2023). Suicide prevention and screening: C-SSRS and PHQ-9 guidance.
Substance Abuse and Mental Health Services Administration. (2023). TIP 57: Trauma-informed care in behavioral health services. SAMHSA.
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9 validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613.
Posner, K., Brown, G. K., Stanley, B., et al. (2011). The Columbia Suicide Severity Rating Scale. American Journal of Psychiatry, 168(12), 1266-1277.
American Nurses Association, American Psychiatric Nurses Association, & International Society of Psychiatric-Mental Health Nurses. (2022). Psychiatric-mental health nursing: Scope and standards of practice (3rd ed.). ANA.
U.S. Department of Health and Human Services. (2023). Cultural Formulation Interview DSM-5-TR.
Berman, A., Snyder, S., & Frandsen, G. (2020). Kozier & Erb's fundamentals of nursing (11th ed.). Pearson.

Foundations of Psychiatric Nursing

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Welcome & Getting Started

Launch RN Simulator

Wellness Center

Nursing Foundations

Fundamentals & Safety

Pharmacology

Dosage Calculations

Leadership, Management & Delegation

Medical-Surgical Body Systems

Neurological System

Sensory System

Endocrine System

Respiratory System

Cardiovascular System

Hematologic/Immune/Lymphatic System

Gastrointestinal (GI) System

Renal & Genitourinary

Reproductive System

Musculoskeletal System

Integumentary System

Specialty Areas

Maternity

Infectious Diseases

Pediatrics

Mental Health

NCLEX Success Center

Clinical Judgment Practice

Prioritization Practice

Delegation Practice

Lab Values

Final Review