Behavioral Health Disorders — NCLEX Nursing Lesson Mental Health Nursing · RN Track · Psychiatric–Mental Health · Conditions · Behavioral Health Disorders Condition Lesson · NCLEX-PN / NCLEX-RN

Two behavioral illnesses with deadly physical consequences—eating disorders (electrolytes, the heart, refeeding syndrome) and substance use disorders (intoxication, withdrawal, and recovery). The physiology, the safety priorities, and the reasoning behind care.

Builds on prior lessons Assumes the psychiatric foundations and assessment lessons, plus your fluid & electrolyte knowledge. These are psychiatric diagnoses with major medical danger—so nursing care is a blend of mental health and med-surg physiology. Recall normal potassium (3.5–5.0), sodium, phosphate, and the reward neurotransmitter dopamine. A note on this topic This lesson discusses eating disorders and substance use in a clinical, educational context to prepare nurses to care safely. If you or someone you know is struggling with an eating disorder, the National Alliance for Eating Disorders helpline (1-866-662-1235) offers support; for substance use, SAMHSA's National Helpline is 1-800-662-HELP (4357). In this lesson

Lesson Objectives
Why This Matters
Disease Overview
Pathophysiology
Risk Factors
Signs & Symptoms
Nursing Assessment
Diagnostic Tests
Laboratory Tests
Medications
Nursing Interventions
Complications
Patient Education
Clinical Judgment
Clinical Connections
NCLEX High-Yield Review
Memory Aids
Case Study
Practice Questions
Key Takeaways
References

Lesson Objectives

Differentiate anorexia nervosa, bulimia nervosa, and binge-eating disorder and explain their physiologic dangers.
Recognize and prevent refeeding syndrome and life-threatening electrolyte/cardiac complications.
Assess intoxication and withdrawal (especially alcohol withdrawal/CIWA) and intervene safely.
Explain why medications are used in eating disorders and in substance use (withdrawal management and medication-assisted treatment).
Apply safety-first, non-judgmental, structured, and interdisciplinary care with clinical judgment.

Why This Matters

Prevalence: eating disorders affect people of all genders and ages and have the highest mortality of any psychiatric illness (from cardiac/electrolyte complications and suicide). Substance use disorders are extremely common and cross every care setting; the opioid crisis makes overdose and withdrawal everyday realities.

Patient safety: both carry medical emergencies—cardiac arrhythmias, severe electrolyte imbalance, and refeeding syndrome in eating disorders; overdose and dangerous withdrawal (alcohol/benzodiazepine withdrawal can be fatal) in substance use. Suicide risk is elevated in both.

NCLEX importance: heavy testing on electrolytes and refeeding syndrome, cardiac monitoring, CIWA and alcohol withdrawal, thiamine before glucose, naloxone, medication-assisted treatment, disulfiram teaching, and therapeutic, non-judgmental communication.

Why nurses encounter this: these patients present on med-surg, ED, ICU, OB, and psychiatric units. Nurses must manage the physical crisis and support behavioral recovery.

Disease Overview

Eating disorders

Disorder	Core features
Anorexia nervosa	Restriction → significantly low body weight, intense fear of weight gain, distorted body image. Restricting or binge-purge subtypes. High medical risk from starvation.
Bulimia nervosa	Recurrent binge eating + compensatory behaviors (self-induced vomiting, laxatives, fasting, excessive exercise); usually normal or near-normal weight.
Binge-eating disorder	Recurrent binges without regular compensatory behavior; distress; often overweight/obese.

Substance use disorders (SUD)

A problematic pattern of using a substance leading to impairment/distress, with features such as loss of control, craving, tolerance, and withdrawal. Involves the brain's dopamine reward system. Nurses manage two clinical states: intoxication (acute effects/overdose) and withdrawal (the body's rebound when the substance is stopped).

How they affect physiology: eating disorders cause starvation/purging physiology (electrolyte loss, cardiac muscle wasting, hormonal shutdown). SUDs hijack the dopamine reward pathway, driving compulsive use despite harm, and produce substance-specific organ effects.

Pathophysiology

Refeeding syndrome & the addiction reward pathway Refeeding syndrome (eating disorders) 1. Starvation → body depletes phosphate/K/Mg stores 2. Refeeding → carbs → insulin surge 3. Insulin drives PO₄/K/Mg INTO cells → plasma levels crash 4. Hypophosphatemia + hypokalemia + hypomagnesemia → cardiac arrhythmia, HF, respiratory failure, seizures PREVENT: start LOW & slow calories, monitor/replace phosphate Addiction reward pathway (SUD) 1. Substance → surge of DOPAMINE in reward circuit 2. Intense reward → reinforces repeated use 3. Brain adapts (tolerance) → needs more for same effect 4. Stop the drug → WITHDRAWAL (rebound opposite effects) → e.g., alcohol/benzo withdrawal can be FATAL TREAT: manage withdrawal safely + support recovery

Refeeding syndrome: feeding a starved body triggers an insulin surge that drives phosphate, potassium, and magnesium into cells—plasma levels crash, threatening the heart. Prevent by feeding low and slow with electrolyte monitoring. Addiction hijacks the dopamine reward pathway; stopping the drug causes withdrawal (rebound effects).

Eating disorders

Normal: balanced intake maintains weight, electrolytes, cardiac function, and hormones. ↓ What goes wrong: restriction/purging → starvation and electrolyte loss. Vomiting loses acid and potassium → hypokalemia and metabolic alkalosis; laxatives lose fluid/electrolytes. ↓ How symptoms arise: the body slows to conserve energy → bradycardia, hypotension, hypothermia, amenorrhea, lanugo, hair loss; low potassium/magnesium → cardiac arrhythmias. Purging → dental erosion, Russell's sign (knuckle calluses), parotid swelling. ↓ Progression: untreated → cardiac arrhythmia/arrest, organ failure, and death. During treatment, aggressive refeeding can cause refeeding syndrome.

Substance use

Normal: the dopamine reward system reinforces survival behaviors in moderation. ↓ What goes wrong: substances cause large dopamine surges → powerful reinforcement → compulsive use; the brain adapts (tolerance and dependence). ↓ How symptoms arise: intoxication reflects the drug's action (CNS depression with alcohol/opioids; stimulation with cocaine/meth). Withdrawal is the rebound opposite—stopping a depressant (alcohol/benzos) causes CNS hyperexcitability (tremor, tachycardia, seizures, delirium tremens). ↓ Progression: escalating use → health, social, and legal harm; overdose (respiratory depression with opioids) or severe withdrawal can be fatal. Recovery is a chronic, relapsing process.

Risk Factors

Category	Examples
Non-modifiable	Genetics/family history (both), female sex & adolescence/young adulthood (eating disorders), personality traits (perfectionism), history of trauma/abuse, comorbid mental illness
Modifiable	Dieting/weight pressures, substance availability/exposure, chronic stress, peer/social influences, untreated depression/anxiety, chronic pain (opioid risk)
Preventable/protective	Early screening & treatment, healthy body-image and coping education, avoiding early substance exposure, strong support, safe prescribing/monitoring of opioids
High-risk populations	Adolescents/young adults, athletes/dancers/models (eating disorders), people with trauma or comorbid psychiatric illness, and those with chronic pain or prior SUD

Signs & Symptoms

Eating disorders

Category	Findings (and WHY)
Anorexia — expected	Very low weight, bradycardia, hypotension, hypothermia, amenorrhea, lanugo, dry skin, constipation, cold intolerance — the body conserves energy in starvation
Bulimia — expected	Near-normal weight, dental erosion, Russell's sign, parotid swelling, sore throat, electrolyte signs — repeated vomiting/purging effects
Unexpected/late	Cardiac arrhythmia, muscle wasting, osteoporosis, edema — advanced starvation/electrolyte loss
Emergency	Severe hypokalemia/hypomagnesemia, arrhythmias, hemodynamic instability, or refeeding syndrome — immediate cardiac danger

Substance use — intoxication vs. withdrawal (high-yield)

Substance	Intoxication	Withdrawal (WHY it's dangerous)
Alcohol	Sedation, slurred speech, incoordination; overdose → respiratory depression	Tremor, tachycardia, HTN, anxiety → seizures → delirium tremens (DTs) at 48–96 hr — CNS hyperexcitability; can be FATAL
Opioids	Pinpoint pupils, respiratory depression, sedation (overdose = emergency → naloxone)	Uncomfortable but rarely fatal: dilated pupils, yawning, rhinorrhea, cramps, diarrhea, gooseflesh
Benzodiazepines/sedatives	Sedation, ataxia; with alcohol → dangerous CNS depression	Like alcohol — seizures possible; potentially fatal; taper, don't stop abruptly
Stimulants (cocaine/meth)	Euphoria, tachycardia, HTN, dilated pupils, agitation, hyperthermia; risk MI/stroke/seizure	"Crash": fatigue, hypersomnia, depression, intense craving (suicide risk)

Nursing Assessment

Subjective

Eating patterns, weight history, body image, purging behaviors, exercise; substance history (what/how much/last use—critical for withdrawal timing), cravings, prior withdrawal/seizures/DTs, and screening tools (CAGE for alcohol). Use a non-judgmental, honest approach to get accurate information.

Objective

Vital signs (bradycardia/hypotension/hypothermia in anorexia; tachycardia/HTN/fever in withdrawal), weight/BMI, cardiac rhythm, hydration, oral/dental exam and Russell's sign (bulimia), neuro status/LOC, pupils, and CIWA-Ar scoring for alcohol withdrawal.

Priority findings & red flags — act & notify immediately

Cardiac arrhythmia or severe electrolyte abnormality (hypokalemia/hypomagnesemia/hypophosphatemia).
Signs of refeeding syndrome (falling phosphate, edema, weakness, cardiac/respiratory changes).
Opioid overdose (pinpoint pupils, respiratory depression) or severe alcohol/benzo withdrawal (rising CIWA, seizures, DTs).
Suicidal ideation (elevated in both).

Why electrolytes and the heart come first In eating disorders, the leading cause of death is cardiac—from hypokalemia/hypomagnesemia (arrhythmias) and starvation-weakened heart muscle. In alcohol/benzo withdrawal, untreated withdrawal can progress to seizures and delirium tremens, which can be fatal. Continuous monitoring and prompt correction are lifesaving.

Diagnostic Tests

Test/tool	Purpose / why ordered	Findings & nursing considerations
ECG / cardiac monitoring	Detect arrhythmias from electrolyte imbalance/starvation	Prolonged QT, bradycardia, dysrhythmias; continuous monitoring in severe cases.
Weight/BMI & vital signs	Assess severity; monitor refeeding	Trend weight; monitor for rapid shifts (fluid) and cardiovascular status.
CAGE / AUDIT screening	Screen for alcohol use disorder	Guides further assessment; non-judgmental delivery.
CIWA-Ar	Score alcohol withdrawal severity	Higher score = more severe; guides symptom-triggered benzodiazepine dosing.
Urine/blood toxicology	Identify substances	Guides withdrawal management; deliver results non-judgmentally.
Bone density (DXA)	Assess osteoporosis in chronic anorexia	Low estrogen + malnutrition → bone loss.

Laboratory Tests

Lab	Purpose / normal	Significance & nursing implications
Potassium	Cardiac safety; 3.5–5.0 mEq/L	Hypokalemia from vomiting/laxatives/refeeding → arrhythmias. Monitor closely; replace; a priority lab in purging.
Phosphate	Refeeding monitoring; ~2.5–4.5 mg/dL	Hypophosphatemia is the hallmark of refeeding syndrome → cardiac/respiratory failure. Monitor and replace during refeeding.
Magnesium	Cardiac/neuromuscular; ~1.5–2.5 mg/dL	Hypomagnesemia worsens arrhythmias and makes potassium hard to correct.
Sodium & other electrolytes / ABG	Fluid/acid–base status	Vomiting → metabolic alkalosis; laxatives/diarrhea → metabolic acidosis. Monitor.
CBC, glucose, renal/hepatic	Assess malnutrition/organ effects, alcohol liver disease	Anemia, low glucose, abnormal LFTs; guide care.
Thiamine / nutritional markers	Alcohol use disorder	Give thiamine BEFORE glucose to prevent Wernicke encephalopathy.

NCLEX pearl — potassium & phosphate are the numbers that kill In purging eating disorders, hypokalemia causes fatal arrhythmias—monitor potassium closely. During refeeding, hypophosphatemia is the danger sign of refeeding syndrome. And in alcohol use disorder, remember "thiamine before glucose" (banana bag) to prevent Wernicke encephalopathy.

Medications

Eating disorders

SSRIs (e.g., fluoxetine) are the best-supported medication for bulimia (reduce binge-purge cycles) and treat comorbid depression/anxiety; bupropion is contraindicated in bulimia/anorexia (seizure risk with purging/electrolyte loss). Electrolyte replacement (potassium, phosphate, magnesium) treats the physical danger. Nutritional rehabilitation is the mainstay—medication is adjunctive. Teaching: SSRIs take 4–6 weeks; a supervised meal plan and monitoring are essential.

Alcohol withdrawal

Benzodiazepines (lorazepam, diazepam, chlordiazepoxide) are first-line—they calm CNS hyperexcitability and prevent seizures/DTs (often symptom-triggered by CIWA). Thiamine, folate, and multivitamins ("banana bag"); thiamine before glucose. Nursing: monitor CIWA, seizure precautions, quiet environment, and airway/sedation.

Opioid overdose & treatment

Naloxone reverses opioid overdose (respiratory depression)—short-acting, so monitor for re-sedation. Medication-assisted treatment (MAT): methadone and buprenorphine (partial agonist; suboxone contains naloxone to deter misuse) reduce cravings/withdrawal; naltrexone (opioid antagonist) blocks effects—patient must be opioid-free first to avoid precipitated withdrawal.

Alcohol use disorder maintenance

Naltrexone (reduces craving/reward), acamprosate (stabilizes brain chemistry), and disulfiram (causes an intensely unpleasant reaction—flushing, nausea/vomiting, tachycardia, headache—if alcohol is consumed). Disulfiram teaching: avoid ALL alcohol, including hidden sources (mouthwash, cough syrup, aftershave, some foods/sauces); the reaction can be severe.

Emergency reflexes Opioid overdose: pinpoint pupils + respiratory depression → naloxone, support ventilation, watch for re-sedation. Severe alcohol/benzo withdrawal: rising CIWA, tremor, hallucinations → benzodiazepine, seizure precautions, thiamine. Refeeding syndrome: falling phosphate/potassium → hold/slow feeds, replace electrolytes, cardiac monitoring.

Black box / safety note Antidepressants (SSRIs) carry a Black Box Warning for increased suicidality in youth—monitor. Disulfiram requires strict alcohol avoidance. Naltrexone requires an opioid-free period (and can affect the liver—monitor LFTs).

Nursing Interventions (Priorities)

Airway/Breathing: in opioid overdose support ventilation/give naloxone; in severe intoxication protect the airway; monitor respiratory status. Why: respiratory depression is the immediate killer in overdose. ↓ Circulation/physiologic stability: cardiac monitoring and electrolyte correction (K, phosphate, Mg) in eating disorders; monitor VS and CIWA in withdrawal; IV fluids/thiamine as ordered. Why: arrhythmias and withdrawal instability are life-threatening. ↓ Safety: seizure precautions (alcohol/benzo withdrawal), fall precautions, suicide risk assessment, and—during refeeding—start low and slow with close monitoring. Why: prevent seizures, refeeding syndrome, and self-harm. ↓ Structure & behavioral care (eating disorders): supervised meals, observation during and ~1 hour after meals (prevent purging), consistent limits, matter-of-fact approach to food/weight, and no power struggles. Why: structure supports refeeding and reduces disordered behavior. ↓ Therapeutic, non-judgmental communication: build trust, address underlying feelings/control, avoid shaming. Why: stigma blocks honesty and recovery. ↓ Education & interdisciplinary care: dietitian, therapy (CBT, family-based therapy for adolescents), physicians, social work, and support groups (AA/NA). Why: recovery is multidisciplinary and long-term. Why you observe after meals in eating disorders For anorexia/bulimia, staff supervise meals and remain with the patient for about an hour afterward to prevent purging or hiding/discarding food. Keep the tone matter-of-fact and supportive—not punitive—and avoid arguing about calories or weight, which fuels control battles.

Potential Complications

Complication	Early signs	Nursing/emergency response
Cardiac arrhythmia (hypokalemia/hypomagnesemia)	Palpitations, irregular pulse, ECG changes	Cardiac monitoring, replace electrolytes, notify—emergency.
Refeeding syndrome	Falling phosphate/potassium, edema, weakness, dyspnea	Slow/hold feeds, replace electrolytes, monitor cardiac/resp—emergency.
Delirium tremens (alcohol)	Rising CIWA, confusion, hallucinations, autonomic instability (48–96 hr)	Benzodiazepines, seizure precautions, close monitoring—emergency.
Opioid overdose	Pinpoint pupils, slow/shallow breathing, decreased LOC	Naloxone, support ventilation, monitor re-sedation—emergency.
Wernicke encephalopathy	Confusion, ataxia, eye movement changes	Give thiamine (before glucose)—emergency; may prevent permanent damage.
Suicide/self-harm	Ideation, hopelessness	Safety measures, close observation, notify—priority.

Patient Education

Disease process: both are treatable illnesses, not choices or moral failings. Recovery takes time and support; relapse is common and part of the process, not failure.

Lifestyle & home care: for eating disorders, follow the meal plan, work with the dietitian and therapist, and challenge distorted body image; for substance use, build coping skills, avoid triggers, and use support groups (AA/NA).

Medication adherence: SSRIs take 4–6 weeks; for disulfiram, avoid all alcohol/hidden sources; for MAT (methadone/buprenorphine/naltrexone), take as prescribed and keep follow-up; keep naloxone available for those at overdose risk and teach families to use it.

Warning signs / when to seek emergency care: chest pain/palpitations or fainting (electrolyte/cardiac), signs of severe withdrawal (tremor, confusion, seizures), overdose (slow breathing, unresponsiveness), or thoughts of self-harm. Provide the appropriate helplines and the 988 Suicide & Crisis Lifeline.

Clinical Judgment (NCSBN Model)

A patient with a history of heavy daily alcohol use was admitted 2 days ago for surgery and hasn't had alcohol since. The nurse notes tremor, diaphoresis, HR 118, BP 168/96, anxiety, and the patient reports "bugs on the wall." CIWA score is rising.

Recognize cues

Tremor, diaphoresis, tachycardia, hypertension, anxiety, and visual hallucinations ~48 hours after last drink with a rising CIWA—signs of alcohol withdrawal progressing toward delirium tremens.

Analyze cues

Untreated alcohol withdrawal can progress to seizures and DTs, which can be fatal—CNS hyperexcitability from the loss of alcohol's depressant effect.

Prioritize hypotheses

Priority: prevent seizures/DTs and ensure safety.

Generate solutions

Symptom-triggered benzodiazepines per CIWA, seizure precautions, thiamine/fluids, a quiet low-stimulation environment, and close monitoring.

Take action

Administer the ordered benzodiazepine, implement seizure precautions, reorient calmly, monitor VS/CIWA frequently, give thiamine, and notify the provider of escalation.

Evaluate outcomes

Success = decreasing CIWA, stable vitals, no seizure, and improving orientation. Continue monitoring—DTs peak around 48–96 hours.

Clinical Connections — Commonly Confused

	Anorexia nervosa	Bulimia nervosa
Weight	Significantly low	Usually normal/near-normal
Core behavior	Restriction (± binge-purge)	Binge + compensatory purging
Key findings	Bradycardia, hypotension, hypothermia, lanugo, amenorrhea	Dental erosion, Russell's sign, parotid swelling, hypokalemia/alkalosis
Priority nursing	Cardiac/electrolytes, refeeding safety, supervised meals	Electrolytes (K), observe after meals to prevent purging

	Alcohol/benzo withdrawal	Opioid withdrawal
Danger level	Can be FATAL (seizures, DTs)	Very uncomfortable but rarely fatal
Assessment	Tremor, ↑HR/BP, hallucinations, CIWA	Dilated pupils, yawning, rhinorrhea, cramps, diarrhea, gooseflesh
Treatment	Benzodiazepines + thiamine; seizure precautions	Supportive care; methadone/buprenorphine, clonidine for symptoms
Priority nursing	Prevent seizures/DTs; monitor closely	Comfort, hydration, monitor; overdose risk if relapse (lost tolerance)

	Opioid intoxication/overdose	Stimulant intoxication
Pupils	Pinpoint (miosis)	Dilated (mydriasis)
Vitals	Respiratory depression, sedation	Tachycardia, HTN, hyperthermia, agitation
Emergency	Naloxone + ventilation	Cooling, sedation, cardiac monitoring (MI/stroke risk)

NCLEX High-Yield Review

What the NCLEX Wants You to Know

Eating disorders have the highest mortality of any psychiatric illness — cardiac/electrolytes first
Hypokalemia (purging) → arrhythmias; monitor potassium
Refeeding syndrome = ↓ phosphate; feed low & slow, replace electrolytes
Observe eating-disorder patients during & ~1 hr after meals
Alcohol/benzo withdrawal can be FATAL → benzodiazepines + seizure precautions (CIWA)
Thiamine BEFORE glucose (prevent Wernicke)
Opioid overdose = pinpoint pupils + respiratory depression → naloxone (watch re-sedation)
Disulfiram → avoid ALL alcohol/hidden sources; naltrexone → must be opioid-free

Common distractors: pushing large meals immediately (refeeding risk); shaming/arguing about food or substance use; treating opioid withdrawal as an emergency but downplaying alcohol withdrawal (it's the reverse for lethality); giving glucose before thiamine; starting naltrexone in someone still using opioids. Delegation: the RN assesses withdrawal/CIWA, gives meds, and does risk assessment; UAP can obtain vitals/weights, provide meal-time observation as directed, and assist with ADLs—not assess withdrawal severity or give medications. Critical values: potassium, phosphate, magnesium; rising CIWA. Most common mistakes: missing hypokalemia/refeeding, underestimating alcohol withdrawal, and non-therapeutic (judgmental) communication.

Memory Aids

Anorexia "slows down": Bradycardia, hypotension, hypothermia, amenorrhea, lanugo — the starved body conserves energy.
Bulimia "purge clues": Russell's sign, dental erosion, parotid swelling, hypokalemia.
Refeeding "low & slow, watch the PHOS": hypophosphatemia is the danger; start feeding low and slow.
Alcohol withdrawal timeline: tremors 6–24 hr → seizures 12–48 hr → DTs 48–96 hr.
"Thiamine before glucose": the banana bag rule—prevent Wernicke encephalopathy.
Opioids "PINPOINT + slow breathing = naloxone": the overdose triad reversed by naloxone.
CAGE: Cut down, Annoyed, Guilty, Eye-opener — quick alcohol screen.
Disulfiram "no alcohol anywhere": even mouthwash/cough syrup can trigger the reaction.

Case Study

A 19-year-old with anorexia nervosa is admitted at a very low weight: HR 44, BP 84/54, temperature 96.4°F, potassium 3.0 mEq/L, phosphate 2.2 mg/dL. A refeeding plan is started. She is anxious about "getting fat" and asks to skip meals and exercise.

Recognize & analyze cues

Severe bradycardia, hypotension, hypothermia, and hypokalemia/low phosphate = high cardiac risk from starvation, with refeeding syndrome risk as nutrition begins.

Prioritize & plan

Priorities: cardiac safety and safe refeeding. Continuous cardiac monitoring, replace potassium/phosphate/magnesium, start calories low and slow, supervised meals with post-meal observation, and no unsupervised exercise.

Take action

Monitor ECG/VS, correct electrolytes, follow the dietitian's graded plan, supervise meals and stay ~1 hour after, use a matter-of-fact non-punitive approach, address anxiety therapeutically, and monitor phosphate for refeeding syndrome.

Evaluate & discharge

Success = stable cardiac rhythm, normalizing electrolytes, gradual weight restoration without refeeding syndrome, and engagement in therapy. Before discharge: reinforce the meal plan, follow-up with the eating-disorder team, therapy, and warning signs.

NCLEX Practice Questions

Answer choices are numbered; the correct answer is given as a number.

1. A patient with anorexia nervosa is beginning nutritional refeeding. Which laboratory value most indicates developing refeeding syndrome?

Elevated sodium
Elevated calcium
Elevated glucose
Decreased phosphate

Rationale

Answer: 4. Hypophosphatemia is the hallmark of refeeding syndrome—insulin drives phosphate into cells as feeding begins. Sodium (1), calcium (2), and glucose (3) elevations are not the defining sign.

2. A patient with bulimia nervosa is admitted after frequent self-induced vomiting. Which finding is the priority for the nurse to address?

Serum potassium of 2.8 mEq/L
Dental enamel erosion
Calluses on the knuckles
Sore throat

Rationale

Answer: 1. Hypokalemia (2.8) can cause fatal arrhythmias—the priority. Dental erosion (2), Russell's sign (3), and sore throat (4) are expected purging findings but not immediately life-threatening.

3. A patient with a history of heavy alcohol use is 2 days without alcohol and develops tremor, HR 120, BP 170/98, and reports seeing bugs on the wall. The nurse anticipates administering:

Naloxone
An antipsychotic as the first-line treatment
A benzodiazepine such as lorazepam
Disulfiram

Rationale

Answer: 3. Benzodiazepines are first-line for alcohol withdrawal—they prevent seizures and DTs. Naloxone (1) is for opioids, antipsychotics (2) aren't first-line, and disulfiram (4) is a maintenance deterrent, not for acute withdrawal.

4. A patient is found unresponsive with pinpoint pupils and a respiratory rate of 6. The nurse's priority action is to:

Administer disulfiram
Support ventilation and administer naloxone
Give IV glucose immediately
Apply cooling measures

Rationale

Answer: 2. Pinpoint pupils + respiratory depression = opioid overdose—support ventilation and give naloxone. Disulfiram (1) and cooling (4) are irrelevant; glucose (3) isn't the priority here.

5. A patient prescribed disulfiram for alcohol use disorder needs teaching. Which statement indicates correct understanding?

"I can have a small glass of wine on special occasions."
"This medication will reduce my cravings so I won't want to drink."
"I only need to avoid hard liquor, not beer or wine."
"I must avoid all alcohol, including mouthwash and cough syrup."

Rationale

Answer: 4. Disulfiram causes a severe reaction with any alcohol, including hidden sources like mouthwash and cough syrup. Options 1 and 3 are unsafe, and 2 describes naltrexone/acamprosate, not disulfiram's mechanism.

6. SATA. Which findings are expected in a patient with anorexia nervosa? Select all that apply.

Bradycardia
Hypotension
Lanugo (fine body hair)
Hypertension and tachycardia
Amenorrhea

Rationale

Answers: 1, 2, 3, 5. Starvation slows the body—bradycardia, hypotension, lanugo, and amenorrhea are expected. Hypertension and tachycardia (4) are not typical of anorexia.

7. SATA. Which nursing actions are appropriate when caring for a patient in alcohol withdrawal? Select all that apply.

Institute seizure precautions
Administer benzodiazepines using CIWA-guided (symptom-triggered) dosing
Give thiamine, ideally before glucose
Provide a bright, highly stimulating environment
Monitor vital signs and CIWA score frequently

Rationale

Answers: 1, 2, 3, 5. Seizure precautions, symptom-triggered benzodiazepines, thiamine before glucose, and frequent monitoring are correct. A bright, stimulating environment (4) worsens agitation—keep it calm and low-stimulation.

8. Priority. The nurse is caring for four patients. Which requires assessment first?

A patient with an eating disorder and a potassium of 2.6 mEq/L with palpitations
A patient in opioid withdrawal with nausea and muscle aches
A patient asking about a support group
A patient with binge-eating disorder requesting a snack

Rationale

Answer: 1. Severe hypokalemia with palpitations risks a fatal arrhythmia—assess first. Opioid withdrawal (2) is uncomfortable but not immediately life-threatening; the others are non-urgent.

9. Delegation. Which task can the RN appropriately delegate to unlicensed assistive personnel (UAP)?

Assessing the patient's CIWA withdrawal score
Administering the scheduled benzodiazepine
Observing an eating-disorder patient during and after meals as directed
Teaching a patient about disulfiram

Rationale

Answer: 3. UAP can observe the patient during/after meals under RN direction. CIWA assessment (1), medication administration (2), and teaching (4) require the RN.

10. NGN Case Study. A 20-year-old with anorexia nervosa is admitted at a critically low weight. HR 42, BP 82/50, temp 96.0°F, K⁺ 2.9 mEq/L, phosphate 2.1 mg/dL. Refeeding is planned.

10a. Which findings require immediate nursing attention? Select all that apply.

Heart rate of 42
Potassium of 2.9 mEq/L
Phosphate of 2.1 mg/dL
Preference for loose clothing
Blood pressure of 82/50

Rationale

Answers: 1, 2, 3, 5. Severe bradycardia, hypokalemia, hypophosphatemia, and hypotension are life-threatening and need immediate attention. Clothing preference (4) is not urgent.

10b. Which interventions are appropriate? Select all that apply.

Begin refeeding with low, gradually increased calories
Provide continuous cardiac monitoring
Encourage the patient to exercise to build appetite
Replace potassium, phosphate, and magnesium as ordered
Supervise meals and remain with the patient afterward

Rationale

Answers: 1, 2, 4, 5. Low-and-slow refeeding, cardiac monitoring, electrolyte replacement, and meal supervision are correct. Encouraging exercise (3) is dangerous in a hemodynamically unstable, malnourished patient.

Key Takeaways

Eating disorders are medically dangerous: the leading cause of death is cardiac (hypokalemia/hypomagnesemia). Monitor electrolytes and rhythm; observe patients during and after meals.
Refeeding syndrome: feed low and slow, watch for hypophosphatemia (plus low K/Mg), and replace electrolytes with cardiac monitoring.
Alcohol/benzodiazepine withdrawal can be fatal: use benzodiazepines (CIWA-guided), seizure precautions, and thiamine before glucose. Opioid withdrawal is miserable but rarely fatal.
Opioid overdose: pinpoint pupils + respiratory depression → naloxone and ventilation (watch for re-sedation). Relapse after abstinence raises overdose risk (lost tolerance).
Recovery medications: SSRIs (bulimia), disulfiram/naltrexone/acamprosate (alcohol), methadone/buprenorphine/naltrexone (opioids)—teach adherence and, for disulfiram, avoid all alcohol.
Communication matters: use a non-judgmental, structured, consistent approach; these are treatable illnesses, and stigma blocks recovery.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). APA.
Halter, M. J. (2022). Varcarolis' foundations of psychiatric-mental health nursing: A clinical approach (9th ed.). Elsevier.
Townsend, M. C., & Morgan, K. I. (2020). Psychiatric mental health nursing: Concepts of care in evidence-based practice (10th ed.). F. A. Davis.
Silvestri, L. A., & Silvestri, A. E. (2023). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier.
Assessment Technologies Institute. (2023). ATI RN mental health nursing review module (11th ed.). ATI Nursing Education.
National Institute on Drug Abuse. (2024). Principles of drug addiction treatment and medications for opioid use disorder. U.S. Department of Health and Human Services. https://nida.nih.gov
Substance Abuse and Mental Health Services Administration. (2024). National Helpline and treatment of alcohol/opioid withdrawal. SAMHSA. https://www.samhsa.gov
National Institute of Mental Health. (2024). Eating disorders. U.S. Department of Health and Human Services. https://www.nimh.nih.gov

Behavioral Health Disorders

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Mental Health

NCLEX Success Center

Clinical Judgment Practice

Prioritization Practice

Delegation Practice

Lab Values

Final Review