NCLEX-RN Crisis Intervention and Suicide Assessment — Practice Questions

Therapeutic communication encourages clients to express thoughts and feelings, helps them work through issues, and supports the nurse-client relationship. Key techniques: (1) Open-ended questions/statements — invite elaboration ('Tell me more...', 'How are you feeling about...?'); (2) Active listening — full attention, eye contact, nodding, reflective responses; (3) Reflecting/restating — 'You're saying that you feel anxious about the surgery'; (4) Clarifying — 'Help me understand what you mean by...'; (5) Silence — allows the client to think and respond at their own pace; (6) Acknowledgment — 'I notice you've been quiet today'; (7) Focusing — 'You mentioned pain earlier — tell me more'; (8) Offering self — 'I'll sit with you for a while'. Non-therapeutic responses to avoid: (1) False reassurance ('Don't worry, everything will be fine') — dismisses feelings and may not be true; (2) Giving advice ('You should...') — disempowers the client; (3) Judgmental statements ('That's a bad decision'); (4) Probing ('Why did you do that?') — defensive; (5) Changing the subject; (6) Closed questions that limit response; (7) Disagreeing or arguing; (8) Approving/disapproving — shifts focus to nurse's evaluation. The therapeutic relationship is the foundation of all nursing care; communication skills are tested throughout the NCLEX.

When suicidal ideation is suggested or stated, the nurse must directly assess for suicide intent — this is the priority intervention. Asking about suicide does NOT plant the idea or increase risk; on the contrary, direct assessment is essential and may relieve the client. Assessment questions: (1) 'Are you thinking of hurting yourself or ending your life?' — direct, non-judgmental; (2) 'Do you have a plan?' — specific method, when, where? (3) 'Do you have means available?' (firearms, medications, etc.); (4) 'Have you tried before?' — past attempts are major risk factor; (5) 'What's keeping you alive right now?' — protective factors. Risk levels: (1) Ideation alone without plan — concerning but lower risk; (2) Ideation with plan — high risk; (3) Ideation, plan, and means — imminent risk requiring immediate safety; (4) Active attempt — emergency. Nursing actions for high risk: (1) Stay with client or arrange constant observation; (2) Remove access to means (medications, sharp objects, firearms); (3) Notify physician and mental health team; (4) Suicide precautions per facility policy (typically including line-of-sight observation, removal of harmful items, ligature risks addressed); (5) Therapeutic, supportive communication; (6) No-suicide contracts have limited evidence — better to focus on safety planning and means restriction. Suicide is a leading cause of death; nurses are often the first to identify risk.

Major Depressive Disorder (DSM-5 criteria): five or more of the following symptoms present during the same 2-week period and representing a change from previous functioning. At least one symptom must be depressed mood or anhedonia. Symptoms: (1) Depressed mood most of the day, nearly every day — sad, empty, hopeless; (2) Markedly diminished interest or pleasure in activities (anhedonia); (3) Significant weight loss or gain (>5% body weight in a month) or appetite changes; (4) Insomnia or hypersomnia nearly every day; (5) Psychomotor agitation or retardation observable by others; (6) Fatigue or loss of energy nearly every day; (7) Feelings of worthlessness or excessive/inappropriate guilt; (8) Diminished ability to think or concentrate, or indecisiveness; (9) Recurrent thoughts of death, suicidal ideation, suicide attempt or specific plan. Symptoms cause clinically significant distress or impairment, not attributable to substance or medical condition, not better explained by other disorder. Treatment: psychotherapy (CBT, IPT especially); antidepressants (SSRIs first-line, SNRIs, atypicals); ECT for severe/treatment-resistant; light therapy for seasonal pattern; exercise as adjunct; emerging treatments (ketamine, TMS). Onset of antidepressant effect: 2-6 weeks for full effect; suicide risk may transiently increase as energy returns before mood lifts — close monitoring critical. Recurrence common; treatment continuation often recommended for at least 6-12 months after remission.

Bipolar disorder involves episodes of mood elevation and depression. Mania (Bipolar I) — duration ≥7 days OR severe enough for hospitalization. Criteria: distinct period of abnormally elevated, expansive, or irritable mood AND increased goal-directed activity/energy; plus 3+ of (or 4+ if irritable): (1) Inflated self-esteem or grandiosity (sometimes delusional); (2) Decreased need for sleep (3 hours and feels rested); (3) More talkative than usual or pressured speech; (4) Flight of ideas or racing thoughts; (5) Distractibility; (6) Increased goal-directed activity or psychomotor agitation; (7) Excessive involvement in activities with painful consequences (spending sprees, sexual indiscretions, foolish business). Hypomania (Bipolar II): similar but less severe, lasting ≥4 days, no severe functional impairment. Bipolar I: mania required (depression typical but not required). Bipolar II: hypomania plus major depression. Cyclothymic disorder: chronic, less severe fluctuations. Treatment: mood stabilizers (lithium — gold standard, requires blood level monitoring 0.6-1.2 mEq/L therapeutic, narrow window, toxicity at 1.5+, watch for dehydration); anticonvulsants (valproate, lamotrigine, carbamazepine); atypical antipsychotics (quetiapine, olanzapine, risperidone, lurasidone, others); ECT for severe/treatment-resistant. Antidepressants used cautiously — can trigger mania. Nursing care during mania: low-stimulation environment, simple structured activities, brief frequent meals and snacks (they can't sit for full meals), set limits on intrusive behavior, ensure rest, monitor for exhaustion.

Schizophrenia (DSM-5): 2+ symptoms present for significant portion of 1 month (or less if treated successfully): (1) Delusions — fixed false beliefs (persecutory, grandiose, somatic, religious, referential — believing TV is talking to you); (2) Hallucinations — false perceptions in any sense; auditory hallucinations (hearing voices) most common; (3) Disorganized speech — derailment, tangentiality, incoherence; (4) Grossly disorganized or catatonic behavior; (5) Negative symptoms — diminished emotional expression, alogia (poverty of speech), avolition (lack of motivation), anhedonia (inability to feel pleasure), asociality. At least one must be hallucinations, delusions, or disorganized speech. Significant impairment in work, relationships, self-care. Continuous signs for 6+ months. Typically: prodromal phase with subtle changes, active phase with full symptoms, residual phase with continuing negative symptoms. Treatment: antipsychotic medications — first-generation (typical) like haloperidol, chlorpromazine; second-generation (atypical) like risperidone, olanzapine, quetiapine, aripiprazole, clozapine. Atypicals are first-line — fewer extrapyramidal symptoms (EPS) but more metabolic side effects (weight gain, diabetes, lipid changes). Side effects to monitor: EPS (tremor, rigidity, akathisia, tardive dyskinesia, neuroleptic malignant syndrome), metabolic changes, anticholinergic effects, sedation. Clozapine — most effective but requires WBC monitoring due to agranulocytosis risk. Psychosocial interventions: psychotherapy, family education, supported employment, social skills training, assertive community treatment. Nursing care: therapeutic communication, reality orientation when needed without arguing about delusions, monitor for medication adherence and side effects, recognize relapse early.

Panic Attack: a discrete period of intense fear or discomfort with abrupt onset, peaking within minutes, including 4+ symptoms: (1) Palpitations, pounding heart, or accelerated heart rate; (2) Sweating; (3) Trembling or shaking; (4) Shortness of breath or smothering sensation; (5) Choking sensation; (6) Chest pain or discomfort (often mistaken for heart attack); (7) Nausea or abdominal distress; (8) Dizziness, unsteadiness, lightheaded, faint; (9) Chills or hot flashes; (10) Paresthesias (numbness/tingling); (11) Derealization or depersonalization (feeling unreal); (12) Fear of losing control or going crazy; (13) Fear of dying. Panic Disorder: recurrent unexpected panic attacks plus persistent concern about additional attacks or maladaptive behavior changes related to attacks (e.g., avoiding situations). Often co-occurs with agoraphobia (fear of situations where escape may be difficult — open spaces, crowds, public transport). Acute panic attack management: (1) Stay with client; (2) Calm, reassuring voice — speak in short simple sentences; (3) Decrease stimulation — quiet environment, dim lights; (4) Encourage slow breathing — count breaths together, breathe with the client; (5) Grounding techniques — name 5 things you see, 4 you hear, 3 you can touch, 2 you smell, 1 you taste; (6) Reassure that the attack will pass and won't cause harm; (7) Acute medications (benzodiazepines like lorazepam) per orders. Long-term treatment: CBT (especially exposure therapy); SSRIs/SNRIs first-line; benzodiazepines used short-term; relaxation techniques, mindfulness. Caffeine and stimulants worsen anxiety. ER presentation of panic attack often mistaken for cardiac event; appropriate medical evaluation rules out other causes.

Kübler-Ross's five stages of grief (developed from observing dying patients in 'On Death and Dying,' 1969): (1) Denial — 'This can't be happening' — protects from initial shock; (2) Anger — 'Why me? It's not fair' — directed at self, others, healthcare team, God; (3) Bargaining — 'If only...' — attempts to negotiate, often with higher power; (4) Depression — 'What's the point?' — sadness, withdrawal, mourning the losses; (5) Acceptance — 'I'm ready for what comes' — peace, not necessarily happiness. Important points: (1) NOT linear — grieving people move between stages, revisit stages, or skip stages; (2) Individual experience — no 'right' way to grieve; (3) Cultural variation — different cultures express and process grief differently; (4) Time variable — there is no fixed timeline; complicated grief lasting >12 months is recognized as a clinical concern. Other grief models: (1) Bowlby's attachment-based grief stages; (2) Worden's tasks of mourning — accept reality, work through pain, adjust to environment without deceased, find ongoing connection while moving forward; (3) Dual process model — alternating between loss-oriented and restoration-oriented coping. Nursing interventions: (1) Therapeutic presence — be there, don't always fill silence; (2) Allow expression of all emotions — anger, fear, sadness are normal; (3) Avoid platitudes ('They're in a better place'); (4) Active listening; (5) Educate family about normal grief; (6) Refer to grief counseling, support groups, palliative care, chaplaincy as appropriate; (7) Recognize complicated grief — prolonged, intense, functional impairment. Anticipatory grief — grieving before the death — is common in terminal illness.

A crisis is a state of disequilibrium caused by a stressor that overwhelms the person's usual coping abilities. Types of crisis: (1) Maturational/developmental — normal life transitions (marriage, parenthood, retirement) that overwhelm; (2) Situational — unexpected events (illness, loss, accident, divorce); (3) Adventitious — disaster, violence, public catastrophe affecting communities. Crisis intervention principles: (1) Short-term focus — typical resolution within 4-6 weeks; if not resolved, evolves into chronic dysfunction; (2) Present-focused — address the immediate problem rather than deep psychological issues; (3) Problem-solving approach — concrete steps to manage the crisis; (4) Mobilize resources — family, friends, community, professional services; (5) Restore previous level of functioning — not aim for transformation; (6) Active and directive — crisis worker takes more active role than typical therapy; (7) Build on strengths — identify and use the person's existing coping abilities. Phases: (1) Pre-crisis — usual functioning; (2) Vulnerable — stressor occurs, usual coping fails; (3) Active crisis — high anxiety, disorganization; (4) Reorganization — new equilibrium achieved (better, same, or worse than pre-crisis). Crisis intervention steps: (1) Assess — what is the precipitating event? safety? supports? coping methods used? (2) Plan — concrete actions to address the crisis; (3) Intervene — implement the plan; (4) Evaluate — was the crisis resolved? at what level? Resources: crisis hotlines, mobile crisis teams, emergency rooms, crisis stabilization units, suicide prevention services (988 in US — Suicide and Crisis Lifeline). Nursing role: assessment, presence, support, resource referral.

Alcohol withdrawal occurs in people physically dependent on alcohol. Severity ranges from mild discomfort to life-threatening. Timeline: (1) 6-24 hours: minor withdrawal — tremors (especially hands), anxiety, headache, nausea/vomiting, sweating, increased pulse and blood pressure, insomnia, agitation; (2) 12-48 hours: withdrawal seizures (typically tonic-clonic, brief) — at-risk window 12-48 hours; (3) 12-48 hours: alcoholic hallucinations — visual hallucinations more common than auditory (different from psychotic hallucinations which are typically auditory); sensorium intact; (4) 48-96 hours: delirium tremens (DTs) — disorientation, severe agitation, hallucinations (often vivid, fearful), severe autonomic instability (very high BP, tachycardia, hyperthermia), tremors, diaphoresis; mortality 5-15% without treatment, <5% with treatment. CIWA scale (Clinical Institute Withdrawal Assessment) quantifies severity and guides medication. Treatment: (1) Benzodiazepines — gold standard; cross-tolerance with alcohol allows controlled detoxification; lorazepam, diazepam, chlordiazepoxide commonly used; can be scheduled or symptom-triggered (CIWA-based); (2) Thiamine BEFORE glucose — to prevent Wernicke encephalopathy (B1 deficiency in alcoholics; characterized by confusion, ataxia, ophthalmoplegia); (3) Folate, multivitamin; (4) Electrolyte replacement (magnesium especially); (5) Fluids; (6) Quiet, well-lit environment; (7) Seizure precautions; (8) Frequent reorientation. Severe cases need ICU monitoring. Long-term treatment for alcohol use disorder: medications (naltrexone, acamprosate, disulfiram), 12-step programs (AA), therapy (CBT, motivational interviewing), residential treatment.

Opioid withdrawal is uncomfortable but not life-threatening in healthy adults (unlike alcohol/benzodiazepine withdrawal). Symptoms: anxiety, restlessness, dysphoria; pupils dilated (mydriasis — opposite of intoxication which causes pinpoint pupils); muscle aches and bone pain; abdominal cramps, diarrhea, nausea/vomiting; runny nose (rhinorrhea), tearing (lacrimation), yawning, sneezing; sweating, chills, fever; piloerection ('goosebumps'); tachycardia, hypertension; insomnia. Duration: short-acting opioids (heroin, oxycodone, morphine) — onset 6-12 hours, peak 36-72 hours, resolves 5-7 days; long-acting (methadone) — onset 24-48 hours, peak 4-6 days, resolves 14+ days. Severity scale: COWS (Clinical Opiate Withdrawal Scale). Treatment options: (1) Medication-assisted treatment (MAT) — gold standard for opioid use disorder. Methadone: full agonist, long half-life, prevents withdrawal and cravings; only at certified clinics. Buprenorphine: partial agonist, ceiling effect on respiratory depression, available through certified providers; often combined with naloxone (Suboxone) to deter injection. Naltrexone: opioid antagonist, oral or monthly injection, requires being opioid-free before starting; (2) Symptomatic management — clonidine (reduces autonomic symptoms), antiemetics, antidiarrheals, analgesics for muscle aches, hydroxyzine for anxiety, melatonin or trazodone for sleep. While withdrawal is not life-threatening directly, complications include dehydration from vomiting/diarrhea, suicidal ideation from acute depression, return to use after detoxification is leading cause of overdose death (tolerance drops during abstinence). Pregnancy: methadone or buprenorphine — withdrawal can cause fetal distress; opioid-dependent pregnant women should NOT detox abruptly.