NCLEX-RN Psychiatric Medications — Lithium, MAOIs, Antipsychotics, and Monitoring

CIWA-Ar SCALE: THE STANDARD: Most commonly used validated tool for alcohol withdrawal monitoring; ITEMS: Nausea/vomiting; tremor; diaphoresis; anxiety; agitation; tactile disturbances (formication); auditory disturbances; visual disturbances; headache; orientation/clouding; SCORING: 0-67 total; INTERPRETATION: <10: Mild — monitoring, no medication unless symptoms progress; 10-15: Moderate — consider benzodiazepine; >15: Severe — benzodiazepine required; >20: Risk for delirium tremens; SYMPTOM-TRIGGERED vs FIXED SCHEDULE: CIWA-Ar allows symptom-triggered dosing — only administer benzodiazepine when score exceeds threshold (reduces total benzodiazepine dose, shortens withdrawal duration, improves safety vs fixed schedule); NURSING ROLE: Assess CIWA-Ar every 1-4 hours per protocol; administer PRN benzodiazepines per orders when threshold reached; monitor vital signs; ensure IV access; COMPARE: CAGE questionnaire = screening tool (Cut-down, Annoyed, Guilty, Eye-opener) for AUD history — not for acute withdrawal monitoring.

MAOI DIETARY RESTRICTIONS — TYRAMINE: MAOIs (phenelzine, tranylcypromine, isocarboxazid, selegiline) inhibit the enzyme that breaks down tyramine; consuming tyramine-rich foods while on an MAOI causes a dangerous spike in blood pressure (HYPERTENSIVE CRISIS). TYRAMINE-RICH FOODS TO AVOID: Aged cheeses; cured/smoked/processed meats (salami, pepperoni); fermented foods (sauerkraut, kimchi, miso); draft/tap beer; red wine; soy sauce; fava beans; overripe fruits; aged/fermented anything; HYPERTENSIVE CRISIS SIGNS: Severe occipital headache, palpitations, neck stiffness, nausea/vomiting, sweating, severe hypertension — MEDICAL EMERGENCY; DRUG INTERACTIONS: MAOIs interact dangerously with many drugs (SSRIs, sympathomimetics, opioids like meperidine) — risk of serotonin syndrome and hypertensive crisis; require washout periods between MAOIs and other antidepressants; PATIENT EDUCATION: Strict dietary compliance, avoid OTC cold/decongestant medications, report severe headache immediately; nursing role: thorough dietary and drug-interaction teaching, monitor for hypertensive crisis, ensure the client understands the serious consequences of dietary non-compliance.

COMPLICATED GRIEF vs NORMAL GRIEF: NORMAL GRIEF: Varies enormously between individuals; no set timeline; acute phase most intense first year; grief does not end — it transforms; sadness and missing the deceased indefinitely is NORMAL; COMPLICATED GRIEF (Prolonged Grief Disorder — DSM-5 2022): Persisting intense yearning; rumination about the deceased; emotional pain; difficulty accepting the death; feeling meaningless; social withdrawal — ALL still significantly present beyond 12 months (6 months for children); NURSING ASSESSMENT FOCUS: Is the person able to function (work, relationships, self-care)? Are they eating and sleeping? Are they experiencing suicidal ideation? Do they have social support?; THERAPEUTIC RESPONSE: Validate that grief is not a schedule; normalise ongoing sadness; assess for functioning and red flags; provide information about grief support resources; THE WRONG RESPONSES: Giving a timeline to 'be over it'; immediately pathologising normal grief; reassuring without assessment; INTERVENTION: Complicated grief may benefit from specialised Complicated Grief Treatment (CGT) — evidence-based therapy.

PATIENT CONFIDENTIALITY AND PAIN MANAGEMENT: PATIENT AUTONOMY: The client has the right to control what medical information is shared with family — even at end of life; confidentiality does not end when prognosis is terminal; COMPETING OBLIGATION: The nurse also has an obligation to ensure adequate pain management — if the client is suffering in silence, that is a care quality issue; THERAPEUTIC APPROACH: Explore the client's concern ('Tell me more about what you're worried about when your family sees your pain'); problem-solve alternatives ('Is there a way we can manage your pain that wouldn't worry them as much?'); address the underlying fear (burden, family distress) rather than just the surface request; ENSURE ADEQUATE PAIN CONTROL: The request not to tell family does not mean accepting inadequate pain management — work with the client to address pain within their disclosure preferences; DOCUMENTATION: Document the client's expressed wishes about information sharing in the medical record; ETHICAL BALANCE: Patient autonomy is primary; the nurse advocates for the client's wellbeing while respecting their choices.

ADOLESCENT COPING WITH CHRONIC ILLNESS: DEVELOPMENTAL CONTEXT: Adolescents are establishing identity and peer belonging — a diagnosis of a chronic, visible disease (requiring injections, diet management, medical equipment) threatens both; denial and minimisation protect against the full psychological weight of the diagnosis; THERAPEUTIC APPROACH: Do NOT confront denial aggressively — this triggers defensiveness and shuts down communication; EXPLORE: 'It sounds like this has a lot to manage. What parts feel most overwhelming?'; 'What questions do you have about how this affects your daily life?'; ASSESS: Is the denial preventing essential self-care (not testing blood sugar, not giving insulin)? If so, it moves from adaptive to dangerous; EDUCATION APPROACH: Start with the client's concerns and questions rather than a lecture; involve the client in care planning; connect with peer support (other teens with T1DM); family involvement as appropriate; LONG-TERM: Adolescent non-compliance is the highest-risk period for T1DM complications — therapeutic relationship that doesn't alienate is critical.

Nurses have an ethical and (in most states) legal duty to report suspected impairment of colleagues. The behavior may be substance use, mental health issues, or medical conditions affecting function. Why report: (1) Patient safety — impaired nurses can harm patients through errors, missed observations, poor judgment; (2) Colleague's welfare — early intervention enables recovery; ignoring enables progression of disease; (3) Profession's integrity — nursing's trust depends on accountability; (4) Mandatory in many states — nurse practice acts require reporting; failure to report can result in nurse's own license discipline. Signs of impairment: (1) Behavior changes — mood swings, isolation, irritability; (2) Performance issues — errors, missed assignments, falling asleep; (3) Physical signs — slurred speech, unsteady gait, dilated/constricted pupils, smell of alcohol; (4) Medication discrepancies — missing controlled substances, frequent waste, unusual patient pain complaints (when nurse is involved); (5) Working extra shifts or unusual hours (access to medications). What to do: (1) Document specific observations factually; (2) Report to charge nurse or nursing supervisor — proper chain of command; (3) Do not confront the colleague yourself or accuse publicly; (4) Maintain confidentiality; (5) Cooperate with subsequent investigation. Outcomes: investigation, drug testing if indicated, intervention if confirmed; many states have alternative-to-discipline programs (peer assistance programs) that allow recovery while licenses are maintained under monitoring. Punitive responses harm individuals and discourage future reporting. Nurses in recovery often return to practice successfully with proper support.

Coping mechanisms are strategies used to manage stress, emotions, and difficult situations. Healthy (adaptive) coping: (1) Problem-focused — addressing the stressor: planning, seeking information, taking action; (2) Emotion-focused (used when problem can't be changed) — acceptance, emotional support, positive reframing; (3) Physical strategies — exercise, sufficient sleep, healthy eating; (4) Social — talking with trusted people, support groups, professional therapy; (5) Cognitive — mindfulness, meditation, journaling, positive self-talk, cognitive restructuring; (6) Behavioral — engaging in hobbies and meaningful activities, creative expression, time in nature; (7) Spiritual — prayer, meditation, attending religious services if part of one's tradition; (8) Self-care — boundaries, time off, relaxation, pleasure activities; (9) Professional help when needed — therapy, counseling, support groups. Unhealthy (maladaptive) coping: (1) Substance use — alcohol, drugs, nicotine to numb feelings; (2) Behavioral excesses — overeating, gambling, shopping, excessive screen time, compulsive sexual behavior; (3) Restriction — undereating, excessive exercise; (4) Self-harm — cutting, burning, hitting self; (5) Aggression — verbal or physical toward others; (6) Avoidance — denial, isolation, sleeping excessively to avoid; (7) Dependence — clinging behavior, excessive reassurance-seeking; (8) Workaholism — using work to avoid feelings. Nursing role: (1) Assess coping strategies clients use; (2) Reinforce healthy strategies; (3) Education about unhealthy patterns; (4) Skills training (relaxation, mindfulness, problem-solving); (5) Refer to therapy when patterns are entrenched. Personal coping: nurses experience stress and benefit from the same strategies; self-care prevents burnout and compassion fatigue.

Cultural competence is an essential nursing capability in increasingly diverse healthcare environments. Components: (1) Self-awareness — recognizing one's own cultural background, biases, and assumptions; (2) Cultural knowledge — understanding common health beliefs, practices, communication styles, and family structures of different groups (while avoiding stereotyping); (3) Cultural skills — applying culturally responsive assessment and intervention; (4) Cultural encounters — meaningful interaction with diverse individuals; (5) Cultural desire — genuine motivation to provide equitable care. Common areas of cultural variation: (1) Communication styles — direct vs indirect, eye contact norms, comfort with silence, gender norms, decision-making (individual vs family); (2) Health beliefs — disease causation (germ theory vs spiritual/balance), preferred treatments (Western vs traditional), prevention practices, role of healers; (3) Dietary practices — religious restrictions (kosher, halal), preferences, food meanings; (4) Family roles — who makes decisions, who provides care, gender roles, elder respect; (5) Personal space and touch — varies significantly; (6) Time orientation — present vs future; (7) Religious/spiritual practices affecting care — prayer times, modesty requirements, end-of-life rituals, blood transfusions, autopsy, organ donation; (8) Pain expression — stoic vs expressive; (9) Modesty — body exposure, same-gender providers. Cultural humility (alternative concept): lifelong learning, acknowledging power imbalances, partnering with patient and family. Avoid assumptions: ask patient about their preferences rather than assuming based on group. Use professional interpreters for non-English speakers (not family members, not staff). Provide culturally appropriate health information. The goal: equitable, respectful, effective care for every individual.

Spiritual care is part of holistic nursing — recognizing that spiritual well-being affects physical and mental health. Spirituality includes religious beliefs but extends beyond — meaning, purpose, connection, transcendence, values. Spiritual assessment: (1) Faith/Beliefs — what is important to you? do you have spiritual or religious beliefs that affect your health care? (2) Importance — how do these beliefs influence how you take care of yourself? (3) Community — are you part of a religious or spiritual community? (4) Address — how would you like me to address these issues in your care? (FICA tool — Faith, Importance, Community, Address). HOPE tool — Sources of Hope, Organized religion, Personal spirituality and practices, Effects on care. Nursing interventions: (1) Active listening to spiritual concerns; (2) Facilitate practices the patient values — quiet time for prayer or meditation, prayer rugs, religious texts available, religious dietary needs, sacraments, ritual objects; (3) Refer to chaplaincy services — most hospitals have multifaith chaplains available 24/7; (4) Coordinate with patient's own clergy; (5) Be present during difficult times; (6) Respect rituals around death — last rites, washing the body, family time. What the nurse avoids: (1) Imposing personal beliefs on patients; (2) Proselytizing; (3) Judging beliefs that differ from one's own; (4) Praying with patients unless they request and the nurse is comfortable; (5) Engaging in theological discussions outside one's expertise (refer to chaplaincy). Spiritual distress: when illness or loss disrupts beliefs/connection — manifests as questioning faith, feeling abandoned by God, fear of death, meaning crisis. Address with presence, reflection, referral to chaplaincy. Nurses respect atheist, agnostic, and secular humanist patients with the same regard.

PTSD (DSM-5) develops in some individuals exposed to trauma — actual or threatened death, serious injury, or sexual violence. Exposure types: directly experiencing, witnessing, learning about (close family/friend), or repeated/extreme exposure (first responders). Symptoms persist >1 month and cause significant distress/impairment. Four symptom clusters (1+ from each cluster required): (1) INTRUSION — recurrent, involuntary memories; nightmares; flashbacks (dissociative reactions where the person feels they are re-experiencing); intense psychological distress at trauma cues; physiological reactivity to trauma cues. (2) AVOIDANCE — efforts to avoid trauma-related memories/thoughts/feelings; efforts to avoid external reminders (people, places, situations). (3) NEGATIVE ALTERATIONS in cognition/mood — inability to remember important aspects of trauma; persistent negative beliefs ('I'm bad,' 'No one can be trusted'); distorted blame; persistent negative emotional state; diminished interest in activities; detachment; inability to experience positive emotions. (4) AROUSAL AND REACTIVITY — irritability/anger outbursts; reckless or self-destructive behavior; hypervigilance; exaggerated startle; concentration problems; sleep disturbance. Subtypes: with dissociative symptoms; with delayed expression (symptoms develop 6+ months later). Acute Stress Disorder: similar to PTSD but lasts 3 days to 1 month. Treatment: (1) Trauma-focused therapy — Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), EMDR (Eye Movement Desensitization and Reprocessing) — gold standard treatments; (2) Medications — SSRIs (sertraline, paroxetine FDA-approved); SNRIs (venlafaxine); prazosin for nightmares; (3) Group therapy; (4) Mind-body practices — yoga, mindfulness; (5) Service animals. Nursing care: trauma-informed approach throughout; recognize triggers; safety; therapeutic alliance.