NCLEX-RN Substance Use and Crisis — Withdrawal, CIWA, and Trauma Response

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.

SPLITTING IN BORDERLINE PERSONALITY DISORDER: DEFINITION: Seeing people as entirely good or entirely bad — unable to hold the ambivalent complexity that everyone is both; 'You're wonderful, everyone else is terrible'; RECOGNITION: Is a classic BPD interpersonal pattern; the 'wonderful' nurse gets idealized; the 'bad' nurses get devalued; this can create division in nursing teams if not recognized; THERAPEUTIC RESPONSE: Acknowledge feelings without reinforcing: 'I'm glad you feel heard. I also want you to know that all of your nurses care about you and work as a team'; WHAT NOT TO DO: Agree that other nurses are bad; become a 'special' nurse who is different from the team; allow special treatment that breaks unit rules; TEAM COMMUNICATION: CRITICAL — document the pattern; hold a team meeting to ensure all staff respond consistently; inconsistent responses allow the splitting to continue; LIMITS AND CONSISTENCY: Clear, compassionate consistent limits from all team members is the most therapeutic approach; BPD clients benefit from predictability and consistency.

ELDER ABUSE IDENTIFICATION AND MANDATORY REPORTING: RED FLAGS PRESENT: Multiple bruises in various stages (suggests repeated injury); fear response to caregiver; flinching (anticipatory fear of being struck); TYPES OF ELDER ABUSE: Physical (most visible); emotional/psychological; sexual; financial; neglect (active or passive); self-neglect; MANDATORY REPORTING: All 50 states require certain professionals (including nurses) to report suspected elder abuse, neglect, or exploitation to Adult Protective Services (APS) — SUSPICION is sufficient; certainty is not required; DOCUMENTATION: Document objective observations (bruise locations, colours, sizes, patient behaviours) without speculative language; REPORTING PROCESS: Call APS or law enforcement; provide factual observations; ASSESSMENT IN PRIVATE: If possible, assess the client ALONE without the suspected abuser present — clients rarely disclose abuse in the presence of the abuser; LEGAL IMMUNITY: Mandatory reporters are immune from liability for good-faith reports; FAILURE TO REPORT: May be a criminal violation; certainly an ethical failure.

PSYCHOLOGICAL FIRST AID (PFA): An evidence-informed approach for helping people in the immediate aftermath of disaster or trauma. PRIMARY GOALS: Reduce initial distress; meet immediate practical needs (safety, food, shelter, information); foster adaptive coping and resilience; connect people with support and resources; promote a sense of safety, calm, connectedness, self-efficacy, and hope; PFA PRINCIPLES: Provide comfort and practical support; do NOT force people to talk about or 'process' the event (premature debriefing can be harmful); listen if they want to share; respect culture and individual coping; protect from further harm; reunite with loved ones; provide accurate information; NOT PFA: Formal psychotherapy; mandatory critical incident debriefing (no longer recommended — can interfere with natural recovery); diagnosing; pathologizing normal stress reactions; TRIAGE: Identify those needing higher-level care while supporting the majority who will recover with basic support; nursing role: provide practical and emotional support, ensure safety and basic needs, foster coping, connect to resources, avoid forcing trauma processing.

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.