Mental health conditions

Mental health items on the NCLEX turn on safety first: feed and protect the manic client, answer psychosis without feeding the delusion, rank suicide risk honestly, catch the drug emergencies that kill, and prep ECT without turning it into folklore. SSRI suicide watch, serotonin syndrome, MAOI diet, and TCA overdose deepen in Antidepressants. How you phrase the conversation once the room is safe lives in Therapeutic Communication.

Mood and psychotic disorders

Mania and psychosis look energetic or convinced, so the untrained eye under-triages them. Priority is not naming the diagnosis first. It is whether the person can eat, sleep, and stay safe long enough for treatment to work. Depression adds the opposite risk: withdrawal and suicidality that you only find if you ask.

Why finger foods beat a full tray in mania: decreased need for sleep and constant motion burn calories and block sitting. Grandiosity and pressured speech make a quiet meal feel optional. Portable high-calorie food and fluids protect nutrition while you lower stimulation and chase sleep. Insight returns after the biology settles, not before.

Psychosis is not a debate you win. Arguing a delusion entrenches it. Agreeing validates a false reality and raises agitation when the content is threatening. Acknowledge the feeling (that sounds frightening), stay concrete about the shared environment, and redirect to a present safety task. The wording craft for that exchange is in Therapeutic Communication. The clinical rule here is: feelings yes, false content no.

The distractor that looks therapeutic is challenging the voice or delusion with logic, or leaving the manic client alone to rest in a stimulating space. Rest without means restriction and milieu control is not rest. It is unsupervised impulsivity.

Suicide risk

Ask directly about ideation, plan, means, and intent. Vague cheerleading (you wouldn't really) teaches that honesty is unsafe and leaves you with a false negative. On the exam and at the bedside, a clear question is the assessment, not a conversation you outsource to hope.

1. Ask directly about thoughts of suicide, plan, means, and intent.
2. Remove means and increase observation for high-risk clients.
3. Do not leave a high-risk client alone while you go check something.
4. Document and communicate the risk level to the team.

• Warning signs: hopelessness, giving away possessions, sudden calm after severe depression, talking about death, rehearsing a plan.
• Highest immediate risk: specific plan with accessible means and clear intent, or active attempt preparation.

Risk rises when a plan meets access. Ideation still demands a full screen and means reduction in the environment you control, but a worked-out method with available means is an emergency workflow: continuous observation per protocol, team notification, secure the room. Not check back later. Sudden calm or gift-giving after severe despair can mean a decision was made. Treat the shift as a red flag, not as recovery.

The distractor that looks caring is contracting for safety as your only intervention, promising secrecy, or leaving the person alone to rest. You cannot keep a lethal plan confidential from the team. Your duty is escalation and means restriction in the setting you control.

Lithium toxicity

Lithium tracks sodium and water. When sodium drops or the patient dehydrates, the kidney reabsorbs lithium in sodium's place. The level climbs without a dose change. NSAIDs, thiazide diuretics, and volume loss (vomiting, diarrhea, heavy sweating) tighten that trap. Therapeutic monitoring is expected. Toxicity is a hold-and-notify event.

Lithium teaching that prevents the crisis

• Take as prescribed. Monitor levels as ordered.
• Keep salt and fluid intake steady. Dehydration and low sodium raise levels.
• Avoid starting NSAIDs casually. Check with the provider.
• Report vomiting, diarrhea, coarse tremor, or unsteady gait immediately.

A level in the toxic range with neurologic signs outranks continuing the schedule because mood was improving. Hold the drug, notify, and fix volume and sodium. That is the when-to-hold rule for lithium.

Antipsychotics: EPS, NMS, and clozapine

Antipsychotics block dopamine pathways. That helps psychosis and creates movement and autonomic emergencies. Mechanism tells you which syndrome and which first move. Delay is the failure.

NMS is lead-pipe rigidity, high fever, and falling LOC after an antipsychotic. Treat as a medical emergency (stop the drug, cool, support), not as mild EPS you can watch overnight. Acute dystonia is airway-adjacent muscle spasm soon after a dose. Ordered parenteral anticholinergic now, not a PO PRN for later. Distinguish NMS from serotonin syndrome: NMS is antipsychotic plus rigidity; serotonin syndrome is serotonergic stack plus clonus/hyperreflexia (see Antidepressants).

Clozapine and agranulocytosis

Clozapine can crush neutrophils. That is why ANC monitoring exists and why fever, sore throat, or flu-like malaise on clozapine is a hold-and-labs event, not a push through because mood was finally stable. Teach clients to report infection signs immediately. Do not give the next dose while you wait and see a febrile clozapine client.

• Other antipsychotic teaching that appears: orthostatic hypotension (rise slowly), sedation, metabolic changes on some atypicals, photosensitivity on some typicals.
• Never crush long-acting or depot rules into casual cheeking assumptions. Follow the ordered form.
• MAOI crisis details and SSRI stacking live in Antidepressants.

ECT: consent, NPO, bite block, recover

Electroconvulsive therapy uses a brief, monitored seizure under anesthesia to treat severe depression and some other indicated illnesses when meds have failed or a fast response is needed (including pregnancy when the stem frames it that way). The nursing job is not debating whether ECT is “barbaric.” It is making the seizure safe: empty stomach, protected airway and teeth, monitoring, and a recovering brain that is confused for a while.

Informed consent is obtained by the provider; your job is that the client (or legally authorized decision-maker) actually understands the plan, including expected short-term memory gaps around the treatment window. Retrograde and anterograde fuzziness for recent events is common teaching, not proof the treatment “fried the brain.” Document questions you cannot answer and get the provider back; do not invent a guarantee of no memory change.

NPO follows anesthesia rules because aspiration during a seizure under anesthesia is the preventable disaster. A breakfast tray “because they look sad” is the distractor. Hold oral meds as the ordered prep says; anticonvulsants may be held so a therapeutic seizure can occur, but only when the protocol names that hold. Do not freelance a lithium or benzodiazepine stop. Remove dentures. The bite block keeps teeth from clenching through the tongue; it is placed when the airway team is ready, not as a hallway gag. Pulse oximetry and ECG (and usually EEG as the team uses it) stay on through the seizure. Afterward, the client is post-ictal and post-anesthesia: stay, reorient, check airway and vitals, then return to the unit plan. Dumping them in a noisy dayroom while still confused is how injury happens.

When to hold psych meds (quick map)

These hold cues sit on top of the mechanisms already taught: lithium follows salt and water, NMS follows antipsychotics, clozapine fails when neutrophils fall, and serotonergic or MAOI crises follow the antidepressant chapter. The table is the bedside stop rule, not a substitute for recognizing the syndrome.

Priority map