NCLEX-RN cheat sheet · Mental health

Depression, bipolar disorder and psychiatric drugs

Mood episodes, depression and mania care, suicide risk, antidepressants, the two drug emergencies, antipsychotics, lithium and benzodiazepines

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Psychiatric drugs can take weeks to help, but cause harm fast. Ask the hardest question directly: are you thinking of suicide?

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At a glance

Mood episodes

Episode	At least	Key features
Major depression	2 weeks	Low mood or lost interest, most of the day, nearly every day
Mania	1 week	Elevated or irritable mood; high energy that impairs function
Hypomania	4 days	Similar but milder; no marked impairment
Cyclothymia	2 years	Milder swings

Caring for mania

Bipolar I has at least one manic episode; bipolar II has hypomania and depression. Mania: grandiosity, little need for sleep, racing thoughts, pressured speech. Poor insight: interview family too.
May not eat or sleep for days: check vital signs, hydration, electrolytes.
High-calorie, high-protein snacks, drinks and finger foods.
Low stimulation, structure, rest periods. No competitive activities. Firm, calm, consistent: short statements, clear limits.

Caring for depression

Round on a varied schedule, often every 15 to 60 minutes, or as the client's observation level requires.
Invite talk about guilt, hopelessness, or thoughts of suicide. Small, frequent, high-calorie snacks and fluids. Open medicines in front of the client. Antidepressants may help within a week or two; full benefit can take 2 to 3 months.
ECT: severe depression that hasn't responded, or that's life-threatening, like a catatonic or suicidal client. Given under anesthesia, usually 2 to 3 times a week, for 6 to 12 treatments. Needs written informed consent.

Antidepressants

Drugs	Key points
All of them	Boxed warning: more suicidal thoughts in children and young adults, up to age 24. Risk peaks early and after dose changes; families report sudden changes right away. Take weeks (up to 12 for fluoxetine). Taper; don't stop suddenly
SSRI (sertraline), SNRI	Usually first. Low sodium in older adults. Bleeding risk with aspirin, anti-inflammatory pain relievers or blood thinners. Insomnia, sexual side effects; venlafaxine can raise blood pressure. No alcohol
Tricyclics (amitriptyline)	Nerve pain and sleep, at bedtime. Dry mouth, constipation, urinary retention, blurred vision, dizziness on standing. Can affect heart rhythm; an overdose can be fatal. Taper
MAO inhibitors (phenelzine)	Hypertensive crisis with tyramine-rich foods or stimulants: avoid aged, fermented, pickled or smoked protein foods (aged cheese, dry sausage), beer, wine, yeast extract, fava beans. Crisis signs: severe back-of-head headache, palpitations, stiff neck, sweating, chest pain

MAO inhibitor gap: direction and drug matter: Wait at least 14 days after an MAO inhibitor, and at least 5 weeks, sometimes longer, after fluoxetine before starting one. Check the product label. Tricyclics are never combined with MAO inhibitors.

Two drug emergencies

	Serotonin syndrome	Neuroleptic malignant syndrome (NMS)
Cause	Serotonin drugs, alone or more often combined, especially with MAO inhibitors	Antipsychotics
Key signs	Agitation, fast pulse, fever, sweating, overactive reflexes, nausea or diarrhea	High fever, rigid muscles, confusion, unstable vital signs
Action	Stop the drug; intensive supportive care. Both can be fatal	Stop the antipsychotic; intensive supportive care

Drug history: At its most severe, serotonin syndrome can look just like NMS. Linezolid and IV methylene blue act as MAO inhibitors too.

Suicide risk and benzodiazepines

Risks: depression, a past attempt, chronic pain or serious illness, job or money loss, substance use, hopelessness. A sudden calm or cheerfulness after a long depression can be a warning sign.
Screen clients 12 and older who are evaluated or treated mainly for a behavioral health condition, and introduce the questions as routine. Ask directly: are you thinking about killing yourself? Asking doesn't plant the idea. A positive screen leads to a full risk assessment: plan, intent, and past attempts.
Remove anything that could be used for self-harm; continuous monitoring for high risk. Written safety plan, in the client's own words. Risk is high after discharge: give follow-up information and the 988 crisis line.
Benzodiazepines (lorazepam): short use; watch breathing, especially after IV doses. Overdose: keep the airway open and support breathing. Flumazenil can trigger seizures in long-term users. Don't stop them suddenly.

Lithium

	Key points
Range	0.8 to 1.2 mEq/L (mmol/L) for acute mania; 0.8 to 1 mEq/L for maintenance. Narrow
Level	12 hours after the last dose, usually just before the morning dose
Toxicity	Can happen near the range; Open RN marks 1.5 mEq/L. Early: vomiting, diarrhea, drowsiness, weakness, poor coordination. Higher: unsteady gait, blurred vision, ringing ears, dilute urine. No antidote
Expected	Fine hand tremor, thirst, frequent urination
Not expected	Severe vomiting or diarrhea, dehydration, or a coarse or worsening tremor: assess, and report to the provider
Salt and fluids	Low sodium raises lithium: keep normal salt and steady fluids, often 2,500 to 3,000 mL a day at first. Assess fluid losses. With fluid limits or kidney disease, follow their fluid plan
Raise the level	Diuretics, anti-inflammatory pain relievers, ACE inhibitors, angiotensin receptor blockers: check the level after medicine changes

Antipsychotics

	Key points
All	Boxed warning: older adults with dementia-related psychosis have a higher risk of death. Don't stop suddenly
Dystonia, parkinsonism	Acute dystonia is a painful muscle spasm. Benztropine often treats dystonia and drug-induced parkinsonism
Akathisia	A distressing restlessness. Anticholinergics aren't a blanket treatment
Tardive dyskinesia	Longer use: involuntary mouth and face movement; can be permanent. Anticholinergics can worsen it
Metabolic	Newer drugs like olanzapine: weight gain, high glucose, abnormal lipids; check them regularly
Clozapine	Severe neutropenia: ANC before starting, and regularly. Seizures, heart inflammation, fainting, severe constipation
Haloperidol	Can prolong the QT interval; not used in Parkinson's disease or Lewy body dementia

Priority and safety calls

★ "My family would be better off without me": ask directly whether she's thinking of killing herself, then assess plan and intent.
★ If danger seems imminent, call for help, and stay with the person. Don't keep a plan secret: make sure the whole team knows.
★ Lithium with vomiting, diarrhea, drowsiness and a worsening tremor: hold the lithium, assess the client, and report it. A new diuretic can raise lithium into the toxic range.
Phenelzine and a sudden severe headache with palpitations: check the blood pressure, and report a possible hypertensive crisis at once.
A young adult on a new antidepressant is more agitated and giving away belongings: treat it as a possible suicide warning; assess safety and notify the provider.
Benzodiazepines with opioids: profound sedation, stopped breathing, coma and death.
Lithium with an antipsychotic: report weakness, fever, tremor and confusion at once. Fainting or an irregular heartbeat needs emergency help.

How the NCLEX tests it

Suicide: ask directly, remove means, stay, safety plan.
Traps: avoiding the word suicide, keeping a plan secret, competitive games in mania, cutting salt on lithium.
Drug traps: stopping when better, expecting fast results, missing NMS.
Mania: a week; finger foods, low stimulation, firm limits.
Serotonin syndrome and NMS: stop the drug and support the client.
Antipsychotics: watch movement and metabolic effects. Clozapine: the ANC.

Practice it next

This sheet comes from Depression, bipolar disorder and suicide risk and Psychiatric drugs in our NCLEX-RN course. Try free practice questions, or see the lessons it was written from.

Free NCLEX practice questions The NCLEX-RN course

Quick self-quiz

Major depression lasts at least ___ weeks.
Show answer
2
Hypomania lasts at least ___ days.
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4
Draw a lithium level ___ hours after the last dose.
Show answer
12
Aged cheese is high in ___, which can cause a hypertensive crisis on an MAO inhibitor.
Show answer
tyramine
ECT needs written informed ___.
Show answer
consent
Anticholinergics can worsen ___ dyskinesia.
Show answer
tardive

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Sources

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