NCLEX-RN cheat sheet · Mental health

Psychosis and substance use

Schizophrenia, antipsychotics, hallucinations and delusions, intoxication and overdose, withdrawal and recovery

AI-checkedChecked by AI against current guidelines, with spot-checks by a registered nurse.

Rule out medical causes of psychosis, and don't argue with or agree with a hallucination or delusion: name the feeling. Watch for withdrawal in any client, whatever they were admitted for.

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At a glance

Schizophrenia symptom groups

Group	What it means	Examples
Positive	Added experiences	Hallucinations, delusions, disorganized speech and behavior
Negative	Losses	Little motivation, little pleasure, flat affect, less speech
Cognitive	Thinking problems	Attention, memory, using information to decide

How long: Schizophrenia: signs for at least 6 months. A brief psychotic episode: at least a day but less than a month. Psychosis from a medical cause is often called delirium.

Hallucinations and delusions

Ask "what do you hear?", not "what are the voices saying?" Don't treat the voices as real.
Ask about commands: is a voice telling you to do something, and do you believe it's real?
Offer your own perception with empathy: "I don't hear voices, but that must be frightening."
A delusion is a fixed, false belief. Don't try to disprove it; don't agree with it. Focus on the fear: what would help you feel safer?
Short, simple sentences, spoken calmly and slowly; short, frequent contacts; the here and now.

Antipsychotics

	What to know
Timing	Agitation and hallucinations may ease within days; delusions, within a few weeks. Full effect can take up to 6 weeks
Adherence	Relapse usually follows stopping the medicine. Stopping suddenly can cause dizziness, vomiting, uncontrolled mouth movements. Long-acting injections, every 2 weeks up to every 6 months, can help
Acute dystonia	Throat dystonia threatens the airway: get help. Injected benztropine or diphenhydramine usually works within 10 to 30 minutes
Tardive dyskinesia	Lip smacking, puckering, grimacing; can persist after the drug stops. Tracked with the Abnormal Involuntary Movement Scale
NMS	Fever, severe rigidity and confusion: stop the drug and call now
Metabolic, clozapine	Second-generation drugs can cause weight gain: check weight, glucose and lipids before starting, then regularly, weight most often. Clozapine needs routine blood counts

Intoxication at a glance

Substance	Look for	Biggest danger, care
Alcohol	Slurred speech, poor coordination, unsteady gait, jerky eye movements	Slow breathing. Protect the airway, check vital signs, prevent low blood sugar
Opioids	Pinpoint pupils, drowsiness	Overdose slows breathing until it stops
Benzodiazepines	Look like alcohol	Most dangerous combined with alcohol or opioids
Stimulants	Dilated pupils, racing heart, agitation that can turn suddenly violent	Heat, arrhythmia, violence
Cannabis	Red eyes, hunger, dry mouth, fast pulse	Large doses can cause psychosis
PCP	Assaultive, unpredictable; jerky eyes, high blood pressure, little response to pain	Calm, low-stimulation room; lorazepam for significant agitation

Alcohol withdrawal: time after the last drink

When	What you see
6 to 24 hours	Anxiety, tremor, sweating, nausea, fast pulse, high blood pressure
12 to 24 hours	Hallucinations, often of insects or animals
6 to 48 hours	Seizures
48 to 96 hours	Delirium tremens (most common): confusion, fever, racing heart, drenching sweats

Emergency: Severe withdrawal is an emergency.

Managing alcohol withdrawal

The CIWA-Ar scale scores 10 signs and guides symptom-triggered doses by protocol.
Benzodiazepines, like lorazepam or chlordiazepoxide, prevent seizures and delirium tremens.
Give IV thiamine with the dextrose to prevent Wernicke's encephalopathy: confusion, unsteady gait, jerky eye movements. Untreated, it can become Korsakoff syndrome.
Replace magnesium and other electrolytes; help clients to the bathroom to prevent falls.

Overdose and stimulant crisis

Opioid overdose: unresponsive, pinpoint pupils, slow or snoring breaths, blue lips.
Call for help, support breathing or start CPR, and give naloxone; repeat it if breathing doesn't improve in 2 to 3 minutes. The goal is adequate breathing, not full arousal.
Consider naloxone for anyone found unresponsive. Watch breathing and oxygen levels, and keep naloxone available.
Flumazenil reverses benzodiazepines, but it can trigger seizures, so it's used cautiously.
Stimulants: IV benzodiazepines calm agitation. Avoid physical restraints. Cool aggressively; fever reducers don't work. Continuous cardiac monitoring.

Opioid and benzodiazepine withdrawal

Opioid withdrawal: craving, anxiety, restlessness, cramping, diarrhea, sweating, fast pulse. Scored with COWS.
Buprenorphine given too early can worsen withdrawal: the client must already be in mild to moderate withdrawal. Methadone doesn't trigger withdrawal.
Clonidine eases sweating, cramps and anxiety; watch for low blood pressure and sedation.
Benzodiazepine withdrawal: seizures 1 to 5 days after stopping suddenly. Switch to a long-acting benzodiazepine; taper slowly.
Tolerance drops during abstinence: using the old amount after detox, or after release from jail, can be fatal.

Substance use disorder and recovery

At least 2 of 11 problems within 12 months. Two or 3 criteria is mild, 4 or 5 moderate, 6 or more severe. A chronic illness: relapse means the plan needs to change.
Alcohol use disorder: acamprosate to stay abstinent, naltrexone to reduce craving, and disulfiram, which causes nausea, flushing and palpitations if the client drinks.
Person-first language. Explore denial rather than confront it: "What do you think others are worried about?" Avoid power struggles and ultimatums.

Priority and safety calls

★ A voice is telling him to hurt his roommate, and he believes it's real: tell the provider and monitor closely. Command hallucinations can lead to suicide or violence.
No psychiatric history, suddenly confused and sees things that aren't there: consider a medical cause, such as delirium, first.
★ A day after surgery: tremulous, sweaty, anxious, pulse 112, drinks every night. Score him on the CIWA scale and give the prescribed benzodiazepine.
Safety comes first, including suicide screening. Ask what else was taken: other drugs raise the risk of overdose.
Pain is still real: use non-opioid options too, and remember opioid users may be more sensitive to pain.
Suspected impaired colleague or diversion (count discrepancies, unusual waste, poor pain relief): report it to the manager.

How the NCLEX tests it

Psychosis traps: asking what the voices say, arguing or agreeing, stopping medicine once better.
Best response: offer your own perception and name the fear. "I don't see anyone, but you look frightened."
Positive symptoms are added; negative ones are losses.
Substance traps: missing withdrawal after surgery, restraints or fever reducers for stimulants, confronting denial.
Alcohol withdrawal: 6 to 24 hours, seizures by 48, delirium tremens most often at 48 to 96.
Benzodiazepines by withdrawal score, and thiamine with dextrose.
Explore denial, and report an impaired colleague.

Practice it next

This sheet comes from Schizophrenia and psychotic disorders and Substance use disorders 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

Schizophrenia signs last at least ___ months.
Show answer
6
A client who doesn't recognize being ill has ___.
Show answer
anosognosia
Repeating another person's words is ___.
Show answer
echolalia
Delirium tremens is most common at ___ to 96 hours after the last drink.
Show answer
48
IV thiamine with dextrose prevents ___ encephalopathy.
Show answer
Wernicke's
Start buprenorphine once the client is in mild to ___ withdrawal.
Show answer
moderate

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Sources

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