NLE NP V Review: Psychiatric and Mental Health Nursing (Plus Critical Care)

NLE NP V Review: Psychiatric and Mental Health Nursing (Plus Critical Care)

In the current NLE program, psychiatric nursing sits in Nursing Practice V: Care of Clients with Maladaptive Patterns of Behavior, together with care of clients with life-threatening conditions, acutely ill/multi-organ problems, high acuity and emergency situations. NP V is the second test on Day 2 (11:30 a.m.–1:30 p.m., 2 hours).

Many BSN programs give psychiatric nursing a short rotation, and its items test judgment and communication more than recall. That combination makes it a common weak spot, and a single test below 60% means you haven't passed, even with a strong average (see the 60% floor rule).

This post covers the psychiatric half in depth and gives a checklist for the critical-care half. It goes with the NLE guide. PRC doesn't publish an item breakdown by topic, so cover everything below.

Therapeutic communication

Therapeutic communication items follow a predictable structure: a patient statement, then four nurse responses. Pick the most therapeutic.

Therapeutic techniques:

• Active listening / silence
• Open-ended questions
• Restating, reflecting, paraphrasing
• Clarification ("Can you tell me more about...")
• Focusing on feelings ("You sound frustrated")
• Offering self ("I'll sit with you")
• Sharing observations ("I notice you've been quiet today")
• Encouraging description ("What was it like?")
• Validation ("That makes sense")
• Exploration

Non-therapeutic techniques (almost always the wrong option):

• Giving advice ("You should...")
• Reassurance ("Don't worry, everything will be fine")
• Disagreement / argument
• Minimizing ("It's not that bad")
• Defending ("The doctor knows best")
• Asking "why" questions (puts patient on defensive)
• Closed yes/no questions in emotional contexts
• Changing the subject
• Probing for more than the patient is offering
• Stereotypical responses

Drill 100+ therapeutic communication items. Pattern recognition makes these close to automatic.

Anxiety disorders

Drill list:

• Generalized Anxiety Disorder (GAD): persistent, excessive worry, multiple domains
• Panic Disorder: recurrent panic attacks, fear of attacks
• Phobic Disorders: specific phobia, social phobia, agoraphobia
• Obsessive-Compulsive Disorder (OCD): obsessions + compulsions, common rituals
• Post-Traumatic Stress Disorder (PTSD): re-experiencing, avoidance, hyperarousal, mood changes
• Acute Stress Disorder

For each: typical presentation, key nursing interventions, common medications (benzodiazepines short-term, SSRIs long-term).

Levels of anxiety (Peplau):

• Mild: alert, increased perceptual field
• Moderate: focus on immediate concern, decreased perceptual field
• Severe: focus on detail, can't see whole, narrow perception
• Panic: dread/terror, disorganized thinking, can't process information

Match nursing intervention to anxiety level. Moderate anxiety: redirect, problem-solve. Severe/panic: stay calm, simple short statements, ensure safety.

Mood disorders

Major Depressive Disorder:

• Symptoms: depressed mood, anhedonia, sleep changes, weight changes, psychomotor changes, fatigue, worthlessness, concentration difficulty, suicidal ideation
• Suicide risk assessment (a high-priority topic)
• Nursing interventions: safety first, structured routine, gradual activity, therapeutic communication
• Medications: SSRIs, SNRIs, tricyclics, MAOIs (and food/drug interactions)

Bipolar Disorder:

• Mania: elevated/irritable mood, decreased need for sleep, grandiosity, pressured speech, flight of ideas, distractibility, increased goal-directed activity, risky behavior
• Nursing interventions during mania: safe environment, low stimulation, redirect, set limits, finger foods (won't sit to eat), monitor exhaustion
• Medications: lithium (toxicity signs at 1.5+ mEq/L: tremor, confusion, ataxia, seizures), valproate, carbamazepine, lamotrigine, atypical antipsychotics

Lithium toxicity is a classic board item. Memorize the signs and the ranges (roughly 0.6–1.2 mEq/L therapeutic; toxicity signs appear from about 1.5 mEq/L). Also know that dehydration and low sodium intake raise lithium levels.

Schizophrenia spectrum

Positive symptoms (added to normal experience):

• Hallucinations (auditory most common)
• Delusions (paranoid, grandiose, somatic)
• Disorganized speech (loose associations, neologisms, word salad)
• Disorganized behavior

Negative symptoms (subtracted from normal experience):

• Affective flattening
• Alogia (poverty of speech)
• Avolition
• Anhedonia
• Asociality

Nursing interventions:

• Acknowledge feelings without reinforcing delusions ("I don't see what you see, but I understand it's frightening")
• Redirect from hallucinations
• Decrease environmental stimulation
• Build trust through consistency

Medications:

• Typical antipsychotics: haloperidol, chlorpromazine — high risk of EPS (extrapyramidal symptoms: dystonia, akathisia, parkinsonism, tardive dyskinesia)
• Atypical antipsychotics: clozapine, olanzapine, risperidone, quetiapine — lower EPS, higher metabolic risk

Clozapine carries a risk of agranulocytosis, so blood counts (WBC/ANC) are monitored closely, weekly at the start of treatment.

Neuroleptic Malignant Syndrome (NMS) — life-threatening reaction to antipsychotics: hyperthermia, muscle rigidity, autonomic instability, altered mental status. Stop drug immediately, supportive care.

Personality disorders

Cluster A (odd/eccentric):

• Paranoid
• Schizoid
• Schizotypal

Cluster B (dramatic/erratic):

• Antisocial
• Borderline (high-yield — dichotomous thinking, fear of abandonment, self-harm, identity disturbance)
• Histrionic
• Narcissistic

Cluster C (anxious/fearful):

• Avoidant
• Dependent
• Obsessive-Compulsive Personality Disorder (different from OCD)

Borderline personality nursing care: consistent limit-setting, validate feelings without reinforcing self-destructive behavior, safety planning, dialectical behavior therapy (DBT) framework.

Substance abuse

Drill withdrawal patterns and management:

• Alcohol withdrawal: tremor (6-12h), seizures (24-48h), DTs (48-96h). Manage with benzodiazepines (CIWA protocol), thiamine, hydration
• Opioid withdrawal: not typically life-threatening but very uncomfortable. Manage with clonidine, methadone or buprenorphine substitution
• Stimulant withdrawal: depression, fatigue, hypersomnia. Mostly supportive
• Sedative-hypnotic withdrawal: similar pattern to alcohol, can be life-threatening

Wernicke-Korsakoff Syndrome from chronic alcohol use + thiamine deficiency. Triad: confusion, ataxia, ophthalmoplegia. Always give thiamine before glucose in alcohol-dependent patient.

Crisis intervention

Suicide risk assessment:

• Direct questions ("Are you thinking about killing yourself?")
• Plan + means + access + lethality
• Previous attempts (strongest single predictor)
• Higher-risk factors: prior attempts, recent loss, substance use, hopelessness, access to lethal means

Always remove means. Always escalate. Don't promise confidentiality on suicide.

Violence assessment:

• Direct threats, history of violence, agitation, intoxication, paranoia
• De-escalation: calm voice, give space, offer choices, don't argue, ensure exit

Grief and loss:

• Kübler-Ross stages: denial, anger, bargaining, depression, acceptance (not necessarily linear)
• Distinguish normal grief from major depressive disorder
• Cultural variation in grief expression

Child and adolescent psychiatric

• ADHD: inattention + hyperactivity-impulsivity, treatment with stimulants (methylphenidate, amphetamines), behavioral therapy
• Autism Spectrum Disorder: social communication deficits + restricted interests/repetitive behavior
• Conduct Disorder vs. Oppositional Defiant Disorder
• Depression in adolescents: irritability often more prominent than sadness

Cognitive disorders

Delirium:

• Acute, fluctuating
• Causes: infection, medication, electrolyte imbalance, hypoxia, withdrawal
• Treat the cause; supportive care

Dementia (Alzheimer's most common):

• Chronic, progressive
• Memory loss + functional decline + behavioral changes
• Nursing care: structured environment, simple instructions, validation therapy, safety

Distinguish delirium (acute, reversible, fluctuating) from dementia (chronic, progressive, stable course).

The critical-care half of NP V

The same test also covers life-threatening, multi-organ, high-acuity and emergency situations. Make sure you can handle:

• Prioritization: airway, breathing, circulation; which patient to see first; triage categories
• Shock: hypovolemic, cardiogenic, septic, anaphylactic — recognition and first nursing actions
• Cardiac and respiratory emergencies: cardiac arrest and CPR sequence, acute MI, pulmonary edema, respiratory failure, ABG interpretation
• Neurologic emergencies: increased intracranial pressure, stroke warning signs, status epilepticus
• Burns, trauma and poisoning: fluid resuscitation principles, the rule of nines, common antidotes
• Multi-organ problems: DIC, acute kidney injury, ARDS
• Disaster nursing: triage in mass-casualty incidents

A 4-week NP V plan

Aim for 70%+ on NP V practice sets so the 60% floor never comes into play.

Review with Super Tutor

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What to read next

The NLE guide covers all five Nursing Practice tests. The 60% floor rule explainer shows what happens if one test falls under 60.