1. This document provides information on psychiatric nursing for the July 2012 PNLE exam, including topics on neurotransmitters, therapeutic and non-therapeutic communication techniques, defense mechanisms, the nurse-patient relationship, anxiety, depression, bipolar disorder, mood disorders, schizophrenia, and antidepressant medications. 2. Key aspects of neurotransmitters like dopamine, norepinephrine, serotonin, acetylcholine, and GABA are discussed. Therapeutic communication techniques include silence, reflection, and clarification, while non-therapeutic techniques include reassurance and advising. 3. Common defense mechanisms, the phases of the nurse-patient relationship, levels of anxiety and interventions, and assessments and treatments for various mood and

1. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
A. Neurotransmitters 8. Agreeing: telling client know that you think, feel alike; nurse
verbalizes agreement
Dopamine Dopamine is generally excitatory and is 9. Disagreeing: letting client know that you do not agree; telling
synthesized from tyrosine, a dietary amino acid. client that you do not believe he is right
* Antipsychotic medications work by blocking 10. Probing: questioning client about a topic he has indicated he
dopamine receptors and reducing dopamine does not want to discuss.
activity. 11. Denial: refusing to recognize client’s perception
Norepinephrine It plays a role in mood regulation. 12. Changing topic: letting client know you do not want to discuss
Epinephrine Controls the fight-or-flight response in the a problem by introducing a new topic.
peripheral nervous system.
Serotonin The function of serotonin is mostly inhibitory, D. Defense Mechanism
involved in the control of food intake, sleep and
wakefulness, temperature regulation, pain  Denial: Refusal to acknowledge a part of reality
control, sexual behavior, and regulation of  Repression: threatening thoughts are pushed into the
emotions unconscious, anxiety and other symptoms are observed; client
Acetylcholine It can be excitatory or inhibitory. It is unable to have conscious awareness of conflicts or events that
synthesized from dietary choline found in red are source of anxiety
meat and vegetables and has been found to  Suppression: consciously putting a threatening / distressing
affect the sleep-wake cycle and to signal muscles thought out of one’s awareness
to become active.  Rationalization: Developing an acceptable, justifiable (to self)
Gamma- Is a major inhibitory neurotransmitter in the reason for behavior
Aminobutyric brain and has been found to modulate other  Reaction-formation: engaging in behavior that is opposite of
Acid (GABA) neurotransmitter systems rather than to provide true desires
a direct stimulus.  Sublimation: anxiety channeled into socially acceptable
behavior
 Compensation: making up for a deficit by success in another
field/area
B. Therapeutic Communications  Projection: placing own undesirable trait onto another;
blaming others for own difficulty
1. Silence: client able to think about self/problems; does not feel  Displacement: Directing feelings about one object/person
pressure or obligation to speak towards a less threatening object/person
2. Offering self: offer to provide comfort to client by presence.  Identification: taking onto oneself the traits of others that one
3. Accepting: Indicate nonjudgmental acceptance of client and his admires
perceptions by nodding and following what client says.  Introjection: symbolic incorporation of another into one’s
4. Giving recognition: indicate to client your awareness of him personality
and his behaviors.  Conversion: anxiety converted into a physical symptom that is
5. Making observations: verbalize what you perceive motor or sensory in nature
6. Encourage description: ask client to verbalize his perception  Symbolization: representing an idea or object by a substitute
7. Using broad openings: encourage client to introduce topic of object or sign
conversation  Dissociation: separation or splitting off of one aspect of mental
8. Offering general leads: encourage client to continue discussing process from conscious awareness
topic.  Undoing: behavior that is opposite of earlier unacceptable
9. Reflecting: direct client’s questions/ statements back to behavior or thought
encourage expression of ideas and feelings.  Regression: behavior that reflects an earlier level of
10. Restating: repeat what client has said. development. Adults hospitalized with serious illnesses
11. Focusing: encourage the client to stay on topic/point. sometimes will engage in regressive behaviors.
12. Exploring: encourage client to express feelings or ideas in more  Isolation: separating emotional aspects of content from
depth cognitive aspects of thought.
13. Clarification: encourage the client to make idea or feeling more  Splitting: viewing self, others, or situations as all good or all
explicit, understandable. bad.
14. Presenting reality: report events/situations as they really are.
15. Translating into feelings: encourage client to verbalize
E. Therapeutic Nurse-Patient Relationship
feelings expressed in another way.
16. Suggesting collaboration: offer to work with client towards
goal  Three (3) phases of nurse-client relationship
C. Non-Therapeutic Communications Orientation
1. Reassuring: telling the client there is no need to worry or be  Nurse explains relationship to client, defines both nurse’s
anxious. and client’s roles.
2. Advising: telling client what you believe should be done  Nurse determines what client expects from the
3. Requesting explanation: asking the client to provide reasons relationship and what can be done for the client.
for his feelings/behavior. The use of “WHY” questions should be  Nurse contracts with client about when and where future
avoided meetings will take place.
4. Stereotypical response: replying to client with meaningless  Nurse asses client and develops a plan of care based on
clichés appropriate nursing diagnoses.
5. Belittling feelings: minimizing or making light of client’s  Limits/termination of relationship are introduced (e.g.,
distress or discomfort “we will be meeting for 30 mins every morning while you
6. Approving: giving approval to client’s behavior or opinion are in the hospital.”)
7. Disapproving: telling client certain behavior or opinions do not
meet your approval
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE

2. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
Working Phase  Provide outlets (e.g., talking, psychomotor
 Client’s problems and needs are identified and explored as activity, crying, tasks)
nurse and client develop mutual acceptance.  Provide support and encourage client to find
 Client’s dysfunctional symptoms, feelings, or interpersonal ways to cope with anxiety.
relationships are identified.
 In panic state nurse must make decisions.
 Therapeutic techniques are employed to reduce anxiety
and to promote positive change and independence  Do not leave client alone.
 Goals are evaluated as therapeutic work proceeds, and  Encourage ventilation of thoughts and
changed as determined by client’s progress. feelings.
 Use firm voice and give short, explicit
Termination Phase directions (e.g., “sit in this chair. I will sit
 Relationship and growth in nurse and client are here next to you”).
summarized  Engage client in motor activity to reduce
 Client may become anxious and react with increased tension (e.g., “We can take a brisk walk
dependence, hostility, or withdrawal. around the day room. Let’s go”).
 These reactions are discussed with client.
 Feelings of nurse and client concerning termination
should be discussed in context of finiteness of
relationship. G. Bipolar Disorder
Transeference: occurs when client transfers  Characterized by hyperactivity and euphoria that may
conflicts/feelings from past to the nurse. become sarcasm or hostility
Example: client becomes overly dependent, clinging to nurse  Assessment findings
who represents (unconsciously to client) the nurturing client  Hyperactivity to the point of physical exhaustion
 Flamboyant dress/makeup
desires from own mother.
 Sexual acting out
 Impulsive behaviors
Countertranseference: occurs when nurse responds to  Flight of ideas: inability to finish one thought before
client emotionally, as if in a personal, not jumping to another
professional/therapeutic relationship.  Loud, domineering, manipulative behavior
Example: Nurse is sarcastic and judgmental to client who has a  Distractibility
history of drug abuse. Client represents (unconsciously to  Dehydration, nutritional deficits
nurse) the nurse’s brother who has abused drugs.  Delusions of grandeur
 Possible short-term depression (risk for suicide)
 Hostility, aggression
F. Anxiety
 Experienced as a sense of emotional or physical  Nursing Intervention:
distress as the individual responds to an unknown  Determine what client is attempting to tell you; use
threat or thwarting of unmet needs. active listening.
 Levels of Anxiety  Assist client in focusing on a topic
 Offer finger foods, high-nutrition foods, and fluids.
Mild Increased awareness; ability to solve problems,  Provide quite environment, decrease stimuli
learn; increase in perceptual field; minimal muscle  Stay with client, use silence
tension.  Remove harmful objects
Moderate Optimal level for learning, perceptual field narrows  Be accepting of hostile statements.
to pay attention to particular details, increased  Do not argue with client
tension to solve problems or meet challenges.
 Use distraction to diver client from behaviors that
Severe Sympathetic nervous system (flight/fight
response): increase in BP, pulse and respirations; are harmful to self or others.
narrowed perceptual field, fixed vision, dilated  Administer medications as ordered and observe for
pupils, can perceive scattered details or only one effects/side effects.
detail; difficulty in problem solving.  Teach clients early sings of toxicity
Panic Decrease in VS (release of sympathetic response),  Maintain fluid and salt intake
distorted perceptual field, inability to solve  Avoid diuretics
problems, disorganized behavior, feelings of  Monitor lithium blood levels
helplessness/terror.
 Assist in dressing, bathing
 Set limits on disruptive behaviors.
 Nursing Interventions:
 Determine the level of client’s anxiety by
assessing the verbal and non-verbal behaviors
and physiologic symptoms.
 Determine cause of anxiety with client.
 Stay with client.
 Reduce anxiety by remaining calm yourself, use
silence, or speak slowly and softly.
 Help client recognize own anxious behavior.
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE

3. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
 Contract with client to report suicidal ideation,
Mood Stabilizing Drugs impulses, plans: check client frequently
 Lithium Carbonate normalizes the reuptake neurotransmitters  Assist with dressing, hygiene, and feeding
such as serotonin, norepinephrine, acetylcholine, and  Encourage discussion of negative/positive
dopamine.
aspects of self
 Initial dose levels: 600mg tid to maintain blood serum
level of 1.0-1.5 mEz/L; blood serum levels should be  Encourage change to more positive topics if
checked 12 hours after last dose, twice a week. self-deprecating thoughts persist
 Maintenance dosage levels: 300mg tid/qid, to maintain  Administer antidepressant medications as
a blood serum level of 0.6-1.2mEq/L; checked monthly. ordered:
 Toxicity when blood levels higher than 2.0 mEq/L:
tremors, nausea and vomiting, thirst,
polyuria, coma, seizures, cardiac arrest Anti Depressant Drugs
 Tricyclic Antidepressants (TCAs)
 Effectiveness increased by antihistamine, alcohol,
H. Disorders of Perceptions benzodiazepines, effectiveness decreased by
 Illusions, stimulus in the environment of barbiturates, nicotine, vitamin C
misperceived  Monoamine Oxidase Inhibitors (MAOIs)
 Delusions, fixed, false set of beliefs that are real to  Effectiveness increased with antipsychotic drugs,
client alcohol, meperidine
 Grandiose: false belief that client has power, wealth,  Avoid foods containing tyramine (e.g., beer, red
or status or is famous person wine, aged cheese, avocados, caffeine, chocolate, cour
 Persecutory: false belief that client is the object of cream, yogurt); these foods or MAOIs taken with
another’s harassment of harmful intent. TCAs may result in hypertensive crisis
 Somatic: false belief that client has some  Be sure client swallows medication. If side effects
physical/physiologic defect disappear suddenly, cheeking/hoarding may have
occurred.
 Ideas of Reference, belief that events or behaviors
 Antidepressant medications do not take effect for 2-3
of others relate to self. weeks. Encourage client to continue medication even
 Hallucinations, sensory perceptions that have no if not feeling better. Be aware of suicide potential
stimulus in environment most common during this time.
hallucinations are auditory and visual.  SSRIs
 venlafaxine, nefazodone, and bupropion are often
Nursing Intervention: better choices for those who are potentially suicidal
 Avoid arguing or highly impulsive
 However, SSRIs are only effective for mild to
 Determine client’s need
moderate depression.
 Reduce anxiety
 Present reality
 After therapeutic relationship has been
established, you can express doubt about
delusions, hallucinations to client. J. Schizophrenia
 Direct client’s attention to non-threatening
topics.  Characterized by disordered thinking, delusions,
hallucinations, depersonalization (feeling of being
I. Depression strange, not oneself), impaired reality testing
 Characterized by loss of ambition, lack of interest in (psychosis), and impaired interpersonal
activities and sex, low self-esteem, and feelings of relationships.
boredom and sadness.  Nursing Assessment:
 Nursing Assessment:  Four A’s
 Feelings of helplessness, hopelessness, worthlessness 1. Affect: flat, blunted
 Reduction in normal activities or agitation 2. Associative looseness: verbalizations are
 Slowing of body function/elimination disorganized
 Loss of appetite 3. Ambivalence: cannot choose between
 Inappropriate guilt conflicting emotions
 Self-deprecation, low self-esteem 4. Autistic thinking: thoughts on self, extreme
 Inability to concentrate, disordered thinking withdrawal, unable to relate to outside world
 Poor hygiene  Any changes in thoughts, speech, affect
 Slumped posture  Ability to perform self-care activities, nutritional
 Crying, ruminating deficits
 Dependency  Suicide potential
 Depressed children: possible separation anxiety  Aggression
 Elderly clients: possible symptoms of dementia  Regression
 Nursing Interventions  Impaired communication
 Monitor I&O
 Weigh client regularly
 Maintain a schedule of regular appointment
 Remove potentially harmful articles
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE

4. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
 Gestures: engaging in nonlethal behaviors
Antipsychotic Drugs  Actions: engaging in behaviors or planning to
 Also known as neuroleptics, are used to treat the symptoms engage in behaviors that have potential to cause
of psychosis, such as the delusions and the hallucinations. death
 Antipsychotic’s work by blocking receptors of the
neurotransmitter, dopamine. WHO WILL COMMIT SUICIDE? SAD PERSON
 Newer, atypical antipsychotic drugs such as clozapine S- ex - Male (more successful); female (hesitant)
(Clozaril) are relatively weak blockers of D2, which may A- ge – 15-25 y/o or above 45 y/o
account for the lower incidence of extrapyramidal side D- epression
effect P- atient with previous attempts (will try again)
 Extrapyramidal Symptoms E- thanol (Alcoholics)
a. Dysthonic reactions R- ational (opposite)
 Sudden contractions of face, tongue, extraoccular S- ocial support (lacks)
muscles O- rganized plan (greater risk)
 Administer antiparkinson agents prn (e.g., N- o family
benztropine (cogentin) 1-8mg or dipenhydramine S- ickness (terminal stage)
(benadryl) 10-50mg), which can be given PO or IM
for faster relief; trihexyphendil (artane) 3-15mg PO
only, can also be used prn).  Nursing Assessment
 Remain with client; this is a frightening experience Verbal cues
and usually occurs when medication is started  Overt: I’m going to kill myself
b. Parkinson syndrome  Disguised: I have the answer to my problems
 Occurs within 1-3 weeks Behavioral cues
 Tremors, rigid, posture, masklike facial appearance  Giving away prized possessions
 Administer antiparkinson agents prn  Getting financial affairs in order, making a will
c. Akathisia  Suicidal ideation/gestures
 Motor restlessness  Indication of hopelessness, depression
 Need to keep moving  Behavioral and attitudinal change
 Administer antiparkinson agents
 Reduce medications to see if symptoms decrease  Nursing Intervention
 Determine if movement is under voluntary control  Contract with client to report suicide attempt
d. Tardive dyskinesia  Assess suicide risk
 Irreversible involuntary movements of tongue, face,  Keep client under constant observation
extremities  Remove any objects that can be used in suicide
 May occur after prolonged use of antipsychotics attempt
e. Neuroleptic malignant syndrome
 Therapeutic intervention
 Occurs days/weeks after initiation of treatment in
1% of clients Support aspect of wish to live
 Elevated VS, rigidity, and confusion followed by Use one-to-one nurse/client relationship
incontinence, mutism, opisthotonos, retrocollis, renal Allow client to express feelings
failure, coma, and death Provide hope
 Discontinue medication, notify physician, monitor VS, Provide diversionary activities
electrolyte balance, I&O
Utilize support groups
 Following a suicide
Encourage survivor to discuss client’s
death, their feelings and fears
 Nursing Interventions: Provide anticipatory guidance to family
 Offer self in development of therapeutic Hold staff meetings to ventilate feelings
relationship
 Use silence L. Eating Disorders
 Set time for interaction with client
 Encourage reality orientation but understand  Bulimia Nervosa: binge eating; the ingestion of large
that delusions/hallucinations are real to client. amount of food in short amount of time, often
 Assist with feeding/dressing as necessary followed by self-induced vomiting.
 Check on client frequently; remove potentially  Anorexia Nervosa: refusal to eat or aberration in
harmful objects eating patterns resulting in severe emaciation that
 Contract with client to tell you when anxiety is can be life threatening.
becoming so high that loss of control is possible
 Administer antipsychotic medications as  Nursing Assessment
ordered; observe for effects  Weight loss of 15% or more of original body weight
 Electrolyte imbalance
 Depression
 Pre-occupation with being thin; inability to recognize
degree of own emaciation (distorted body image).
 Social withdrawal and poor family and individual
coping skills.
K. Suicide  History of high activity and achievement in
 Ideation: verbalization of wish to die academics, athletics.
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE

5. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
 Amenorrhea
 Nursing Interventions:
 Monitor VS N. Child Abuse
 Measure I&O
 Weigh client 3 times/week at the same time  Nursing Assessment:
(check to be sure client has not hidden heavy
objects or water loaded before being weighed, Physical Abuse Sexual Abuse
weigh in hospital gown). Pattern of bruises/welts Pain/itching of genitals
 Do not comment on weight loss or gain. Burns (cigarette, scald, rope) Bruised/bleeding genitals
 Set limits on time allotted for eating. Unexplained Stains/blood on underwear
 Record amount eaten. fractures/dislocations Withdrawn or aggressive
Withdrawn or aggressive behavior
 Stay with client during meals, focusing on behavior Unusual sexual behaviors
client, not on food. Unusual fear of parent/desire to
 Accompany client to bathroom for at least ½ please parent
hour after eating to prevent self-induced
vomiting.  Nursing Interventions
 Individual/family therapy may be necessary.  Provide SAFETY ENVIRONMENT
 Encourage client to express feelings.  Provide nursing care specific to
 Help client to set realistic goal for self and to physical/emotional symptoms
reduce need for being perfect.  Conduct interview in private with child and
 Encourage client to discuss own body image; parent/s separated
present reality; do not argue with client.  Inform parent/s of requirement to report
 Teach client relaxation techniques. suspected abuse.
 Help client identify interests and positive  Do not probe for information or try to prove
aspects of self. abuse
 Be supportive and nonjudgmental
M. Alcohol Withdrawal Syndrome  Provide referrals for assistance and therapy
 Alcohol consumption reduce/discontinued
following continuous consumption for many days or
longer
 Withdrawal is progressive and has four stages:
 At least 8hrs after last drink: symptoms
include mild tremors, tachycardia, increased
BP, diaphoresis, nervousness.
 gross tremors: hyperactivity, profound
confusion, loss of appetite, insomnia, weakness,
disorientation, illusions, auditory and visual
hallucinations.
 12-48 hours after last drink: symptoms
include (in addition to those found in I and II)
severe hallucinations, grand mal seizures.
 3-5 days after last drink (24-72 hours if
untreated): delirium tremens, confusion,
agitation, severe psychomotor activity,
hallucinations, insomnia, tachycardia.
 Withdrawal may last less than a week or may evolve
into alcohol withdrawal delirium (delirium
tremens).
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE

6. WHAT YOU SHOULD KNOW BEFORE THE PNLE
JULY 2012 PNLE PEARLS OF SUCCESS
PART 5: PSYCHIATRIC NURSING
O. Personality Disorders
Personality Symptoms / Characteristics Nursing Interventions
Disorder
Paranoid Mistrust & suspicions of others; Serious, straightforward approach; teach client to
guarded, restricted affect validate ideas before taking action; involve client in
treatment planning
Schizoid Detached from social relationships; Improve client’s functioning in the community; assist
restricted affect; involved with client to find case manager
things more than people
Schizotypal Acute discomfort in relationships; Develop self-care skills; improve community
cognitive or perceptual distortions; functioning; social skills training
eccentric behavior
Antisocial Disregard fro rights of others, rules, Limit setting; confrontation; teach client to solve
and laws problems effectively and manage emotions of anger or
frustration
Borderline Unstable relationships, self-image, Promote safety; help client to cope and control
and affect; impulsivity; self- emotions; cognitive restructuring techniques; structure
mutilation time; teach social skills
Histrionic Excessive emotionality and Teach social skills; provide factual feedback about
attention seeking behavior
Narcissistic Grandiose; lack of empathy; need Matter-of-fact approach; gain cooperation with needed
for admiration treatment; teach client any needed self-care skills
Avoidant Social inhibitions; feelings of Support and reassurance; cognitive restructuring
inadequacy; hypersensitive to techniques; promote self-esteem
negative evaluation
Dependent Submissive and clinging behavior; Foster client’s self-reliance and autonomy; teach
excessive need to be taken care of problem-solving and decision-making skills; cognitive
restructuring techniques
Obsessive- Preoccupation with borderlines; Encourage negotiation with others; assist client to make
compulsive perfectionism, and control timely decisions and complete work; cognitive
restructuring techniques
Depressive Pattern of depressive cognitions Assess self-harm risk; provide factual feedback; promote
and behaviors in a variety of self-esteem; increase involvement in activities
contexts
Passive-aggressive Pattern of negative attitudes and Help client to identify feelings and express them directly;
passive resistance to demands for assist client to examine own feelings and behavior
adequate performance in social and realistically
occupational situations
POSSIBLE TOPICS ON PSYCHIATRIC NURSING FOR THE UPCOMING JULY 2012 PNLE
*Patterned on the previous board exams from December 2006 – December 2011… the purpose of this note is to GUIDE students
on the possible topics that might be part of the upcoming July 2012 PNLE