4.3 Psychosis, Alcohol Withdrawal & Neuroleptic Malignant Syndrome

🎯 Key NCLEX-RN® Clinical Takeaways

• When managing hallucinations: validate feelings without reinforcing the hallucination, and assess command content for self-harm.
• Alcohol withdrawal delirium (Delirium Tremens) occurs 48-72h post-cessation; administer IV benzodiazepines immediately.
• Neuroleptic Malignant Syndrome (NMS) triad: extreme fever (104F), 'lead-pipe' muscle rigidity, and autonomic instability; stop antipsychotic immediately!
• Refeeding syndrome in severe anorexia nervosa triggers life-threatening hypophosphatemia, cardiac failure, and arrhythmias upon caloric resumption.

Schizophrenia presents with positive symptoms (hallucinations, delusions) and negative symptoms (flat affect, avolition). When managing command hallucinations, the nurse assesses what the voices are commanding to evaluate immediate danger.

Alcohol withdrawal progresses from tremors and insomnia (6-12h) to seizures (12-48h) and Delirium Tremens (48-72h). Benzodiazepines (lorazepam) provide GABAergic sedation to prevent status epilepticus and death.

Neuroleptic Malignant Syndrome (NMS) is an acute toxic reaction to dopamine receptor antagonists. Cardinal signs: severe hyperthermia, lead-pipe rigidity, autonomic instability, and rhabdomyolysis. Immediate actions: discontinue antipsychotics, aggressive cooling, and dantrolene.

⚠️ Common Pearson VUE / NCLEX Traps

• Arguing with a psychotic client about whether hallucinations are real, or pretending to hear the voices.
• Treating NMS rigidity and fever as an ordinary extrapyramidal symptom with oral anticholinergics while continuing antipsychotics.