Psychosocial questions may only be 6–12% of the NCLEX—but they’re some of the most high-stakes questions you’ll see. In this episode of Think Like a Nurse, Brooke Wallace breaks down abuse and neglect, restraints, alcohol withdrawal vs. opioid withdrawal, suicide risk, therapeutic communication, cultural humility, cognition, and end-of-life care. Learn how to spot red flags, prioritize safety, and answer psychosocial NCLEX questions with confidence.
00:00 – Welcome to Think Like a Nurse
Host intro: Brooke Wallace – ICU nurse, organ transplant coordinator, clinical instructor, published author
Mission: Make complex nursing topics easier to understand, absorb, and apply
Why psychosocial integrity matters: only ~6–12% of the licensing exam, but extremely high-stakes
Focus: safety, ethics, crisis management, communication, culture, cognition, and end-of-life care
Mandatory reporting laws: the key rule → “Report suspicion, not proof.”
The nurse is not a detective; the duty starts at reasonable suspicion
Biggest mistake: waiting, “investigating,” or hoping it doesn’t happen again
Red flags: unexplained bruises, stories that don’t match, fearful or withdrawn client, possible trafficking
Classic NCLEX-style scenario:
Child with spiral fracture, twisting mechanism, terrified of parent → immediate report
Behavioral hierarchy: always least restrictive to most restrictive
Start with: verbal de-escalation, limit setting, behavioral contracts, CPI techniques
When restraints are used:
Only for immediate safety
One-to-one observation required
Safety checks every 15 minutes (skin, circulation, comfort)
Provider order within 1 hour
RN responsibilities vs. UAP:
RN: assess, decide on restraints, re-evaluate need
UAP: may be delegated to sit one-to-one and perform 15-minute safety checks per policy
High-risk withdrawals: alcohol vs. opioids
Alcohol withdrawal (especially DTs) → can be fatal
Patho: loss of GABA “brakes” → CNS hyperdrive, seizures, autonomic instability
Opioid withdrawal → miserable but rarely fatal
Nausea, vomiting, pain, anxiety
Priority sequence in suspected alcohol withdrawal:
Give thiamine and glucose first to prevent Wernicke–Korsakoff
Then treat withdrawal with benzodiazepines
Tools mentioned: CIWA for alcohol, COWS for opioids
NCLEX scenario: client with DTs seeing bugs/spiders on the wall → safety + benzos
Rule #1: Suicide risk is always the priority
Crisis basics: usually time-limited (~6–8 weeks) → aim is return to pre-crisis functioning
Steps: assess lethality and safety → stabilize → support understanding → build coping alternatives
Suicide precautions: one-to-one observation, remove sharps, no cords/belts, environment safety check
These interventions protect both the patient and your license
Adaptive vs. maladaptive coping
Common defense mechanisms: denial, regression, projection, displacement, rationalization
Example:
Patient says “I’m fine” after a devastating diagnosis → denial
Patient insists “All the nurses hate me, they’re trying to mess up my recovery” → projection
Therapeutic response:
Do not argue with content or delusion
Name and validate the feeling underneath:
“It sounds like you feel like people are working against you right now.”
LEARN model:
L – Listen to the client’s perspective
E – Explain your perception
A – Acknowledge differences and similarities
R – Recommend treatment
N – Negotiate a plan together
Key cultural examples:
Jehovah’s Witness → refusal of blood products
Some Hispanic families → strong family involvement in decisions
Muslim clients → modesty, gender concordance if possible
Herbal tea/folk remedies: assess safety and interactions, don’t reflexively say no
FICA framework for spiritual assessment: Faith, Importance, Community, Address in care
Goal: build trust and keep the focus on the client’s emotions
What works:
Broad openings (“Tell me more about…”)
Reflection, paraphrasing, clarifying
Open-ended questions
Feeling-focused statements
Example after miscarriage:
Avoid: “It’ll be okay.”
Use: “This is so painful. Tell me what you’re feeling right now.”
What to avoid (communication blocks):
False reassurance (“Don’t worry, everything will be fine.”)
Giving advice
Changing the subject
“Why” questions (makes clients defensive)
Distinguishing:
Delirium – acute, fluctuating, often reversible, worsens at night (sundowning)
Dementia – chronic, progressive decline
Depression – may mimic dementia (pseudodementia), associated with SIG E CAPS–type symptoms
Alzheimer’s example:
“I want to go home.” → use validation (“It sounds like you miss home. Tell me about it.”)
Reserve reorientation for acute delirium
Hospice vs. palliative care:
Hospice: comfort care with limited prognosis, no curative treatment
Palliative: symptom management and quality of life, can occur alongside curative care
Kubler–Ross stages: denial, anger, bargaining, depression, acceptance
Physical signs of impending death: mottling, cool extremities, breathing pattern changes
Family questions about “how long”: focus on listening, fear, and comfort rather than specific timelines
Normal vs. complicated grief: function vs. long-term inability to function (e.g., widowed person still unable to leave home after years)
Therapeutic communication is key – focus on feelings, open-ended questions, no false reassurance.
Abuse and neglect – report on suspicion, don’t wait, don’t investigate independently.
Suicide risk is always priority number one – one-to-one observation and environmental safety.
Alcohol withdrawal can kill – give thiamine and glucose first, then treat with benzodiazepines.
Cultural humility – use frameworks like LEARN to negotiate a care plan that respects the patient’s values and beliefs.
Welcome back to Think Like a Nurse. It's great to be here. This is a show created by Brooke Wallace, a 20-year ICU nurse, organ transplant coordinator, clinical instructor, and well, a published author [i]. And we have one simple mission. Right. Exactly. Taking complex nursing topics and making them easier for you to understand, absorb, and apply [i]. You can always find more at think like a nurse.org [i]. Today, we are getting into psychosocial integrity [i]. And uh I know this area can sometimes feel like a minor box to check off [i].
Yeah. Like something on the side [i]. But clinically, it is absolutely foundational [i]. We're talking about patient safety, ethical practice, and how you manage an acute crisis. It's huge [i]. It really is. I mean, it's maybe only what, 6 to 12% of your licensing exam, something like that [i]. But the questions are so crucial [i]. They're testing your judgment, your prioritization [i]. If you can master these concepts, reporting, communication, crisis management, you're showing you think like a safe nurse [i]. And our goal for you today isn't just to, you know, list a bunch of facts. We want you to really get the why behind the rules [i].
so you can internalize it [i]. Yes. Internalize those priority interventions that keep you compliant and your patients safe when things get really charged [i]. Okay, let's start with the absolute foundation of safety [i]. Yeah, abuse and neglect. What is the number one must know rule here? It all comes down to mandatory reporting laws [i]. And here's the point that trips so many people up [i]. You are required to report suspicion, not proof [i]. Exactly. You do not need proof [i]. Your job isn't to be a detective or gather evidence [i]. The second you reasonably suspect something is wrong, your legal duty kicks in [i].
That distinction is so, so important [i]. So, if a new nurse is feeling nervous about making that call, what's the biggest mistake they could make? The biggest mistake is waiting [i]. Trying to investigate it on their own or thinking, well, just wait and see if it happens again [i]. That a huge risk [i]. A huge risk to the patient and to your license [i]. You see red flags like unexplained bruises, stories that don't match up, or even signs of human trafficking, you have to act [i]. Give us a classic example, a high priority finding [i].
Okay. A child comes in with a spiral fracture [i]. Big red flag right there. The twisting injury, right [i]? And the child is they're just terrified of their parent. They won't make eye contact [i]. That combination, that fear means you report it immediately [i]. Got it. Okay. So, moving from abuse to managing aggressive behavior, there's a clear hierarchy here, isn't there? Yes. The guiding principle is always, always, always always least restrictive to most restrictive [i]. You have to try everything else first [i].
So, you're starting with your words [i]. You're starting with verbal deescalation, setting limits, maybe a behavioral contract [i]. A lot of hospitals use CPI crisis prevention intervention, which is all about managing behavior without force first [i]. but sometimes you have to escalate. So, let's talk about restraints. This is a huge area for liability [i]. The rules are incredibly strict for a reason [i]. You're taking away someone's autonomy [i]. So, restraints are only for for immediate safety [i]. And what are the non-negotiables [i]?
Onetoone observation. Someone has to be with that client at all times [i]. Okay? You have to do checks every 15 minutes, checking circulation, skin, making sure everything's okay [i]. And you have to get that provider order within 1 hour of putting them on [i]. And the 15-minute check isn't just a rule to follow. It's to prevent real harm [i]. Exactly. Permanent nerve damage is a real risk [i]. Now, common point of confusion is delegation [i]. What can the UAP actually do here? Great question [i]. The RN is responsible responsible for the assessment, the decision to restrain and evaluating if the restraints are still needed [i].
But the UAP can the UAP can be delegated the task of sitting one to one and doing those 15-minute safety checks [i]. That makes sense. Great. Okay, let's pivot from physical safety to physiological crisis, chemical dependency, right [i]? And when we talk about substance use, we need to zero in on the two highest risk withdrawals, alcohol and opioids [i]. And the difference in danger between them is massive [i]. It is this is a key point for prioritizing [i]. Alcohol withdrawal, specifically delirium tremens or DTS, can kill you [i].
It's a true medical emergency [i]. It is because chronic alcohol use messes with your brain's GABA receptors, the natural breaks [i]. You take the alcohol away and the whole system goes into hyperdrive [i]. Seizures, autonomic instability, it's deadly [i]. Whereas opioid withdrawal, opioid withdrawal is absolutely miserable [i]. Vomiting, pain, anxiety, it feels awful, but it's very very rarely fatal [i]. It's a different mechanism [i]. Okay. So, a client comes in, you suspect alcohol withdrawal [i].
What is the absolute first thing you do? The top priority. It's actually nutritional [i]. You have to give thamine and glucose before you do anything else [i]. Why is that? Thamine prevents vernick cors syndrome [i]. We're talking about preventing serious permanent brain damage [i]. After that, then you give bzzoazipines to treat the withdrawal itself [i]. And you'll see those screening tools in the chart, right? CIW ash for Alcohol NCS for opioids clinical opiate withdrawal scale [i]. Okay, classic scenario. Your client with DTS is shouting that they see spiders on the wall. What's the priority [i]?
Safety and meds [i]. Protect them from hurting themselves because of the hallucination and get those benzo in to calm that central nervous system down fast [i]. Excellent. Now, let's talk suicide and crisis [i]. Rule number one is simple, non-negotiable. Suicide risk is always the priority [i]. Always [i]. And a quick fact about crisis itself, it's usually time limited, right [i]? Yeah. Typically, at least 6 to 8 weeks [i]. The goal is just to get the person back to how they were functioning before the crisis hit [i]. And the steps are safety first [i].
Assess for lethality, then stabilize [i]. And if someone is a suicide risk, the precautions are your legal shield and their safety net [i]. Let's list them. One to one observation. Remove all sharps, no cords, no belts [i]. Anything they could use to harm themselves is gone [i]. Okay, let's transition to a softer skill that's just as vital [i]. Communication, culture, and coping [i]. Right. So, coping mechanisms, we have adaptive, which helps you deal, and maladaptive, which doesn't [i]. Things like denial, regression, projection [i].
Exactly. Maladaptive mechanisms get in the way of a person actually accepting their situation and getting better [i]. We see denial all the time [i]. The person who just got a terrible diagnosis and says, "I'm fine." Really [i]? That's a classic [i]. Or how about projection [i]? That's when you take your own feelings and put them onto someone else [i]. Like, like a patient who's angry about being sick says, "The nurses all hate me. They're trying to mess up my recovery [i]. They're projecting their own anger and lack of control [i].
So, your response can't be, "No, we don't hate you." No, you don't argue with the delusion [i]. You acknowledge the feeling underneath [i]. It sounds like you feel like people are working against you right now [i]. You focus on the emotion [i]. That's a great transition to cultural humility [i]. We need a framework for this [i]. The learn model is perfect [i]. It's a way to guide that conversation respectfully [i]. Let's break it down [i]. L listen, you have to listen to the client's perspective [i]. First E is explain your perception [i]. A is acknowledge the differences and similarities [i].
R is recommend treatment [i]. And N is negotiate [i]. It's a partnership [i]. And we have to know some specifics [i]. You absolutely have to know that Jehovah's Witness clients will refuse blood [i]. Absolutely [i]. Or that with some Hispanic cultures, femaleismo is huge, so the whole family might need to be involved [i]. Or a Muslim client who needs to maintain modesty [i]. Your job is to accommodate, find another way [i]. Exactly. And if a family wants to bring in an herbal tea. You don't just say no [i]. You assess it for safety and potential interactions first [i].
We also have the FICA tool for a spiritual assessment [i], right? Faith, importance, community, and address in care [i]. It's a quick way to see how big a role spirituality plays for them [i]. Okay. Now, for the most tested skill of all, therapeutic communication [i]. This is how you build trust [i]. It's everything [i]. So, what works? Broad openings, reflection, open-ended questions, focusing on feelings, Mhm [i]. A client is crying after a miscarriage [i]. You don't say, "It'll be okay." You say, "This is so painful. Tell me what you're feeling right now" [i].
And just as important is knowing what not to say. The communication blocks [i]. Oh yes. Top of the list [i]. False reassurance. Never ever say, "Don't worry, everything will be fine" [i]. Because you don't know that [i]. You don't [i]. Also, avoid giving advice [i]. Changing the subject and asking why questions why just makes people defensive [i]. That is such a powerhouse of strategy [i]. Okay, final segment. Cognition and end of life [i]. All right, we've got to be able to tell the big three apart [i]. Delirium, acute, it fluctuates and it's often reversible [i]. Think of sundowning gets worse at night [i].
Dementia, that's chronic progressive [i]. It's a slow decline [i]. And depression, which can sometimes look like dementia [i]. We call it pseudo dementia [i]. You'll see those sig pantaps symptoms [i]. Knowing the difference changes how you intervene [i]. Totally. An Alzheimer's patient says, "I want to go home." You don't reorient them [i]. You use validation therapy [i]. So you'd say something like, It sounds like you miss home [i]. Tell me about your favorite room there [i]. You validate the feeling, not the reality [i]. You'd only reorient for an acute delirium [i].
And for end of life care, let's clarify two terms [i]. Hospice is comfort care, six-month prognosis or less [i]. No more curative treatment [i]. And paliative care. It's all about symptom management and quality of life [i]. It can happen at the same time as curative treatment [i]. When we're supporting families, we often think of the Kubler Ross stages [i]. We can use the demonic DBDA, right [i]? Denial, anger, bargaining, depression, and acceptance [i].
And we should also recognize those physical signs of impending death, modeling cool extremities, changes in breathing [i]. And when a family asks how long, the best response is never a timeline [i]. It's to listen to their fear and offer comfort [i]. Finally, grief [i]. There's normal and then there's complicated grief [i]. Normal grief hurts, but you still function [i]. Complicated grief is when, say, two years later, a wid is still crying daily and can't leave the house [i]. That person needs a referral [i]. Wow, that was a huge amount of critical information [i]. Let's do a really quick high yield review [i].
Okay, top five takeaways [i]. Let's do it [i]. One, therapeutic communication is your key [i]. Focus on feelings, use open-ended questions, and don't give false reassurance [i]. Two, for abuse, you report on suspicion [i]. Don't wait, don't investigate, just report [i]. Three, suicide risk is always priority number one [i]. That means strict one-to-one observation [i]. Four, alcohol withdrawal can kill [i]. Give thymine and glucose first, then treat with benzo [i]. And five, cultural humility [i]. Use a model like learn to negotiate a plan of care that truly respects the patient [i].
Perfect. Remember the psychosocial care [i]. This is what makes you a great comprehensive nurse [i]. You're not just treating a disease [i]. You're caring for a whole person [i]. Amazing. Hopefully, we've given you the tools to confidently handle those questions and more importantly to think safely in these highstakes situations [i]. Thank you so much for tuning in to Think Like a Nurse [i]. Thanks everyone [i]. We'll be back with more conversations each week [i]. And don't forget to visit think like a nurse.org for more resources to help you succeed [i]. We'll talk to you next time [i].