Chapter 67: Addictions

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You know, usually when we talk about a medical diagnosis,

there's this expectation of precision.

It's almost like engineering.

Oh, absolutely.

Yeah, like you break your femur, the x -ray shows that jagged white line and the doctor just points at the screen and says, you know, there it is.

That's the problem.

Right.

It's very binary.

It's either broken or it's not broken.

The visual evidence is clean and well, the treatment plan is usually just as straightforward.

And it's comforting.

I mean, we like things to be visible.

We like them neatly categorized.

But in mental health and addiction, that x -ray machine is completely useless.

Totally useless.

It is the absolute definition of diagnostic muddy waters.

Yeah, exactly.

And the NCLEX still expects you to know exactly how to diagnose, stabilize and set boundaries for these patients.

But you are looking at a diagnostic landscape that is entirely invisible to a scanner.

You really are.

Yeah.

Because you aren't treating a localized injury.

You're treating deeply ingrained coping mechanisms,

profound physiological dependencies and physically altered brain chemistry.

So welcome to a very special custom tailored edition of our deep dive.

We are thrilled to be doing this.

We know exactly what your mission is right now.

You are preparing to conquer the NCLEX.

That's right.

And today we are handing you the cheat codes to mastering mental health.

Specifically, we're focusing entirely on Chapter 67 of the Saunders Comprehensive Review that covers addictions and coping mechanisms.

Big shout out to the Last Minute Lecture team for requesting this custom prep for you.

We love the Last Minute Lecture team and we're going to build this from the ground up following the chapter exactly.

We'll start with how the brain uses behaviors to cope, then transition into chemical coping and finally put you right in the test taking seat.

Apply all of it to clinical reasoning and priority patient care.

So let's jump right into part one.

Right.

The foundation of coping and control eating disorders.

What is so vital to understand here is the cyclical nature of these conditions.

In figure 67 .1, right?

Exactly.

The test makers want you to recognize that this isn't simply about food.

It is a maladaptive coping mechanism fueled by biological,

psychological and sociocultural pressures.

It's basically a closed loop.

Think about the classic binge and purge cycle.

A binge leads to purging, which leads to weight loss.

And that weight loss triggers this massive intoxicating feeling of power and control for the patient.

But that feeling is incredibly fragile, right?

It requires more weight loss and incredibly strict dieting to maintain.

So eventually the body's sheer biological drive to survive just kicks in.

Intense hunger.

Intense hunger and emotional anger related to that deprivation.

And that physical starvation simply forces another binge.

Restarting the whole agonizing cycle.

So let's break down the specific disorders the NCLEX will actually test you on, starting with compulsive overeating.

The key distinction here is that it's binge eating without the purge.

The patient feels completely out of control during the episode.

And a really important detail to understand here, they are usually repulsed by the eating.

Yeah, that's a huge misconception.

Right.

People think binge eating is driven by a love of food.

It really isn't.

The eating relieves deep psychological tension, but it does not produce pleasure.

They eat secretly and they feel entirely helpless.

Now contrast that with anorexia nervosa.

Anorexia is driven by an intense paralyzing fear of obesity and a profoundly distorted body image.

When you're doing your nursing assessment, what are the big red flags?

You are looking for a refusal to eat, compulsive exercising, and usually a personality profile of an extreme overachiever or perfectionist.

The physical alterations with anorexia are honestly terrifying when you understand what's actually happening.

I always compare it to a house in the dead of winter.

Oh, that's a good analogy.

Yeah, it's like shutting off electricity to non -essential rooms just to keep the furnace running.

The body is literally starving to death.

So what does it do to survive?

It drops to the core temperature.

Right.

It decreases the pulse into severe bradycardia.

It drops the blood pressure.

You see a manneria, the loss of menstruation.

Because the body recognizes it absolutely cannot support a pregnancy.

So it just shuts the reproductive system down entirely.

Wow.

And you also see lanugo, right?

Yes, lanugo.

Yes.

It has fine downy hair growth on the face and extremities.

The body has metabolized all its insulating fat, so it is desperately trying to grow a fur coat to keep warm.

That is just wild.

It is.

These aren't just symptoms.

They are the body cannibalizing itself.

Death can occur from starvation, severe electrolyte imbalances, or cardiomyopathies.

Because the heart muscle itself is wasting away.

Exactly.

Now when you look at bulimia nervosa, the absolute key NCLEX differentiator is the patient's weight.

Because they usually look fine, right?

Right.

Most clients with bulimia remain within a normal weight range.

That makes it incredibly easy to hide.

But underneath that normal appearance, their lives are entirely dominated by the binge purge cycle.

Using self -induced vomiting, laxatives, or diuretics.

They have a profound sense of powerlessness despite this desperate need for control.

And a quick safety note.

If they are inducing vomiting, you have to be vigilant in monitoring for esophageal varices.

That's life -threatening bleeding in the esophagus from the constant acid exposure.

Absolutely.

So, how do we intervene?

How do we keep these patients safe on the floor?

Your priorities are to establish a one -to -one therapeutic relationship.

You must be accepting and entirely non -judgmental.

And you establish a strict nutritional plan and set a definitive time limit for each meal.

Usually about 30 minutes, right?

Right.

You supervise them during the meal.

And for a specified period after the meal, usually an hour or two.

So they don't immediately go to the bathroom and purge.

But let's talk about the ultimate medical safety alert from this chapter.

When a patient's weight drops below 75 % of their ideal body weight, immediate inpatient medical stabilization is required.

That is a hard threshold to memorize for the exam, 75%.

At that point, outpatient therapy is no longer an option because sudden cardiac arrest is a very real imminent threat.

And regarding the clinical routine,

the NCLEX will definitely test you on the protocol for weighing these patients.

You weigh them daily, but the parameters must be exact.

At the exact same time.

Using the exact same scale.

Wearing the exact same clothes as the previous day.

And always after they void.

There's a brilliant psychological reason for that strictness, too.

It removes variables.

If they weigh a pound more today, you don't want them panicking and thinking, oh, is it because I'm wearing a heavier sweater?

Did I drink too much water?

Consistency kills that specific anxiety and crucially, always assess their suicide potential.

Always.

All right.

So moving into part two, we see this exact same desperate pursuit of control when we shift from behavioral coping like restricting food to chemical coping.

The underlying themes of a loss of control and severe physiological changes transition seamlessly into substance use disorders.

To succeed on the NCLEX here, we have to lock down the precise clinical terminology.

Let's start with dependence.

This isn't just a bad habit, right?

No, not at all.

This is a pattern of repeated use, resulting in tolerance,

intense withdrawal symptoms, and compulsive drug -taking behavior that destroys the patient's life.

And that tolerance is a biological adaptation.

It's the physiological need for increased amounts of the substance just to achieve the same desired baseline effect.

Because the brain literally down -regulates its own receptors.

It's being flooded with chemicals, so it turns down its own sensitivity.

Which perfectly explains withdrawal.

When you take the substance away, the brain is left with this massive chemical deficit.

The physiological and cognitive symptoms hit you like a freight train as soon as those blood levels drop.

Right.

So when you suspect a dependency during an intake assessment, the gold standard for screening is the cage questionnaire, box 67 .1.

Imagine you are sitting with a patient.

You ask four specific questions.

C, have you ever felt the need to cut down on your use?

A, have you ever been annoyed at criticism of your use?

G, have you ever felt guilty about your use?

And E,

have you ever had an eye -opener?

Meaning taking a drink or a hit first thing in the morning just to get your day going or to avoid the shakes.

I have to pause here because I think a lot of nursing students struggle with the reality of treating these patients.

It can be very difficult.

Yeah, I get the clinical terms, but practically speaking, when you read the list of behaviors associated with active addiction manipulation, lying, impulsiveness, verbal abuse, this grandiose sense of self -importance, it just sounds like a nightmare patient.

It really does.

How is a nurse supposed to walk into that room and not take that manipulation personally?

It is one of the hardest things to learn in practice.

But you have to view those behaviors, the manipulation, the aggressive denial, the rationalization, as a cluster of dysfunctional defense mechanisms.

So the patient isn't doing it to spite you.

Exactly.

The addiction has become their central survival tool.

Their brain believes it needs the substance to live, so it builds a fortress of lies and manipulation to protect the supply.

Wow.

If you view it as a symptom of the disease rather than a personal attack, you can maintain that therapeutic boundary.

And that fortress of denial often traps the family unit, too.

That's where we see codependency.

Right.

Codependency.

It happens when a significant other essentially absorbs the chaos of the addiction.

They enable the addict to continue their destructive patterns by shielding them from the consequences.

It's the spouse who calls in to work for the addict and says they have the flu when they're actually hungover.

Or the parent who pays the rent the addict belonged drugs out of a misguided sense of love.

Treating the family's codependency is just as critical as treating the patient's addiction.

Otherwise you're just sending a sober patient right back into a sick environment.

Exactly.

So let's zoom in on the single most commonly tested central nervous system depressant on the board exams.

Alcohol.

Alcohol affects virtually every tissue in the body, but the chronic neurological complications are what you really need to watch for, specifically related to malnutrition.

Heavy drinkers get a large portion of their daily calories from alcohol, which has zero nutritional value, so they develop severe vitamin deficiencies.

A vitamin B deficiency causes peripheral neuropathy, that tingling and burning in the hands and feet.

But the massive red flag is thiamine, or vitamin B1 deficiency.

Because thiamine is absolutely essential for the brain to metabolize glucose, right?

Yes.

Without it, the neurons literally starve and die.

That leads directly to Wernicke's encephalopathy.

Which presents as profound confusion, ataxia or loss of physical coordination, and abnormal eye movements.

And if left untreated, it progresses to Korsakoff syndrome, where the brain damage becomes permanent, resulting in severe, irreversible memory loss.

But before we even worry about chronic brain damage, we have to get them through the immediate life -threatening danger of alcohol withdrawal.

The timeline is everything here.

Really signs develop within just a few hours after their last drink.

We assess this using the CIWA scale.

You are actively looking for hypertension, tachycardia, hand tremors, heavy sweating, anxiety, and tactile disturbances.

Like formication.

Which is the terrifying sensation of bugs crawling just under the skin.

Awful.

If that early withdrawal isn't aggressively managed with medication, it progresses to a state called delirium tremens, or the DTs.

Box 67 .2 outlines this.

This is a full -blown medical emergency that typically peaks 48 to 72 hours after the last drink.

The manifestations are extreme, dangerously high fever, intense visual and auditory hallucinations, and severe physical agitation.

Death can occur quickly from a myocardial infarction, fat emboli, or total cardiovascular collapse.

Here is the best way to understand why alcohol withdrawal is so violent.

Think of the central nervous system as a car engine.

Alcohol is a powerful depressant.

It acts like the brakes.

If someone drinks heavily for years, their brain is constantly flooring the gas pedal just to counteract those brakes and function at a somewhat normal level.

Okay, so then they get admitted to the hospital and the alcohol stops.

The brakes are instantly ripped out.

But the brain is still flooring the gas pedal.

The engine just revs completely out of control.

That autonomic hyperactivity dictates every single one of our priority interventions.

You are doing neuro and vital checks constantly, sometimes every 15 minutes.

You initiate strict seizure precautions.

And you must provide a quiet, incredibly low -stimulation environment.

Why?

Because that hyperactive brain is like a powder keg.

A slammed door, a blaring TV, or even suddenly turning on bright fluorescent lights can be the exact spark that triggers a massive grand mal seizure.

You also want to provide small, frequent, high -carbohydrate foods to prevent their blood sugar from crashing, since their liver is usually compromised.

And you have to firmly hold the patient accountable for their behaviors, as moded in boxes 67 .3 and 67 .4.

Moving from alcohol, we have to look at the broader spectrum of drug dependency.

That's table 67 .1 and box 67 .5.

Let's organize this by drug class, starting with other CNS depressants.

Your benzodiazepines and barbiturates.

Intoxication looks very much like alcohol drunkenness.

Extreme drowsiness, slurred speech, unsteady gait.

An overdose shuts down the respiratory drive.

The specific NCLEX antidote you must know for a benzo overdose is IV flumazenil.

Right, but here is a massive safety alert.

You cannot just stop a CNS depressant cold turkey.

Never.

If a patient has been abusing Xanax for two years and you just cut them off, the rebound overactivity in the brain will cause lethal seizures.

Abrupt withdrawal is deadly.

It must be treated with a carefully titrated similar drug, like phenobarbital or a long -acting benzo, to slowly, safely step the brain down over weeks.

Now on the complete opposite end of the spectrum, we have CNS stimulants, amphetamines, cocaine, crack.

Intoxication looks like massive hyperarousal.

You'll see widely dilated pupils, severe tachycardia, euphoria, and intense paranoia.

And an overdose overworks the cardiovascular system so much that it produces stroke, seizures, and myocardial infarction.

And the withdrawal from stimulants is the ultimate crash.

Because the brain's dopamine stores have been completely depleted, the patient experiences profound fatigue, hypersomnia where they sleep for days.

And most importantly for your nursing assessment, severe crushing depression and suicidal ideation.

Keeping them safe from themselves is your priority during stimulant withdrawal.

Next, let's look at opioids,

heroin, fentanyl, morphine, oxycodone.

Intoxication severely suppresses the system.

You will see pinpoint constricted pupils, bradypnea, which is dangerously slow breathing hypotension, and severe drowsiness.

Overdose produces shock, coma, and death.

Now the clinical cues for opioid withdrawal are incredibly high yield for the NCLE -X.

The recognized cues clinical judgment box focuses on this.

We use the CLWS scale here.

The cues for withdrawal are the exact opposite of intoxication.

You look for dilated pupils and it's almost like the body is just leaking fluids from everywhere.

You see rhinorrhea, which is a constantly runny nose, lacrimation or tearing eyes, explosive diarrhea, vomiting, piloerection, which is severe goosebumps,

and constant uncontrollable yawning.

And the mechanism behind that fluid loss is fascinating.

Opioids significantly slow down the gastrointestinal tract and dry out mucous membranes.

It's why opioid users are chronically constipated.

Right, so when you suddenly remove the opioid, the autonomic nervous system rebounds into massive overdrive.

The floodgates open and every fluid system in the body expels what it was holding back.

We also have to be vigilant regarding the opioid crisis.

This requires an interprofessional approach.

Box 67 .5 details the red flags pharmacists and prescribers look for.

Behavioral red flags that indicate a patient is abusing the system.

Things like a patient traveling highly unusual geographic distances just to fill a prescription at a specific pharmacy.

Or constantly requesting early refills because their medication was allegedly stolen, paying entirely in cash to circumvent insurance tracking databases is another massive red flag.

And of course, making sure you know that naloxone nasal spray is the critical opioid antagonist used to instantly reverse a legal overdose.

Moving on to hallucinogens.

LSD, PCP, mushrooms.

Intoxication brings bizarre, sometimes incredibly violent behavior, hallucinations, and paranoia.

For LSD and mushrooms, treatment involves a very low stimuli environment.

You speak slowly, clearly, and in a low voice to avoid agitating their hallucinations.

Watch out for flashbacks too, which can happen months later.

But for PCP specifically, there is a unique physiological intervention.

You may need to administer medications to acidify the patient's urine.

Right, and the chemistry there is brilliant.

It's called ion trapping.

By making the urine highly acidic, it changes the electrical charge of the PCP molecule as it passes through the kidneys.

Once it's charged, it gets trapped in the urine and flushed out of the body, preventing it from being reabsorbed back into the bloodstream.

Then we have club drugs like MDMA or ecstasy.

The severe adverse effects you need to watch for are extreme hypothermia and rhabdomyolysis.

Where muscle tissue breaks down so rapidly, it clogs and destroys the kidneys.

And finally, marijuana.

Long -term heavy dependence can result in ammotivation syndrome, characterized by extreme apathy and short -term memory loss.

Before we jump into testing strategies, we have to talk about dual diagnoses.

This is when a psychiatric disorder, like bipolar disorder or schizophrenia, is present alongside a substance use disorder.

What's crucial to understand is that it is nearly impossible to accurately diagnose the psychiatric condition while the patient is actively using.

You have to get the substance completely out of the system through sustained abstinence to see their true psychiatric baseline.

And we cannot ignore the reality of impaired professionals.

Addiction happens in healthcare.

The suspicious signs the NCLEX wants you to recognize in a coworker include a nurse who frequently reports that narcotic drugs were wasted without having another nurse properly witness it.

Or a nurse who consistently administers the absolute maximum PRN doses of controlled substances when other nurses don't seem to need to.

Or someone who always volunteers to carry the narcotic keys and chooses night shifts with less supervision.

Remember, as a nurse, you have a strict professional, legal, and ethical obligation to report impaired coworkers to your supervisor immediately to protect patient safety.

You have to.

Okay, let's pull all this together into part five.

Let's put you right in the testing seat.

Picture yourself at the testing center, the screen glows, and we are going to walk through how to apply all this clinical reasoning to the actual practice questions you will face.

Let's start with questions focusing on therapeutic communication.

Questions one and nine hit on this.

The golden rule here is simple.

Never use the word why.

If an answer choice starts with, why did you start taking illegal drugs?

Or why don't you just tell your spouse, eliminate it immediately.

It is inherently judgmental and immediately puts the patient on the defensive.

Instead, you look for the non -judgmental, direct, open -ended questions.

What do you find difficult about this situation?

Or tell me more about how that made you feel.

That is how you build the one -to -one therapeutic relationship.

Now, imagine question four, dealing with legal rights.

You have a hospitalized client being treated for severe alcohol withdrawal who suddenly unplugs their IV and says,

I am leaving right now.

I don't want any more treatment.

What is your first action?

The correct answer is to notify the nursing supervisor and the provider.

The distractors in these types of questions are classic NCLEX traps.

Do you call security to physically block the doors?

No.

Do you apply soft restraints until the provider can get there to evaluate them?

Absolutely not.

Remind yourself physically blocking doors or using any form of restraint on a patient who simply wants to leave.

Against medical advice constitutes the tort of false imprisonment.

Unless they are under a legal psychiatric hold, all clients have a fundamental right to refuse health care.

You notify the supervisor, explain the medical risks to the patient, and follow AMA protocols.

Excellent point.

Let's look at limit setting with eating disorders.

Question six,

you enter the room of a recently admitted severely anorexic patient and note they are engaged in rigorous rapid -fire push -ups on the floor.

What is the most appropriate nursing action?

The correct choice is to interrupt the client and offer to take them for a walk.

Let's break down the why here.

Anorexic patients are entirely preoccupied with rigorous exercise to burn calories.

You cannot just let them finish the push -ups.

That's passively allowing harmful calorie -debleeding behavior.

But you also shouldn't just stand over them and sternly yell that exercise isn't allowed.

That spikes their severe anxiety without offering them a way to cope with it.

Offering a leisurely walk physically stops the harmful rigor, but provides a safe, low -impact alternative to bleed off that anxious energy.

Another clinical reasoning staple is roommate selection, like in question seven.

You have a client with anorexia nervosa in a profound state of starvation.

Do you pair them in a room with a patient recovering from pneumonia?

No way.

A starving patient has leukopenia.

Their bone marrow doesn't have the nutrients required to manufacture white blood cells.

They are severely immunocompromised.

Putting them in a room with a respiratory infection places them at massive risk for sepsis.

You pair them with someone undergoing non -infectious diagnostic tests.

Also, watch out for distractors that suggest pairing the anorexic patient with someone who needs help eating so the anorexic patient can assist them.

That is a terrible idea.

It just allows the anorexic patient to focus entirely on the nutritional needs of others while continuing to suppress and ignore their own hunger.

Finally, let's look at body image in question 10.

An anorexic patient in a pre -discharge prep group tries on some everyday clothes brought in by family.

The patient looks in the mirror, complains the clothes are much too tight, and immediately declares they are cutting their daily intake to 800 calories.

How do you evaluate this behavior?

You evaluate it as direct evidence of a disturbed body image.

The wrong answers will try to tell you this is normal pre -discharge anxiety or ambivalence about leaving the safety of the hospital.

It isn't.

It is the core pathology of the disorder presenting itself right in front of you.

And as the nurse, you have to address that distorted perception directly.

If we pull back and look at the bigger picture we've painted today in this deep dive,

the golden thread running through psychiatric nursing is clear.

Caring for mental health and addictions relies on three unshakable pillars.

Maintaining absolute physical safety, deeply understanding the severe predictable physiological shifts of intoxication and withdrawal, and consistently setting firm therapeutic boundaries.

You have to know the physiology just as well as the psychology.

We want to deliver a huge warm thank you from all of us here, and from our friends over at the Last Minute Lecture Team, for trusting us with your NCLEx prep.

You are putting in the hard work, you understand the why behind the what, and you are going to absolutely crush this exam.

But before we sign off, I want to leave you pondering what we call the dual diagnosis paradox.

Think about it.

How can you truly assess a patient's baseline psychiatric health?

How can you know who they really are?

When the very substances they are using to cope are actively physically altering the chemistry of their brain.

It's the ultimate chicken and egg scenario, and it is the perfect reminder of why sustained abstinence is the only way to meet the real person buried underneath the addiction.

Until you have that abstinence, you aren't looking at a clear x -ray of a broken bone.

You're just standing there doing your best to navigate those diagnostic muddy waters.

Good luck out there.

You are going to be an amazing nurse.