NSG 3450 EXAM 4
PSYCHIATRIC-MENTAL HEALTH NURSING
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ||
100% GUARANTEED PASS!!
<LATEST VERSION>
1. A patient with schizophrenia reports hearing voices telling him to harm himself.
Which is the most appropriate initial nursing action?
A. Tell the patient the voices are not real.
B. Place the patient on one-to-one observation and notify the provider.
C. Encourage the patient to ignore the voices.
D. Ask the patient to describe the voices in detail.
Answer: B
Rationale: Immediate safety is the priority. One-to-one observation reduces risk,
and notifying the provider ensures timely intervention. Telling the patient the
voices are unreal or encouraging ignoring may increase anxiety or risk.
2. A patient with schizophrenia has flat affect, poor hygiene, and social
withdrawal. These are examples of:
A. Positive symptoms
B. Negative symptoms
C. Cognitive symptoms
D. Mood symptoms
Answer: B
Rationale: Negative symptoms involve a loss of normal functioning (affect,
motivation, social engagement), whereas positive symptoms involve excesses such
as hallucinations and delusions.
,3. A patient with borderline personality disorder engages in splitting behaviors.
Which behavior best illustrates splitting?
A. Alternating between extreme idealization and devaluation of staff
B. Frequently lying to obtain attention
C. Avoiding social interaction
D. Demonstrating obsessive planning
Answer: A
Rationale: Splitting is a defense mechanism in BPD where the patient sees others
as “all good” or “all bad,” causing abrupt shifts in perception of relationships.
4. A nurse notes a patient is pacing, clenching fists, and shouting threats to staff.
According to the assault cycle, this behavior corresponds to which phase?
A. Triggering phase
B. Escalation phase
C. Crisis phase
D. Recovery phase
Answer: B
Rationale: The escalation phase includes rising agitation and increased risk for
aggression. Interventions focus on de-escalation before crisis.
5. Which personality disorder is characterized by a pervasive disregard for others,
deceitfulness, impulsivity, and lack of remorse?
A. Borderline Personality Disorder
B. Antisocial Personality Disorder
C. Histrionic Personality Disorder
D. Avoidant Personality Disorder
Answer: B
Rationale: Antisocial personality disorder involves violation of others’ rights,
manipulation, and absence of guilt.
,6. When caring for a child suspected of physical abuse, the nurse’s first
responsibility is:
A. Notify the child’s parents
B. Ensure the child’s safety and follow mandatory reporting laws
C. Conduct a full physical assessment before reporting
D. Document findings without reporting
Answer: B
Rationale: Ensuring safety and reporting is legally mandated. Documentation
supports investigations, but reporting cannot be delayed.
7. A patient with schizophrenia is experiencing command hallucinations. The nurse
should:
A. Attempt to reason with the hallucination
B. Provide reality orientation and ensure safety
C. Encourage the patient to respond to the commands
D. Avoid discussing the hallucinations
Answer: B
Rationale: Command hallucinations may be dangerous; reality orientation and
safety measures are critical. Reasoning with hallucinations is ineffective.
8. A patient with borderline personality disorder frequently threatens self-harm.
Which intervention is most therapeutic?
A. Immediate discharge to reduce risk
B. Consistently set boundaries and maintain a safe environment
C. Ignore threats to prevent reinforcement
D. Allow frequent self-expression without limits
Answer: B
Rationale: Clear boundaries, structured care, and a safe environment reduce
manipulation risk and support stabilization.
, 9. A nurse observes a patient suddenly hitting a wall after being asked to follow
unit rules. What is the most effective immediate intervention?
A. Ignore the behavior
B. Use physical restraint immediately
C. Implement verbal de-escalation and maintain safe distance
D. Yell to assert authority
Answer: C
Rationale: Verbal de-escalation reduces risk and promotes patient dignity.
Physical restraint is a last resort.
10. Which of the following is considered a positive symptom of schizophrenia?
A. Anhedonia
B. Delusions
C. Social withdrawal
D. Blunted affect
Answer: B
Rationale: Delusions are positive symptoms—additions to normal functioning—
while anhedonia, social withdrawal, and blunted affect are negative symptoms.
11. A patient with antisocial personality disorder is manipulative and lies
frequently. Which nursing approach is most effective?
A. Confrontation with anger
B. Consistency, clear boundaries, and documentation
C. Ignoring manipulative behavior
D. Sharing personal experiences to build rapport
Answer: B
Rationale: Consistency and clear boundaries prevent manipulation.
Documentation protects the nurse and patient legally.
PSYCHIATRIC-MENTAL HEALTH NURSING
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ||
100% GUARANTEED PASS!!
<LATEST VERSION>
1. A patient with schizophrenia reports hearing voices telling him to harm himself.
Which is the most appropriate initial nursing action?
A. Tell the patient the voices are not real.
B. Place the patient on one-to-one observation and notify the provider.
C. Encourage the patient to ignore the voices.
D. Ask the patient to describe the voices in detail.
Answer: B
Rationale: Immediate safety is the priority. One-to-one observation reduces risk,
and notifying the provider ensures timely intervention. Telling the patient the
voices are unreal or encouraging ignoring may increase anxiety or risk.
2. A patient with schizophrenia has flat affect, poor hygiene, and social
withdrawal. These are examples of:
A. Positive symptoms
B. Negative symptoms
C. Cognitive symptoms
D. Mood symptoms
Answer: B
Rationale: Negative symptoms involve a loss of normal functioning (affect,
motivation, social engagement), whereas positive symptoms involve excesses such
as hallucinations and delusions.
,3. A patient with borderline personality disorder engages in splitting behaviors.
Which behavior best illustrates splitting?
A. Alternating between extreme idealization and devaluation of staff
B. Frequently lying to obtain attention
C. Avoiding social interaction
D. Demonstrating obsessive planning
Answer: A
Rationale: Splitting is a defense mechanism in BPD where the patient sees others
as “all good” or “all bad,” causing abrupt shifts in perception of relationships.
4. A nurse notes a patient is pacing, clenching fists, and shouting threats to staff.
According to the assault cycle, this behavior corresponds to which phase?
A. Triggering phase
B. Escalation phase
C. Crisis phase
D. Recovery phase
Answer: B
Rationale: The escalation phase includes rising agitation and increased risk for
aggression. Interventions focus on de-escalation before crisis.
5. Which personality disorder is characterized by a pervasive disregard for others,
deceitfulness, impulsivity, and lack of remorse?
A. Borderline Personality Disorder
B. Antisocial Personality Disorder
C. Histrionic Personality Disorder
D. Avoidant Personality Disorder
Answer: B
Rationale: Antisocial personality disorder involves violation of others’ rights,
manipulation, and absence of guilt.
,6. When caring for a child suspected of physical abuse, the nurse’s first
responsibility is:
A. Notify the child’s parents
B. Ensure the child’s safety and follow mandatory reporting laws
C. Conduct a full physical assessment before reporting
D. Document findings without reporting
Answer: B
Rationale: Ensuring safety and reporting is legally mandated. Documentation
supports investigations, but reporting cannot be delayed.
7. A patient with schizophrenia is experiencing command hallucinations. The nurse
should:
A. Attempt to reason with the hallucination
B. Provide reality orientation and ensure safety
C. Encourage the patient to respond to the commands
D. Avoid discussing the hallucinations
Answer: B
Rationale: Command hallucinations may be dangerous; reality orientation and
safety measures are critical. Reasoning with hallucinations is ineffective.
8. A patient with borderline personality disorder frequently threatens self-harm.
Which intervention is most therapeutic?
A. Immediate discharge to reduce risk
B. Consistently set boundaries and maintain a safe environment
C. Ignore threats to prevent reinforcement
D. Allow frequent self-expression without limits
Answer: B
Rationale: Clear boundaries, structured care, and a safe environment reduce
manipulation risk and support stabilization.
, 9. A nurse observes a patient suddenly hitting a wall after being asked to follow
unit rules. What is the most effective immediate intervention?
A. Ignore the behavior
B. Use physical restraint immediately
C. Implement verbal de-escalation and maintain safe distance
D. Yell to assert authority
Answer: C
Rationale: Verbal de-escalation reduces risk and promotes patient dignity.
Physical restraint is a last resort.
10. Which of the following is considered a positive symptom of schizophrenia?
A. Anhedonia
B. Delusions
C. Social withdrawal
D. Blunted affect
Answer: B
Rationale: Delusions are positive symptoms—additions to normal functioning—
while anhedonia, social withdrawal, and blunted affect are negative symptoms.
11. A patient with antisocial personality disorder is manipulative and lies
frequently. Which nursing approach is most effective?
A. Confrontation with anger
B. Consistency, clear boundaries, and documentation
C. Ignoring manipulative behavior
D. Sharing personal experiences to build rapport
Answer: B
Rationale: Consistency and clear boundaries prevent manipulation.
Documentation protects the nurse and patient legally.
