## Mental Health
Nursing and Psychiatric
Disorders (Part 3)
### Question 1
A patient with schizophrenia is experiencing auditory hallucinations. The patient tells the nurse, "The
voices are telling me that I'm worthless." Which response by the nurse is most therapeutic?
A. "I don't hear any voices. You're safe here."
,B. "Try to ignore the voices and focus on what's real."
C. "The voices are not real. They are a symptom of your illness."
D. "I understand you're hearing voices. Do they frighten you?"
💫RATIONALE✔️✔️: The nurse should acknowledge the patient's experience without reinforcing the
hallucination. Asking about the emotional response to the voices validates the patient's feelings while
maintaining a therapeutic connection. The nurse should not argue with the patient about the
hallucinations or tell them to ignore them. Validating the experience while focusing on the patient's
feelings is the most therapeutic approach.
💫ANSWER✔️✔️: D. "I understand you're hearing voices. Do they frighten you?"
---
### Question 2
A patient with borderline personality disorder is experiencing intense anger and threatens to leave the
unit against medical advice. Which nursing intervention is most appropriate?
A. Tell the patient they cannot leave until they calm down
B. Call security to restrain the patient
C. Use a calm, firm approach and set clear limits on behavior
D. Ignore the behavior and allow the patient to leave
💫RATIONALE✔️✔️: Patients with borderline personality disorder benefit from consistent, calm limit-
setting. The nurse should use a firm but non-punitive approach to help the patient maintain control
while reinforcing boundaries. Setting clear limits helps the patient feel safe and reduces manipulative
behaviors. The nurse should also explore the patient's feelings and offer alternatives to elopement.
, 💫ANSWER✔️✔️: C. Use a calm, firm approach and set clear limits on behavior
---
### Question 3
The nurse is caring for a patient with generalized anxiety disorder. Which finding is most consistent with
this diagnosis?
A. Panic attacks occurring unpredictably
B. Excessive worry about multiple topics for at least 6 months
C. Intense fear of social situations
D. Recurrent intrusive thoughts and compulsive behaviors
💫RATIONALE✔️✔️: Generalized anxiety disorder is characterized by excessive, uncontrollable worry
about multiple topics that persists for at least 6 months. Physical symptoms such as restlessness,
fatigue, and muscle tension may also be present. Panic attacks are characteristic of panic disorder, social
fear of social situations is social anxiety disorder, and intrusive thoughts/compulsions are OCD.
💫ANSWER✔️✔️: B. Excessive worry about multiple topics for at least 6 months
---
### Question 4
Nursing and Psychiatric
Disorders (Part 3)
### Question 1
A patient with schizophrenia is experiencing auditory hallucinations. The patient tells the nurse, "The
voices are telling me that I'm worthless." Which response by the nurse is most therapeutic?
A. "I don't hear any voices. You're safe here."
,B. "Try to ignore the voices and focus on what's real."
C. "The voices are not real. They are a symptom of your illness."
D. "I understand you're hearing voices. Do they frighten you?"
💫RATIONALE✔️✔️: The nurse should acknowledge the patient's experience without reinforcing the
hallucination. Asking about the emotional response to the voices validates the patient's feelings while
maintaining a therapeutic connection. The nurse should not argue with the patient about the
hallucinations or tell them to ignore them. Validating the experience while focusing on the patient's
feelings is the most therapeutic approach.
💫ANSWER✔️✔️: D. "I understand you're hearing voices. Do they frighten you?"
---
### Question 2
A patient with borderline personality disorder is experiencing intense anger and threatens to leave the
unit against medical advice. Which nursing intervention is most appropriate?
A. Tell the patient they cannot leave until they calm down
B. Call security to restrain the patient
C. Use a calm, firm approach and set clear limits on behavior
D. Ignore the behavior and allow the patient to leave
💫RATIONALE✔️✔️: Patients with borderline personality disorder benefit from consistent, calm limit-
setting. The nurse should use a firm but non-punitive approach to help the patient maintain control
while reinforcing boundaries. Setting clear limits helps the patient feel safe and reduces manipulative
behaviors. The nurse should also explore the patient's feelings and offer alternatives to elopement.
, 💫ANSWER✔️✔️: C. Use a calm, firm approach and set clear limits on behavior
---
### Question 3
The nurse is caring for a patient with generalized anxiety disorder. Which finding is most consistent with
this diagnosis?
A. Panic attacks occurring unpredictably
B. Excessive worry about multiple topics for at least 6 months
C. Intense fear of social situations
D. Recurrent intrusive thoughts and compulsive behaviors
💫RATIONALE✔️✔️: Generalized anxiety disorder is characterized by excessive, uncontrollable worry
about multiple topics that persists for at least 6 months. Physical symptoms such as restlessness,
fatigue, and muscle tension may also be present. Panic attacks are characteristic of panic disorder, social
fear of social situations is social anxiety disorder, and intrusive thoughts/compulsions are OCD.
💫ANSWER✔️✔️: B. Excessive worry about multiple topics for at least 6 months
---
### Question 4
