Mental Health Nursing Quiz

Correct Answer: A. Self-mutilation used to garner a rescue response

Rationale: Individuals with BPD often engage in impulsive self-harm (cutting) as a means to manage overwhelming emotions or to elicit a caring response. While some patients with BPD may occasionally lie or engage in risky behavior, the hallmark is self-mutilation linked with intense fear of abandonment.

Correct Answer: C. Set consistent limits and hold frequent team meetings for staff communication

Rationale: With BPD, patients may use “splitting” or manipulation to pit staff against each other. Consistent limits and team communication (e.g., assigning one specific nurse to handle certain requests) reduces these behaviors.

Correct Matches: 1 → A, 2 → B

Rationale: Predictable schedules reduce the patient’s anxiety and manipulative requests; assessing for suicide risk is crucial even if self-harm is said to be “for attention.”

Correct Answer: A. “I care about you, but we have professional boundaries I must follow.”

Rationale: This answer is empathetic but also reaffirms professional limits. It addresses the patient’s distress without reinforcing dependency or blurring boundaries.

Correct Answer: B. “I can see you’re in pain. Let’s talk about healthier ways to cope.”

Rationale: A compassionate response validates the patient’s emotional distress and invites them to explore alternative coping strategies, rather than resorting to self-harm.

Correct Answer: A. Clean and dress the wound and perform a suicide risk assessment

Rationale: Physical injury care comes first, followed by thorough assessment of suicidal intent. Even if the behavior is not overtly suicidal, it’s critical to evaluate for risk.

Correct Answer: B. Maintain consistent responses across the entire staff

Rationale: Splitting occurs when patients perceive individuals as all-good or all-bad. Consistent team communication and unified approaches are key to preventing this dynamic.

Correct Answer: B. Bringing the patient homemade cookies and personal gifts

Rationale: Providing personal items/gifts blurs professional boundaries. The other actions fall within normal therapeutic care.

Correct Answer: B. “I will administer your medication as scheduled, but threats are not acceptable.”

Rationale: This response acknowledges the patient’s need (medication at the scheduled time) while clearly setting limits on threatening behavior.

Correct Answer: B. “I hear what you’re saying, but violence is not acceptable. Let’s focus on problem-solving.”

Rationale: This response recognizes the patient’s statement without condoning the behavior, and redirects them to more appropriate coping strategies.

Correct Matches: 1 → A, 2 → B

Rationale: Antisocial individuals often deny responsibility and show no remorse; BPD is characterized by manipulative or attention-seeking behavior.

Correct Answer: B. Set firm, clear limits on threatening behavior

Rationale: Patients with antisocial traits often test boundaries. A calm, firm approach with clear limits is most effective.

Correct Answer: B. Explain medication times and assess pain thoroughly, while setting limits on demands

Rationale: It is critical to validate the complaint and assess pain but also clarify schedule boundaries.

Correct Answer: C. Blaming others and lacking remorse for harmful behaviors

Rationale: Lacking remorse and refusing accountability are key antisocial traits.

Correct Matches: 1 → B, 2 → A, 3 → C

Rationale: Agraphia = difficulty writing/labeling, Confabulation = made-up stories, Hyperorality = mouthing objects.

Correct Answer: C. Vomiting, diarrhea, and possible fainting

Rationale: Donepezil commonly causes GI upset and can contribute to syncope. Educating caregivers is essential for safety and monitoring.

Correct Answer: C. Calmly guide them back to a safe area and reorient them gently

Rationale: Ensuring safety and providing reassurance/orientation is a priority for wandering patients.

Correct Answer: C. Fluid and electrolyte imbalances

Rationale: Electrolyte disturbances or infections (e.g., UTI) frequently precipitate delirium in dementia patients.

Correct Answer: B. “It’s best to acknowledge their feelings and let them share; it helps relieve anxiety.”

Rationale: Acknowledging the patient’s reality and allowing them to reminisce can reduce agitation and anxiety.

Correct Answer: C. Call the provider to report possible infection and be prepared to obtain orders

Rationale: Infection is a leading cause of delirium/agitation in older adults. Prompt assessment and treatment are critical.

Correct Answer: B. Provide a safe, clutter-free area where touching objects won’t cause harm

Rationale: Hypermetamorphosis is an uncontrollable impulse to touch. Making the environment safe is more appropriate than restraints or total restriction.

Correct Answer: B. Assigning a sitter or using an electronic safety device/one-to-one observation

Rationale: Continuous monitoring (one-to-one or safety alarms) is crucial for preventing elopement.

Correct Answer: B. Providing distraction or engaging the patient in a safe activity

Rationale: Distracting from unsafe behaviors is a frequently used technique in dementia care.

Correct Matches: 1 → A, 2 → B

Rationale: Adequate lighting decreases confusion, and helping with ADLs ensures both safety and maximal independence.

Correct Answer: B. “Explain that it’s best to refrain until after the exam to preserve DNA evidence.”

Rationale: Showering can destroy forensic evidence crucial for the exam.

Correct Answer: B. “The patient will agree to follow up with counseling sessions.”

Rationale: Ensuring the patient seeks ongoing care (e.g., therapy, counseling) is a critical short-term outcome.

Correct Matches: 1 → B, 2 → A

Rationale: Victims may feel further traumatized by invasive procedures, so ensuring consent is crucial, and open-ended questions allow them to share freely.

Correct Answer: B. “No one deserves to be abused. It’s not your fault.”

Rationale: Reinforcing that abuse is never the victim’s fault helps reduce self-blame and promotes empowerment.

Correct Answer: B. “Tell me about what’s been happening at home.”

Rationale: A broad, open-ended approach encourages disclosure without placing blame or suggesting the child is lying.

Correct Answer: A. Call child protective services immediately

Rationale: Nurses are mandated reporters. Suspicion of child abuse must be reported to the authorities, even without proof.

Correct Answer: B. Provide resources for shelters/safe houses and continue to offer nonjudgmental support

Rationale: The nurse can provide information and support but should not coerce; the patient must decide when and how to seek help.

Correct Answer: B. Multiple bruises of varying colors and a spiral fracture of the humerus

Rationale: Spiral fractures and bruises in different healing stages often indicate repeated trauma and potential abuse.

Correct Answer: C. Gradual escalation of arguments and yelling

Rationale: Tension-building phase involves rising anger/arguing, which may progress to acute battering.

Correct Answer: B. Accepting the abuser’s remorse and gifts

Rationale: The honeymoon phase includes excessive affection and apologies, which can reinforce the victim’s hope that the abuse won’t happen again, perpetuating the cycle.

Correct Answer: D. Powerlessness due to financial abuse

Rationale: Withholding financial resources is a form of control and abuse, contributing to the victim’s powerlessness.

Correct Matches: 1 → A, 2 → B

Rationale: Enmeshment involves blurred boundaries, while minimization or justification of abusive behavior is common among abusers.

Correct Answer: B. “It’s not your fault. I can give you information on shelters and support.”

Rationale: Reinforcing that abuse is not the victim’s fault and providing resources respects the patient’s autonomy and promotes safety planning.

Correct Answer: C. Respect the patient’s silence while ensuring safety and offering support

Rationale: Trauma victims need a sense of control. Pushing for details can retraumatize them; offering safety and support is more therapeutic.

Correct Answer: C. Post-Traumatic Stress Disorder

Rationale: Recurrent flashbacks, nightmares, and hypervigilance are classic signs of PTSD.

Correct Answer: A. Report suspected abuse to protective services

Rationale: Nurses are mandatory reporters. Suspicion alone warrants a report—do not attempt to investigate or confront directly.

Correct Answer: B. Check vital signs, oxygenation, and assess for possible infection or electrolyte imbalance

Rationale: Sudden changes in mental status often indicate a physiological cause (e.g., infection, electrolyte issues). Addressing those first is crucial.

Correct Answer: C. Enmeshment and neglect

Rationale: This scenario shows poor boundaries and neglect (the older child is used as a caretaker), characteristic of “enmeshment.”

Correct Answer: B. “You have a right to keep a journal. I will administer pain medication as scheduled, but not on demand.”

Rationale: Acknowledges the patient’s autonomy (journaling) yet maintains boundaries about medication times.

Correct Answer: B. Teach the patient more effective ways to communicate pain and reinforce boundaries around threats

Rationale: Encouraging healthy communication and clearly stating that threats are unacceptable is an appropriate initial step.

Correct Answer: A. “You seem upset; can you tell me more about your child’s bruises?”

Rationale: Staying therapeutic and open-ended helps gather information without placing immediate blame—though suspicion of abuse must still be reported.

Correct Answer: B. “You’re safe here. This is the hospital, and I’m your nurse. Let’s talk about how you’re feeling.”

Rationale: Providing reality orientation and reassurance reduces anxiety.

Correct Matches: 1 → A, 2 → B

Rationale: Confabulation is creating stories; aphasia is difficulty in communication or using language.

Correct Answer: B. “Everyone follows the same rules regardless of who they are.”

Rationale: Consistency and fairness, with clear limit-setting, is critical when dealing with manipulative behavior in antisocial personalities.

Correct Answer: C. A patient with multiple bruises in varied healing stages and vague explanations

Rationale: Bruises at different stages of healing and inconsistent explanations raise suspicion of ongoing abuse.

Correct Answer: C. Conduct a suicide risk assessment and ensure the patient is not left alone

Rationale: Any threat of self-harm in BPD warrants a thorough risk assessment and safety measures, regardless of perceived secondary gain or manipulation.