A patient in alcohol rehabilitation reveals to the nurse. "I feel terrible guilt for sexually abusing my 6-year-old before I was admitted." Select the nurse's most important action.
Respect nurse-patient relationship confidentiality.
File a written report with the agency's ethics committee.
Anonymously report the abuse by phone to the local child protection agency.
Reply, I'm glad you feel comfortable talking to me about it."
The Correct Answer is C
A. Respecting confidentiality is important, but the nurse has a legal and ethical duty to report child abuse, even if the patient discloses it in confidence.
B. Filing a report with the ethics committee does not fulfill the mandatory reporting requirement for child abuse.
C. The nurse must report suspected or disclosed child abuse to the appropriate child protection agency, even if the patient is now in rehabilitation. Anonymity may be used if allowed, but reporting is legally required.
D. Reassuring the patient about comfort in sharing does not address the immediate need to protect the child and fulfill mandatory reporting obligations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This occurs when the nurse projects personal feelings about someone from their own life onto the patient (e.g., comparing the patient to a grandparent and feeling sadness).
B. This refers to severe emotional outbursts in cognitively impaired patients, not nurse behavior.
C. This would involve the nurse using defense mechanisms to protect themselves from anxiety, not relating to the patient as a grandparent.
D. Transference is when the patient projects feelings onto the nurse, not the other way around.
Correct Answer is A
Explanation
A. Word salad refers to a jumble of incoherent words and phrases without logical connection, as seen in the patient’s statement.
B. Echolalia is the repetition of another person’s spoken words, not unrelated word combinations.
C. Neologism is the invention of new, made-up words, not a random string of real words.
D. Anhedonia is the inability to experience pleasure, not a speech disturbance.
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