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. Key features include severe weight loss, distorted body image, restrictive eating, and preoccupation with food (e.g., cooking for others but eating very little). Wearing loose layers to hide weight is also typical.
B. This disorder involves recurrent episodes of eating large amounts of food, often rapidly, which is not described here.
C. This category is used when symptoms do not fully meet criteria for anorexia or bulimia; the patient’s presentation fits anorexia nervosa criteria.
D. Bulimia involves bingeing and compensatory behaviors like vomiting or laxative use; no binge episodes are described in this case.
Correct Answer is B
Explanation
A. Judging the patient can shut down communication and make the patient feel defensive rather than heard.
B. This technique, also called reflective listening, shows the patient that the nurse is actively listening and trying to understand their perspective, encouraging further expression.
C. Direct questions can be useful, but they may limit patient expression and can feel leading rather than supportive.
D. While intended to show empathy, this phrase can be perceived as dismissive if the nurse has not fully explored the patient’s feelings.
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