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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Using silence allows the patient time to process thoughts and feelings, encourages introspection, and can facilitate deeper communication during interviews.

B. While prolonged silence can sometimes make patients uncomfortable, its intentional and therapeutic use is beneficial when appropriately timed.

C. Reflecting or paraphrasing communicates understanding; silence alone does not confirm comprehension.

D. In therapeutic communication, the nurse does not have to immediately fill silence; allowing moments of quiet can be purposeful.

A. Neurological B. Respiratory C. Hepatic D. Cardiovascular

Correct Answer is B

Explanation

A. Neurological assessment is important, but not the priority since opioid overdose primarily causes life-threatening respiratory depression.
B. Respiratory assessment is the highest priority because opioids suppress the respiratory center, leading to hypoventilation, hypoxia, or apnea.
C. Hepatic assessment is not the immediate concern in acute overdose.
D. Cardiovascular assessment is necessary, but respiratory status takes precedence because airway and breathing are life-sustaining priorities.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which principle should guide the nurse in determining the extent of silence to use during patient interview sessions?

Correct Answer is A

Explanation

A nurse cares for a patient experiencing an opioid overdose. Which focused assessment has the highest priority?

Correct Answer is B

Explanation

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?

A nurse is caring for a client who has major depressive disorder and is scheduled for electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible side effects of the ECT. Which of the following responses should the nurse make?

A nurse is teaching the parents of a school-age child who has ADHD about atomoxetine. Which of the following instructions should the nurse include in the teaching?

When assessing a patient's plan for suicide, what aspect has priority?

A nurse is caring for a client in the emergency department (ED) Exhibits Which of the following client findings should the nurse report to the provider Immediately? (Select all that apply.)

A health care provider considers which antipsychotic medication to prescribe for a patient diagnosed with schizophrenia who has auditory hallucinations and poor social function. The patient is also overweight and hypertensive. Which drug should the nurse advocate?

A cruel and abusive person often uses rationalization to explain their behavior. Which comment demonstrates use of this defense mechanism?

Documentation in a patient's chart shows. "Throughout a 5-minute interaction, patient fidgeted and tapped their left foot, periodically covered their face with their hands, and looked under chair while stating, 1 enjoy spending time with you." Which analysis is most accurate?