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 B
Explanation
A. Making positive statements about body image is important for psychological recovery but is secondary to restoring physical health.
B. Achieving a healthy weight is the priority goal, as physical stabilization is essential to prevent life-threatening complications of malnutrition.
C. Feeling in control of behavior is a therapeutic goal, but it is not the immediate priority compared to addressing life-threatening weight loss.
D. Identifying family dynamics is important for long-term support and autonomy but is secondary to immediate physical health needs.
Correct Answer is C
Explanation
A. Anger is a common emotion in psychiatric patients but is less predictive of suicide risk.
B. Elation may occur in some mood disorders but is not strongly associated with imminent suicide risk.
C. Hopelessness is the feeling most strongly correlated with suicidal ideation and attempts, making it a key predictor for elevated suicide risk.
D. Sadness is a symptom of depression but alone does not reliably predict suicide risk without accompanying hopelessness.
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