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. Offering platitudes can minimize the patient’s feelings and may shut down further disclosure.
B. Directly asking about suicidal thoughts is the most important and therapeutic response because the statement expresses hopelessness, a major risk factor for suicide. This question assesses immediate safety and guides next steps (ask about intent, plan, means; implement suicide precautions and notify the provider as indicated).
C. Exploring past interests can be therapeutic later, but it does not address the immediate safety concern suggested by the patient’s hopeless statement.
D. Saying you don’t understand is vague and avoids addressing the potential crisis; a direct, nonjudgmental assessment of suicidal ideation is required.
Correct Answer is ["B","C","F","I"]
Explanation
A. Blood pressure – Within normal range (115/76 mm Hg). No immediate concern.
B. Lithium level – 1.7 mEq/L is above the therapeutic range (0.8–1.2). Toxicity is likely, especially with the client’s symptoms (tremor, confusion, GI upset). Requires urgent follow-up.
C. Sodium level – 128 mEq/L indicates hyponatremia. Low sodium increases the risk for lithium toxicity because lithium and sodium compete for renal reabsorption.
D. WBC count – Within normal range (7,000/mm³).
E. TSH level – Mildly elevated (6). Suggests hypothyroidism (a side effect of lithium) but not immediately life-threatening. Requires follow-up, but not urgent.
F. BUN level –Elevated at 30 mg/dL (normal 10–20). Indicates impaired renal function, which reduces lithium clearance and increases toxicity risk.
G. Levothyroxine dosage – No immediate safety issue noted; managed long term.
H. Acetaminophen – Daily 325 mg is safe; not a concern.
I. Lithium dosage – Current dose (600 mg BID) is likely contributing to toxicity and must be reassessed immediately.
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