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. This is more commonly associated with phencyclidine (PCP) or alcohol intoxication, not cocaine.
B. Cocaine is a powerful stimulant that activates the sympathetic nervous system. This results in mydriasis (dilated pupils), increased heart rate, elevated blood pressure, hypervigilance, and euphoria.
C. Depression is more likely during cocaine withdrawal, not intoxication.
D. Like depression, hypersomnia is a withdrawal symptom. Intoxication typically causes insomnia and restlessness.
Correct Answer is B
Explanation
A. The patient’s symptoms are physiological and neurological, not intentional behaviors for attention.
B. Alcohol withdrawal delirium (delirium tremens) typically occurs 48–72 hours after the last drink and includes tremors, agitation, anxiety, diaphoresis, tachycardia, hallucinations, and nightmares—all present in this patient.
C. Although head injury can cause confusion and agitation, the timing of symptoms following alcohol withdrawal aligns more closely with delirium tremens.
D. Acute psychosis can present with hallucinations, but in this case, the onset following alcohol cessation and accompanying autonomic hyperactivity point toward alcohol withdrawal delirium.
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