A nurse is caring for a child who has had diarrhea for 3 days.
Which of the following actions should the nurse take?

Choice A rationale

While acknowledging that hitting a child is wrong is important, the nurse must use therapeutic communication techniques to support the adolescent. Directly stating that the parent was wrong may cause the adolescent to feel defensive or ashamed, and it may not be the most effective way to provide emotional support. The goal is to create a safe and trusting environment where the adolescent feels comfortable discussing their experiences. The nurse should focus on providing empathetic and non-judgmental support to help the adolescent process their feelings and access appropriate resources.

Choice B rationale

Telling the adolescent not to disclose their abuse to anyone else unless it is okay by them is inappropriate and goes against the principles of safeguarding and mandatory reporting. Healthcare professionals have a duty to protect vulnerable individuals and report suspected abuse to the appropriate authorities. This response could inadvertently discourage the adolescent from seeking help or disclosing further information. It is essential to follow protocols for reporting abuse while ensuring the adolescent feels supported and understands that the nurse is taking steps to ensure their safety.

Choice C rationale

Reassuring the adolescent that the abuse is not their fault is an important aspect of providing emotional support and validation. Victims of abuse often struggle with feelings of guilt, shame, and self-blame. By explicitly stating that it is not their fault, the nurse helps to alleviate these feelings and reinforces that the adolescent is not to blame for the abusive behavior. This response aligns with principles of trauma-informed care and helps to build a trusting relationship between the nurse and the adolescent, which is crucial for their emotional healing.

Choice D rationale

Implying that the other parent did nothing to stop the abuse can lead to further emotional distress for the adolescent and may cause feelings of betrayal or abandonment. This response may not provide the necessary support or validation the adolescent needs in that moment. The nurse should focus on addressing the immediate emotional needs of the adolescent and providing reassurance and support. Discussions about the roles of other family members should be handled delicately and may require the involvement of counseling or social services.

Choice A rationale

Collecting vital signs every 2 hours may not provide comfort and support to the child or family. Instead, it may contribute to unnecessary stress and anxiety for the child and family during this sensitive time. It is important to balance medical assessments with compassionate care.

Choice B rationale

Avoiding discussions about death may not be helpful for the child or family. Children, even those who are terminally ill, have the right to receive honest and age-appropriate information about their condition. Open communication helps them process their feelings and can provide a sense of closure.

Choice C rationale

Encouraging the family to involve siblings in caring for the terminally ill child can provide emotional support to both the ill child and the siblings. It fosters a sense of togetherness and helps siblings cope with the situation. It also allows siblings to express their love and support, which can be therapeutic for the entire family.

Choice D rationale

Performing passive range of motion to the child's extremities every 4 hours may be beneficial in maintaining joint flexibility and preventing contractures. However, it is not the primary focus in providing compassionate end-of-life care. Comfort measures and emotional support are more critical during this time.