A nurse is caring for an 8-year-old boy who has been neglected by his father. The nurse observes that the boy is underweight, has poor hygiene, and shows signs of developmental delay. Which of the following nursing diagnoses is most appropriate for this child?

Choice A Reason: The nurse should collect forensic evidence using a sexual assault kit, which may include swabs, slides, envelopes, labels, and instructions for collecting specimens from various body sites. The nurse should follow the protocol for preserving and labeling the evidence.

Choice B Reason: The nurse should document any physical findings using body maps or diagrams, which can provide visual evidence of any injuries, bruises, abrasions, lacerations, or scars on the child's body. The nurse should also describe any findings using objective and precise language.

Choice C Reason: The nurse should not ask the mother to leave the room during the examination, unless she is suspected of being involved in the abuse or interfering with the assessment. The mother can provide emotional support and comfort to the child during this stressful situation.

Choice D Reason: The nurse should use open-ended questions to elicit information from the child, such as "What happened?" or "How do you feel?" The nurse should avoid leading or suggestive questions that may influence or distort the child's responses.

Choice E Reason: The nurse should not perform a pelvic examination using a speculum on a 4-year-old girl, unless it is medically indicated or ordered by a physician. A speculum examination can be traumatic and painful for a young child, and it may not yield useful information in cases of sexual abuse.

The correct answer is C. The nurse should document any evidence of abuse or neglect in detail using objective and factual language. This can include physical findings, behavioral observations, statements from the child or the child or the parents, and any actions taken by the nurse or other professionals. This can help provide accurate and reliable information for the investigation and intervention of the case.

Choice A Reason: The nurse should report any case of suspected or confirmed abuse or neglect to the appropriate authorities within 24 hours. This is a legal and ethical obligation of the nurse to protect the child from further harm and to comply with the mandatory reporting laws of the state or country.

Choice B Reason: The nurse should not obtain written consent from the parents or guardians before reporting any case of suspected or confirmed abuse or neglect. This is not a legal or ethical requirement of the nurse, and it may jeopardize the safety of the child or the nurse. The nurse should report the case without notifying the parents or guardians, unless it is in the best interest of the child.

Choice D Reason: The nurse should not confront the suspected abuser directly and demand an explanation for the abuse or neglect. This is not a legal or ethical responsibility of the nurse, and it may endanger the child or the nurse. The nurse should leave the investigation and intervention of the case to the appropriate authorities, such as child protective services, law enforcement, or social workers.