A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Explanation:

A. "I promise I won't tell anyone about this."

This statement is not appropriate because nurses are mandated reporters of suspected child abuse. Promising confidentiality in cases of abuse goes against legal and ethical responsibilities. The nurse must report suspected abuse to the appropriate authorities for the safety and well-being of the child.

B. "Your family is bad for doing this to you."

This statement is judgmental and may make the child feel guilty or conflicted about their family. It is essential to avoid blaming or shaming language when addressing a child who has been abused. The focus should be on providing support, validation, and appropriate intervention.

C. "Let's discuss what you have told me with your family members."

This statement is not appropriate because it suggests involving the family members in the discussion of abuse, which can potentially put the child at risk of further harm. It's essential to prioritize the safety of the child and follow appropriate reporting procedures rather than involving potentially abusive family members in discussions about abuse.

D. "It is not your fault that this happened."

This statement is appropriate and supportive. It reassures the child that they are not to blame for the abuse they have experienced. It acknowledges the child's feelings and helps them understand that they are not responsible for the actions of the abuser. This statement can provide comfort and validation to the child during a difficult time.

Explanation:

A. Whisper to the patient that she will be saved.

This action is inappropriate and does not address the underlying issues of the patient's condition or the presence of the family friend. Whispering such a statement may also be confusing or alarming to the patient.

B. Confront the family friend to allow the patient to ask questions.

While it's important to facilitate open communication with the patient, confronting the family friend directly may not be the most effective approach initially. It's crucial to first assess the patient's comfort level and safety before addressing the situation with the friend.

C. Consult the healthcare team about the suspicions and call local authorities to investigate.

Jumping to conclusions and involving authorities without gathering more information or assessing the patient's feelings directly could escalate the situation unnecessarily. It's important to handle such concerns with sensitivity and professionalism, involving appropriate resources only when needed.

D. Ask the patient if she feels safe, while the friend is in the room.

This is the most appropriate action initially. By directly asking the patient about her feelings of safety, the nurse can gauge the patient's comfort level and assess any potential concerns or risks. This approach allows the nurse to gather information and address any issues in a supportive and patient-centered manner. If the patient expresses concerns or discomfort, further assessment and appropriate interventions can be implemented, which may include involving other members of the healthcare team or authorities if necessary.