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. Incorporate the treatment into the client's care:

Once the nurse has determined whether the client's grieving is healthy or complicated, they can integrate appropriate treatments and interventions into the client's care plan. Treatment options may include counseling, therapy, support groups, medication (if indicated), and holistic approaches to address physical, emotional, and spiritual aspects of grief.

B. Develop client-specific goals and outcomes:

Collaborating with the client, the nurse establishes client-specific goals and outcomes related to grief management and coping. These goals should be realistic, measurable, and aligned with the client's needs and preferences. Examples of goals may include improving coping skills, reducing emotional distress, fostering acceptance, and promoting resilience.

C. Determine whether coping strategies were successful:

Throughout the care process, the nurse continuously evaluates the effectiveness of coping strategies implemented to support the client in managing grief. Assessment of coping strategies involves monitoring the client's emotional state, functional status, coping skills utilization, and progress toward achieving established goals and outcomes. Adjustments to the care plan may be made based on the assessment findings.

D. Establish whether the client's grieving is healthy or complicated:

This step involves assessing the client's grief to determine whether it is a normal, healthy response to loss or if it has become complicated, characterized by intense, prolonged, or dysfunctional grief reactions. Assessing the client's grief status is crucial for tailoring appropriate interventions and support.

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.