A patient diagnosed with moderate dementia consistently appears to be distorting the truth resulting in his wife asking, "What should I do when he lies to me about unimportant things?" Upon what rationale should the nurse's response be based?

A. "I will help you leave this relationship" is not an appropriate response because it assumes the nurse knows what is best for the patient and does not respect her autonomy or immediate choices. The patient has clearly stated she does not want to leave the relationship at this time.
B. "You need to report your husband to the police" is an invasive and potentially coercive statement. While reporting abuse is important, the nurse should provide information and support, not force actions the patient may not be ready to take. Pressuring her could escalate the situation and harm the patient’s trust in healthcare providers.
C. "Let's develop a safety plan for repeated violence" is the most supportive and patient-centered response. It acknowledges the reality of the abuse while offering a non-judgmental, practical approach to help her stay safe. The nurse is giving the patient the option to make informed decisions about her safety, which is empowering.
D. "Here is a list of services that can help you" is helpful, but it lacks the active engagement the patient may need. Developing a personalized safety plan is more immediate and relevant for someone experiencing ongoing abuse.

A. Possible child abuse is the most likely assessment. The presence of numerous bruises and the mother's vague, inconsistent details about the falls are concerning and may indicate that the child is being abused. Children at this age may sustain some bumps or bruises due to falls, but repeated and unexplained injuries, especially if the mother provides few details, should raise suspicion. The nurse should report this concern to appropriate authorities for further investigation.
B. Knowledge deficit pertaining to home safety could be a possibility if the mother is unaware of safety precautions in the home, but the vague and inconsistent explanation of the injuries makes this less likely. A knowledge deficit would typically present with more specific concerns and less concern for frequent injury.
C. A child with delayed milestones does not explain the frequent bruises or the vague details provided by the mother. While developmental delays can occur in some children, they are unlikely to account for such a pattern of injuries.
D. Normal behavior for a 2-year-old typically involves some bumps and bruises, but frequent falls resulting in numerous bruises are not considered normal. Most 2-year-olds are still learning motor skills, but they should not be falling down stairs repeatedly.