Delirium occurs in response to all the following stressors except

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.

A. Obtain information as covertly as possible is not recommended. While it's important to handle the situation with sensitivity, the nurse should maintain transparency and create an environment where the family feels safe to share information. Covert questioning can raise suspicion and might not facilitate open communication.
B. Avoid responding to hints that abuse has occurred is not appropriate. If there are hints of abuse, it’s crucial for the nurse to respond with empathy, concern, and to acknowledge those hints, as this can help the child and family feel supported. Ignoring signs of potential abuse could lead to further harm.
C. Be open, concerned, and honest is the best approach. The nurse should express concern in a non-judgmental, empathetic manner. This builds trust and encourages the family to provide accurate information, which is crucial for the child’s safety and well-being. It also ensures the nurse can assess the situation appropriately.
D. Separate the family from the child during the interview may be necessary in some cases if the nurse suspects abuse and needs to speak with the child alone to avoid further pressure or influence from family members. However, this is not a first-step intervention; it should only be done if the nurse has reason to believe that the family’s presence may hinder the interview or prevent the child from being honest.