Which of the following is an appropriate outcome for a client experiencing an acute episode of delirium?

A. "Your friends will understand when you tell them." This response, while well-meaning, may minimize the victim's feelings and pressure them to disclose something they might not be ready to share. It does not directly address the immediate emotional crisis the victim is experiencing.
B. "Are you thinking of suicide?" This is the most important response, as it directly addresses the risk of self-harm or suicide, which is a critical concern for victims of violent trauma, especially after a violent assault. The victim's statement, "There is no sense of trying to go on," may indicate feelings of hopelessness or despair, which are warning signs for suicidal ideation. It is essential to assess for any thoughts of suicide immediately to ensure the patient's safety.
C. "It will take time, but you will feel the same as before." While this response is intended to provide reassurance, it is unrealistic and does not acknowledge the trauma and emotional distress the victim is experiencing. Recovery from such an event is complex and often involves long-term emotional and psychological adjustments.
D. "You will be able to find meaning in this experience as time goes on." This response may sound dismissive and may not resonate with the victim at this time. Finding meaning can be part of the healing process later, but this statement may feel like an oversimplification or invalidation of the victim's current emotions.

A. Teach the mother about symptoms of UTI is not the nurse's first priority. While educating the mother about UTIs is important, the presence of bruises in the genital and rectal areas raises immediate concern for potential sexual abuse, which requires immediate action to ensure the child's safety.
B. Report suspected sexual abuse to protective services is the nurse's first priority. Any signs of physical trauma or injury in areas typically covered by clothing, such as the genital and rectal areas, must be reported immediately. The nurse is a mandated reporter and is legally required to report any suspected abuse. Ensuring the safety of the child is paramount, and protective services will investigate the situation and take appropriate steps.
C. Interview mother for child’s health history may be necessary later, but at this moment, the immediate concern is the possibility of sexual abuse. The nurse should report the findings to the appropriate authorities before discussing the situation further with the mother.
D. Obtain a urine sample to confirm UTI is important for diagnosing the UTI but does not address the immediate concern regarding possible abuse. The child’s safety and well-being must be prioritized, and reporting the possible abuse is more urgent than confirming the UTI at this point.