A hospice nurse is performing a home visit for a client who is being cared for by their partner. Which of the following statements made by the partner indicates the partner is experiencing denial?

Rationale for Correct Choices

• A change in mood: Isotretinoin can cause psychiatric adverse effects, including depression and suicidal ideation. Adolescents are particularly at risk, so any mood changes must be reported immediately to the provider for timely intervention and possible medication adjustment.

• Engagement in sexual activity: Isotretinoin is highly teratogenic, and pregnancy must be strictly avoided during therapy. Adolescents must notify the provider immediately if they engage in sexual activity, so proper pregnancy prevention measures and monitoring can be implemented.

Rationale for Incorrect Choices

• Dry mouth: While common with isotretinoin therapy, dry mouth is generally mild and manageable with hydration; it does not require immediate notification to the provider.

• The development of dry eyes: This is a known side effect of isotretinoin, often treated with lubricating drops. It is uncomfortable but not an urgent adverse effect requiring immediate reporting.

• Nausea: Mild gastrointestinal upset may occur but is typically self-limiting and does not necessitate urgent notification unless severe or persistent.

• Worsening of acne: Acne flare-ups can occur at the beginning of isotretinoin therapy but are expected and not considered an emergency; ongoing follow-up is sufficient.

• Sunburn: Increased photosensitivity is a known side effect. While the adolescent should take precautions, sunburn does not require immediate notification unless severe.

• Decreased night vision: Rare and usually reversible; it should be monitored but is not an immediate emergency unless it significantly impairs function.

Rationale:
A. Reassure the client that their injuries are not life threatening: While reassurance may seem supportive, minimizing the client’s experience or focusing on injury severity too early may invalidate their emotional trauma and hinder trust-building.

B. Limit the number of staff members providing care for the client: Limiting staff exposure promotes a sense of safety and control for the client, who may feel vulnerable and traumatized. Consistency in caregivers helps reduce anxiety and supports trauma-informed care principles by minimizing re-traumatization and promoting trust.

C. Ask the client for details about the assault: The nurse should not probe for specific details because repeated questioning can intensify trauma and emotional distress. Instead, the nurse should allow the client to share voluntarily when ready and defer detailed questioning to a trained sexual assault nurse examiner (SANE).

D. Instruct the client to shower and change their clothes: The client should not bathe, change, or wash clothing before evidence collection. The nurse should explain the importance of preserving evidence and provide clean clothing after the forensic examination is complete.