A nurse is caring for a client who has AIDS. The client states, "My mouth is sore when I eat." Which of the following instructions should the nurse provide?

Rationale:

A. Make an audio recording of the adolescent's responses: Audio recordings require consent and may not be legally or ethically appropriate in suspected abuse cases. Documentation should be written, factual, and follow institutional policies and mandatory reporting laws.

B. Promise not to disclose information shared during the interview: Nurses must never promise confidentiality in suspected abuse cases, as they are mandated reporters. All disclosures of abuse must be reported to child protective services or appropriate authorities.

C. Obtain a history from both the adolescent and their caregiver: Gathering information from both parties helps identify inconsistencies and assess the situation fully. However, this should be done separately to allow the adolescent to speak freely and without coercion.

D. Use leading questions during the interview: Leading questions can influence the adolescent’s responses and compromise the integrity of the assessment. Open-ended, nonjudgmental questions are essential to support accurate and unbiased information gathering.

Rationale:

A. Avoid talking to the client about the newborn: Avoidance may intensify the client’s sense of isolation and loss. Acknowledging the newborn and offering opportunities to express emotions helps validate the grief and supports emotional healing.

B. Offer to take pictures of the newborn for the client: Creating mementos such as photographs allows the client and family to honor the baby’s memory and supports healthy grieving. These keepsakes may become meaningful in the healing process over time.

C. Assure the client that she can have additional children: While well-intended, this statement can minimize the significance of the loss. Grief must be acknowledged in the present without shifting focus to future pregnancies, which may feel dismissive.

D. Discourage the client from allowing friends to see the newborn: Families should be supported in making choices about how they wish to say goodbye. Discouraging this may interfere with personal grieving preferences and disrupt closure.