A nurse is caring for an adolescent client who has a history of depression and suicidal ideation. Which of the following client statements should the nurse identify as requiring further intervention?

D. In the immediate aftermath of a sexual assault, the primary focus of the SANE nurse is to ensure the safety and well-being of the client. This includes providing a safe and supportive environment for the client, assessing and treating any physical injuries, addressing immediate medical needs, and offering emotional support and crisis intervention.

A, B, and C involve aspects of legal procedures and involvement of law enforcement, but they may not be appropriate or feasible for every client in every situation. Additionally, the decision to involve law enforcement or pursue legal action should be made in collaboration with the client and should prioritize their safety, autonomy, and well-being.

C. Dissociative amnesia is characterized by difficulty remembering important personal information, typically of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. The manifestation of guilt is common in individuals experiencing dissociative amnesia, as they may feel guilty about their inability to recall events or about any actions that occurred during the period of amnesia.

A. Hallucinations involve perceiving sensations that are not present in reality, such as hearing voices or seeing things that others do not. While hallucinations can occur in various psychiatric disorders, they are not a typical manifestation of dissociative amnesia.

B. Delusions are false beliefs that are firmly held despite evidence to the contrary. Like hallucinations, delusions can occur in various psychiatric disorders, but they are not characteristic of dissociative amnesia.

D. Anhedonia refers to a reduced ability to experience pleasure or interest in previously enjoyable activities. It is not directly related to dissociative amnesia.