A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Explanation:

A. "I promise I won't tell anyone about this."

This statement is not appropriate because nurses are mandated reporters of suspected child abuse. Promising confidentiality in cases of abuse goes against legal and ethical responsibilities. The nurse must report suspected abuse to the appropriate authorities for the safety and well-being of the child.

B. "Your family is bad for doing this to you."

This statement is judgmental and may make the child feel guilty or conflicted about their family. It is essential to avoid blaming or shaming language when addressing a child who has been abused. The focus should be on providing support, validation, and appropriate intervention.

C. "Let's discuss what you have told me with your family members."

This statement is not appropriate because it suggests involving the family members in the discussion of abuse, which can potentially put the child at risk of further harm. It's essential to prioritize the safety of the child and follow appropriate reporting procedures rather than involving potentially abusive family members in discussions about abuse.

D. "It is not your fault that this happened."

This statement is appropriate and supportive. It reassures the child that they are not to blame for the abuse they have experienced. It acknowledges the child's feelings and helps them understand that they are not responsible for the actions of the abuser. This statement can provide comfort and validation to the child during a difficult time.

Explanation:

A. The child was brought to the facility 30 minutes after the injury occurred:

The timing of seeking medical attention alone may not necessarily indicate abuse. However, if there are inconsistencies in the reported mechanism of injury or if there is a delay in seeking medical care without a valid explanation, it can raise suspicion and warrant further investigation.

B. The parents report that the child injured herself by falling off the couch:

While falls are common causes of fractures in toddlers, spiral fractures are more commonly associated with twisting or torsional forces, which can raise concerns about non-accidental trauma. If the reported mechanism of injury does not align with the type of fracture or if there are inconsistencies in the history provided, it may indicate potential abuse.

C. The child begins to cry when her arm is examined by the provider:

It is common for children to cry or show discomfort during a physical examination, especially if they are in pain or feeling anxious. While this finding alone may not indicate abuse, it is essential to assess the child's behavior, pain response, and overall presentation for any additional signs or patterns of abuse.

D. The child's examination shows a single injury:

The presence of a single injury does not necessarily rule out abuse. Abusive injuries can be single or multiple, and the absence of other injuries does not negate the possibility of abuse. It is crucial to consider the context, history, and clinical findings comprehensively when evaluating for abuse.