A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?

Explanation:

A. Have a pen and paper.

Having a pen and paper can be helpful during the conversation as it allows the nurse to jot down important points, keywords, or reminders. However, it's not directly related to active listening itself but can aid in retaining and recalling information.

B. Use intermittent eye contact.

Intermittent eye contact is a crucial aspect of active listening. It shows that the nurse is engaged and attentive to the client's communication. However, it's essential to maintain a balance and avoid prolonged staring, which can be perceived as intimidating or intrusive.

C. Sit side-by-side with the client.

Sitting side-by-side with the client can create a sense of partnership and equality in the conversation. It can also help in establishing a comfortable and open environment for communication, which is beneficial for active listening.

D. Lean back in the chair.

Leaning back in the chair can convey a relaxed and open posture, which can contribute to a positive communication atmosphere. However, it's crucial to maintain an attentive posture and avoid appearing disinterested or unengaged.

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.