The nurse is assisting with patient data collection in a clinic. The nurse is assigned to a young female patient who has an older male friend present at her bedside. The patient is nervous, timid, very thin, and with poor hygiene and lets the friend answer all of the nurse's questions. What actions should the nurse take?

Explanation:

A. "The client has developed drooping facial features."

This statement provides specific information about a recent change in the client's condition, which is relevant background information. It helps the provider understand one of the key reasons for the communication.

B. "The client may benefit from a neurology consult."

While suggesting a neurology consult is a potential recommendation (R) in the SBAR tool, it is not part of the Background (B) component. Background information typically focuses on factual data about the client's history, current condition, and pertinent details relevant to the situation.

C. "The client is disoriented and pupils are slow to respond to light."

Similar to option B, this statement describes the client's assessment findings and current condition rather than providing background information. It would be more appropriate in the Assessment (A) component of the SBAR tool.

D. "The client has a history of hypertension."

This statement provides relevant background information about the client's medical history, specifically their history of hypertension. Including this information in the Background component helps the provider understand the client's baseline health status, which is important for evaluating the current situation.

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.