Mary Lou is an 85-year-old female client who is brought to the emergency department due to a fractured clavicle. On physical assessment, the nurse notes bruises in varying coloration on the upper arms, thorax, and upper legs. The client informs the nurse that her daughter hits her every time she fails to quiet down her granddaughter. Which of the following is the most appropriate response of the nurse?
Explanation
Answer: C- The correct response is: “Violence at home is a legal issue. I have to report this, but I am assuring you that the information will be kept confidential.” The client should be assured that the nurse will keep the information confidential, unless the nurse is under a legal obligation to share the information. Options A, B, and D do not address the legal consequences of the situation. Although assuring the client that she is safe is encouraged, the nurse should avoid asking why questions. Questions that start with why puts the client in a defensive stance.
