A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck. When asked what happened she states, "I walked into a door.”. What are the most appropriate interventions by the nurse? (Select All that Apply)

Choice A rationale Confronting the boyfriend about possible abuse is not an appropriate initial intervention as it can escalate the situation and put the client at further risk. The nurse's priority is to ensure the client's safety and establish trust, which can be undermined by an accusatory approach towards the alleged abuser. A confrontational stance may also deter the client from disclosing information. Choice B rationale Contacting the police is a crucial intervention when abuse is suspected, especially given the visible injuries and the client's inconsistent explanation. Nurses are mandated reporters for suspected child abuse, and for adults, reporting is often required or strongly recommended when there's an imminent threat of harm, which physical violence indicates. This ensures legal protection and investigation. Choice C rationale Asking the teen if she feels safe is a direct and empathetic way to assess her immediate safety needs and empower her to express her situation. This open-ended question allows the client to articulate her fears and concerns, providing valuable information for developing a safety plan and determining appropriate interventions. Choice D rationale Maintaining a calm, caring, professional demeanor is essential to establish trust and rapport with the client. This approach helps to de-escalate anxiety and create a safe environment where the client feels comfortable disclosing sensitive information without fear of judgment or further distress. It promotes a therapeutic relationship. Choice E rationale Talking to the client privately is paramount to ensure her safety and facilitate open communication. The presence of the alleged abuser can prevent the client from speaking freely due to fear of retaliation or further harm. Privacy allows the client to disclose information about the abuse without coercion or intimidation.