During the nurse's assessment of a female patient, the patient reveals that she experienced sexual abuse when she was a young woman. What is the nurse's most appropriate response to this disclosure?
A) Reassure her that this information will be kept a secret.
B) Begin the process of intensive psychotherapy.
C) Encourage the patient to phone 911.
D) Facilitate appropriate resources and referrals.
Ans: D
Feedback:
The nurse's primary roles in light of this disclosure are to provide empathy and to arrange for appropriate resources and referrals. There is no need to phone 911 and psychotherapy is beyond the nurse's scope of practice. The patient's confidentiality will be respected, but this does not mean that the nurse can promise to keep it a secret.
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