A nurse is assessing a client during a routine check-up. The client appears anxious and withdrawn and has several unexplained bruises on their upper arms and shoulders. When asked how they got the bruises, the client hesitates and offers an inconsistent explanation. What is the nurse's most appropriate next step?
Wait for the client to voluntarily disclose more information before taking further action.
Document the findings and assess the client during the next visit to gather more information.
Report the findings to the appropriate authorities in accordance with the facility's policy.
Ask the client additional detailed questions to clarify the cause of the injuries.
The nurse's priority is to ensure the client's safety and well-being. Reporting the situation to the appropriate authorities or following mandated reporting guidelines for suspected abuse is the critical first step. The nurse is legally and ethically obligated to report any suspicion of abuse or neglect. While other answers suggest temporary measures like documenting findings or further questioning, they delay the immediate action needed to address potential risk and ensure safety.
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NCLEX RN
Psychosocial Integrity
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