A nurse is performing an assessment on an older adult client who lives with her caregiver. The client appears withdrawn and has multiple bruises in various stages of healing on her arms and legs. When the nurse asks about the bruises, the client avoids eye contact and states she is clumsy. What should the nurse do next?
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Encourage the client to share more about her relationship with the caregiver during her next visit.
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Ask the caregiver about the bruises to clarify what happened.
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Document the client’s explanation and monitor for further injuries during future visits.
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Report the findings to the appropriate authorities, as you suspect abuse.
The correct answer is to report the findings to the appropriate authorities, as nurses are mandated reporters when they suspect abuse or neglect. The nurse does not need definitive proof to report, only reasonable suspicion based on evidence or behaviors observed during the assessment. While asking the caregiver could provide additional information, it is not the nurse's role to investigate or validate suspicions of abuse, as this could potentially place the client at greater risk. Similarly, documentation and ongoing monitoring are important but insufficient without taking immediate protective action. Encouraging the client to share more in the future delays necessary intervention in what could be an unsafe situation for the client.
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NCLEX RN
Psychosocial Integrity
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