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NCLEX Question of the Day
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A home health nurse is visiting an elderly client who lives alone. The nurse notes multiple bruises in various stages of healing on the client's arms and upper back. The client appears fearful and withdrawn when their adult child, who is the primary caregiver, is present. What is the nurse's primary responsibility?
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Ask the adult child directly about the cause of the bruises.
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Teach the adult child about safe methods for transferring the client.
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Document the bruises and the client's behavior in the chart.
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Correct answer Report the findings to the appropriate adult protective services agency.
Rationale
The nurse has a legal and ethical obligation to report suspected elder abuse or neglect. The presence of multiple bruises in various stages of healing, particularly on the upper back (an area unlikely to be bruised accidentally), combined with the client's fearfulness and withdrawal in the caregiver's presence, are significant indicators of potential physical abuse. Reporting these findings to Adult Protective Services (APS) or the designated state agency is the nurse's primary responsibility to ensure the client's safety.
Confronting the potential abuser directly may escalate the situation and place the client at further risk. While documentation is essential, it does not fulfill the mandatory reporting requirement. Teaching transfer methods is inappropriate as it ignores the strong possibility of abuse being the cause of the injuries.
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