A practical nurse (PN) is conducting a home health visit for an older adult client and observes unexplained patterned bruising on the client's upper arms. The client appears fearful when their family caregiver enters the room. In which order should the PN take the following actions? Arrange the actions from first to last.
- 1Ensure the immediate safety of the client.
- 2Interview the client privately using open-ended questions.
- 3Document the objective physical findings and the client's exact words.
- 4Report the observations to the supervising registered nurse (RN).
Answer
The correct sequence is to first ensure the client's immediate safety, then interview the client privately, document the objective findings, and finally report the observations to the supervising RN.
In suspected abuse scenarios, prioritization frameworks dictate that immediate client safety comes first. After safety is secured, the practical nurse gathers further data by interviewing the client privately. Next, objective findings and exact statements are documented clearly in the medical record. Finally, the PN reports these findings up the chain of command to the supervising RN to facilitate the legally mandated reporting process.
Step-by-Step Solution
Key Concept
Prioritization and sequence of actions for data collection and mandated reporting of suspected abuse.