During a routine bed bath at a long-term care facility, a practical nurse discovers multiple unexplained bruises in various stages of healing and small, circular burns on an older adult client's back. The client becomes visibly anxious and withdrawn when asked about the injuries. Arrange the following actions the nurse should take in the correct priority order.
- 1Ensure the client's immediate safety and well-being.
- 2Collect objective data regarding the characteristics of the bruises and burns.
- 3Notify the charge nurse or nursing supervisor of the suspected abuse.
- 4Report the suspected abuse to Adult Protective Services or the designated state agency.
- 5Document the objective physical findings, notifications, and actions taken in the client's health record.
Answer
The correct sequence of actions is to first ensure client safety, followed by collecting objective data, notifying the internal chain of command, making the external mandated report, and finally documenting the event.
The sequence follows standard nursing prioritization: immediate physiological safety is the absolute highest priority. This is followed by data collection to ascertain the facts. Once the objective data is gathered, the practical nurse must inform the internal chain of command, ensure the legal mandate to report to external authorities is met, and finally complete a thorough documentation of the objective findings and the sequence of actions taken.
Step-by-Step Solution
Key Concept
Mandatory Reporting and Prioritization in Suspected Abuse