A practical nurse (PN) enters a client's room on a rehabilitation unit and witnesses an unlicensed assistive personnel (UAP) holding a client firmly by the wrists. The UAP states, "If you do not get up for a shower right now, you will not get any breakfast." The client is visibly distressed and attempting to pull away. In what order should the PN perform the following actions? Arrange them from highest priority (first) to lowest priority (last).
- 1Instruct the UAP to release the client's wrists and step away immediately.
- 2Direct the UAP to leave the client's room and wait at the nursing station.
- 3Evaluate the client's wrists for physical injury and assess their emotional state.
- 4Notify the charge nurse and the facility supervisor about the suspected abuse.
- 5Document the objective observations of the event and the client's condition.
Answer
The correct sequence is to first instruct the UAP to release the client, direct the UAP to leave the room, evaluate the client for injuries, notify the charge nurse, and finally document the objective observations.
In situations involving suspected abuse or immediate threats to client safety, the nurse's first action must always be to intervene and stop the harm. Next, securing the environment by removing the offending staff member ensures ongoing safety. Only after the environment is safe can the nurse accurately and effectively assess the client for injuries. Once the client's medical and emotional needs are addressed, the nurse fulfills mandated reporting obligations by notifying leadership. Finally, objective documentation of the event is completed to create a legal record.
Step-by-Step Solution
Key Concept
Prioritization in suspected abuse and client rights violations emphasizes immediate physical safety, removal of the threat, patient assessment, and subsequent administrative reporting.