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Question

Difficulty: MediumAbuse or Neglect

A practical nurse is assisting with a dressing change for an older adult client at an outpatient wound care center. The client has moderate dementia and is accompanied by a family caregiver. During the procedure, the nurse observes multiple fading grip-mark bruises on the client's inner arms and notes that the client appears unusually fearful whenever the caregiver speaks. Which of the following is the priority action for the practical nurse?

  1. Report the objective physical and behavioral findings to the supervising registered nurse immediately.Answer
  2. B
    Question the client extensively in private to confirm exactly how the bruises occurred before taking further action.
  3. C
    Capture images of the injuries using a personal smartphone to ensure evidence is preserved for authorities.
  4. D
    Ask the caregiver why they are being rough and suggest looking into a long-term care facility.

Answer

Report the objective physical and behavioral findings to the supervising registered nurse immediately.
The correct action is to immediately report the objective physical findings and behavioral observations to the supervising registered nurse or healthcare provider. Nurses are mandated reporters, and reporting suspicions up the chain of command ensures patient safety, allows for proper documentation, and initiates appropriate reporting to adult protective services.

Step-by-Step Solution

1
Identify the clinical indicators of potential abuse or neglect present in the scenario.
Grip-mark bruises on the inner arms and fearful behavior in the presence of the caregiver are recognized as clear red flags for elder abuse.
Early recognition of physical and behavioral signs is essential for protecting vulnerable populations.
2
Determine the appropriate legal and professional responsibility.
The practical nurse recognizes the duty as a mandated reporter to act on reasonable suspicion without needing to conduct a thorough investigation.
Delaying a report to investigate independently can further endanger the client and falls outside the nursing scope of practice.
3
Select the safest priority intervention.
The findings are escalated to the supervising registered nurse immediately.
Prompt escalation ensures the client's immediate safety and triggers the facility's formal interdisciplinary reporting procedures to adult protective services.

Key Concept

Mandated Reporting and Client Safety
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Topics

Abuse or Neglect

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