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?
- Report the objective physical and behavioral findings to the supervising registered nurse immediately.Cevap
- BQuestion the client extensively in private to confirm exactly how the bruises occurred before taking further action.
- CCapture images of the injuries using a personal smartphone to ensure evidence is preserved for authorities.
- DAsk the caregiver why they are being rough and suggest looking into a long-term care facility.
Cevap
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.
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Anahtar Kavram
Mandated Reporting and Client Safety