A registered nurse (RN) is caring for a 75-year-old client who was admitted with severe confusion and dehydration. During the assessment, the RN notes multiple unexplained bruises in varying stages of healing on the client's torso and upper arms. The client suddenly becomes highly agitated and repeatedly attempts to climb over the bed rails. Which action by the RN demonstrates adherence to legal rights and responsibilities?
- Move the client to a room near the nurses' station and notify the designated state authority about the suspected abuse.Cevap
- BDelay notifying adult protective services regarding the bruising until conclusive evidence of physical abuse is obtained.
- CApply soft wrist restraints immediately to prevent the client from sustaining an injury from falling out of bed.
- DInstruct the unlicensed assistive personnel (UAP) to perform a comprehensive skin assessment to document the exact location of all bruises.
Cevap
The RN must implement a less restrictive alternative to restraints by moving the client closer for observation, while simultaneously fulfilling the legal mandate to report the suspected abuse.
The correct action addresses both critical legal priorities simultaneously. The RN fulfills the role of a mandatory reporter by notifying the state authority based on reasonable suspicion, without waiting for absolute proof. Furthermore, moving the client near the nurses' station is a legally sound, least-restrictive alternative to physical restraints, thereby preserving the client's rights.
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Anahtar Kavram
Legal requirements for mandatory abuse reporting and the implementation of least restrictive alternatives prior to restraint use.