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Soru

Zorluk: ZorAbuse and Neglect

During a routine follow-up appointment at an outpatient clinic, a client with early-stage dementia is accompanied by a family caregiver. While the nurse is preparing to obtain vital signs, the caregiver suddenly grasps the client's forearm tightly and speaks in a harsh, threatening tone. The nurse observes several distinct, fading bruise marks resembling fingertips on the client's bilateral upper arms. What is the priority nursing action?

  1. Intervene calmly to separate the client and caregiver by stating that a private physical examination is a standard clinic requirement.Cevap
  2. B
    Document the interaction objectively in the medical record and monitor the client for additional signs of maltreatment at the next scheduled visit.
  3. C
    Confront the caregiver regarding the forceful behavior and explain that it constitutes grounds for an elder abuse investigation.
  4. D
    Assign an unlicensed assistive personnel (UAP) to remain in the room as a safety witness while continuing the clinical assessment.

Cevap

The priority action is to separate the client from the caregiver using a non-confrontational rationale, such as stating that a private examination is a standard clinic policy.
The correct answer addresses the most critical and immediate need: client safety. By using a standard clinic policy as the reason for separation, the nurse de-escalates the situation, avoids putting the caregiver on the defensive, and creates a safe environment to interview the vulnerable client privately. Once the client is safe, the nurse can proceed with a thorough assessment, precise documentation using direct quotes, and mandatory reporting.

Adım Adım Çözüm

1
Assess the immediate environment for safety and identify the primary risk.
The client is in immediate proximity to an aggressive caregiver, and there are physical signs (fingerprint bruises) suggesting ongoing abuse.
According to Maslow's Hierarchy of Needs, physiological safety is the highest priority in an acute situation.
2
Determine the most therapeutic and safe intervention to protect the client.
A non-confrontational separation strategy prevents escalation while allowing the nurse to interview the client privately.
Direct confrontation can trigger increased violence and cause the caregiver to remove the client from the healthcare setting, blocking further assistance.
3
Plan subsequent mandatory actions after immediate safety is secured.
Once separated, the nurse will conduct a full assessment, document findings objectively (using direct quotes), and fulfill the legal obligation of mandated reporting.
Mandatory reporting is triggered by reasonable suspicion, but securing the client's physical safety must occur first.

Anahtar Kavram

In suspected abuse scenarios, the nurse's immediate priority is client safety through non-confrontational separation from the suspected abuser, followed by objective documentation and mandatory reporting.
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Abuse and Neglect

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