A nurse is caring for an older adult client admitted with severe dehydration. The client exhibits acute agitation, attempts to remove their intravenous (IV) catheter, and has unexplained bilateral bruising on the inner arms and torso. The client's adult child, who is the designated legal healthcare proxy, states, "You need to tie my parent's hands down immediately before they ruin the IV." Which action by the nurse demonstrates the appropriate legal and ethical response?
- AComply with the healthcare proxy's directive by immediately applying bilateral soft wrist restraints to secure the intravenous line.
- BDelegate the assessment of the client's agitation triggers and the decision to use protective mitts to the unlicensed assistive personnel (UAP).
- CPostpone notifying the designated authorities about the bruising until the healthcare provider can definitively prove that physical abuse occurred.
- Implement non-restrictive safety measures to protect the intravenous line and initiate a mandatory report for suspected elder abuse.Cevap
Cevap
The correct action is to implement non-restrictive safety measures to protect the intravenous line and initiate a mandatory report for suspected elder abuse.
The nurse has a legal mandate to report suspected elder abuse based on unexplained bruising, without needing definitive proof. Furthermore, the nurse must legally and ethically implement the least restrictive alternatives before applying restraints, regardless of a healthcare proxy's demands.
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Anahtar Kavram
Legal obligations regarding restraint alternatives, mandatory reporting of suspected abuse, and appropriate delegation.