A home health nurse makes weekly visits to an 87-year-old client who lives with her son. When home alone, the client is talkative and friendly, but when the son is home, the client is observed to be withdrawn and appears anxious. The client has bruises, which she states is from "bumping into things," and a weight loss of 10 pounds in the past month. With these objective findings, the nurse is required to do which of the following?

Ask the client if she has any concerns about her living situation, maintaining an objective, non-accusatory role.
Report suspected abuse to Adult Protective Services so an investigation into the client''s welfare can be performed.

Explanation

•All states have statutes requiring mandatory reporting by nurses and other healthcare workers of any suspected abuse and neglect of children, the disabled, and the elderly.

•Clients suffering from abuse and neglect will often have bruising, welts, burns, and weight loss. These clients often appear anxious or have personality changes.

•The nurse should privately discuss with the client any concerns about the client's safety.

•The nurse is also required by law to report any suspected abuse or neglect because all nurses are mandated reporters

•The nurse should not confront the suspected abuser with accusations or expect the abuser to seek help voluntarily.

Visit our website for other NCLEX topics now!