A nurse is assessing a middle-aged client admitted for a wrist fracture. During the examination, the client winces when their wrist is touched and hesitates when asked how the injury occurred, providing vague and inconsistent explanations. What is the best initial action the nurse should take to address this situation?
Focus on stabilizing the wrist injury and avoid pushing the client for more details at this time.
Ask the client to provide a more detailed and consistent explanation about the cause of the injury.
Document the findings and report suspected abuse to the appropriate authorities.
Tell the client they are safe and recommend discussing the situation with a counselor after discharge.
The correct answer is to document the findings and report suspected abuse to the appropriate authorities. Nurses are mandated reporters and must act to protect client safety by escalating any concerns about abuse. Proper documentation ensures a clear record for legal and investigative purposes, while reporting initiates the process to safeguard the client.
Other answers, such as probing for more detailed explanations, may inadvertently compromise the investigation or cause further distress to the client. Offering reassurances or delaying action overlooks the priority of client safety and does not fulfill the nurse’s legal obligation to report suspected abuse.
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NCLEX RN
Psychosocial Integrity
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