A nurse is assessing a nonverbal client who has multiple bruises in various stages of healing on their body. When questioned, the caregiver providing information for the client appears evasive and agitated. What should the nurse do next?
Document the bruises in the client’s chart and reassess during the next visit.
Report suspicions to the appropriate authorities for further investigation.
Ask the caregiver indirect questions to gather additional information.
Focus on treating the client’s physical injuries without escalating concerns.
The correct answer is to report the findings to the appropriate authorities, as mandated reporters are legally and ethically obligated to report suspicions of abuse or neglect. This action ensures the initiation of an investigation to protect the client. While documenting findings, asking indirect questions, and assessing injuries are essential parts of care, failing to report suspected abuse leaves the client vulnerable to ongoing harm. Reporting should be done even if there is only reasonable suspicion, as investigators determine validity—not the nurse.
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NCLEX RN
Psychosocial Integrity
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