A nurse in the emergency department is caring for female client.

Exhibits

For each of the client's findings, click to specify if the assessment finding is consistent with Cushing syndrome, hyperthyroidism, or diabetes mellitus. Each finding may support more than 1 disease process.

A. Report the findings to a supervisor:Nurses are mandated reporters. If abuse is suspected-especially when physical evidence (bruises in various stages of healing) contradicts the client's story-the priority is to activate the chain of command or legal reporting mechanisms to ensure the client's safety. Reporting to a supervisor (or directly to Adult Protective Services, depending on facility policy) is the actionable step to intervene.

B. Discuss respite care with the client's family:While caregiver strain is a common cause of abuse, and respite care is a valid long-term intervention, it does not address the immediate safety of the client or the legal requirement to report suspected abuse.

C. Document the bruises in the client's chart: Documentation is essential for evidence, but it is not the first priority. Ensuring safety and following legal reporting mandates takes precedence over charting. You report, then document the findings and the fact that you reported.

D. Provide the client with a crisis hotline number: This places the burden of seeking help on the victim, who may be cognitively impaired (as implied by "older adult" checks) or too fearful to use it. The nurse must take a more active role in protecting the client.

A. No venipuncture or blood pressure in left arm:This precaution is typically used for clients with lymphedema (e.g., post-mastectomy) or an arteriovenous fistula for dialysis. It is not specific to Wilms' tumor.

B. Collect all urine:Urine collection (often 24-hour) is used to test for vanillylmandelic acid (VMA) levels in Neuroblastoma, a tumor of the adrenal glands. It is not a standard precaution for Wilms' tumor.

C. Contact precautions:Wilms' tumor is a malignancy (cancer), not an infectious disease. Standard precautions are sufficient.

D. Do not palpate abdomen: Wilms' tumor (nephroblastoma) is an encapsulated tumor of the kidney found in children. The most critical safety precaution is to avoid palpating the abdomen. Palpation can cause the tumor capsule to rupture, which would spread (seed) cancer cells throughout the abdominal cavity and bloodstream. A sign is placed over the bed to warn all staff and family members.