A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

Ask the client's son to go to the waiting area.

Ask the client about his injuries with the son present.

Treat and discharge the client.

File an incident report.

Answer and Explanation

The Correct Answer is A

A.   Asking the client's son to go to the waiting area allows the nurse to have a private conversation with the client, which is crucial in suspected cases of elder abuse to gather information without potential interference or intimidation.
B.   Asking about injuries with the son present might hinder the client from disclosing information due to fear or pressure.
C.   Treating and discharging the client without addressing the suspected elder abuse could potentially put the client in further danger.
D.   Filing an incident report might be necessary but should follow an assessment and investigation of the situation.

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Correct Answer is A

Explanation

A. Placing the client's ring in the facility safe ensures that it is securely stored and prevents loss or misplacement, which is standard procedure for valuable personal items before surgery.
B. Placing the ring in the bag with the client’s clothing is not secure, as it increases the risk of loss or theft.
C. Taping the ring to the client’s finger is not ideal because jewelry should generally be removed before surgery to prevent complications such as swelling, circulation issues, or electrical burns from cautery equipment.
D. Keeping the ring for the client is inappropriate because staff should not personally hold onto a client’s valuables. Instead, valuables should be properly documented and stored per facility policy.

A. Find out which staff member left the documentation program on the screen B. Tell the charge nurse that a visitor viewed a client's protected health information C. Inform the visitor that client records are confidential. D. Close the computer program

Correct Answer is D

Explanation

Choice A Rationale: While it is important to identify the staff member responsible for leaving sensitive information accessible, it is not the first action that should be taken. The immediate risk of a confidentiality breach must be addressed before investigating the cause.
Choice B Rationale: Notifying the charge nurse is a necessary step, but it is not the most immediate action required. The priority is to secure the confidentiality of the client's information.
Choice C Rationale: Informing the visitor about the confidentiality of records is crucial, but the first action should be to prevent further viewing of the information.
Choice D Rationale: Closing the computer program is the first and most direct action to secure the client's medical information and prevent any further unauthorized access. This action immediately addresses the privacy breach and protects the client's confidential information.

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A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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