A nurse is inserting an indwelling urinary catheter for a male client.
Which of the following actions should the nurse take?

The correct answer is choice d. Privately interview the client about the injuries.

Choice A rationale:

Contacting the family regarding the client’s condition might not be appropriate if the family is suspected of being involved in the abuse. It could potentially put the client at further risk.

Choice B rationale:

Notifying risk management is important for documentation and internal review, but it does not directly address the immediate need to assess and ensure the client’s safety.

Choice C rationale:

Informing the transferring agency of the client’s condition is necessary for continuity of care, but it does not address the immediate need to investigate the cause of the injuries and ensure the client’s safety.

Choice D rationale:

Privately interviewing the client about the injuries allows the nurse to gather more information about the cause of the injuries in a safe and confidential manner. This step is crucial in assessing the situation and determining if further action, such as reporting to authorities, is needed. It ensures the client’s safety and helps in identifying any potential abuse.

The correct answer is B. The nurse should encourage the family to express their feelings of loss and provide emotional support and comfort during this difficult time. The nurse should also respect their cultural and religious beliefs and practices regarding death and dying, and allow them to spend as much time as they need with their loved one's body, unless there are infection control issues or legal requirements that prevent it. The other options are incorrect because they are insensitive and disrespectful to the family's needs and wishes.