A nurse is preparing a client's body for a postmortem family viewing. Which of the following actions should the nurse take?

A. Documenting suspicions in the client's medical record: While accurate documentation of objective findings is important, simply recording suspicions without following mandated reporting procedures does not fulfill the nurse’s legal responsibility. Documentation supports care but is not the primary legal action.

B. Notifying the caregiver of the findings: Informing the caregiver may be inappropriate and could place the client at further risk, especially if the caregiver is the suspected abuser. Legal obligations prioritize protecting the client over notifying the caregiver.

C. Reporting findings to social services: Nurses are mandated reporters of suspected elder abuse or neglect. Reporting objective findings of malnutrition and unexplained bruising to social services ensures that the client’s safety is addressed and fulfills the nurse’s legal responsibility.

D. Including findings during hand-off report: Communicating relevant findings during hand-off is part of good nursing practice, but it does not meet the legal requirement to report suspected abuse to appropriate authorities.

A. "I will notify my doctor if the stoma starts to look purple.": A stoma that appears purple can indicate compromised blood flow or ischemia, which is a medical emergency. Recognizing this sign and notifying the healthcare provider demonstrates understanding of proper stoma care and potential complications.

B. "I will irrigate the colostomy every day.": Ascending colostomies typically produce liquid to semi-liquid stool and are not routinely irrigated. Daily irrigation is usually reserved for descending or sigmoid colostomies to regulate bowel movements.

C. "I should expect my stool to be formed.": Stool from an ascending colostomy is usually liquid or semi-liquid because the stool has not yet passed through the majority of the colon where water absorption occurs. Expecting formed stool indicates a misunderstanding of colostomy output.

D. "I will empty the pouch every 2 to 3 hours.": Ascending colostomy output is frequent and liquid, but pouches are generally emptied when they are one-third to one-half full, not on a strict schedule. Overly frequent emptying is unnecessary and may increase the risk of skin irritation.