During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the wall in the wheelchair. What is the priority nursing action?

Question

Quizplus · Accepted Answer

The client's injuries are inconsistent with the explanation given in that bumping into furniture could explain bruising on the extremities but does not account for the bruises on the torso (trunk). In addition, the bruises are in various stages of healing, which suggests that the injuries occurred over multiple occasions. The nurse's findings are suggestive of elder abuse but not conclusive. Further assessment is needed to confirm the nurse's suspicions and to determine the extent of the abuse. The nurse will assess the client for general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements by the client suggesting neglect. During the assessment and client interview, the nurse will need to maintain a neutral, nonjudgmental attitude to facilitate a trusting nurse-client relationship. (Option A) Asking the client to explain the bruises on the torso is a "why" type of question, places the client on the defensive, and does not facilitate a trusting nurse-client relationship. (Option C) Reporting the bruises to the HCP is an appropriate nursing action but is not the priority. The nurse needs additional information about the client's status and situation. (Option D) Talking to the client's child and/or other family members may be an appropriate nursing action. However, the nurse needs more information about the client's status to determine needed interventions. Further assessment for indications of elder abuse is the priority. Educational objective: When elder abuse is suspected, the nurse needs to perform further assessment to validate and confirm any initial findings and to determine the extent of the abuse and/or neglect. Areas of assessment for elder abuse include the client's general hygiene, clothing, nutritional and hydration status, presence of other injuries, inappropriate medication administration, signs of depression, and other statements suggesting neglect.

During a Home Visit, the Community Health Nurse Observes Bruises