# A nurse is caring for an 85-year-old client who was admitted to the hospital with multiple bruises in various stages of healing on the arms and back. The client's adult grandson, who is the primary caregiver, appears anxious and frequently interrupts when the client tries to speak. Which nursing action should the nurse take FIRST to address suspected elder abuse?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319646  
> language: ko  
> subject: Mental Health

## 문제

A nurse is caring for an 85-year-old client who was admitted to the hospital with multiple bruises in various stages of healing on the arms and back. The client's adult grandson, who is the primary caregiver, appears anxious and frequently interrupts when the client tries to speak. Which nursing action should the nurse take FIRST to address suspected elder abuse?

## 보기

1. Document all physical findings and report to the physician immediately
2. Confront the daughter directly about the suspected abuse
3. Contact Adult Protective Services to file a report
4. Interview the client privately without the daughter present **✔ 정답**

**정답: 4**

## 해설

When elder abuse is suspected, the priority is to interview the client privately to gather accurate information and ensure safety, away from the suspected abuser.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question assesses the nurse's priority action when suspecting elder abuse. The core principle is Key Point! **Ensuring the safety and autonomy of the vulnerable adult**. The nursing process begins with Assessment. Before any reporting or confrontation, the nurse must first gather a complete and reliable assessment from the client, which is only possible in a safe, private environment free from the potential abuser's influence or intimidation.

**Answer Rationale**: The FIRST action is to Interview the client privately without the daughter present. This is critical for several reasons: 1) It removes the barrier of the anxious caregiver who is interrupting, allowing the client to speak freely. 2) It respects the client's right to confidentiality and self-determination. 3) It enables the nurse to conduct a focused assessment, asking direct but sensitive questions about safety, injuries, and the home environment. A private interview is the foundational step upon which all subsequent interventions (documentation, reporting, safety planning) depend.

**Distractor Analysis**:

Watch out for confusion! Option ①, "Document all physical findings and report to the physician immediately," is an important but **not first** action. Thorough documentation is essential, but the nurse needs the client's private account to understand the context of the injuries before making a complete report.

Option ②, "Confront the daughter directly about the suspected abuse," is **contraindicated**. Confrontation can escalate the situation, put the client at immediate risk for retaliation, and is not the nurse's role. The focus must remain on the client's safety and assessment.

Option ③, "Contact Adult Protective Services (APS) to file a report," is a **mandated action** but typically comes *after* the private assessment. The nurse needs information from the private interview to make an informed and accurate report to APS.

**Related Concepts**: This scenario integrates mandatory reporting laws, therapeutic communication in crisis, safety and security as a basic human need, and ethical principles of beneficence (doing good) and nonmaleficence (preventing harm).

Concept Summary

| Concept | Key Takeaway |
| --- | --- |
| Suspected Abuse Protocol | Private Interview → Thorough Assessment & Documentation → Report per Facility Policy & Law → Safety Planning |
| Nurse's Role | Client Advocate, Mandated Reporter, Safe Environment Creator |
| Priority Principle | Client Safety & Accurate Information Gathering Come First |

Side-by-Side Comparison!

| Action | When It's Appropriate | Why It's Not the FIRST Step Here |
| --- | --- | --- |
| Private Client Interview | Whenever abuse is suspected; to establish safety and gather facts. | This IS the first step. It's the foundation for all other actions. |
| Confronting the Caregiver | Almost never by the nurse alone. May be done by APS or law enforcement in a controlled setting. | Can endanger the client, violates assessment principles, and is not therapeutic. |
| Reporting to Authorities (APS) | After assessment confirms or strongly suggests abuse; a mandated legal duty. | Requires information from the private interview to make a valid report. |

Anatomy, Physiology & Pharmacology Points
While not directly about anatomy, consider the physiological impact of stress and fear (elevated cortisol, increased heart rate) which can affect an elderly client's ability to communicate. The nurse's calm, private approach helps mitigate this stress response. No specific pharmacology is primary here, but be aware that certain medications (sedatives, analgesics) could be misused in an abuse situation.

Memory Tips
**Acronym: P.A.S.S.**

**P**rivate interview first.

**A**ssess and document thoroughly.

**S**afety plan for the client.

**S**ubmit mandated report.

Remember: You can't report effectively what you haven't assessed privately.

High-Frequency NCLEX Topics
Elder abuse, child abuse, and domestic violence are High Yield topics. The NCLEX consistently tests the **sequence of nursing actions**, emphasizing that assessment and ensuring safety precede reporting and confrontation. Know your role as a mandated reporter but also as a client advocate.

Watch Out for Question Variations!
* Instead of "first action," the question might ask for the **"priority"** or **"most therapeutic"** action.

* The scenario could shift to **suspected child abuse**. The principle is similar: separate the child from the parent/guardian to interview (with appropriate personnel) and assess safely.

* A question might ask what to do **after** the private interview confirms abuse (Answer: Document objectively and file a mandated report).

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are a nurse on a medical-surgical unit. Mr. Johnson, 85, is admitted for "weakness." During the bath, you note multiple ecchymoses (bruises) of varying colors (yellow/green, purple) on his upper arms and back in patterns not consistent with a simple fall. His grandson, who brought him in, is hovering, answering questions for him, and seems overly defensive.

**Nursing Intervention Strategy**:

1.  **Create Privacy**: "Mr. Johnson, I need to check your vital signs and ask you a few more questions about your health. It will just be the two of us for a few minutes." Escort the grandson to the waiting area politely but firmly.

2.  **Conduct a Private, Sensitive Interview**: Use open-ended, non-judgmental questions. "Some of the bruises I see look like they happened at different times. Can you tell me how you got them?" "Do you feel safe at home?" "Has anyone ever hurt you or made you feel afraid?"

3.  **Document Objectively**: Use a body map diagram. Note size, color, shape, and location of each injury. Use direct quotes from the client. Avoid conclusions like "client was abused." Instead, "client stated, 'My grandson gets frustrated and grabs my arm too hard.'"

4.  **Report and Collaborate**: Immediately report findings to the charge nurse, physician, and hospital social worker. Follow your facility's protocol for filing a report with Adult Protective Services (APS).

5.  **Develop a Safety Plan**: Collaborate with the team. Can the client be discharged safely? Does he need a temporary shelter or APS involvement for home assessment?

**Patient Safety and Precautions**: Key Point! Never conduct the initial assessment with the suspected abuser present. Do not promise the client complete confidentiality, as you are a mandated reporter. Explain, "I want to help keep you safe, and that might mean I need to talk to some other people who can help us." Ensure the client's immediate safety in the hospital.

Nursing Procedure & Medication Flow
While no specific medication procedure is central here, the nurse's role is procedural:

1.  **Procedure: Conducting a Private Interview for Suspected Abuse**

*   Step 1: Ensure a private room/curtains closed.

*   Step 2: Use therapeutic communication techniques (active listening, empathy).

*   Step 3: Perform a focused physical assessment of injuries with consent.

*   Step 4: Document findings meticulously using objective language.

*   Step 5: Initiate the facility's incident reporting and APS reporting protocol.

A Word from Your Senior Nurse
"Spotting the signs of abuse is a critical nursing skill, but knowing what to do next is what truly protects your patient. That moment of creating a safe, private space for them to speak can be terrifying for them but is our most powerful tool. Remember, we are often the only safe person they may encounter. Your calm, non-judgmental approach and your commitment to following through with reporting can literally save a life. On the NCLEX and in practice, always let the principle of 'client safety first' guide your sequence of actions."

## 핵심 개념

- **Elder Abuse** — The intentional or negligent act by a caregiver or trusted person that causes harm or risk of harm to a vulnerable adult aged 60 or older. Includes physical, emotional, sexual, financial abuse, and neglect.
- **Mandated Reporter** — A professional (like a nurse) who is legally required to report suspected abuse or neglect of children, elders, or other vulnerable populations to the appropriate authorities (e.g., Adult Protective Services).
- **Adult Protective Services** — A state-run social services program responsible for investigating reports of abuse, neglect, and exploitation of elderly and dependent adults, and for providing interventions and services to ensure safety.
- **Therapeutic Communication** — Verbal and nonverbal communication techniques used by healthcare professionals to promote a positive relationship, encourage open expression of feelings, and obtain accurate information, especially in sensitive situations.
- **Ecchymosis** — A medical term for a bruise, a discoloration of the skin resulting from bleeding underneath, typically caused by trauma. Bruises in various stages of healing (different colors) can be a red flag for repeated injury.

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