# A home health nurse visiting a 78-year-old with dementia notices unexplained bruises in various stages of healing and the family caregiver becomes hostile when the client is asked questions privately. The client tearfully says please do not tell anyone. Which is the nurse most appropriate response?

> source: MyMerci (mymerci.kr)  
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> language: en  
> subject: NCLEX-RN  
> category: SIPC

## Question

A home health nurse visiting a 78-year-old with dementia notices unexplained bruises in various stages of healing and the family caregiver becomes hostile when the client is asked questions privately. The client tearfully says please do not tell anyone. Which is the nurse most appropriate response?

## Option

1. Honor the client request and document the findings only
2. Confront the son directly and demand an explanation
3. Report the suspicion to Adult Protective Services as legally required **✔ Correct answer**
4. Wait until the next visit to see if the bruises worsen

**Correct answer: 3**

## Explanation

Nurses are mandatory reporters of suspected elder abuse in every U.S. state. The legal threshold is REASONABLE SUSPICION, not proof, and confidentiality cannot be promised when abuse is suspected. The report goes to Adult Protective Services. Confronting the alleged abuser may escalate harm and compromise an investigation. Delaying for additional bruises violates the duty to report.

## In-depth explanation

Mandatory reporter teaching point: report suspicion not certainty. Telling the client that you must share concerns to keep them safe respects autonomy while complying with the law.

## Clinical scenario

Home visit for diabetic foot care. Caregiver is the adult son, the only listed contact. Home is unkempt, refrigerator nearly empty, multiple expired medications.

## Key concepts

- **mandatory reporter** — Professional legally required to report suspected abuse to designated authority.
- **Adult Protective Services** — State agency that investigates abuse, neglect, or exploitation of vulnerable adults.
- **reasonable suspicion** — Legal threshold for reporting; does not require proof of abuse.

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