# A nurse is caring for a 78-year-old client admitted to the medical unit with dehydration and malnutrition. During assessment, the nurse observes unexplained fractures on X-ray, pressure ulcers, and signs of financial exploitation. The client appears fearful and withdrawn, avoiding eye contact and giving minimal responses to questions. When the client's adult daughter arrives, she becomes immediately defensive about the client's condition and insists that her mother 'has always been frail.' What is the nurse's most appropriate initial intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543481 > language: ko > subject: Mental Health ## 문제 A nurse is caring for a 78-year-old client admitted to the medical unit with dehydration and malnutrition. During assessment, the nurse observes unexplained fractures on X-ray, pressure ulcers, and signs of financial exploitation. The client appears fearful and withdrawn, avoiding eye contact and giving minimal responses to questions. When the client's adult daughter arrives, she becomes immediately defensive about the client's condition and insists that her mother 'has always been frail.' What is the nurse's most appropriate initial intervention? An 82-year-old client is admitted to the medical unit with dehydration and malnutrition. During assessment, the nurse observes unexplained fractures on X-ray, pressure ulcers, and signs of financial exploitation. The client appears fearful and withdrawn, avoiding eye contact and giving minimal responses to questions. When the client's adult daughter arrives, she becomes immediately defensive about the client's condition and insists that her mother 'has always been frail.' ## 보기 1. Immediately confront the daughter about the suspected abuse in front of the client 2. Document the findings but take no further action until more evidence is gathered 3. Discharge the client home with instructions for better care 4. Report the suspected abuse to Adult Protective Services and ensure the client's immediate safety **✔ 정답** **정답: 4** ## 해설 The priority is to report suspected abuse to Adult Protective Services to ensure immediate safety, as nurses are mandated reporters. Confronting the caregiver or delaying action can compromise patient safety. ## 심화 해설 Clinical Judgment This scenario tests a nurse's legal and ethical duties in a Mandatory Reporting situation. The core is immediate safety assurance and reporting to protective services. The patient's condition (bruises in various stages of healing, malnutrition, fear, neglect) and the caregiver's defensive attitude are clear indicators of suspected elder abuse. The nurse's first priority is to protect the patient from further harm, which is done through reporting and in-hospital safety measures. Reporting is mandatory even at the 'suspicion' stage. Delaying the report to gather more evidence could jeopardize patient safety. Memory Tip: Remember elder abuse response as "**S**AFE **F**IRST." **S**afety, **A**dult Protective Services report, **F**actual documentation, and **E**motional support come **F**irst. KR vs US: In South Korea, the system primarily involves reporting to the Elder Protection Agency (dial 1391 without an area code) or the police. In the US, each state has a dedicated agency called Adult Protective Services (APS), and healthcare providers must make a direct mandatory report to this agency. The principle of reporting immediately upon suspicion of abuse is the same in South Korea. ## 임상 시나리오 Clinical Practice Guide When dealing with cases of elder abuse: 1) Place the patient in a safe location (e.g., a hospital room) and avoid private interviews with the caregiver. 2) Conduct a thorough physical examination and assessment, and document objectively, including photographs. 3) Explain to the patient that confidentiality may not be fully guaranteed (due to mandatory reporting obligations), and listen to their story with a warm and supportive attitude. Caution: In SATA (Select All That Apply) questions, the option "document" is almost always included in the correct answer, but the option "only document and take no further action" can never be the correct answer. Reporting is a **mandatory action** separate from documentation. ## 핵심 개념 - **Elder Abuse** — Elder abuse. A comprehensive concept that includes physical, emotional, and sexual abuse, neglect, and financial exploitation. - **Mandatory Reporter** — Mandatory reporter. A professional group (such as medical personnel, teachers, etc.) who are legally obligated to report suspected abuse of children, the elderly, or vulnerable populations. - **Adult Protective Services** — Adult Protective Services. A state agency in the United States that protects vulnerable adults (elderly, disabled) from abuse, neglect, and exploitation. - **Neglect** — Neglect. The act of failing to provide basic needs (meals, hygiene, medical care, supervision), including both active actions and omissions (failure to act). - **Dehydration & Malnutrition** — Dehydration and malnutrition. 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