# 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, along with signs of malnutrition. 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=543483 > 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, along with signs of malnutrition. 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 grandson 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 Understanding the Priority Action The correct first action is to interview the client privately without the grandson present. In any suspected case of elder abuse, the immediate priority is to ensure the older adult’s safety and obtain an unbiased account of their situation. The clinical presentation here—multiple bruises in various stages of healing and signs of malnutrition—raises a strong suspicion of physical abuse and neglect by a caregiver. The grandson’s anxious demeanor and controlling behavior, such as frequently interrupting the client, is a classic red flag that the caregiver may be attempting to dominate the narrative and prevent disclosure. Rationale Based on Evidence The foundational principle guiding this action is that effective intervention must be rooted in the perspectives of the older person themselves. A qualitative study on elder abuse intervention emphasizes that any meaningful response must start from the needs and viewpoint of the older adult, a concept central to their empowerment [1]. By separating the client from the potential abuser, you create a safe, confidential space that directly supports this empowerment. This allows the client to speak freely, without fear of retaliation, which is essential for a thorough assessment. Why Other Actions Are Not the First Step - Documenting and reporting to the physician (Option 1): While meticulous documentation of physical findings is a critical nursing responsibility, it is not the immediate priority. The physician will need a complete history, including the client’s own account of how the injuries occurred, to guide medical treatment and further intervention. Gathering that history must come first. - Confronting the grandson (Option 2): Direct confrontation is contraindicated. It can escalate the situation, placing the client at greater risk of harm after the healthcare encounter ends. It also contradicts the need for a sensitive, victim-centered approach, as the caregiver may become more controlling or aggressive. - Contacting Adult Protective Services (Option 3): Filing a report with Adult Protective Services (APS) is a mandatory legal and ethical duty for nurses when abuse is suspected. However, a report is most effective and protective when it is based on a comprehensive assessment, including a private interview with the victim. Prematurely filing a report without this critical information could lead to an incomplete investigation and may not immediately secure the client’s safety during the current care encounter. Connecting to Screening and Intervention Principles The nurse’s role in the emergency department or acute care setting is often the first line of detection. A scoping review on nurse-administered screening tools highlights the pivotal role nurses play in identifying elder abuse, but the effectiveness of any tool or protocol hinges on the ability to conduct a private, focused assessment . The act of separating the client for a confidential interview is, in itself, the most direct and immediate screening tool available. Furthermore, this action aligns with the global research priority of developing effective, victim-centered interventions. A project aimed at accelerating interventions for abuse of older people underscores that candidate interventions must be rigorously evaluated, but the common starting point for any successful strategy is ensuring the older person’s voice is heard and their immediate safety is secured . The private interview is the clinical embodiment of that principle.References (research sources) - [1]Multidisciplinary Perspectives on Elder Abuse in Belgium: Challenges and Strategies for Intervention.Research articleLieve P, Maxime C, Naomi A, Hilde B, Paul VR, Kristof VA. (2025) · DOI: 10.1177/30495334251355098 ## 임상 시나리오 Suspected Elder Abuse: Initial Nursing ActionPrioritize a private, safe interview before documentation or reporting. When elder abuse is suspected, the first priority is to separate the client from the potential abuser to conduct a private interview. This ensures safety and allows for an unbiased assessment. Red flags include injuries in various stages of healing, malnutrition, and a caregiver who is overly controlling or refuses to leave the client alone. Clinical AlertDo not confront the suspected abuser. This can escalate the situation and endanger the client. After the private assessment, follow your facility's protocol and state laws for mandated reporting to Adult Protective Services. ## 핵심 개념 - **Elder Abuse** — An intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult. - **Mandated Reporter** — A professional, such as a nurse, who is legally required to report any known or suspected cases of abuse, neglect, or exploitation to the appropriate authorities. - **Adult Protective Services (APS)** — A social services program provided by state and local governments serving older adults and adults with disabilities who are in need of intervention due to abuse, neglect, or exploitation. ## 같은 주제 문제 - [A nurse is assessing an 82-year-old client who was brought to the emergency department by …](https://mymerci.kr/pages/nclex_q.php?qn_id=543479) - [A nurse is assessing an 82-year-old client who was brought to the emergency department by …](https://mymerci.kr/pages/nclex_q.php?qn_id=543480) - [A nurse is caring for a 78-year-old client admitted to the medical unit with dehydration a…](https://mymerci.kr/pages/nclex_q.php?qn_id=543481) - [A nurse is caring for an 85-year-old client who has been admitted to the hospital with mul…](https://mymerci.kr/pages/nclex_q.php?qn_id=543482) - [A nurse is caring for an 82-year-old client who was admitted to the emergency department w…](https://mymerci.kr/pages/nclex_q.php?qn_id=543484) - [A nurse is caring for a 90-year-old client who was admitted to the emergency department wi…](https://mymerci.kr/pages/nclex_q.php?qn_id=543485) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._