# A nurse is caring for an 82-year-old client who was admitted to the emergency department with multiple bruises in various stages of healing on the arms and back, and the client appears fearful. The client's adult daughter, who is the primary caregiver, states, 'Mom is so clumsy and falls all the time.' When the nurse attempts to assess the client privately, the daughter insists on staying in the room. What is the nurse's priority action? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543484 > language: ko > subject: Mental Health ## 문제 A nurse is caring for an 82-year-old client who was admitted to the emergency department with multiple bruises in various stages of healing on the arms and back, and the client appears fearful. The client's adult daughter, who is the primary caregiver, states, 'Mom is so clumsy and falls all the time.' When the nurse attempts to assess the client privately, the daughter insists on staying in the room. What is the nurse's priority action? ## 보기 1. Document the bruises and accept the daughter's explanation of frequent falls 2. Confront the daughter directly about suspected abuse in front of the client 3. Discharge the client home with fall prevention education materials 4. Separate the client from the daughter to conduct a private assessment for abuse **✔ 정답** **정답: 4** ## 해설 The nurse's priority is to separate the client from the daughter for a private assessment to evaluate potential elder abuse, as multiple bruises in various stages of healing and controlling caregiver behavior are red flags. Other options delay safety assessment or are inappropriate. ## 심화 해설 Understanding the Clinical Scenario This question presents a classic clinical picture of potential elder abuse. The key findings are the physical evidence of multiple bruises in various stages of healing on the client's back and arms. In the context of an 82-year-old client, this finding is a major red flag. Bruises on the torso and upper arms are not typical of accidental falls, which usually cause injuries to bony prominences on the front of the body, like knees and shins. The caregiver's dismissive explanation ("Mom is so clumsy") is a common tactic to normalize the injuries, and the client's fearful demeanor is a critical behavioral cue. The daughter's insistence on remaining in the room directly obstructs the nurse's ability to conduct a confidential assessment, which is a fundamental step in screening for abuse. Why the Priority Action is to Separate and Privately Assess The nurse's priority is to ensure the client's immediate safety and conduct a thorough, confidential assessment. A foundational principle in caring for suspected victims of violence, as highlighted in trauma- and violence-informed care (TVIC) frameworks, is to prioritize safety, trust-building, and collaboration [4]. You cannot build trust or assess safety when a potential abuser is present. The caregiver's controlling behavior is a significant barrier to disclosure. Research on managing elder abuse consistently identifies that clinicians need effective strategies to navigate these sensitive situations, and creating a private space for assessment is the essential first step [2]. Without separation, the client has no safe opportunity to disclose abuse or ask for help, and the nurse cannot visually inspect all injuries or ask sensitive screening questions. The scoping review on elder abuse screening in emergency departments reinforces that validated tools must be administered in a private setting to be effective [1]. Analysis of Incorrect Options - Option 1: Document the bruises and accept the daughter's explanation of frequent falls. This is a dangerous and negligent action. The pattern of injury is inconsistent with the history provided. Bruises on the back and arms in various healing stages are highly specific for non-accidental trauma. Accepting an implausible explanation without further investigation fails the professional duty to protect a vulnerable adult. - Option 2: Confront the daughter directly about suspected abuse in front of the client. Direct confrontation is contraindicated. It can escalate the situation, endanger both the client and the nurse, and cause the caregiver to become more controlling and restrictive after the visit. The goal is not to accuse but to assess and ensure safety, which requires a non-judgmental, private approach [2]. - Option 3: Discharge the client home with fall prevention education materials. This action ignores the clear signs of potential abuse. Discharging a client back into an unsafe environment without a proper assessment is a failure to provide safe care. Fall prevention education is irrelevant when the mechanism of injury is likely physical assault, not an accident. Connecting to Nursing Practice and the Evidence The nurse's role in the emergency department is a critical opportunity for detection. Educational programs and interventional strategies for nurses emphasize that the first step in managing elder abuse is always identification through a private, patient-centered interview . The process involves respectfully but firmly separating the client from the caregiver. A practical and non-confrontational way to achieve this is by stating a hospital policy, such as, "It is our standard procedure to have a few minutes alone with every patient to discuss their health. We can escort you to a waiting area and will come get you as soon as we're finished." This aligns with the TVIC principle of creating a safe environment without directly accusing the caregiver [4]. Once alone, the nurse can use a validated screening tool to ask direct, non-judgmental questions about safety at home [1]. The priority is to create a safe zone where the client's unspoken fear can be voiced, and a proper plan of care, including a social work consult and mandatory reporting, can be initiated.References (research sources) - [1]Nurse-Administered Screening Tools for Detecting Elder Abuse in Emergency Departments: A Scoping Review.Research articleEl Hussein M, Sheehan D. (2025) · DOI: 10.1111/jan.16650 - [2]Healthcare Clinicians' Perspectives on Managing Suspected Elder Abuse: "We Don't Want to Just Swoop in and Do What We Think Is Best".Research articleMakaroun LK, Shin N, Hruska KL, Rosen T, Dichter ME, Thorpe CT, Rodriguez KL, O'Hare A, Rosland AM. (2025) · DOI: 10.1093/geroni/igaf012 - [4]Trauma- and Violence-Informed Care Practices in the Emergency Department for Survivors of Intimate Partner Violence.Research articleTiyyagura G, Abeyaratne D, Asnes A, Schaeffer P, Gawel M, Jaferi N, Oakley B, Crawley D, Serrechia P, Frechette A, Balmer DF. (2026) · DOI: 10.1001/jamanetworkopen.2026.0034 ## 임상 시나리오 Elder Abuse Screening: The Private InterviewSeparating the client from the caregiver is the critical first step When elder abuse is suspected, the priority nursing action is to create a safe, private environment for assessment. A caregiver who refuses to leave the room is a significant red flag for controlling behavior and potential abuse. Use a non-confrontational, routine-sounding reason to separate the caregiver, such as needing a urine specimen or stating that a hospital policy requires a private assessment for all patients. This avoids direct accusation and escalation. Key physical indicators of abuse include bruises in various stages of healing on the torso, back, or upper arms. These locations are atypical for accidental falls, which usually involve bony prominences on the front of the body. CautionDo not confront the suspected abuser directly. This can increase the victim's risk of harm. The goal is to assess the client alone, document findings objectively, and follow mandated reporting laws. ## 핵심 개념 - **Trauma- and Violence-Informed Care (TVIC)** — A framework prioritizing safety, trust, and collaboration, recognizing the impact of trauma and avoiding re-traumatization in care. - **Elder Abuse** — An intentional act or failure to act by a caregiver that causes or creates a risk of harm to an older adult, including physical, emotional, or financial abuse. - **Mandated Reporter** — A professional legally required to report suspected abuse or neglect to authorities; nurses are mandated reporters in all states. - **Confidential Assessment** — A private interview conducted without the potential abuser present, essential for safety screening and allowing the victim to disclose abuse. ## 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 85-year-old client who was admitted to the hospital with multiple…](https://mymerci.kr/pages/nclex_q.php?qn_id=543483) - [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._