# Situation: The public health nurse visits a family in which the grandfather, 76, has type 2 diabetes with blood sugar that stays high and was recently found to have early dementia. His wife, 70, cares for him and is scheduled for cataract surgery next month. Their son, 45, who lives with them, collects the grandfather's monthly pension. The house has loose rugs and a dimly lit stairway, and the grandfather fell once last month. When they are alone, the grandfather tells the nurse that his son keeps the whole pension and often leaves him without food or his medicines. The nurse finds none of his diabetes medicines in the house. Which entry should the nurse write in the family record?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627243  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The public health nurse visits a family in which the grandfather, 76, has type 2 diabetes with blood sugar that stays high and was recently found to have early dementia. His wife, 70, cares for him and is scheduled for cataract surgery next month. Their son, 45, who lives with them, collects the grandfather's monthly pension. The house has loose rugs and a dimly lit stairway, and the grandfather fell once last month.

When they are alone, the grandfather tells the nurse that his son keeps the whole pension and often leaves him without food or his medicines. The nurse finds none of his diabetes medicines in the house. Which entry should the nurse write in the family record?

## 보기

1. Client states, 'My son keeps my whole pension'; no medicines seen at home **✔ 정답**
2. Client has early dementia, so his report about his son may be unreliable
3. Family conflict over the pension; to be discussed later with the son
4. Client is being financially abused and neglected by his son at home

**정답: 1**

## 해설

Suspected abuse is documented objectively, in the client's own words in quotation marks plus observed findings, without conclusions or opinions; the record then supports referral to the municipal social welfare office. A diagnosis of abuse is a conclusion, dismissing the report because of dementia can leave him unprotected, and planning to discuss it with the suspected abuser can raise the risk.

## 심화 해설

Why option 1 is the correct documentation

When elder mistreatment is suspected, the nurse’s entry in the family record must capture what was directly observed and what the client said, without adding interpretation, diagnosis, or opinion. The correct note states the client’s own words in quotation marks and the objective finding that no diabetes medicines were visible in the home. This creates a factual record that can later support referral to protective services or a social welfare office.

Documentation that includes a conclusion, such as “financially abused and neglected,” moves beyond the nurse’s immediate data. A diagnosis of abuse is a legal and investigative determination, not a bedside nursing observation. The record should preserve the raw evidence so that the appropriate agency can act on it. Suspected abuse is recorded objectively, in the client’s own words plus observed findings, without conclusions or opinions.

Why the other options create risk

Watch out! Dismissing the grandfather’s report because he has early dementia is unsafe. Cognitive impairment does not automatically make a person’s statement unreliable. In fact, older adults with cognitive impairment are at increased risk for caregiver neglect and financial exploitation, and their reports must be taken seriously and documented. If the nurse writes that the report “may be unreliable,” the concern may never be investigated, leaving the client unprotected.

Watch out! Planning to discuss the pension issue later with the son is also dangerous. The son is the suspected abuser. Confronting or involving the suspected perpetrator can escalate the situation, increase the client’s risk, or give the son time to hide evidence or isolate the grandfather further. The nurse should not negotiate with the suspected abuser; the priority is to document and refer.

Clinical reasoning in elder mistreatment

The scenario contains several red flags that should raise suspicion for both financial abuse and neglect. The son collects the grandfather’s entire pension, the grandfather reports being left without food or medicines, and the nurse confirms that no diabetes medicines are present in the house. The home environment also shows fall hazards—loose rugs and a dimly lit stairway—and the grandfather fell once last month. Uncontrolled blood sugar in a client with type 2 diabetes who has no access to prescribed medication is a serious safety concern that can lead to hyperglycemia, dehydration, and complications.

Elder mistreatment often involves more than one form of abuse. A cognitively impaired older adult may experience financial exploitation and neglect at the same time, and the neglecting caregiver is frequently an adult child. This makes the grandfather’s situation a high-risk pattern that requires careful, objective documentation and prompt referral through the appropriate reporting pathway.

What belongs in the family record

| Documentation element | Example from this case | Why it matters |
| --- | --- | --- |
| Client’s exact words in quotation marks | “My son keeps my whole pension” | Preserves the allegation without the nurse interpreting or judging it |
| Objective observation | No diabetes medicines seen in the home | Records a verifiable fact that supports the concern |
| Conclusion or diagnosis | “Financially abused and neglected” | Not appropriate for nursing documentation; this is an investigative determination |
| Opinion about reliability | “Report may be unreliable due to dementia” | Unsafe; can block protection and investigation |
| Plan to discuss with suspected abuser | “To be discussed later with the son” | Unsafe; may escalate risk or alert the abuser |

Linking documentation to action

The purpose of the record is not to solve the case but to create a clear, factual account that supports the next step. When the nurse writes the client’s statement and the missing medicines as observed findings, the record becomes a tool for referral to the municipal social welfare office or adult protective services. The record then supports referral without the nurse having to prove abuse or confront the family.

Key point! In suspected elder abuse, document facts and quotes—not conclusions. A diagnosis of abuse is a conclusion, dismissing the report because of dementia can leave the client unprotected, and planning to discuss the concern with the suspected abuser can increase the risk.

## 임상 시나리오

Documenting Suspected Elder AbuseObjective facts over conclusions in the family record
When elder mistreatment is suspected, the nurse must record what the client said using direct quotation marks and what was observed, such as the absence of diabetes medications in the home.

The entry should contain no interpretation, opinion, or diagnosis. A statement like "financially abused and neglected" is a legal conclusion, not a nursing observation, and belongs to investigative agencies, not the bedside record.

CautionDo not dismiss a report because the client has early dementia. Cognitive impairment increases vulnerability to exploitation, and every report must be documented and taken seriously. Never discuss the concern with the suspected abuser before protective services are involved, as this can escalate risk.

## 핵심 개념

- **Objective Documentation** — Recording only what is directly observed or stated by the client, without adding interpretation, opinion, or diagnostic conclusions.
- **Elder Mistreatment** — Abuse, neglect, or exploitation of older adults, including financial abuse and caregiver neglect, which requires factual documentation and referral.
- **Financial Abuse** — Illegal or improper use of an elder's funds, property, or assets; suspicion must be documented factually, not diagnosed by the nurse.
- **Protective Services** — Agencies such as municipal social welfare offices that investigate suspected abuse and provide interventions based on documented evidence.
- **Quotation in Documentation** — Using the client's exact words in quotation marks to preserve the raw statement as evidence without paraphrasing or interpreting.

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