A nurse is caring for a client in the emergency department (ED) who was brought in by her adult child for vague, flu-like symptoms. While helping the client to change into a gown, the nurse notices numerous bruises on the client's back and arms
When questioned, the client is distracted and ambiguous with her answers. Which action should the nurse take?
1. Report the situation to law enforcement.
2. Report the situation to social services.
3. Question the adult child who brought the client to the ED.
4. File a written report in the client's chart.
Correct Answer: 2
Rationale 1: In this case, social services should be notified. Law enforcement would be notified if the results of social services' investigation warrant it.
Rationale 2: Nurses are considered mandated reporters. As a result, they must report any situation when an injury is present and appears to be the result of abuse, neglect, or exploitation. The situation described may or may not be one of abuse or neglect, but the nurse is required to report it to the proper authorities. In this case, social services should be notified.
Rationale 3: Questioning the client's adult child is appropriate, but the incident needs to be reported regardless of the questioning.
Rationale 4: Documentation in the chart is extremely important, but this would be part of the nurse's notes, not a separate written report.
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