An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first?
a. Notify an elder protective services agency about the possible abuse.
b. Make a referral for a home assessment visit by the home health nurse.
c. Have the family member stay in the waiting area while the patient is assessed.
d. Ask the patient how the injury occurred and observe the family member's reaction.
ANS: C
The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document data before notifying the elder protective services agency.
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