A nurse is caring for a female client, 84 years old, in the home environment. The client was recently hospitalized for an exacerbation of heart failure (HF) and moved in with her daughter after the hospitalization. Below is the information available to the nurse for interpretation:

Exhibits

Which of the following are the most appropriate interventions for this client? Select all that apply.

Choice A rationale

The nurse’s signature on the surgical consent form does not verify the client’s understanding of the procedure. This responsibility lies with the physician or surgeon, who must ensure that the client is fully informed about the nature, risks, benefits, and alternatives of the procedure. The nurse’s role is to witness the client’s signature, confirming that the client has signed the form without coercion and is competent to do so.

Choice B rationale

The client’s competence to sign the consent form is a crucial aspect that the nurse witnesses. By signing as a witness, the nurse attests that the client is mentally sound and capable of making informed decisions about their medical care. This includes verifying that the client is not under the influence of substances that could impair judgment and that they understand the nature of the consent they are giving.

Choice C rationale

The client voluntarily granting permission for the procedure is another key element of the nurse’s witnessing role. The nurse’s signature confirms that the client has signed the consent form of their own free will, without any undue pressure or coercion. This ensures the validity of the consent and protects the client’s rights and autonomy in making healthcare decisions.

Choice D rationale

The explanation of the procedure, its necessity, and potential outcomes are the responsibility of the surgeon or physician. The nurse does not provide this detailed explanation but ensures that the client has had the opportunity to receive this information from the appropriate healthcare provider. The nurse’s signature does not verify that the surgeon has explained the procedure; it simply confirms the witnessing of the client’s signature.

Choice E rationale

Understanding the risks and benefits of the procedure is part of the informed consent process, which the physician or surgeon must explain to the client. The nurse’s role is to witness the client’s signature, ensuring that the client has had the opportunity to receive this information. The nurse’s signature does not confirm the client’s understanding of these details but indicates that the consent was signed voluntarily and competently.

Choice A rationale: Developing a safety plan is essential to ensure the client's immediate and long-term safety. This involves planning for safe living arrangements and other protective measures.

Choice B rationale: Performing a thorough physical assessment helps document the extent of injuries or neglect and provides critical information for further actions and interventions.

Choice C rationale: Reporting findings to Adult Protective Services is a necessary step to ensure that the client receives the appropriate protection and support from authorities.

Choice E rationale: Taking photographs to document the abuse or neglect provides visual evidence that can be used in investigations and legal actions to protect the client.

Choice F rationale: Completing a comprehensive history helps understand the full context of the client's situation, including past medical history, social support, and potential risk factors for mistreatment.

Choice D rationale: Confronting the abuser about concerning actions is not advisable as it can escalate the situation and put the client at greater risk.

Choice G rationale: Throwing away soiled clothing may destroy potential evidence and is not a priority intervention in the context of suspected elder mistreatment.

Choice H rationale: Querying the client in front of the suspected abuser can intimidate the client and prevent them from speaking freely about their situation.