A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment.

Exhibits

Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Choice A rationale

Demonstrating the self-injection technique is a practical way for the nurse to evaluate the adolescent's ability to perform the procedure correctly. This hands-on approach allows the nurse to observe technique accuracy and provide corrective feedback if needed. It also helps build the adolescent’s confidence in self-administering insulin, which is crucial for managing type 1 diabetes mellitus independently. Furthermore, demonstrating skills to peers can reinforce learning as it involves active engagement and peer teaching, which have been shown to enhance knowledge retention and skill proficiency.

Choice B rationale

Asking the adolescent to describe his level of comfort with injecting himself provides subjective feedback rather than an objective measure of his ability to perform the procedure correctly. Comfort level does not necessarily correlate with competency in technique. However, assessing comfort can be part of a comprehensive evaluation but should not be the sole method. Comfort levels might influence adherence to the injection regimen, but they do not directly indicate whether the injection is being done correctly.

Choice C rationale

Reviewing glycosylated hemoglobin (HbA1c) levels can provide information about long-term blood glucose control but does not directly evaluate the adolescent's insulin injection technique. HbA1c reflects average blood glucose levels over the past 2-3 months and is influenced by multiple factors, including diet, physical activity, and overall diabetes management. While important for monitoring diabetes control, it is not a specific measure of the effectiveness of teaching self-injection techniques.

Choice D rationale

Having the adolescent list the procedural steps for safe insulin administration tests his recall of the steps but does not ensure that he can perform the injection correctly. Verbalizing steps is important for cognitive understanding but does not equate to the physical ability to execute the procedure. This approach may reveal gaps in knowledge but does not provide a comprehensive assessment of the actual injection technique.

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.