An older adult client who was admitted to a long-term care facility yesterday is confused about what day of the week it is. The history does not indicate that the client was confused prior to admission. Which action should the practical nurse (PN) take?

A. Throw away soiled clothing.
Not Applicable
Throwing away soiled clothing does not address the issue of elder mistreatment and may not be relevant to the investigation of abuse or neglect. Instead, the focus should be on assessing the situation, documenting evidence, and ensuring the client’s safety. The PN’s role includes observing signs of mistreatment and reporting them, not managing personal items.
B. Report findings to Adult Protective Services.
Applicable
Reporting to Adult Protective Services is crucial for initiating a formal investigation into suspected elder mistreatment. These agencies are equipped to handle allegations of abuse and neglect through professional investigation and intervention. This step ensures that the client receives the appropriate protection and that any mistreatment is addressed legally.
C. Complete a comprehensive history.
Applicable
A comprehensive history helps the PN understand the client’s background, current living conditions, and any potential patterns of mistreatment. This information is essential for identifying signs of abuse or neglect and for making an informed report to the appropriate authorities. It also assists in documenting the client’s experiences and concerns.
D. Perform a thorough physical assessment.
Applicable
A thorough physical assessment allows the PN to identify and document signs of physical abuse or neglect, such as injuries or unsanitary conditions. This documentation is important for supporting the findings in the report to Adult Protective Services and for planning further interventions. The assessment provides evidence of mistreatment and helps in evaluating the client’s overall well-being.
E. Question the client in front of the suspected abuser.
Not Applicable
Questioning the client in front of the suspected abuser can be unsafe and may lead to further mistreatment of the client. It is important to conduct these discussions privately to protect the client and obtain accurate information. The PN should gather information discreetly and report findings to the authorities without risking the client’s safety.
F. Develop a safety plan.
Applicable
Developing a safety plan is essential for ensuring the client’s immediate safety and preparing for any potential risks of mistreatment. This plan addresses how the client can be protected from further harm and outlines steps for seeking help if needed. It is a proactive measure to safeguard the client’s well-being.
G. Take photographs to document the abuse or neglect.
Applicable
Photographs serve as objective evidence of abuse or neglect, which is valuable for investigations by Adult Protective Services. Documenting visual evidence helps in assessing the severity of the mistreatment and supports the report made to authorities. It provides a clear record of conditions that might otherwise be subjective or difficult to convey.
H. Confront the abuser about concerning actions.
Not Applicable
Confronting the abuser can escalate the situation and put the client at further risk of mistreatment. This action should be handled by professionals trained to manage such situations. The PN’s role is to observe, document, and report findings rather than directly addressing the suspected abuser

A. Notifying the charge nurse is important but should come after confirming the accurate heart rate assessment.
B. Holding a prescribed morning dose of digoxin may be necessary if bradycardia is confirmed, but the first step is to accurately assess the heart rate.
C. Obtaining a full minute apical pulse assessment is the first step to verify the radial pulse rate reported by the UAP and ensure an accurate and comprehensive assessment of the client's heart rate.
D. Reviewing the client's baseline vital signs is useful but should follow a thorough and accurate assessment of the current heart rate.