Exhibits

The client is being considered for discharge to home where he will continue to recover. The nurse reassesses the client and evaluates him for discharge readiness.

For each body system, click to specify the assessment finding(s) that would indicate the client is ready for discharge to home.

Each body system may support more than one finding. Each category must have at least one response option selected.

 

Body system	Findings
Cardiovascular	Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities Pedal pulse of 2+ or better
Neurovascular	Pupils equal and nonresponsive to light Absence of numbness or tingling in feet Skin that is pale, cool to touch
Renal Perfusion	Client has urine output of 1,600 mL in 24 hours Creatinine of 1.2 mg/dL (106 mmol/L)

Rationale for Correct Choices

• Neglect: The client presents with signs of poor hygiene, untreated pressure injuries, confinement to bed without a clear medical reason, and a reduction in social interaction and autonomy. These factors collectively indicate neglect, which is the failure of a caregiver to meet the basic physical, emotional, and social needs of a dependent adult.
• Adult Protective Services: Adult Protective Services is the appropriate authority to report suspected abuse or neglect of older adults living in private homes. As a mandated reporter, the nurse is legally required to report suspected elder mistreatment to APS to initiate an investigation and protect the client.

Rationale for Incorrect Choices

• Sexual abuse: There are no indicators such as bruising in private areas, fear of the caregiver, or behavioral cues that might suggest sexual trauma. The case centers on physical neglect, not sexual abuse.
• Financial exploitation: The client has not reported any unauthorized financial activity, and there is no evidence of the caregiver misusing or controlling the client’s finances. This makes financial exploitation an unlikely concern.
• Long Term Care Program: This agency oversees long-term care facilities like nursing homes. Since the client resides in a private home, the situation falls outside the jurisdiction of this program.
• State Department of Health: The Department of Health primarily monitors healthcare providers and facilities, not private caregiving situations. Therefore, it is not the correct agency to report suspected elder abuse in this context.

Rationale:

• Depression or withdrawn behaviour: This behavior is often seen in neglected elders who lack meaningful interaction, care, or stimulation. Emotional neglect and isolation can lead to signs of withdrawal and sadness.
• Oversedation : Overmedicating a client to control behavior or suppress activity is considered physical abuse. It reflects intentional harm or misuse of medications, especially when used to subdue.
• Untreated pressure injuries: Failure to address and treat pressure ulcers indicates neglect, especially when the wounds are visible and advanced. It shows a lack of basic caregiving and health maintenance.
• Bruises in various stages of healing: Multiple bruises at different stages suggest repeated physical trauma over time. This is a strong red flag for physical abuse rather than accidental injury.
• Poor personal hygiene: Long, dirty nails and unclean conditions point to inadequate caregiving. Basic hygiene neglect often reflects poor or absent daily care practices.
• Leaving an older adult in a public space: Leaving an elder alone in public with no supervision or support meets the definition of abandonment. It places the individual in a vulnerable and unsafe situation.