The nurse caring for a toddler with Kawasaki disease who is receiving intravenous immunoglobulin for severe coronary inflammation is planning discharge teaching for the parents. Which instruction should the nurse provide during the discharge education?

Rationale:

A. Complete a comprehensive history: Gathering a full medical and psychosocial history helps the nurse identify patterns of neglect, dependency, or caregiver control. It also provides critical context about baseline function and recent changes in the client’s condition.

B. Confront the abuser about concerning actions: Directly confronting the suspected abuser may increase the risk of retaliation against the client and compromise the safety of both client and provider. It may also hinder legal investigations if not handled properly.

C. Develop a safety plan: Developing a safety plan is essential when elder mistreatment is suspected. It outlines strategies and resources to protect the client from further harm, including steps to ensure physical and emotional safety within or outside the home.

D. Perform a thorough physical assessment: A comprehensive physical exam allows the nurse to document injuries, skin breakdown, hygiene status, and other signs of neglect. Objective findings support the identification and substantiation of potential mistreatment.

E. Report findings to Adult Protective Services: Mandatory reporting is required in suspected elder abuse cases. Reporting to APS initiates an investigation and can mobilize protective services and interventions, including caregiver support or removal if needed.

F. Question the client in front of the suspected abuser: Interviewing the client in the presence of the suspected abuser can lead to incomplete or falsified responses due to fear, coercion, or shame. Private questioning ensures more honest communication.

G. Throw away soiled clothing: Soiled clothing may contain forensic evidence such as bodily fluids, skin cells, or wound drainage. Disposing of it could compromise the legal investigation or documentation of neglect.

H. Take photographs to document the abuse or neglect: Photographic evidence provides visual documentation that supports clinical findings. This can strengthen the case when authorities investigate, and helps track the healing or progression of injuries over time.

Rationale:

• Assess for pattern of bowel movements: Sertraline, a SSRI, commonly causes gastrointestinal side effects, including diarrhea or constipation. Monitoring the client's bowel movement pattern is essential to detect and manage these potential adverse effects.
• Monitor suicidal ideation: Clients with PTSD and major depressive symptoms, especially those recently expressing suicidal intent, require close monitoring for suicidality when initiating SSRIs like sertraline, as energy to act on suicidal thoughts may increase before mood improves.
• Weigh client weekly: SSRIs, including sertraline, can lead to weight changes. Regular weight monitoring helps detect significant weight gain or loss, especially in clients with changes in appetite or nutrition due to mood disorders.

• Offer frequent sips of fluids: There is no current evidence of dehydration or dry mouth. SSRIs like sertraline do not routinely require fluid intake encouragement unless side effects or clinical symptoms indicate a need.
• Watch for hypotension: Sertraline is not commonly associated with hypotension. Orthostatic hypotension is more typical with tricyclic antidepressants or antipsychotics, not SSRIs.