NCLEX-RNPsychosocial IntegrityHard
A home health nurse visits an 82-year-old client who lives with an adult child caregiver. The nurse notes the client is underweight, has an unexplained stage 2 pressure injury, and appears fearful when the caregiver enters the room, becoming quiet and avoiding eye contact. What is the nurse's priority action?
- ASeparate the client from the caregiver to conduct a private assessment and interview.
- BDocument the findings and continue routine monitoring at the next visit.
- CAsk the caregiver directly if they have been neglecting the client.
- DEducate the caregiver on proper nutrition and skin care techniques.
Show answer & explanationAnswer & explanation
Correct answer: A. Separate the client from the caregiver to conduct a private assessment and interview.
The combination of unexplained injury, malnutrition, and fearful behavior specifically in the caregiver's presence are red flags for elder abuse or neglect; the priority is to safely separate the client from the suspected abuser to obtain an honest assessment and ensure immediate safety before further action, such as reporting.
Why the other options are wrong
- B. Waiting to intervene delays protecting a potentially at-risk older adult.
- C. Confronting the caregiver directly in front of the client, or at all before assessment, could endanger the client and prompt denial or retaliation.
- D. Education assumes lack of knowledge rather than addressing possible abuse and does not ensure the client's safety or truthful assessment.
Elder Abuse/Neglect Recognition
Nurses must recognize red flags of elder mistreatment, including unexplained injuries, malnutrition, and fearful behavior around a caregiver, and prioritize the client's safety.
- Fearful behavior specific to caregiver presence is a key red flag
- Private, separate assessment allows honest disclosure
- Nurses are mandatory reporters of suspected elder abuse
- Confronting caregiver before assessment can endanger the client
Memory trick: Fear near caregiver = separate first, ask questions after.