Question

The nurse is gathering data from a client in the home setting for care of a pressure wound. The nurse observes multiple areas of ecchymosis in various stages of healing. The client states, "They do the best care for but get frustrated when i wet the bed." What is the priority nursing action?

A. Ask the family why they are abusing the client
B. Place the client in the car and take the client to the nearest ER.
C. Ensure the clients safety and notify adult protective services
D. Call the police department and file a complaint.

Answer 1

The nurse's priority is to ensure the client's safety and report the situation to adult protective services for further investigation and protection of the client.

Step-by-step explanation:

The priority nursing action after observing multiple areas of ecchymosis in various stages of healing is C. Ensure the client's safety and notify adult protective services. It is important to address the physical signs of potential abuse, as well as the client's statements which may imply neglect or mistreatment. The nurse must take immediate action to protect the client from further harm, which involves notifying appropriate authorities to intervene, assess, and provide the necessary protection and services for the client.