A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first?

Choice A reason: Waiting until the next visit to check the bruises delays intervention and places the client at continued risk of harm. Suspected abuse requires immediate action, not postponement. This option neglects the urgency of protecting the client. Choice B reason: Following the agency’s guidelines for reporting suspected abuse is the correct first action. Nurses are mandated reporters and must act promptly to ensure the client’s safety. Reporting initiates protective measures, legal processes, and further investigation to prevent ongoing harm. This aligns with professional and ethical responsibilities. Choice C reason: Arranging family therapy may be beneficial in addressing stressors, but it is not appropriate as the first step when abuse is suspected. Therapy cannot proceed safely until the client is protected and the abuse is reported. This option overlooks immediate safety needs. Choice D reason: Instituting more frequent visits increases monitoring but does not directly address the abuse or ensure protection. While additional visits may provide support, they do not fulfill the nurse’s legal obligation to report suspected abuse.