Best Answer: All of these options could be appropriate in some way (although you don't ever want to ignore or "look pass" client statements of this magnitude).
As RNs, when faced with ethical dilemmas it is important to assess the whole situation. It is important to review the patient's past medical history, and to try to understand the whole situation. In my experience, if there are holes in the story or the story just isn't making sense I have found that I am not usually getting the whole truth. It is important to collaborate with others like your charge nurse and social work team. If something is unsettled in you, do not hesitate to report to EPS.
I often have students jump to reporting to a protective agency. This is never a wrong answer. However, reporting to agencies like EPS or CPS should not be taken lightly; there are serious repercussions for those involved when you report to such agencies. As a mandatory reporter, you want to make sure that you have the complete story and as much objective data as you can before you report. If you do not have or are not able to safely obtain that information and you feel unsettled, do not hesitate to report to EPS. It is always nice to collaborate with another provider to make sure you are doing the right thing.
I have actually had this exact scenario happen with a student nurse whom I was her clinical instructor. We reported it to the facility manager and the manager went on to explain that they have investigated this claim 3 different times and had meetings with the client's family. There was no abuse occurring in this particular situation, it was part of the client's dementia.
Other questions to consider are: