The nurse observes a clinic visit for a client who may be experiencing intimate partner violence. Which actions require follow-up? Highlight the actions that can reduce privacy, safety, or client autonomy.
Highlight in Table
Choose your responses, then check the answer.
Explanation
Screening in front of the partner, using the partner as interpreter, hiding discoverable material, and demanding immediate separation require follow-up. Private, collaborative support better protects safety and autonomy.
Quick answer Highlight screening while the partner remains present, asking that partner to interpret, secretly putting hotline material in a purse the partner may search, and requiring the client to leave today before support is offered. Each action can increase danger or remove the client's control.
Why this is correct IPV screening and response should occur privately, with clear confidentiality limits, safe language assistance, immediate-safety assessment, and access to multicomponent ongoing support. A controlling partner should not remain for screening or interpret, and resources or departure plans should not be imposed in a way that may trigger retaliation.[2][3]
Easy analogy or mental picture Think of the nurse as opening a safe exit with the client, not pushing the client through a door. Privacy reveals the options, safety planning checks the path, and the client helps choose the next step. The analogy does not override mandatory reporting laws.
NCLEX decision rule In suspected IPV, first create privacy and explain confidentiality limits. Use a professional interpreter when needed, validate without blame, assess immediate danger, and collaborate on safe resources. Avoid confrontation, coercion, or actions that the partner could discover and use against the client.
Why the other choices are wrong Using a neutral universal introduction, explaining confidentiality, validating the disclosure, assessing immediate danger, offering a private phone and ongoing referral, and documenting objective findings preserve privacy and support informed choices. These are appropriate parts of a trauma-informed response.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
USPSTF: Intimate Partner Violence ScreeningU.S. Preventive Services Task Force
[3]
ACOG: Intimate Partner ViolenceAmerican College of Obstetricians and Gynecologists