Situation: During a follow-up home visit, the nurse learns that the father, 38, lost his job 2 months ago and now drinks heavily every night. The mother, 33, has a bruise on her upper arm. Their 4-year-old son has bruises of different colors on his back and buttocks, and the mother says he "falls a lot." There is also a 7-month-old daughter. Alone with the nurse, the mother says her husband hits her when he is drunk, but she will not leave him because she has no income and no place to go. Which action by the nurse is MOST appropriate?

A competent adult decides whether and when to leave; pressuring her can raise the danger and break trust. The nurse respects her decision and develops a safety plan with her, covering a safe place, emergency contacts, and an escape bag, and tells her about support services. Advising her to avoid angering him blames the victim, and waiting for the job and the drinking to change ignores that violence tends to repeat and escalate.

Core nursing judgment
A competent adult has the right to decide whether and when to leave an abusive relationship. The nurse’s most appropriate action is to respect her decision and work with her to build a safety plan. Pressuring her to leave immediately can increase danger and undermine trust, while advising her to simply avoid angering him places blame on the victim. Waiting for the husband’s job or drinking to change ignores the reality that intimate partner violence tends to repeat and escalate over time.

Why the other options are unsafe or inappropriate

Option	Nursing concern
1. Urge her to take both children to a shelter before nightfall	Removes the mother’s autonomy and may trigger retaliation if she is not ready. The decision to leave is hers, not the nurse’s.
2. Advise her to stay calm and avoid angering him when he drinks	Implies the victim controls the abuser’s behavior. This is victim-blaming and does not address safety.
3. Encourage her to wait until he finds work and stops drinking	Assumes violence is caused only by unemployment or alcohol. Violence often continues even when these factors change.

Pathophysiology and mechanism of intimate partner violence
Intimate partner violence is a pattern of coercive control that includes physical, sexual, psychological, and economic abuse. Alcohol use can lower inhibitions and increase the severity of violent episodes, but it is not the root cause. The underlying mechanism is the abuser’s need for power and control. Removing alcohol or restoring employment does not reliably stop the violence because the controlling behavior persists independently of those stressors. The mother’s statement that she has no income and no place to go reflects economic abuse, which is itself a form of control that limits her ability to leave safely.

Why a safety plan is the priority intervention
A safety plan is a personalized, practical strategy that helps a victim reduce risk whether she stays or leaves. It typically includes identifying a safe place to go, memorizing emergency contacts, preparing an escape bag with important documents and medications, and planning how to leave quickly. The nurse’s role is not to make the decision for her, but to provide information, resources, and support so she can act when she is ready. This approach aligns with the transtheoretical model, which recognizes that victims move through stages of change and benefit from interventions matched to their current readiness.

Clinical application from the evidence
Community health professionals, including nurses, are often the first point of contact for victims of intimate partner violence in homes and other community settings ^[1]. Their role includes identifying abuse, providing counseling, and connecting victims to support services. A public health nurse-led training and counseling program based on the transtheoretical model was associated with improvements in victims’ stages of change, decisions to avoid partner violence, and self-efficacy ^[2]. This supports the idea that structured, respectful counseling—not coercion—helps victims move toward safety. Early recognition by nurses is critical because victims often present with vague complaints or injuries that are not initially attributed to abuse ^[3].

Child protection considerations
The 4-year-old son has bruises of different colors on his back and buttocks. Bruises in various stages of healing over protected areas such as the back and buttocks are a classic sign of non-accidental trauma. The mother’s explanation that he “falls a lot” is inconsistent with the location and pattern of injuries. Key point! While the nurse respects the mother’s autonomy regarding her own situation, child abuse requires a separate response. The nurse must follow mandatory reporting laws for suspected child abuse, regardless of the mother’s wishes. The presence of a 7-month-old daughter also raises concern because infants are highly vulnerable and cannot report abuse themselves.

Ethical and legal tension
Domestic violence involving competent adults presents an ethical dilemma because mandatory reporting laws are less clear than for child or elder abuse ^[4]. Reporting without the patient’s consent may breach trust and increase danger. The nurse must balance the duty to protect the mother with the duty to respect her autonomy and confidentiality. In this scenario, the most appropriate immediate action is to develop a safety plan together with her, while separately addressing the child’s injuries through the appropriate reporting pathway. The nurse should also document findings objectively, including the location, size, color, and pattern of all bruises, using body diagrams when possible.

How to differentiate the correct answer in exam format

Concept	Correct approach	Incorrect approach
Decision to leave	Belongs to the competent adult victim	Nurse pressures or urges immediate departure
Nurse’s role	Provide safety planning, resources, and support	Give advice that blames the victim or delays action
Child with suspicious bruises	Separate mandatory reporting pathway	Assume the mother’s explanation is sufficient
Alcohol and unemployment	Risk factors that may worsen violence	Root causes that will resolve the violence if removed

Watch out! The question asks for the most appropriate action, not the only action. Respecting the mother’s decision and making a safety plan is the correct first step, but the nurse must also recognize the child’s injuries as a separate protection issue requiring mandatory reporting. A safety plan reduces immediate risk; it does not replace the legal duty to report suspected child abuse.