Situation: A 30-year-old woman comes to the emergency room (ER) with bruises on both upper arms in different stages of healing. She says she fell down the stairs. Her husband stays in the waiting area. In a private room with the nurse, she admits that her husband has hit her many times over the past 2 years. She adds that last night he squeezed her neck with both hands until she nearly fainted. Faint marks are visible on her neck, but she is alert, and her voice and breathing are normal now. She wants to go home tonight. The nurse plans the following actions, and all of them are appropriate. Which should the nurse do FIRST?

Strangulation severe enough to nearly cause loss of consciousness can produce delayed airway swelling or vascular injury even when the client looks well, so the possible life-threatening injury is addressed first by having the physician evaluate her neck. Assessing current danger, which is very high after strangulation, then guides the safety plan, documentation, and referrals.

Clinical priority in IPV with strangulation

The first priority is 1. Have the physician assess her neck before discharge. This is not a routine documentation step; it is a medical-urgency decision. The woman's statement that her husband squeezed her neck with both hands until she nearly fainted is a red flag for near-fatal strangulation, and the visible marks on her neck confirm that significant force was applied.

Strangulation that reaches the point of near-syncope can injure the carotid arteries, laryngeal cartilages, and upper airway mucosa even when the patient is alert with a normal voice and breathing at the moment of assessment. Delayed edema, hematoma expansion, or intimal tearing of the carotid or vertebral arteries can evolve over hours and lead to airway compromise or stroke. Because the patient wants to go home tonight, the nurse must ensure that a physician evaluates the neck before any discharge decision is made.

The other actions are all appropriate components of IPV care, but they are secondary to ruling out life-threatening injury. In the nursing process, physiologic integrity and airway/circulation threats take precedence over psychosocial assessment, documentation, and resource referral.

Action	Why it is appropriate	Why it is not first
1. Physician assessment of neck	Detects delayed airway edema, vascular injury, or laryngeal fracture	Key point! Must precede discharge because the patient appears stable but may deteriorate
2. Ask about danger if she goes home	Strangulation is a strong predictor of future homicide risk	Safety planning is critical but follows medical stabilization
3. Photograph neck marks with consent	Forensic documentation supports legal protection and future care	Can be done after the physician exam; does not address immediate physiologic risk
4. Provide shelter and crisis hotline numbers	Connects the patient to IPV-specific resources	Referral is essential but not the first action when a potentially lethal injury is present

Watch out! A normal voice and normal breathing do not rule out significant strangulation injury. Edema can progress over 24–48 hours, and carotid dissection may present later with neurologic symptoms. The nurse should not interpret the patient's current alertness as evidence that the neck is safe.

Key point! Strangulation is one of the strongest risk factors for subsequent homicide in intimate partner violence. Even after the physician clears the neck, the nurse must complete danger assessment, safety planning, documentation, and referral before the patient leaves — but the medical evaluation comes first because it determines whether leaving is safe at all.