# A nurse is caring for a 28-year-old female client who was admitted to the emergency department with multiple bruises and a fractured wrist. The client's husband is present and answers all questions directed to the client. When the nurse attempts to speak with the client privately, the husband insists on staying. What is the most appropriate initial nursing intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=319669  
> language: ko  
> subject: Mental Health

## 문제

A nurse is caring for a 28-year-old female client who was admitted to the emergency department with multiple bruises and a fractured wrist. The client's husband is present and answers all questions directed to the client. When the nurse attempts to speak with the client privately, the husband insists on staying. What is the most appropriate initial nursing intervention?

## 보기

1. Document the client's injuries and accept the husband's explanation of how they occurred
2. Confront the husband directly about suspected domestic violence in front of the client
3. Use hospital security or policy to separate the client from her husband for a private assessment **✔ 정답**
4. Wait until the husband leaves voluntarily before attempting to assess the client further

**정답: 3**

## 해설

In suspected domestic violence, the priority is ensuring client safety through private assessment away from the potential abuser, using hospital policy/security. Other options compromise safety or delay essential intervention.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question assesses the nurse's role in identifying and responding to potential Intimate Partner Violence (IPV) or domestic violence. The core nursing principle is client safety and autonomy. When a potential abuser is present and controlling the interaction, it creates a significant barrier to a truthful assessment and places the client at risk for further harm. The nurse's primary ethical and legal duty is to create a safe environment where the client can speak freely.

**Answer Rationale**: Key Point! The most appropriate initial intervention is to safely separate the client from the potential abuser to conduct a private assessment. Option ③ correctly implements this by utilizing hospital security or established policy. This action prioritizes the client's immediate physical and psychological safety, respects her right to confidentiality, and is the essential first step in any protocol for suspected abuse. It allows for a genuine nursing assessment without coercion or fear of retaliation.

**Distractor Analysis**:

Watch out for confusion! Option ① (Document and accept the husband's explanation) is dangerous because it fails to assess the client's perspective, potentially colludes with an abuser's narrative, and misses a critical opportunity for intervention. Nursing assessment must be independent.

Option ② (Confront the husband directly in front of the client) is a major safety error. Direct confrontation in the presence of the client can escalate the situation, increase the client's danger after discharge, and violate principles of non-maleficence (do no harm).

Option ④ (Wait until the husband leaves voluntarily) is passive and ineffective. An abuser may never leave voluntarily, causing an indefinite and dangerous delay in assessment and care. The nurse must take proactive, safe steps to facilitate the private interview.

**Related Concepts**: This scenario integrates principles of trauma-informed care, mandatory reporting (in many jurisdictions for suspected abuse of adults in vulnerable situations), and the nursing process. Assessment must always precede planning and intervention. A private, safe environment is a non-negotiable prerequisite for an accurate assessment in cases of suspected violence.

Concept Summary

| Concept | Key Takeaway |
| --- | --- |
| Client Safety (Primary) | The nurse's first responsibility is to ensure a physically and emotionally safe environment for assessment. |
| Private Assessment | Essential for obtaining truthful information in suspected abuse. Must be facilitated by the nurse. |
| Trauma-Informed Care | Approach that realizes the impact of trauma, recognizes signs, and resists re-traumatization. |
| Nurse's Role in IPV | Screen, assess privately, validate, ensure safety, document objectively, provide resources, and report as required by law. |
| Ethical Principles | Autonomy (client's right to speak freely), Beneficence (promote good), Non-maleficence (prevent harm). |

Side-by-Side Comparison!

| Action | Why It's Effective/Appropriate | Why Other Actions Are Ineffective/Dangerous |
| --- | --- | --- |
| Use policy/security to separate for private assessment | Proactively ensures safety, enables truthful communication, follows standard protocols for abuse. | Other options either delay care, accept a potentially false narrative, or actively increase risk. |
| Wait for abuser to leave | Passive; may never happen. Delays critical intervention. | Fails the duty to act in the client's best interest and ensure safety. |
| Confront abuser in client's presence | Directly escalates risk of retaliation against the client, violates safety principles. | Puts the client in immediate and future danger. Never appropriate. |

Anatomy, Physiology & Pharmacology Points
While this is a psychosocial/legal scenario, understanding the "fight-or-flight" stress response is relevant. A client in an abusive situation is in a chronic state of hyperarousal and fear. The presence of the abuser activates this physiological stress response, making truthful disclosure impossible. Creating a private, safe space helps lower this physiological stress, enabling clearer communication.

Memory Tips
**S.A.F.E. First**: A mnemonic for the nurse's priority actions in suspected IPV.

**S**eparate the client safely.

**A**ssess privately and non-judgmentally.

**F**acilitate a safety plan.

**E**ducate and provide resources (e.g., hotline numbers, shelters).

High-Frequency NCLEX Topics
Client safety, ethical/legal responsibilities, and appropriate communication techniques are High Yield NCLEX topics. Questions on abuse (child, elder, intimate partner) frequently test the nurse's knowledge of mandatory reporting laws and the initial steps of ensuring a safe, private environment for assessment. The NCLEX wants to ensure you prioritize safety and know how to act within your scope and hospital policy.

Watch Out for Question Variations!
*   **Shift from Intervention to Assessment**: "What is the *priority* assessment for this client?" Answer: Assess the client's safety and immediate risk of harm in a private setting.
*   **Shift to Legal/Ethical Duty**: "The nurse's primary ethical responsibility in this situation is to..." Answer: Protect client autonomy and safety (Non-maleficence).
*   **Shift to Documentation**: "When documenting the client's injuries and statements, it is most important for the nurse to..." Answer: Use direct quotes and document objectively without judgment (e.g., "Client states, 'I fell down the stairs.'" not "Client gave a unlikely story about her injuries.").

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are the triage nurse in a busy ED. A young woman, Ms. Jones, presents with a visibly deformed wrist and multiple bruises in various stages of healing on her arms. Her partner, Mr. Smith, is hovering, speaking loudly for her, and becomes agitated when you ask Ms. Jones to describe what happened.

**Nursing Intervention Strategy**:
1.  **Assessment & Safety Creation**: Do not attempt assessment with the partner present. Calmly state, "Mr. Smith, I need to take Ms. Jones to the treatment area for her initial exam. Hospital policy requires that I speak with her alone first for part of the assessment. You can wait in the waiting area, and I will update you as soon as I can." If he refuses or becomes hostile, this is your cue to **immediately** use a pre-arranged signal or call for security/another staff member to assist.
2.  **Private Interview**: Once in a private room (with the door closed or monitored), use a calm, non-judgmental tone. Start with open-ended questions: "I'm concerned about your injuries. Can you tell me what happened?" Use validating statements: "You are not alone. We are here to help you. Nothing you say will be shared with anyone without your permission, unless you are in immediate danger."
3.  **Safety Planning & Resources**: If she discloses abuse, ask directly: "Do you feel safe going home today?" Collaborate to develop a safety plan. Provide written resources (local domestic violence hotline, shelter information). Document everything objectively.

**Patient Safety and Precautions**:
*   Key Point! **Never** use the term "abuse" or "domestic violence" in front of the suspected abuser. It can trigger violence.
*   **Documentation is Critical**: Use body maps to document the location, size, color, and shape of all injuries. Use the client's own words in quotes. This documentation can become legal evidence.
*   **Know Your State Laws**: Understand mandatory reporting requirements for IPV. In many places, reporting is required if injuries are from a weapon, or if the victim is a vulnerable adult (e.g., elderly, disabled).

Nursing Procedure & Medication Flow
While not a medication procedure, the protocol for separating a client from a potential abuser is a critical nursing action.
1.  **Preparation**: Be aware of your unit's security protocol and panic buttons. Inform a colleague discreetly if you suspect a situation may escalate.
2.  **Implementation**: Use a firm, polite, and policy-based script to separate the individuals. Your goal is de-escalation, not accusation. "For our patient's privacy during the exam, we need family to step out for a moment."
3.  **Evaluation**: After the private interview, evaluate the client's emotional state and immediate safety needs. Determine if a social work consult or a safe discharge plan is needed.

A Word from Your Senior Nurse
Nursing is not just about physical care; it's about being a vigilant advocate and a safe harbor. In cases like this, your calm, confident action in creating a private space can be the first step that changes—or even saves—a client's life. On the NCLEX and in practice, always let safety and the client's voice guide your first intervention. Remember, you are often the only professional who has this private moment with the client. Use it wisely, compassionately, and courageously.

## 핵심 개념

- **Intimate Partner Violence** — A pattern of abusive behavior used by one partner to gain or maintain power and control over another intimate partner. It includes physical, sexual, emotional, economic, or psychological actions or threats.
- **Trauma-Informed Care** — An organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma. It emphasizes physical, psychological, and emotional safety for both providers and survivors.
- **Mandatory Reporting** — A legal requirement for certain professionals (often including nurses) to report suspected cases of abuse and neglect (of children, elders, or vulnerable adults) to the appropriate government authority.
- **Non-maleficence** — An ethical principle meaning "do no harm." It is a fundamental duty in healthcare to avoid causing injury or suffering to patients.
- **Safety Plan** — A personalized, practical plan to improve safety while experiencing abuse, preparing to leave, or after leaving. It includes strategies for various situations (e.g., during an argument, if preparing to leave, after leaving).

## 같은 주제 문제

- [A nurse is caring for a 35-year-old female client who was admitted to the emergency depart…](https://mymerci.kr/pages/nclex_q.php?qn_id=319666)
- [A nurse is caring for a client who has been admitted to the emergency department with inju…](https://mymerci.kr/pages/nclex_q.php?qn_id=319667)
- [A nurse is caring for a 35-year-old male client who was admitted to the emergency departme…](https://mymerci.kr/pages/nclex_q.php?qn_id=319668)
- [A nurse is caring for a 35-year-old client who has been admitted to the emergency departme…](https://mymerci.kr/pages/nclex_q.php?qn_id=319670)
- [A nurse is conducting an initial assessment of a 28-year-old woman who presents to the eme…](https://mymerci.kr/pages/nclex_q.php?qn_id=319671)
- [A nurse is assessing a 25-year-old female client who presents to the emergency department …](https://mymerci.kr/pages/nclex_q.php?qn_id=319672)
- [A nurse is assessing a 45-year-old male client who presents to a primary care clinic with …](https://mymerci.kr/pages/nclex_q.php?qn_id=319673)
- [A nurse is assessing a 28-year-old female client who presents to the emergency department …](https://mymerci.kr/pages/nclex_q.php?qn_id=319674)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._