# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=494742&lang=en  
> language: en  
> subject: Mental Health Concepts  
> category: PSI

## Question

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.

| Visit step | Observed action |
| --- | --- |
| Privacy | The nurse begins relationship-safety screening while the partner remains in the room. |
| Confidentiality | The nurse explains privacy and the specific limits required by law. |
| Language support | The nurse asks the client's partner to interpret the screening questions. |
| Screening approach | The nurse introduces relationship-safety questions as routine for all clients. |
| Initial response | The nurse validates the disclosure and assesses immediate danger to the client and children. |
| Resource safety | The nurse secretly puts a hotline card in a purse that the partner routinely searches. |
| Ongoing support | The nurse offers a private phone and referral to multicomponent support services. |
| Documentation | The nurse records the client's words and objective injury findings without blame. |
| Autonomy | The nurse says the client must leave the relationship today before any support is offered. |

## 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.

## In-depth explanation

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.

Memory hook
Private screen, validate, assess danger, offer choices, connect ongoing support.

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

## Related questions

- [A client hospitalized for depression says, "My family would be better off without me." Whi…](https://mymerci.kr/pages/nclex_q.php?qn_id=393687&lang=en)
- [A client with schizophrenia says, "The voices are telling me to do something bad." Which r…](https://mymerci.kr/pages/nclex_q.php?qn_id=394025&lang=en)
- [A client arrives with bruises at different stages of healing. The partner answers all ques…](https://mymerci.kr/pages/nclex_q.php?qn_id=394098&lang=en)
- [A client with anorexia nervosa is admitted with dizziness, heart rate 44/min, and potassiu…](https://mymerci.kr/pages/nclex_q.php?qn_id=394175&lang=en)
- [A hospitalized client with major depression says, "Everyone would be better off if I did n…](https://mymerci.kr/pages/nclex_q.php?qn_id=394754&lang=en)
- [A client with acute mania is pacing, speaking rapidly, and trying to enter other clients' …](https://mymerci.kr/pages/nclex_q.php?qn_id=397175&lang=en)
- [A client on an inpatient unit is 18 hours after the last alcohol intake and is tremulous, …](https://mymerci.kr/pages/nclex_q.php?qn_id=397292&lang=en)
- [An adult who reports a recent sexual assault wants medical treatment but is unsure about e…](https://mymerci.kr/pages/nclex_q.php?qn_id=397294&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=494742&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=494742&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=494742&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=494742&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=494742&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._