# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629983  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

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?

## 보기

1. Have the physician assess her neck before discharge **✔ 정답**
2. Ask whether she is in danger if she goes home tonight
3. Photograph the marks on her neck after she agrees
4. Give her the numbers of a shelter and a crisis hotline

**정답: 1**

## 해설

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.

## 심화 해설

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.

## 임상 시나리오

Strangulation in IPV: First PriorityRule out delayed life-threatening injury before discharge
A report of near-fatal strangulation with visible neck marks requires physician assessment of the neck before any discharge decision, even if the patient is alert with normal voice and breathing.

Strangulation severe enough to cause near-syncope can injure the carotid arteries, laryngeal cartilages, and upper airway mucosa. Delayed edema or vascular injury may evolve over hours and lead to airway compromise or stroke.

CautionA patient who appears stable after strangulation can deteriorate rapidly. Do not let a normal voice or breathing at the time of assessment rule out serious injury. Physician evaluation must precede safety planning, documentation, or referral.

## 핵심 개념

- **Strangulation** — External compression of the neck that can cause airway obstruction, vascular injury, or neurological damage, even without visible external signs.
- **Near-syncope** — A state of almost losing consciousness, indicating significant reduction in cerebral blood flow during strangulation.
- **Delayed airway edema** — Swelling of the airway that develops hours after injury, potentially causing respiratory compromise in a patient who initially appears stable.
- **Intimal tearing** — Damage to the inner lining of blood vessels such as the carotid or vertebral arteries, which can lead to clot formation and stroke.
- **Intimate partner violence (IPV)** — Abuse or aggression that occurs in a romantic relationship, including physical, sexual, or psychological harm.

## 같은 주제 문제

- [Situation: A 38-year-old woman with bipolar I disorder is admitted to the psychiatric ward…](https://mymerci.kr/pages/nclex_q.php?qn_id=629966)
- [Situation: A 38-year-old woman with bipolar I disorder is admitted to the psychiatric ward…](https://mymerci.kr/pages/nclex_q.php?qn_id=629967)
- [Situation: A 38-year-old woman with bipolar I disorder is admitted to the psychiatric ward…](https://mymerci.kr/pages/nclex_q.php?qn_id=629968)
- [Situation: A 38-year-old woman with bipolar I disorder is admitted to the psychiatric ward…](https://mymerci.kr/pages/nclex_q.php?qn_id=629969)
- [Situation: The nurse in a community mental health program leads a psychoeducation session …](https://mymerci.kr/pages/nclex_q.php?qn_id=629970)
- [Situation: The nurse in a community mental health program leads a psychoeducation session …](https://mymerci.kr/pages/nclex_q.php?qn_id=629971)
- [Situation: The nurse in a community mental health program leads a psychoeducation session …](https://mymerci.kr/pages/nclex_q.php?qn_id=629972)
- [Situation: A 29-year-old factory worker is admitted to the psychiatric unit of a general h…](https://mymerci.kr/pages/nclex_q.php?qn_id=629973)

---

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

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