A nurse is assessing a client who is a caregiver for his spouse with Alzheimer's disease. The nurse notices that the client has lost weight, appears fatigued, and reports feeling overwhelmed. What is the priority nursing intervention for this client?

Rationale: The nurse should recognize that the client is in an abusive relationship and may be at risk of harm or retaliation if they try to leave or seek help. The nurse should provide discreet and confidential support to the client, without alerting or provoking the partner. The nurse should also give the client information and resources that may help them escape or cope with their situation.

Incorrect options:

A) Confront the partner and tell them that their behavior is unacceptable and abusive. - This action may be dangerous or counterproductive, as it may escalate the partner's anger or violence towards the client or the nurse. The nurse should avoid confronting or challenging the partner, as this may jeopardize their safety or trust.

B) Ignore the partner and focus on providing education and care to the client and the baby. - This action may be ineffective or unethical, as it may ignore or enable the partner's abuse towards the client. The nurse should not overlook or disregard signs of domestic violence, as this can put the client and the baby at further risk.

C) Report the partner to the authorities for domestic violence and child abuse. - While reporting the partner to the authorities may be necessary in some cases, it is not the most appropriate immediate action for the nurse in this situation. The nurse should prioritize the safety and well-being of the client and the baby and provide them with resources to seek help and support.

The nurse's primary responsibility is to ensure the safety and well-being of the client and the baby. By giving the client a phone number for a domestic violence hotline and asking them to call when they are safe, the nurse provides them with a confidential resource that can offer guidance, support, and help in planning a safe exit from the abusive situation. It allows the client to reach out for assistance when they feel ready and secure enough to do so.

Rationale: The nurse should use a trauma-informed approach, which involves providing safety, trust, choice, collaboration, and empowerment to the client. The nurse should express empathy and compassion, without assuming or labeling the client's diagnosis or condition. The nurse should also offer options and resources, without imposing or forcing them on the client.

Incorrect options:

A) "You are suffering from post-traumatic stress disorder (PTSD). You need to see a psychiatrist as soon as possible." - This statement may sound alarming or stigmatizing, as it labels the client's condition and prescribes a specific treatment without involving the client in the decision-making process. The nurse should avoid making assumptions or diagnoses based on limited information.

B) "You have been through a lot of trauma. It is normal to have these symptoms. They will go away with time." - This statement may sound dismissive or minimizing, as it normalizes the client's symptoms and does not acknowledge the impact or severity of their trauma. The nurse should avoid making generalizations or predictions about the client's recovery.

D) "You are in denial. You have to face your past and deal with it. Otherwise, you will never heal." - This statement may sound harsh or blaming, as it criticizes the client's coping mechanism and implies that they are responsible for their own healing. The nurse should avoid using guilt-tripping or shaming tactics that may damage the therapeutic relationship.