Which of the following questions should the nurse ask to assess intimate partner safety?
Do you ever feel pressured to do something that you did not want to do or felt uncomfortable doing?
Are you afraid of anyone with whom you have had a previous relationship?
Do you feel safe in your relationship?
Has your caretaker hurt you or threatened to harm you?
Correct Answer : A,B,C
Choice A reason: Asking if the client feels pressured to do things they do not want to do helps identify coercion or abuse. This is a direct way to assess safety and autonomy in the relationship.
Choice B reason: Fear of a previous partner can indicate ongoing threats, stalking, or unresolved trauma. This question helps assess risk of continued abuse even after the relationship has ended.
Choice C reason: Asking if the client feels safe in their relationship is a broad but essential screening question. It allows the client to express concerns about current safety and potential abuse.
Choice D reason: Asking about a caretaker threatening harm is more relevant to elder abuse or dependent care situations rather than intimate partner violence. While important in other contexts, it does not directly assess intimate partner safety.
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Correct Answer is B
Explanation
Choice A reason: Assisting the client in prioritizing decisions is important in crisis intervention, but it is not the first priority. Before helping the client make decisions, the nurse must ensure that the client is safe and not at risk of harming themselves. Decision-making can only be effective once immediate safety is established.
Choice B reason: Determining whether the client is at risk for self-harm is the priority because the client is in acute distress and has expressed confusion and inability to think clearly. These are red flags for potential self-harm or suicidal ideation. Safety is always the first priority in crisis situations, and assessing risk ensures that urgent interventions can be implemented if needed.
Choice C reason: Helping the client identify personal strengths is a supportive intervention that can aid in coping, but it is not the immediate priority. This step comes after ensuring that the client is safe and stable.
Choice D reason: Identifying a support person to notify and take the client home is helpful for providing external support, but it is secondary to assessing immediate risk of self-harm. Without first ensuring safety, this intervention may not adequately address the client’s urgent needs.
Correct Answer is D
Explanation
Choice A reason: Displaying disapproval toward the perpetrator is non-therapeutic. The nurse’s role is to support the client, not express personal judgment.
Choice B reason: Probing for details can retraumatize the client and may feel invasive. The nurse should allow the client to share at their own pace.
Choice C reason: Inviting family members may compromise the client’s safety and confidentiality, especially if the perpetrator is a family member.
Choice D reason: Being direct and honest fosters trust and helps the client feel safe. Clear communication is therapeutic and supports recovery.
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