The emergency department nurse cares for a client with multiple bruises, a possible arm fracture, and a facial laceration. The client's spouse is at the bedside and appears angry. Which action is the priority at this time?
The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential harm to the client or staff (Option 3).
(Option 1) Notifying social services of suspected abuse should occur with the client's permission after any immediate threats are removed and after physiological needs are met. This should not be done in the presence of any potential abusers.
(Option 2) Cleaning the laceration and preparing for sutures are appropriate interventions but are done after a suspected abuser is removed. The nurse also follows facility guidelines for documenting, gathering evidence, and/or photographing injuries before cleaning and further treatment.
(Option 4) The arm should be x-rayed to assess for fractures and may require a sling for immobilization, but potential sources of harm are removed from the room first.
Educational objective:
If a client shows possible signs of abuse or neglect, the priority is to remove any sources of immediate danger (eg, suspected abuser) from the room to prevent further harm. Assessments and further interventions can occur after ensuring the client's safety.
The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential harm to the client or staff (Option 3).
(Option 1) Notifying social services of suspected abuse should occur with the client's permission after any immediate threats are removed and after physiological needs are met. This should not be done in the presence of any potential abusers.
(Option 2) Cleaning the laceration and preparing for sutures are appropriate interventions but are done after a suspected abuser is removed. The nurse also follows facility guidelines for documenting, gathering evidence, and/or photographing injuries before cleaning and further treatment.
(Option 4) The arm should be x-rayed to assess for fractures and may require a sling for immobilization, but potential sources of harm are removed from the room first.
Educational objective:
If a client shows possible signs of abuse or neglect, the priority is to remove any sources of immediate danger (eg, suspected abuser) from the room to prevent further harm. Assessments and further interventions can occur after ensuring the client's safety.
