Upon entering the exam room of a client and spouse, the client appears withdrawn and fearful of the spouse. What action should the nurse take?

Upon entering the exam room of a client and spouse, the client appears withdrawn and fearful of the spouse. What action should the nurse take?

• A. Find a way to interview the client in private
• B. Ask the spouse to step outside but interview together
• C. Ignore the fear and proceed with assessment
• D. Address only the spouse’s concerns

Answer: (A)

When a client appears withdrawn and fearful of a partner, safety and the opportunity to speak openly are the priorities. The best action is to arrange a private interview with the client, separate from the spouse, so the patient can disclose any abuse or safety concerns without fear of retaliation or coercion. This private setting builds trust, allows accurate assessment of risk, and enables immediate planning for safety, needed support, and referrals. If the patient agrees, asking the partner to step out briefly for the conversation is appropriate; interviewing together in the presence of the partner can inhibit honest disclosure and may place the patient at greater risk. After the private discussion, document objective signs and statements, assess for injuries, and follow up with safety planning and resources as needed.

When a client appears withdrawn and fearful of a partner, safety and the opportunity to speak openly are the priorities. The best action is to arrange a private interview with the client, separate from the spouse, so the patient can disclose any abuse or safety concerns without fear of retaliation or coercion. This private setting builds trust, allows accurate assessment of risk, and enables immediate planning for safety, needed support, and referrals. If the patient agrees, asking the partner to step out briefly for the conversation is appropriate; interviewing together in the presence of the partner can inhibit honest disclosure and may place the patient at greater risk. After the private discussion, document objective signs and statements, assess for injuries, and follow up with safety planning and resources as needed.