A nurse is caring for a client who has bruises on the face and arms; the husband refuses to leave the bedside and answers questions for the client. Which intervention is most appropriate?

• A. Document all observations and findings in the chart.
• B. Collaborate with the physician to make a referral to social services.
• C. Confront the husband and ask him to step out.
• D. Summon security to remove the husband.

Answer: (B)

This item tests recognizing and responding to intimate partner violence and patient safety in a hospital setting. When someone has bruises on the face and arms and the partner refuses to leave and answers questions for the patient, it signals potential coercion and ongoing abuse. The priority is to connect the patient with appropriate support and safety resources while preserving the patient’s autonomy.

Collaborating with the physician to refer to social services (social work) is the best move because social workers can conduct a confidential abuse assessment, provide resources, help the patient develop a safety plan, and connect her with protective services if needed. This action moves beyond merely observing or deterring behavior and directly addresses the patient’s safety and access to support.

Documenting observations remains important as part of the medical record, but it doesn’t ensure safety or connect the patient with necessary resources. Confronting the husband could provoke retaliation or escalation of danger. Summoning security might be appropriate only if there is imminent harm, but it bypasses the essential step of providing ongoing support and planning through social services. In this scenario, involving social services through the physician’s referral offers the most comprehensive, protective approach.