A nurse is performing an assessment on an alert and oriented 32-year-old client in an outpatient clinic. The nurse notes various stages of bruising on the client's torso. The client confides that their domestic partner caused the injuries but explicitly begs the nurse, "Please do not involve the police or tell anyone else. I am afraid of what will happen if they find out." Which of the following actions best demonstrates the nurse's adherence to confidentiality and legal guidelines?
- Honor the client's request for privacy, document the objective physical findings, and offer contact information for domestic violence support services.Answer
- BNotify local law enforcement immediately to file an assault report, as intimate partner violence falls under mandatory reporting requirements.
- CDelegate an unlicensed assistive personnel (UAP) to remain in the room with the client and gather a more detailed history of the abusive incidents.
- DAsk the client, "Why do you stay if you are being hurt?" and inform the client's emergency contact about the situation to ensure a safe discharge environment.
Answer
The correct answer is to honor the client's request for privacy, document the objective physical findings, and offer contact information for domestic violence support services.
The correct action respects the competent adult client's right to privacy and autonomy. Because the client is alert and oriented, they have the legal right to decide whether to report intimate partner violence to authorities. The nurse fulfills their legal and ethical duties by thoroughly documenting the objective findings, maintaining strict confidentiality as requested, and providing empowering resources, such as domestic violence shelter information.
Step-by-Step Solution
Key Concept
Confidentiality and Mandatory Reporting Exceptions