A nurse is caring for a client who has reported experiencing abuse at home. Which of the following actions should be a priority for the nurse?

Choice A reason: Referring the client to a community support group is an important intervention because it provides emotional support, resources, and connection with others who have experienced similar situations. However, this is not the immediate priority when abuse is reported. Before referral, the nurse must ensure that the client and any children are safe from imminent harm. Support groups are valuable for long-term coping and recovery but do not address urgent safety needs. Choice B reason: Instructing the client on how to leave the relationship may be helpful, but it is not the priority. Leaving an abusive relationship can be dangerous if not carefully planned, and the nurse must first assess whether there is immediate risk of harm. Without this assessment, advising the client to leave could inadvertently increase danger, as abusers often escalate violence when they perceive loss of control. Choice C reason: Implementing the safety plan is a critical step in protecting the client, but it comes after assessing the level of immediate danger. A safety plan includes strategies such as identifying safe places, emergency contacts, and escape routes. However, the nurse must first determine whether the client or children are currently at risk of harm before deciding which safety measures to activate. Choice D reason: Assessing for risk of immediate harm to the patient or children is the priority because it directly addresses the most urgent concern—whether lives are in danger. This assessment guides all subsequent interventions, including safety planning, referrals, and education. Immediate risk assessment ensures that emergency measures, such as contacting law enforcement or child protective services, can be taken if necessary. It is the foundation of all other actions and aligns with the nurse’s duty to protect clients from harm.