The ED nurse is caring for a female client who was just brought in following a sexual assault. Which interventions by the nurse are appropriate for this client?
help the client bathe and change into fresh clothing before the examination begins
preserve any evidence, including clothing, and take photographs of injuries as appropriate
assure the client that surviving the assault is most important, and she did what was needed to stay alive
take the client to a quiet, private room for assessment to assess stress levels before beginning examination or treatments
tell the client that she should avoid wearing skimpy clothing in questionable areas of the city to avoid another incident
Numbers 2, 3, and 4 are correct.
Rationale: All evidence must be preserved and collected following a strict chain of custody in order to be admissible in court, should the client pursue legal action. Rape kits are available in the ED that utilize a standard format of what information and items to collect. Some EDs have SANE (sexual assault nurse examiner) nurses who perform forensic nursing functions with specialized training. Photographing injuries provides further evidence for the medical record. Reassuring the client that she did what was needed to survive offers comfort. Before beginning any assessments or treatments, the client’s mental condition should be evaluated. If the client is in extreme distress, it may be necessary to delay certain treatments or provide medication per the health care provider. The nurse should remain with the client at all times, as the pelvic examination may be painful and/or trigger flashbacks. If possible, ask the client if she would prefer a female physician. Advising the client on clothing choices implies that the client is to blame for the assault and may make the client defensive or less compliant with treatment. The client should receive information on rape crisis groups or other forms of support and counseling once she is able to comprehend and process the information.
