An adult who reports a recent sexual assault wants medical treatment but is unsure about evidence collection. Which response by the nurse is most appropriate?
1Evidence collection is required before we can provide treatment for your injuries
2The examination must continue once it begins so the evidence remains legally useful
3I will explain each option, and you can decline any part or withdraw consent at any time✓ Correct answer
4You need to report to law enforcement before deciding whether to receive medical care today
Explanation
Trauma-informed care uses ongoing informed consent to restore control. The client may accept medical treatment while declining some or all evidence collection and may withdraw consent during the examination. Care is not conditioned on police reporting or a completed evidence kit.
Quick answer Explain each option and preserve the client's right to decline any procedure or withdraw consent.
Why this is correct Sexual assault removes personal control, so the examination should return choices to the client rather than create another coercive experience. Consent applies separately and continuously to medical care, examination steps, photographs, and evidence collection.
Easy analogy or mental picture Consent is a series of doors the client chooses to open, not a door that locks behind them. The analogy emphasizes ongoing choice but does not replace jurisdiction-specific reporting rules or capacity assessment.
NCLEX decision rule For a capable adult after sexual assault, prioritize safety, understandable options, and procedure-by-procedure consent; do not make treatment depend on police reporting or evidence collection.
Why the other choices are wrong Forcing evidence collection, treating initial consent as irrevocable, or requiring a police report undermines autonomy and can increase trauma. Necessary medical treatment remains available regardless of evidence-kit participation.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
National Protocol for Sexual Assault Medical Forensic ExaminationsU.S. Department of Justice Office on Violence Against Women
Clinical Practice GuideFor Direct suicide risk assessment, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Suicide Risk — The possibility that a client may intentionally harm or kill themselves.
Depression — A mood disorder that can include sadness, hopelessness, and suicidal thoughts.
Safety Assessment — Evaluation of immediate risk and protective actions needed.