A client tells the emergency nurse, "I was sexually assaulted, but I am not sure I want a forensic examination." Which response should the nurse make first?
1You need a complete examination today if you might want the assailant prosecuted in the future
2Finishing the examination now is safest because evidence collection cannot be declined
3Thank you for telling me. You can choose each part of care, and I will explain the options✓ Correct answer
4The police should decide which evidence must be collected before medical care begins
Explanation
Trauma-informed care restores safety, control, and informed choice. The client may accept or decline each part of medical and forensic care, so the nurse should explain options without coercion while addressing urgent health and safety needs.
Quick answer Acknowledge the disclosure and return control to the client by explaining that each part of care is voluntary. This supports safety and informed consent after an experience that involved loss of control.
Why this is correct A medical forensic examination has health and evidence-collection purposes, but its components require the client's consent. Clear options, permission to pause or decline, and nonjudgmental communication reduce retraumatization while allowing urgent injuries and other health needs to be addressed.
Easy analogy or mental picture Think of the nurse as offering a map with several routes rather than pushing the client onto one road. The map represents informed options and the client chooses the route; this does not remove mandatory reporting duties that may apply under local law.
Memory hook After trauma, restore control: acknowledge, explain choices, obtain consent, and avoid coercion.
NCLEX decision rule When a capable client considers sexual-assault care, protect immediate safety and obtain consent for each component. Do not make treatment, forensic evidence collection, or law-enforcement involvement sound compulsory when the applicable protocol allows client choice.
Why the other choices are wrong Linking care to prosecution pressures the client. Claiming evidence collection cannot be declined removes informed consent, and asking police to direct medical care reverses the client-centered role of the clinical team.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
DOJ: National Protocol for Sexual Assault Medical Forensic ExaminationsU.S. Department of Justice, Office on Violence Against Women