# Place the nursing actions in order after an adult privately discloses a recent sexual assault and requests help.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394883&lang=en  
> language: en  
> subject: Crisis Intervention  
> category: PSI

## Question

Place the nursing actions in order after an adult privately discloses a recent sexual assault and requests help.

Ask permission before sensitive questions or touch and explain why each immediate assessment step is needed

Document objective findings and the client's words, then arrange chosen follow-up, safety resources, and discharge support

Offer choices about advocacy, support persons, medical care, and a forensic examination without pressuring the client to report

Listen without demanding a detailed narrative, acknowledge the disclosure, and state that the assault was not the client's fault

Provide a private setting, address urgent physical safety and medical needs, and limit unnecessary staff interruptions

## Explanation

Begin with privacy and urgent safety. Ask permission and explain each step so the client retains control. Listen and validate without conducting an unnecessary interrogation. Offer informed choices and specialized resources, then document objectively and coordinate the follow-up the client accepts within legal and policy requirements.

## In-depth explanation

Correct sequence
Create privacy and safety → ask permission and explain → listen and validate → offer choices and specialized support → document and arrange follow-up.

Why this is correct
Trauma-informed care emphasizes safety, trust, collaboration, voice, and choice while actively avoiding retraumatization. The nurse addresses urgent medical needs but does not force disclosure details, reporting, touch, or an examination when the client can decide.

NCLEX decision rule
Return control whenever clinically possible. Explain, ask permission, believe the disclosure, and connect the client with choices rather than commands.References
1SAMHSA Trauma-Informed Care
2NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Trauma-informed first response
The client is medically stable, the alleged assailant is not present, and a trained sexual-assault response service is available. Follow jurisdictional reporting law and facility policy while preserving the client's autonomy.

## Key concepts

- **Trauma-Informed Care** — Care that recognizes trauma effects, creates safety, supports voice and choice, and actively avoids retraumatization.
- **Retraumatization** — A renewed trauma response triggered when care removes control, repeats coercive dynamics, or exposes the person unnecessarily.
- **Forensic Examination** — A specialized examination that addresses health needs and, with informed consent, collects and preserves potential evidence.

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