# A 22-year-old client arrives at the emergency department and reports being sexually assaulted 2 hours ago. The client is tearful and states, 'I just want to go home.' Which nursing actions are appropriate? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=505791&lang=en  
> language: en  
> subject: Psychosocial Integrity  
> category: PSI

## Question

A 22-year-old client arrives at the emergency department and reports being sexually assaulted 2 hours ago. The client is tearful and states, 'I just want to go home.' Which nursing actions are appropriate? Select all that apply.

1

Ask the client to describe the assault in detail to document the event accurately.

2

Explain that a physical examination is mandatory for evidence collection.

3

Offer the option of a sexual assault nurse examiner for the examination.

4

Obtain verbal consent before touching the client during the assessment.

5

Provide information about local advocacy and counseling resources.

6

Allow the client to shower and change clothes before the examination.

## Explanation

Offering a sexual assault nurse examiner provides specialized, trauma-informed care and preserves evidence properly. Obtaining verbal consent before any touch respects the client's autonomy and reinforces safety, a core principle of trauma-informed care. Providing advocacy and counseling resources supports the client's ongoing emotional needs and empowers informed decision-making. Asking the client to describe the assault in detail can be retraumatizing and is not required for initial care; a brief medical history suffices. A physical examination is not mandatory; the client has the right to decline any part of the exam. Allowing the client to shower or change clothes before evidence collection can destroy forensic evidence and should be delayed until after the examination if the client consents to evidence collection.

## Related questions

- [A patient with bipolar I disorder on chronic lithium therapy presents to the ED after seve…](https://mymerci.kr/pages/nclex_q.php?qn_id=372860&lang=en)
- [A patient with severe contamination obsessive-compulsive disorder is starting exposure and…](https://mymerci.kr/pages/nclex_q.php?qn_id=372864&lang=en)
- [A 19-year-old patient is admitted with severe anorexia nervosa: BMI 13.5, heart rate 38, B…](https://mymerci.kr/pages/nclex_q.php?qn_id=373260&lang=en)
- [A 28-year-old woman is at her 6-week postpartum visit. The Edinburgh Postnatal Depression …](https://mymerci.kr/pages/nclex_q.php?qn_id=374202&lang=en)
- [A patient on a psychiatric inpatient unit is becoming increasingly agitated — pacing, rais…](https://mymerci.kr/pages/nclex_q.php?qn_id=374880&lang=en)
- [A nurse working in a trauma-informed care (TIC) framework is caring for a patient with a h…](https://mymerci.kr/pages/nclex_q.php?qn_id=374923&lang=en)
- [A nurse is using motivational interviewing (MI) to help a patient consider changing alcoho…](https://mymerci.kr/pages/nclex_q.php?qn_id=374931&lang=en)
- [A client on day 7 of unfractionated heparin for DVT shows a platelet drop from 245 to 95 t…](https://mymerci.kr/pages/nclex_q.php?qn_id=374971&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=505791&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=505791&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=505791&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=505791&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=505791&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._