# A nurse is conducting an initial assessment of a 22-year-old female client who was brought to the emergency department following a reported sexual assault that occurred 3 hours ago. Which assessment finding would be the MOST concerning and require immediate intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543486  
> language: ko  
> subject: Mental Health

## 문제

A nurse is conducting an initial assessment of a 22-year-old female client who was brought to the emergency department following a reported sexual assault that occurred 3 hours ago. Which assessment finding would be the MOST concerning and require immediate intervention?

## 보기

1. The client reports feeling contaminated and urgently requests to shower to cleanse herself
2. The client displays a blunted emotional response and provides brief, monosyllabic answers to questions
3. The client shows signs of dissociation, is disoriented to time and place, and gives inappropriate responses to questions **✔ 정답**
4. The client declines to permit any male healthcare staff to enter the examination room

**정답: 3**

## 해설

Dissociation with confusion about time/place indicates severe psychological distress requiring immediate intervention for safety. Other options are common trauma responses that do not indicate the same level of acute instability.

## 심화 해설

Clinical Judgment
This question assesses the ability to determine risk priority in the initial evaluation of a sexual assault survivor. The key is to identify, among the survivor's various psychological responses, a state that can cause immediate safety risk and functional impairment. The dissociative symptoms in option 3 (disorientation, unresponsiveness) mean the patient is disconnected from reality, severely impairing their self-care ability and safety judgment. This can lead to self-harm or additional harm, requiring the most immediate nursing intervention.

Memory Tip: **D**issociation = **D**anger. Dissociative symptoms mean the patient is 'away' from reality, and in this state, they cannot ensure their own safety. Other reactions fall into the category of a **N**ormal **R**eaction to trauma.

KR vs US: In Korea, the focus may be on physical evidence collection and legal procedures rather than the survivor's psychological response. However, the NGN/US approach emphasizes Trauma-Informed Care, prioritizing the survivor's psychological stability and empowerment. A patient in a dissociative state may lack decision-making capacity, so it may not even be appropriate to seek consent for a physical exam or evidence collection. Their mental state must be stabilized first.

## 임상 시나리오

Clinical Practice Guide
The SANE (Sexual Assault Nurse Examiner) program is important in the care of sexual assault survivors. During initial intake: 1) Provide a safe environment, 2) Maintain a non-judgmental attitude, 3) Offer choices to restore a sense of control (e.g., "Would it be okay if someone stays here with you?"), 4) If dissociative symptoms are observed, use grounding techniques (e.g., "Feel the sensation of your feet touching the chair," "Let's count the blue objects you can see around you").

Caution: In SATA (Select All That Apply) questions, when asked to choose the "MOST concerning" single item, all options may represent 'problematic' situations. However, the priority in clinical judgment is safety risk (dissociation, self-harm ideation) > functional impairment > normal trauma response. "Refusal of male healthcare providers" should be respected as the patient exercising control and documented as a 'limitation,' not a nursing intervention.

## 핵심 개념

- **Dissociation (해리)** — A psychological defense mechanism where thoughts, identity, consciousness, and memory become disconnected to cope with overwhelming stress or trauma. It may be accompanied by derealization or depersonalization, and requires immediate psychiatric intervention.
- **Trauma-Informed Care (트라우마 중심 간호)** — A nursing approach that understands the patient's experience, prevents re-traumatization, and promotes safety, control, and empowerment. It views the patient's responses as 'adaptations to trauma' rather than 'symptoms'.
- **SANE (Sexual Assault Nurse Examiner)** — A nurse specially trained to provide comprehensive care (physical, psychological, forensic) for sexual assault survivors. Integrates evidence collection, physical examination, and survivor support.
- **Grounding Techniques (접지 기법)** — Techniques to help a person in a dissociative state or intense emotional distress reconnect with the present moment and reality. These include the 5-4-3-2-1 technique (focusing on the senses).
- **Informed Consent (충분한 설명에 근거한 동의)** — Consent given voluntarily by a patient who understands the procedure's risks, benefits, and alternatives. Patients in a dissociative state or severe psychological distress may have impaired capacity for this, so their mental state must be stabilized first.

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