# A 35-year-old male client presents to the emergency department 6 hours after being sexually assaulted. He appears withdrawn, speaks in a monotone voice, and states 'I just want to forget this ever happened.' Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=543488 > language: ko > subject: Mental Health ## 문제 A 35-year-old male client presents to the emergency department 6 hours after being sexually assaulted. He appears withdrawn, speaks in a monotone voice, and states 'I just want to forget this ever happened.' Which nursing intervention should be the priority? ## 보기 1. Encourage the client to immediately discuss details of the assault to process the trauma 2. Provide detailed information about all available legal options and encourage immediate reporting 3. Administer prescribed anxiolytic medication to help the client relax and sleep 4. Establish a trusting therapeutic relationship and validate the client's feelings and responses **✔ 정답** **정답: 4** ## 해설 Establishing trust and validating feelings is the priority to create a safe therapeutic foundation for recovery. Other interventions may be harmful or premature without this trust. ## 심화 해설 Clinical Context and Client Presentation This scenario presents a male client in the immediate aftermath of a sexual assault. His presentation—withdrawal, a monotone voice, and a stated desire to "forget this ever happened"—is a classic manifestation of the acute stress response. These are not signs of effective coping but rather indicators of emotional numbing and dissociation, which are common peritraumatic reactions. The priority is not to force a confrontation with the trauma but to stabilize the client's psychological state and prevent further harm. Analysis of the Correct Answer (Option 4) **Establishing a trusting therapeutic relationship and validating the client's feelings and responses** is the foundational priority. This intervention directly addresses the core principles of trauma-informed care: safety, trustworthiness, and empowerment. By validating his feelings, the nurse communicates that his reactions are normal responses to an abnormal event, which helps to reduce the immediate shame, self-blame, and isolation that are highly prevalent after sexual assault [1]. This approach creates a secure base from which all other interventions can proceed. The qualitative findings from therapists in the EIR study underscore that the therapeutic alliance is a prerequisite for any effective trauma-focused intervention, as it provides the necessary psychological safety for the client [2]. Why Other Options Are Incorrect - **Option 1 (Encourage immediate discussion of details):** This is contraindicated. Forcing a detailed narrative in the acute phase, especially when the client is dissociating, can be re-traumatizing and overwhelm fragile coping mechanisms. The modified prolonged exposure therapy (mPE) studied in the EIR trial is a structured intervention delivered by trained therapists, not an unstructured debriefing by a nurse in the emergency department . The priority is stabilization, not trauma processing. - **Option 2 (Provide detailed legal information and encourage immediate reporting):** This action disregards the client's current psychological capacity and autonomy. A traumatized individual in a state of shock and numbing cannot process complex information. Pressuring a client to make legal decisions immediately after an assault can compound the loss of control that is central to the trauma experience. The nurse's role is to offer support and present options only when the client is ready, respecting his pace. - **Option 3 (Administer prescribed anxiolytic to help the client relax and sleep):** While pharmacotherapy may eventually have a role, using medication as a first-line intervention to suppress emotions and induce sleep is a form of chemical restraint that bypasses the client's psychological needs. It does not address the underlying trauma and can interfere with the natural processing that begins with establishing safety and connection. The client's statement, "I just want to forget," reflects a desire for avoidance, and medicating him into sleep reinforces this maladaptive coping strategy rather than fostering healthy processing. Deep Dive into the Rationale The research evidence strongly supports a phased, relationship-first approach. The study on Somatic Experiencing® highlights the global need for interventions that address the body's trauma response, but the first phase of any trauma therapy is always "stabilization and resourcing," which begins with the therapeutic relationship [1]. The EIR study's exploration of modified prolonged exposure therapy explicitly notes that the intervention is delivered after a foundation of psychosocial support is established by trained personnel [2, 3]. The pilot study's focus on feasibility confirms that even brief, evidence-based early interventions require a safe and trusting context to be effective . The phenomenological study on trauma in Botswana further reinforces that a client's lived experience and subjective distress must be the guide for care, not a standardized, one-size-fits-all protocol . The client's presentation of emotional numbing is a clear signal that the nervous system is overwhelmed; the nurse's priority is to provide a calm, non-demanding presence that signals safety to the client's dysregulated physiology. References (research sources) - [1]Study protocol for a randomized controlled trial of a group-adapted Somatic Experiencing® intervention for Indonesian women survivors of sexual assault with PTSD symptoms.RCT/clinical trialAyudia L, Purba FD, Samuels A, Iskandarsyah A. (2025) · DOI: 10.1371/journal.pone.0336956 - [2]Therapists perspectives on the Early Intervention after Rape study: a qualitative process evaluation of a randomized controlled trial.RCT/clinical trialHaugen T, Halvorsen JØ, Friborg O, Schei B, Hagemann CT, Kjelsvik M. (2025) · DOI: 10.1080/20008066.2024.2443279 ## 임상 시나리오 Trauma-Informed Initial ResponsePrioritizing Psychological Safety After Sexual Assault The immediate priority is to establish psychological safety through a trusting therapeutic relationship. Validate the client's feelings as normal reactions to an abnormal event to reduce shame and isolation. A client presenting with a monotone voice and withdrawal is exhibiting peritraumatic dissociation or emotional numbing, not effective coping. Do not interpret this as readiness to discuss details. CautionAvoid encouraging immediate detailed recall of the assault; this can cause re-traumatization. Pharmacological sedation should not be the first-line intervention before psychological stabilization is attempted. ## 핵심 개념 - **Acute Stress Reaction** — A temporary psychological reaction that appears immediately after an extremely traumatic event such as sexual violence. Symptoms include emotional numbness, withdrawal, avoidance, and hyperarousal. - **Trauma-Informed Care** — An approach to care that understands how trauma affects a person’s health and behavior, prevents re-traumatization, and promotes recovery. Its core principles are safety, trust, transparency, collaboration, and empowerment. - **Therapeutic Relationship** — A professional relationship built on trust between a nurse and a patient. It is characterized by acknowledging the patient's feelings, maintaining a non-judgmental attitude, and respecting the patient's autonomy. - **Validation** — A therapeutic communication technique that acknowledges the patient's thoughts, feelings, and experiences as valid and understandable. It uses expressions such as "The emotions you are feeling right now are completely natural." - **Emotional Numbness** — Absence or blunting of emotional reactions following trauma. It can act as a psychological defense mechanism, but must be appropriately addressed during the recovery process. ## 같은 주제 문제 - [A nurse is conducting an initial assessment of a 22-year-old female client who was brought…](https://mymerci.kr/pages/nclex_q.php?qn_id=543486) - [A 17-year-old adolescent client presents to the emergency department 6 hours after a sexua…](https://mymerci.kr/pages/nclex_q.php?qn_id=543487) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._