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When providing care for a client who reports to the emergency department immediately after a sexual assault, which nursing actions are appropriate?

Explanation

• The nurse should provide support and reassurance so that a consent for the exam can be obtained by the provider. The client should not be forced or pressured to consent to the exam because it is optional.

• The nurse should let the client know that she or he has the right to have a friend or family member present and that a crisis center advocate may be available to come instead.

• The nurse should call law enforcement so that a report can be made if legally required or at the client's request.  Some states mandate reporting any sexual assault, while other states only mandate reporting sexual assault for children or elders.

• After emotional support is provided, the nurse should then assist with performing the exam and collecting specimens. Document all objective evidence, including the client's physical condition and response.

• As a victim of sexual assault, the patient may be in a state of shock or may have feelings of guilt or confusion about the situation. It is never appropriate to question the client about the assault or in any way imply that the client may have been at fault. 

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