When assessing a client in the emergency department following a sexual assault, what is the most appropriate first action for the forensic nurse to take?

Perform a detailed forensic evidence collection using a rape kit.

Provide the client with emergency contraception immediately.

Administer prophylactic treatment for sexually transmitted infections.

Create a private and secure environment, assuring the client of their safety.

Answer and Explanation

The Correct Answer is D

A. Performing a forensic evidence collection is an important step, but it should only be done after the client feels safe, is medically stable, and gives informed consent. Jumping straight to evidence collection without establishing safety and trust may increase trauma and reduce cooperation.

B. Providing emergency contraception is part of post-assault care if indicated, but it is not the immediate first action. This intervention occurs after ensuring the client’s safety and obtaining consent.

C. Administering prophylactic treatment for sexually transmitted infections is also an important component of care, but it is secondary to establishing a safe and supportive environment. Medical interventions require consent and a stable client.

D. Creating a private and secure environment and assuring the client of their safety is the first priority. Establishing physical and emotional safety helps reduce trauma, allows the client to regain a sense of control, and lays the foundation for all subsequent assessments, interventions, and forensic procedures.

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Correct Answer is C

Explanation

A. "Some people really enjoy making new friends through the internet." is dismissive and may minimize the client’s feelings of isolation. It does not provide direct support or resources.

B. "Perhaps you are being too particular about potential friends." is judgmental and could make the client feel blamed or misunderstood. This is not therapeutic.

C. "I can provide you with some information on divorce support groups." is correct. therapeutic communication demonstrates empathy, support, and practical assistance. Offering resources allows the client to explore social connections in a safe and structured way and acknowledges their feelings of isolation without judgment.

D. "Have you thought about dating again? Perhaps a member of your community?" is inappropriate at this stage. It shifts focus to personal relationships prematurely and may feel intrusive or dismissive of the client’s current emotional state.

A. Advise the parents to limit playtime to reduce overstimulation. B. Focus purely on managing anxiety without considering social skills. C. Encourage the child to participate in activities with peers to improve social skills. D. Recommend individualized play activities to avoid peer interaction,

Correct Answer is C

Explanation

A. Advising parents to limit playtime to reduce overstimulation may help manage sensory overload, but it does not address social withdrawal or promote development of social skills. Limiting interaction can worsen social isolation, so this is not the priority intervention.

B. Focusing purely on managing anxiety without considering social skills is incomplete. While anxiety management is important, children with autism spectrum disorder also benefit from interventions that enhance social engagement. Ignoring social skill development would not address the child’s withdrawal.

C. Encouraging the child to participate in activities with peers to improve social skills is correct. Social interaction is a core area of difficulty in ASD. Structured and supportive peer activities can help the child practice communication, cooperation, and social engagement, while also addressing concurrent withdrawal. This intervention promotes social development in a safe and guided manner, making it the priority.

D. Recommending individualized play activities to avoid peer interaction may reduce anxiety but does not help the child develop social skills. Avoiding peers reinforces social withdrawal and delays social competence, so this is not the most appropriate intervention.

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When assessing a client in the emergency department following a sexual assault, what is the most appropriate first action for the forensic nurse to take?

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