Difficulty: Medium
Average Score: 90%
Simulated
A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?
Correct answer
C
Rationale
The correct first action for the nurse is to document the client's verbatim statements. This is crucial for legal and forensic purposes, ensuring accurate and timely documentation of the client's account of the assault. It helps preserve evidence, maintain confidentiality, and guide further assessment and care. Asking for permission to take photographs, providing support contacts, and determining physical signs of injury are important but should come after documenting the client's statements. These actions may be secondary to establishing a detailed and accurate record of the client's initial report.