A 32-year-old woman brought to the emergency department reports ...

[Beheh]

A 32-year-old woman brought to the emergency department reports being sexually assaulted. The patient is confused about where she is and she has a large laceration above the right eye. Which action should the nurse take first?
 
  a. Assess the patient's neurologic status.
  b. Assist the patient to remove her clothing.
  c. Contact the sexual assault nurse examiner (SANE).
  d. Ask the patient to describe what occurred during the assault.

Question 2

A 48-year-old woman in the emergency department reports that she has been sexually assaulted. Which action by the nurse will be most important in maintaining the medicolegal chain of evidence?
 
  a. Labeling all specimens and other materials obtained from the patient.
  b. Assisting the patient in filling out the application for financial compensation.
  c. Discussing the availability of the morning-after pill for pregnancy prevention.
  d. Educating the patient about baseline sexually transmitted infection (STI) testing.

[ryrychapman11]

Answer to Question 1

ANS: A
The first priority is to treat urgent medical problems associated with the sexual assault. The patient's head injury may be associated with a head trauma such as a skull fracture or subdural hematoma. Therefore her neurologic status should be assessed first. The other nursing actions are also appropriate, but they are not as high in priority as assessment and treatment for acute physiologic injury.

Answer to Question 2

ANS: A
The careful labeling of specimens and materials will assist in maintaining the chain of evidence. Assisting with paperwork, and discussing STIs and pregnancy prevention are interventions that might be appropriate after sexual assault, but they do not help maintain the legal chain of evidence.