The emergency department nurse is assigned to provide care for a victim of a sexual assault. When following legal and agency guidelines, which intervention is most important?

Correct Answer: D. Ensure an unbroken chain of evidence

Establishing an unbroken chain of evidence is essential in order to ensure that the prosecution of the perpetrator can occur. Explain the forensic specimens you plan to collect; inform the client that they can be used for identification and prosecution of the rapist, for example blood, combing pubic hairs, semen samples, skin from underneath nails.

• Option A: Arrange for support follow-up: crisis counseling, group therapy, individual therapy, rape counselor, or a support group. Many individuals carry with them constant emotional distress and trauma. Depression and suicidal ideation are frequent sequelae of rape. As soon as the intervention is carried out, the less complicated the recovery may be.
• Option B: The nurse will also need to preserve the client’s privacy and identify the extent of an injury. However, it is essential that the nurse follows legal and agency guidelines for preserving evidence. Provide strict confidentiality. The client’s situation is not to be talked over with anyone other than the medical staff involved unless the client gives consent to it.
• Option C: Identifying the assailant is the job of law enforcement, not the nurse. Approach the client in a nonjudgmental manner. Nurses’ attitudes can have an important therapeutic impact. Displays of shock, horror, disgust, or disbelief are not appropriate. Never use judgmental language.