💊 NCLEX-RN Exam Prep

A nurse is providing care for a client admitted to the emergency department after experiencing a sexual assault earlier in the day. What is the priority nursing intervention in the immediate post-assault phase?

A Encourage the client to discuss the details of the assault.
B Ensure the client's safety and provide a sense of control over immediate decisions.
C Administer prophylactic antibiotics immediately.
D Begin gathering evidence for legal proceedings.

✓ Correct Answer: Option B

The priority is to establish safety and empower the client, who has just experienced a violation of control. Providing choices (e.g., who to call, what to wear) helps restore a sense of autonomy. Evidence collection and antibiotics follow after immediate safety and client consent.

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