A female client presents in the emergency department (ED) and states, "I was raped tonight." Which intervention is most important for the nurse to implement?

A. Instruct the client to remove all clothing carefully: Preservation of forensic evidence is a priority immediately following a sexual assault. Clothing may contain biological material such as semen, blood, hair, or fibers that are critical for legal investigation. The client should undress carefully, and each item should be placed separately in paper bags to prevent contamination or degradation of evidence. Early evidence preservation supports both medical and legal processes. B. Assess client's sexual activity for the past 30 days: A sexual history is important for differentiating preexisting conditions from assault-related findings, especially when evaluating for pregnancy or sexually transmitted infections. However, it is not the first priority upon presentation. Immediate forensic preservation and physical safety take precedence. C. Ask the client if she can identify the attacker: Identification of the perpetrator may be relevant for legal investigation, but this line of questioning is typically conducted by law enforcement or a trained forensic examiner. The nurse’s primary role initially is to provide medical stabilization, emotional support, and protect forensic evidence. D. Obtain a history of sexually transmitted diseases: Knowledge of prior sexually transmitted infections assists in planning prophylaxis and follow-up testing. However, this assessment can occur after immediate safety needs and evidence collection measures are addressed. Preservation of potential forensic material must occur before other history-taking to avoid compromising evidence.