A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?

Choice A reason: Asking the client to describe the situation is the most appropriate initial action. It allows the nurse to gather essential information in a supportive and nonjudgmental manner while maintaining therapeutic communication. This step respects the client’s autonomy, validates their experience, and provides critical details for both medical care and legal documentation. It also ensures that the nurse can prioritize safety and evidence preservation. Choice B reason: Informing the client that photographs of injuries are required for a police report is premature and may cause additional distress. While documentation of injuries is important, the nurse’s role is to provide immediate support and allow the client to share their account first. Legal procedures should follow after medical stabilization and consent. Choice C reason: Giving the client a bed bath prior to physical examination is inappropriate because it can destroy forensic evidence needed for legal investigation. Preserving evidence is critical in cases of sexual assault, and cleansing the client before examination would compromise this process. Choice D reason: Discussing self-defense techniques with the client is not appropriate in the immediate aftermath of sexual assault. The priority is to provide emotional support, ensure safety, and preserve evidence. Self-defense education may be useful later but is not part of acute care management.