Based on the assessment findings, which of the following actions should the nurse take? Select all that apply.

Rationale for correct choices: Offer emergency contraception: In cases of sexual assault, emergency contraception should be offered as soon as possible to prevent pregnancy. This is a standard part of care for survivors of sexual violence, ideally within 72 hours after the assault. Collect and preserve evidence: Collecting and preserving physical evidence is critical for legal and forensic purposes. This includes clothing, swabs, and other materials that may help in a potential investigation. The nurse should follow proper protocols to ensure evidence is preserved without contamination. Administer sexually transmitted infection prophylaxis: Given the risk of sexually transmitted infections (STIs) following sexual assault, prophylaxis should be provided immediately, especially for high-risk infections such as chlamydia, gonorrhea, and HIV. Document the assessment findings in written and photographic form: Proper documentation of the client's physical findings, including bruising, broken fingernails, and other injuries, is essential for both legal purposes and ongoing medical care. Rationale for incorrect choices: Allow the client to shower prior to their genital examination: The client should not be allowed to shower or change clothes before the genital examination or evidence collection, as this could wash away important forensic evidence, such as bodily fluids or hair. Initiate a prescription for an antidepressant: While it is important to offer psychological support and follow-up care, prescribing an antidepressant should not be the immediate action. The client may require further assessment by a mental health professional to determine the most appropriate treatment. Perform a rapid HIV test: While HIV exposure is a concern after sexual assault, a rapid HIV test immediately following an assault will likely be negative as there is an incubation period (window period) before antibodies can be detected. Post-exposure prophylaxis (PEP) for HIV is the more appropriate immediate intervention.