44. When caring for a client who has been raped, which action should a nurse take first?
. Explore legal issues and prosecution.
. Acknowledge client's anxiety and fear.
. Explore client's feelings about recovery.
. Introduce defensive tactics.
Test-Taking Tip
Note the clue regarding which nursing action to take "first."
Content Area: Mental Health, Rape, Sexual Abuse; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Psychosocial Integrity/Stress Management
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Answer 1 is incorrect because the nurse would assist the client to explore legal issues (e.g., prosecution) after the medical evidence is collected and initial trauma has passed. Answer 2 is correct because it may be difficult for the client to process any information the nurse will be giving until anxiety is reduced and the client's feelings are acknowledged. Answer 3 is incorrect because the nurse would explore feelings (e.g., plans for the future) with the client after anxiety is lessened and coping behaviors are improved (e.g., increased control over fear and acceptance of what happened). Answer 4 is incorrect because this is an issue that can be addressed much later in the rape-trauma syndrome.