A 32-year-old woman brought to the emergency department reports being sexually assaulted. The patient is confused about where she is and she has a large laceration above the right eye. Which action should the nurse take first?
a. Assess the patient's neurologic status.
b. Assist the patient to remove her clothing.
c. Contact the sexual assault nurse examiner (SANE).
d. Ask the patient to describe what occurred during the assault.
ANS: A
The first priority is to treat urgent medical problems associated with the sexual assault. The patient's head injury may be associated with a head trauma such as a skull fracture or subdural hematoma. Therefore her neurologic status should be assessed first. The other nursing actions are also appropriate, but they are not as high in priority as assessment and treatment for acute physiologic injury.
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