— 心理社會完整性 · HARD · SATA —
護理師照護一位剛經歷性侵害的病人。哪些護理措施是適當的？（選所有適合的）
A nurse is caring for a client who has just experienced a sexual assault. Which nursing interventions are appropriate? (Select all that apply.)
- AEncourage the client to wash thoroughly to feel clean鼓勵個案徹底清洗以保持清潔
- BDocument the client's statements using their own words✓ 正解使用個案的原話記錄其陳述
- CProvide a non-judgmental and supportive environment✓ 正解提供非評判性且支持性的環境
- DEnsure the client has a support person during the examination✓ 正解確保個案在檢查時有支持者陪同
- EAdvise the client to discuss the event publicly for closure建議個案公開討論此事以獲得釋懷
— Explanation · 中文詳解 —
性侵害（Sexual assault）護理的核心在於證據保存、心理支持與病人自主權的維護。護理師應提供非評判性（Non-judgmental）的支持，並確保病人有信任的支援系統（Support person）陪伴。紀錄時必須如實使用病人的原始描述，這對於後續的法律程序至關重要。絕對禁止洗澡、刷牙或更換衣物，以防破壞採證。
Nursing care for sexual assault victims prioritizes preserving forensic evidence, providing non-judgmental emotional support, and maintaining patient autonomy. Nurses should document the client's statements verbatim for legal accuracy and ensure a support person is present during examinations to reduce trauma. Clients must be advised against washing, brushing teeth, or changing clothes to prevent destruction of critical evidence.