Question 1

A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? (Select all that apply.)&#10;A) Allow the patient to talk at a comfortable pace.&#10;B) Place the patient in a private room with a caregiver.&#10;C) Pose questions in nonjudgmental, empathetic ways.&#10;D) Invite the patient's family members to the examination room.&#10;E) Put an arm around the patient to demonstrate support and compassion.

Accepted Answer

Neutral, nonjudgmental care and emotional support are critical to crisis management for the rape victim. The rape victim should have privacy but not be left alone. The rape victim's anxiety may escalate when touched by a stranger, even when the stranger is a nurse. Some rape victims prefer not to have family involved. The patient's privacy may be compromised by family presence.

Question 2

The nursing diagnosis Rape-trauma syndrome applies to a rape victim in the emergency department. Select the most appropriate outcome to achieve before discharging the patient.&#10;A) The memory of the rape will be less vivid and less frightening.&#10;B) The patient is able to describe feelings of safety and relaxation.&#10;C) Symptoms of pain, discomfort, and anxiety are no longer present.&#10;D) The patient agrees to a follow-up appointment with a rape victim advocate.

Accepted Answer

Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department.

Question 3

A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman's level of anxiety?

A) Weak
B) Mild
C) Moderate
D) Severe

Severe

Accepted Answer

Acute anxiety results from the personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level.

Question 4

An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important?&#10;A) The patient's vital signs&#10;B) Consent signed by the patient&#10;C) Supervision and credentials of the examiner&#10;D) Storage location of the patient's personal effects

Accepted Answer

Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps.

Question 5

After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome?&#10;A) Decreased motor activity&#10;B) Confusion and disbelief&#10;C) Flashbacks and dreams&#10;D) Fears and phobias

Accepted Answer

Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase.

Question 6

A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on." Select the nurse's most appropriate response.

A) "Are you thinking of harming yourself?"
B) "It will take time, but you will feel the same as before the attack."
C) "Your friends will understand when you explain it was not your fault."
D) "You will be able to find meaning from this experience as time goes on."

Accepted Answer

The patient's words suggest hopelessness. Whenever hopelessness is present, so is suicide risk. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment.

Question 7

An unconscious teenager is treated in the emergency department. The teenager's friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on&#10;A) preserving rape evidence.&#10;B) maintaining physiological stability.&#10;C) determining what drugs were ingested.&#10;D) obtaining a description of the rape from a friend.

Accepted Answer

Because the patient is unconscious, the risk for airway obstruction is present. The nurse's priority will focus on maintaining physiological stability. The distracters are of lower priority than preserving physiological functioning.

Question 8

A nurse in the emergency department assesses an unresponsive victim of rape. The victim's friend reports, "That guy gave her salty water before he raped her." Which question is most important for the nurse to ask of the victim's friend?

A) "Does the victim have any kidney disease?"
B) "Has the victim consumed any alcohol?"
C) "What time was she given salty water?"
D) "Did you witness the rape?"

Accepted Answer

Salty water is a slang/street name for GHB (g-hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1 to 12 hours, but the duration is less important than the potential for respiratory depression. Seeking evidence is less important than the victim's physiologic stability.

Question 9

A victim of a sexual assault comes to the hospital for treatment but abruptly decides to decline treatment and leaves the facility. While respecting the person's rights, the nurse should&#10;A) say, &#34;You may not leave until you receive prophylactic treatment for sexually transmitted diseases.&#34;&#10;B) provide written information about physical and emotional reactions the person may experience.&#10;C) explain the need and importance of infectious disease and pregnancy tests.&#10;D) give verbal information about legal resources in the community.

Accepted Answer

All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to later. Patients may not be kept against their will or coerced into treatment. This constitutes false imprisonment.

Question 10

A rape victim visited a rape crisis counselor weekly for 8 weeks. At the end of this counseling period, which comment by the victim best demonstrates that reorganization was successful and the victim is now in recovery?

A) "I have a rash on my buttocks. It itches all the time."
B) "Now I know what I did that triggered the attack on me."
C) "I'm sleeping better although I still have an occasional nightmare."
D) "I have lost 8 pounds since the attack, but I needed to lose some weight."

Accepted Answer

Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victim's sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing.

Question 11

A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for&#10;A) coma.&#10;B) seizures.&#10;C) hypotonia.&#10;D) respiratory depression.

Accepted Answer

The answer of A nurse cares for a rape victim...

Question 12

A rape victim says to the nurse, &#34;I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?&#34; Which communication by the nurse is most therapeutic?&#10;A) Support the victim to separate issues of vulnerability from blame.&#10;B) Emphasize the importance of using a buddy system in public places.&#10;C) Reassure the victim that the outcome of the situation will be positive.&#10;D) Pose questions about the rape and help the patient explore why it happened.

Accepted Answer

The answer of A rape victim says to the nurse,...

Question 13

A nurse interviews a 17-year-old male victim of sexual assault. The victim is reluctant to talk about the experience. Which comment should the nurse offer to this victim?&#10;A) &#34;Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs.&#34;&#10;B) &#34;Male victims of sexual assault often experience physical injuries and are assaulted by more than one person.&#34;&#10;C) &#34;Do you have any male friends who have also been victims of sexual assault?&#34;&#10;D) &#34;Why do you think you became a victim of sexual assault?&#34;

Accepted Answer

The answer of A nurse interviews a 17-year-old male victim...

Question 14

Before a victim of sexual assault is discharged from the emergency department, the nurse should&#10;A) notify the victim's family to provide emotional support.&#10;B) offer to stay with the patient until stability is regained.&#10;C) advise the patient to try not to think about the assault.&#10;D) provide referral information verbally and in writing.

Accepted Answer

The answer of Before a victim of sexual assault is...

Question 15

A victim of a sexual assault who sits in the emergency department is rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which stage of rape-trauma syndrome?

A) The acute phase reaction
B) The long-term phase
C) A delayed reaction
D) The angry stage

Accepted Answer

The answer of A victim of a sexual assault who...

Question 16

The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response.

A) "Your plan is not adequate. You could still be raped or sexually assaulted."
B) "I am glad you have this excellent safety plan. Would others like to comment?"
C) "It's better to walk with someone or call security when you enter or leave a building."
D) "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

Accepted Answer

The answer of The nurse at a university health center...

Question 17

A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I shouldn't have been there alone. I knew it was a dangerous area." What is the patient's present coping strategy?

A) Projection
B) Self-blame
C) Suppression
D) Rationalization

Accepted Answer

The answer of A nurse interviews a patient abducted and...

Question 18

When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase, which symptoms should be included? (Select all that apply.)&#10;A) Development of fears and phobias&#10;B) Decreased motor activity&#10;C) Feelings of numbness&#10;D) Flashbacks, dreams&#10;E) Syncopal episodes

Accepted Answer

The answer of When an emergency department nurse teaches a...

Question 19

A nurse works at rape telephone hotline. Communication with potential victims should focus on&#10;A) explaining immediate steps victims should take.&#10;B) providing callers with a sympathetic listener.&#10;C) obtaining information for law enforcement.&#10;D) arranging counseling.

Accepted Answer

The answer of A nurse works at rape telephone hotline....

Question 20

A rape victim tells the nurse, &#34;I should not have been out on the street alone.&#34; Select the nurse's most therapeutic response.&#10;A) &#34;Rape can happen anywhere.&#34;&#10;B) &#34;Blaming yourself increases your anxiety and discomfort.&#34;&#10;C) &#34;You are right. You should not have been alone on the street at night.&#34;&#10;D) &#34;You feel as though this would not have happened if you had not been alone.&#34;

Accepted Answer

The answer of A rape victim tells the nurse, &#34;I...

Question 21

Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.)&#10;A) Coping mechanisms, the patient is using&#10;B) The patient's previous sexual experiences&#10;C) The patient's history of sexually transmitted diseases&#10;D) Signs and symptoms of emotional and physical trauma&#10;E) Adequacy and availability of the patient's support system

Accepted Answer

The answer of Which aspects of assessment have priority when...

Question 22

An emergency department nurse prepares to assist with examination of a sexual assault victim. What equipment will be needed to collect and document forensic evidence? (Select all that apply.)&#10;A) Camera&#10;B) Body map&#10;C) DNA swabs&#10;D) Pulse oximeter&#10;E) Sphygmomanometer

Accepted Answer

The answer of An emergency department nurse prepares to assist...

Question 23

Which scenarios describe completed rape? (Select all that apply.)&#10;A) A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects.&#10;B) A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision.&#10;C) A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant.&#10;D) A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient.&#10;E) A perpetrator grabs a potential victim, tears off most of her clothing, and fondles her breasts before she escapes.

Accepted Answer

The answer of Which scenarios describe completed rape? (Select all...

Question 24

A rape victim tells the emergency nurse, &#34;I feel so dirty. Help me take a shower before I get examined.&#34; The nurse should (Select all that apply.)&#10;A) arrange for the victim to shower.&#10;B) explain that bathing destroys evidence.&#10;C) give the victim a basin of water and towels.&#10;D) offer the victim a shower after evidence is collected.&#10;E) explain that bathing facilities are not available in the emergency department.

Accepted Answer

The answer of A rape victim tells the emergency nurse,...

Deck 29: Sexual Assault