Deck 25: Sexual Assault

Question 1

An unconscious teenager is treated in the emergency department. The teenager's friends suspect a rape occurred at a party and tell the nurse the teenager received ketamine. Priority action by the nurse should focus on which of the following?

A) Preserving rape evidence
B) Maintaining physiologic stability
C) Determining what drugs were ingested
D) Obtaining a description of the rape from a friend

Answer 1

Maintaining physiologic stability

Question 2

The nurse at a university health centre 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."

Answer 2

"Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

Question 3

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?

A) The patient's vital signs
B) Consent signed by the patient
C) Supervision and credentials of the examiner
D) Storage location of the patient's personal effects

Answer 3

Consent signed by the patient

Question 4

A rape victim says to the nurse, "I always try to be so careful. I know I should not have walked to my car alone. Was this attack my fault?" Which communication by the nurse is most therapeutic?

A) Support the victim to separate issues of vulnerability from blame.
B) Emphasize the importance of using a buddy system in public places.
C) Reassure the victim that the outcome of the situation will be positive.
D) Pose questions about the rape and help the patient explore why it happened.

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?

A) Decreased motor activity
B) Confusion and disorientation
C) Flashbacks and dreams
D) Fears and phobias

Question 6

A rape victim visited a rape crisis counsellor weekly for 8 weeks. At the end of this counselling period, which comment by the victim best demonstrates that reorganization was successful?

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."

Question 7

A nurse interviews a patient who was abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's present coping strategy?

A) Compensation
B) Somatization
C) Projection
D) Denial

Question 8

A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response.

A) "Rape can happen anywhere."
B) "Blaming yourself increases your anxiety and discomfort."
C) "You are right. You should not have been alone on the street at night."
D) "You feel as though this would not have happened if you had not been alone."

Question 9

Before a victim of sexual assault is discharged from the emergency department, which of the following should the nurse do?

A) Notify the victim's family to provide emotional support
B) Offer to stay with the patient until stability is regained
C) Advise the patient to try not to think about the assault
D) Provide referral information verbally and in writing

Question 10

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 behaviour is characteristic of which stage of rape-trauma syndrome?

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

Question 11

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."

Question 12

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?

A) "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs."
B) "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person."
C) "Do you have any male friends who have also been victims of sexual assault?"
D) "Why do you think you became a victim of sexual assault?"

Question 13

Which situation describes consensual sex rather than rape?

A) A husband forces vaginal sex when he comes home intoxicated from a party. The wife objects.
B) A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision.
C) A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant.
D) A dentist gives anesthesia for a procedure and then has intercourse with the unconscious patient.

Question 14

Where do the majority of sexual assaults occur?

A) Private home
B) City street at night
C) Commercial establishment
D) Person's own motor vehicle

Question 15

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

Question 16

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, which of the following should the nurse do?

A) Say, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases."
B) Provide written information about physical and emotional reactions the person may experience.
C) Explain the need and importance of infectious disease and pregnancy tests.
D) Give verbal information about legal resources in the community.

Question 17

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.

A) The memory of the rape is less vivid and less frightening.
B) The patient is able to describe feelings of safety and relaxation.
C) Symptoms of pain, discomfort, and anxiety are no longer present.
D) The patient agrees to a follow-up appointment with a rape victim advocate.

Question 18

When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase of reorganization, which symptoms should be included?

A) Development of fears and phobias
B) Decreased motor activity
C) Feelings of numbness
D) Flashbacks, dreams
E) Syncopal episodes

Question 19

A nurse cares for a rape victim who was given a drink that contained GHB ( $\gamma$ -hydroxybutyric acid) by an assailant. Which intervention has priority?

A) Monitoring for coma
B) Monitoring for seizures
C) Monitoring for hypotonia
D) Monitoring for respiratory depression

Question 20

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?"

Question 21

Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting?

A) Coping mechanisms the patient is using
B) The patient's previous sexual experiences
C) The patient's history of sexually transmitted diseases
D) Signs and symptoms of emotional and physical trauma
E) Adequacy and availability of the patient's support system

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?

A) Camera
B) Body map
C) DNA swabs
D) Pulse oximeter
E) Sphygmomanometer

Question 23

A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." Which of the following should the nurse do?

A) Arrange for the victim to shower.
B) Explain that bathing destroys evidence.
C) Give the victim a basin of water and towels.
D) Offer the victim a shower after evidence is collected.
E) Explain that bathing facilities are not available in the emergency department.

Question 24

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?

A) Allow the patient to talk at a comfortable pace.
B) Place the patient in a private room with a caregiver.
C) Pose questions in nonjudgemental, empathetic ways.
D) Invite the patient's family members to the examination room.
E) Put an arm around the patient to demonstrate support and compassion.