Question 1

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

A reflective communication technique is most helpful.Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible.The distracters discount the victim's perceived role and interfere with further discussion.

Question 2

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

Although the victim may have made choices that made her vulnerable,she is not to blame for the rape.Correcting this distortion in thinking allows the victim to begin to restore a sense of control.This is a positive response to victimization.The distracters do not permit the victim to begin to restore a sense of control or offer use of non-therapeutic communication techniques.In this interaction,the victim needs to talk about feelings rather than prevention.

Question 3

A nurse interviews a patient 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

Denial

Accepted Answer

The patient's statements reflect use of denial,an ego defense mechanism.This mechanism may be used unconsciously to protect the person from the emotionally overwhelming reality of the rape.The patient's statements do not reflect somatization,compensation,or projection.

Question 4

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?&#10;A) &#34;I have a rash on my buttocks. It itches all the time.&#34;&#10;B) &#34;Now I know what I did that triggered the attack on me.&#34;&#10;C) &#34;I'm sleeping better although I still have an occasional nightmare.&#34;&#10;D) &#34;I have lost 8 pounds since the attack, but I needed to lose some weight.&#34;

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 5

Which situation describes consensual sex rather than rape?&#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.

Accepted Answer

Only the key describes a scenario in which the sexual contact is consensual.Consensual sex is not considered rape if the participants are of legal age.

Question 6

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

Immediately after the assault,rape victims are often disorganized and unable to think well or remember instructions.Written information acknowledges this fact and provides a solution.The distracters violate the patient's right to privacy,evidence a rescue fantasy,and offer a platitude that is neither therapeutic nor effective.

Question 7

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."

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Accepted Answer

Females know their offenders in almost 70% of all violent crimes committed against them,including rape.The nurse should share this information along with encouraging discussion of safety measures.The distracters fail to provide adequate information or encourage discussion.

Question 8

An unconscious teenager is treated in the emergency department.The teenager's friends suspect a rape occurred at a party.Priority action by the nurse should focus on:&#10;A) preserving rape evidence.&#10;B) maintaining physiologic 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 physiologic stability.The distracters are of lower priority than preserving physiological functioning.

Question 9

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

Few rape survivors seek help,even with serious injury; so,it is important for the nurse to help the victim discuss the experience.The correct response therapeutically gives information to this victim.A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants.Males experience the same devastation,physical injury,and emotional consequences as females.Although they may cover their responses,they too benefit from care and treatment."Why" questions represent probing,which is a non-therapeutic communication technique.The victim may or may not have friends who have had this experience,but it's important to talk about his feelings rather than theirs.

Question 10

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 11

A nurse cares for a rape victim who was given a drink that contained flunitrazepam (Rohypnol)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 nurse works a 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 a rape telephone hotline.Communication...

Question 13

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

Accepted Answer

The answer of A woman was found confused and disoriented...

Question 14

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

The answer of After an abduction and rape at gunpoint...

Question 15

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

The answer of The nursing diagnosis Rape-trauma syndrome applies to...

Question 16

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 17

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?"

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Accepted Answer

The answer of A nurse in the emergency department assesses...

Question 18

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."

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Accepted Answer

The answer of A victim of a violent rape was...

Question 19

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

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

Question 20

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? Select all that apply.

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

Accepted Answer

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

Question 21

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 22

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 23

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

The answer of A patient was abducted and raped at...

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,&#34;I...

Deck 29: Sexual Assault