Deck 27: Sexual Assault

Question 1

The nursing diagnosis Rape-trauma syndrome is established for a rape victim in the emergency department.Select the most important outcome to achieve before discharging the patient.

A) The patient will describe feelings of safety and relaxation.
B) The memory of the rape will be less vivid and less frightening.
C) Physical symptoms of pain and discomfort are no longer present.
D) The patient will agree to keep a follow-up appointment with a rape victim advocate.

Answer 1

The patient will agree to keep a follow-up appointment with a rape victim advocate.

Question 2

A nurse works a rape telephone hotline.Communication should focus on:

A) explaining immediate steps victims should take.
B) providing callers with a sympathetic listener.
C) obtaining information for law enforcement.
D) arranging long-term counseling.

Answer 2

explaining immediate steps victims should take.

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

Which aspect of assessment has priority when a nurse interviews a rape victim?

A) Coping mechanisms the patient is using
B) The patient's previous sexual experiences
C) Adequacy of the patient's interpersonal relationships
D) Whether the patient has ever had a sexually transmitted disease

Question 5

A woman was bound,taken to a remote location,and raped at gunpoint.When found,she was examined and treated in the emergency department.Which aspect of this crisis produced the greatest amount of psychological trauma?

A) The threat to her life
B) Collection of evidence
C) Physical pain experienced
D) Being in a remote location

Question 6

A rape victim tells the emergency room nurse,"I feel so dirty.Help me take a shower before the doctor examines me." The nurse should:

A) arrange for the patient to shower.
B) explain that bathing would destroy evidence.
C) give the patient a basin of water and towels.
D) explain that bathing facilities are not available in the emergency department.

Question 7

A victim of rape says,"My family is not very supportive." Which belief contributes to a negative family response?

A) No one asks to be raped.
B) Rape is an act of aggression.
C) Rape should not be discussed.
D) Anyone is a potential rape victim.

Question 8

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

When a victim of sexual assault is discharged from the emergency department,the nurse should:

A) notify the patient's family of the event to ensure support for the patient.
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

After a rape victim visited a rape crisis counselor weekly for 8 weeks,which finding best demonstrates that reorganization was successful?

A) Absence of signs or symptoms of posttraumatic stress disorder
B) Presence of mild somatic reactions
C) Moderate doubts about self-worth
D) Occasional episodic nightmares

Question 11

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) Somatization
B) Repression
C) Projection
D) Denial

Question 12

A patient in the long-term phase of the rape-trauma syndrome had intrusive thoughts of the attack and developed fears of being alone.Which finding best demonstrates the patient has improved? The patient:

A) uses increased activity to reduce fear.
B) plans coping strategies for fearful situations.
C) temporarily withdraws from social situations.
D) expresses willingness to engage in sexual activity.

Question 13

A victim of a sexual assault sits in the emergency department rocking back and forth and repeatedly saying,"I can't believe I've been raped." This behavior is characteristic of:

A) the acute phase reaction.
B) the angry stage of rape-trauma syndrome.
C) a delayed reaction to rape-trauma syndrome.
D) the long-term phase of rape-trauma syndrome.

Question 14

A friend brings a teenager to the emergency department.The friend found the patient unconscious in a bedroom at a party.Semen is observed on the patient's underclothes.Priority actions by the nurse should focus on:

A) preserving rape evidence.
B) maintaining the patient's airway.
C) obtaining a description of the rape.
D) determining what drugs were ingested.

Question 15

A person who was raped comes to the hospital for treatment.The person abruptly decides to decline treatment and leave the facility.Before this person leaves,the nurse should:

A) say,"You may not leave until you're given 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 HIV and pregnancy tests.
D) give verbal information about legal resources.

Question 16

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."
C) "Your friends will understand when you explain it was not your fault."
D) "You will be able to find meaning in this experience as time goes on."

Question 17

After a person was abducted and raped at gunpoint by an unknown assailant,which assessment finding best indicates the acute phase of the rape-trauma syndrome?

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

Question 18

A rape victim asks a nurse,"How do I know whether this attack was my fault?" Which response by the nurse is therapeutic?

A) Support the victim to separate issues of vulnerability from blame.
B) Make decisions for the victim because of the temporary confusion.
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 19

Which situation is 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 then 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 20

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

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

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.

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

Question 22

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.

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 nonjudgmental,empathetic ways.
D) Invite the patient's family members to the examination room.
E) Put an arm around the patient to demonstrate support,caring,and compassion.

Question 23

A nurse cares for a rape victim who was given flunitrazepam (Rohypnol)by the assailant.Which intervention has priority? Monitoring for:

A) Coma
B) Seizures
C) Hypotonia
D) Respiratory depression

Question 24

When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may be experienced during the long-term phase,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