Deck 22: Sexual Violence

Question 1

A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the person's level of anxiety?

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

Answer 1

Severe

Question 2

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on:

A) maintaining gas exchange.
B) preserving rape evidence.
C) obtaining a description of the rape.
D) determining what drug was ingested.

Answer 2

maintaining gas exchange.

Question 3

A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic?

A) Pose questions about the rape, helping the patient explore why it happened.
B) Reassure the victim that the outcome of the situation will be positive.
C) Make decisions for the victim because of the temporary confusion.
D) Support the victim to separate issues of vulnerability from blame.

Answer 3

Support the victim to separate issues of vulnerability from blame.

Question 4

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response.

A) "Are you thinking of suicide?"
B) "It will take time, but you will feel the same as before."
C) "Your friends will understand when you tell them."
D) "You will be able to find meaning in this experience as time goes on."

Question 5

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

A) arrange support from the victim's family.
B) provide referral information verbally and in writing.
C) advise the victim to try not to think about the assault.
D) offer to stay with the victim until stability is regained.

Question 6

A victim of a sexual assault that occurred approximately 1 hour earlier 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 which phase of the rape trauma syndrome?

A) Anger phase
B) Acute phase
C) Outward adjustment phase
D) Long-term reorganization phase

Question 7

The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge?

A) Patient states, "I feel safe and entirely relaxed."
B) Memory of the rape is less vivid and frightening.
C) Physical symptoms of pain and discomfort are no longer present.
D) Patient agrees to keep a follow-up appointment with the rape crisis center.

Question 8

A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely?

A) "She was very beautiful."
B) "I gave her what she wanted."
C) "I have issues with my mother."
D) "I've been depressed for a long time."

Question 9

Which situation constitutes consensual sex rather than rape?

A) After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects.
B) A person's lover pleads to have oral sex. The person gives in but then regrets the decision.
C) A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant.
D) A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

Question 10

A person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome?

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

Question 11

What is the primary motivator for most rapists?

A) Anxiety
B) Need for humiliation
C) Overwhelming sexual desires
D) Desire to humiliate or control others

Question 12

A survivor in the long-term organization (delayed) phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? The survivor:

A) temporarily withdraws from social situations.
B) describes coping strategies for fearful situations.
C) uses increased activity to reduce fear.
D) expresses a desire to be with others.

Question 13

A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care?

A) Anger
B) Concern
C) Empathy
D) Compassion

Question 14

A nurse working a rape telephone hotline should focus communication with callers to:

A) arrange long-term counseling.
B) serve as a sympathetic listener.
C) obtain information to relay to the local police.
D) explain immediate steps that a victim of rape should take.

Question 15

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

A) arrange for the patient to shower.
B) explain that washing would destroy evidence.
C) give the patient a basin of hot water and towels.
D) instruct the victim to wash above the waist only.

Question 16

A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should:

A) tell the patient, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases."
B) provide written information concerning the physical and emotional reactions that may be experienced.
C) explain the need and importance of human immunodeficiency virus (HIV) testing.
D) offer verbal information about legal resources.

Question 17

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

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

Question 18

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

A) Somatic reaction
B) Repression
C) Projection
D) Denial

Question 19

A nurse works with a person who was raped four years ago. This person says, "It took a long time for me to recover from that horrible experience." Which term should the nurse use when referring to this person?

A) Victim
B) Survivor
C) Plaintiff
D) Perpetrator

Question 20

The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention?

A) Use accepting, nurturing, and empathetic communication techniques.
B) Educate the victim about strategies to avoid attacks in the future.
C) Discourage the expression of feelings until the victim stabilizes.
D) Maintain a matter-of-fact manner and objectivity.

Question 21

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? (Select all that apply.)

A) Alleged
B) Reported
C) Penetration
D) Intercourse
E) Refused
F) Declined

Question 22

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? (Select all that apply.)

A) Allow the person to talk at a comfortable pace.
B) Pose questions in nonjudgmental, empathic ways.
C) Place the person in a private room with a caregiver.
D) Reassure the person that a family member will arrive as soon as possible.
E) Invite family members to the examination room and involve them in taking the history.

Question 23

When an emergency department nurse teaches a victim of rape about reactions that may occur during the long-term organization (delayed) 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
F) Put an arm around the person to offer reassurance that the nurse is caring and compassionate.

Question 24

When working with rape victims, immediate care focuses first on:

A) collecting evidence.
B) notifying law enforcement.
C) helping the victim feel safe.
D) documenting the victim's comments.

Question 25

Which activities are in the scope of practice of a sexual assault nurse examiner? (Select all that apply.)

A) Requiring HIV testing of a victim
B) Collecting and preserving evidence
C) Providing long-term counseling for rape victims
D) Obtaining signed consents for photographs and examinations
E) Providing pregnancy and sexually transmitted disease prophylaxis

Question 26

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.