Question 1

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

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,"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?

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?

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?

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?

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:

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.

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:

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?

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:

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:

Accepted Answer

Monitoring for respiratory depression takes priority over hypotonia,seizures,or coma.

Question 12

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

Accepted Answer

The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately.Counseling is not the focus until immediate problems are resolved.The victim remains anonymous.The other distracters are inappropriate or incorrect because counselors are trained to be empathetic rather than sympathetic.

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?

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 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?

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 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.

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 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?

Accepted Answer

The victim's response is typical of the acute phase and shows cognitive,affective,and behavioral disruptions.This response is immediate and does not include a display of behaviors suggestive of the long-term (reorganization)phase,anger,or a delayed reaction.

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?

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 1-12 hours,but the duration is less important that the potential for respiratory depression.Seeking evidence is less important than the victim's physiologic stability.

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.

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 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?

Accepted Answer

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

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.

Accepted Answer

These reactions are common to the long-term phase.Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase.Syncopal episodes would not be expected.

Quiz 29: Sexual Assault