Chapter 29 : Sexual Assault

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.

"Are you thinking of harming yourself?"

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?

"Has the victim consumed any alcohol?"

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?

"I'm sleeping better although I still have an occasional nightmare."

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.

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

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

"You feel as though this would not have happened if you had not been alone."

Select all that apply. 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?

- Allow the patient to talk at a comfortable pace. - Place the patient in a private room with a caregiver. - Pose questions in nonjudgmental, empathetic ways.

Select all that apply. 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?

- Camera - Body map - DNA swabs

Select all that apply. Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting?

- Coping mechanisms the patient is using - Signs and symptoms of emotional and physical trauma - Adequacy and availability of the patients support system

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.

- Development of fears and phobias - Feelings of numbness - Flashbacks, dreams

Select all that apply. A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should:

- explain that bathing destroys evidence. - offer the victim a shower after evidence is collected.

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

explaining immediate steps victims should take.

Which situation describes consensual sex rather than rape?

A woman's lover pleads with her to have oral sex. She gives in but later regrets the decision.

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?

Confusion and disbelief

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?

Consent signed by the patient

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?

Denial

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?

Severe

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?

Support the victim to separate issues of vulnerability from blame.

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?

The acute phase reaction

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.

The patient agrees to a follow-up appointment with a rape victim advocate.

n 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:

maintaining physiologic stability.

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

provide referral information verbally and in writing.

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:

provide written information about physical and emotional reactions the person may experience.

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:

respiratory depression.