Varcarolis 29: Sexual Assault
b
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
abc
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. Camera b. Body map c. DNA swabs d. Pulse oximeter e. Sphygmomanometer
b
An unconscious teenager is treated in the emergency department. The teenager's friends suspect the teenager was drugged and raped at a party. Priority action by the nurse should focus on a. preserving rape evidence. b. maintaining physiological stability. c. determining what drugs were ingested. d. obtaining a description of the rape from a friend.
d
A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Which intervention has priority? Monitoring for a. coma. b. seizures. c. hypotonia. d. respiratory depression.
bcd
A nurse caring for a patient who was sexually assaulted reports to the primary healthcare provider that the patient has effectively recovered. Which responses by the patient led the nurse to identify the patient's effective recovery? Select all that apply. a. The patient identifies emotions. b. The patient expresses the right to be protected. c. The patient starts interacting with family members. d. The patient expresses anger in a nondestructive way. e. The patient starts interacting verbally and nonverbally.
b
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?"
b
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? a. "Male victims of sexual assault are usually better equipped than women to deal with the emotional pain that occurs." b. "Male victims of sexual assault often experience physical injuries and are assaulted by more than one person." c. "Do you have any male friends who have also been victims of sexual assault?" d. "Why do you think you became a victim of sexual assault?"
b
A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, "I shouldn't have been there alone. I knew it was a dangerous area." What is the patient's present coping strategy? a. Projection b. Self-blame c. Suppression d. Rationalization
a
A nurse works at rape telephone hotline. Communication with potential victims 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 counseling.
abc
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 and compassion.
a
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? a. Support the victim to separate issues of vulnerability from blame. b. Emphasize the importance of using a buddy system in public places. 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.
bd
A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." The nurse should (Select all that apply.) a. arrange for the victim to shower. b. explain that bathing destroys evidence. c. give the victim a basin of water and towels. d. offer the victim a shower after evidence is collected. e. explain that bathing facilities are not available in the emergency department.
d
A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic 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."
c
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 and the victim is now in recovery? a. "I have a rash on my buttocks. It itches all the time." b. "Now I know what I did that triggered the attack on me." c. "I'm sleeping better although I still have an occasional nightmare." d. "I have lost 8 pounds since the attack, but I needed to lose some weight."
a
A student nurse interacts with the sexual assault nurse examiner (SANE) during internship. The student nurse asks the SANE to share an experience while caring for victims of sexual assault. Which response given by the SANE is appropriate? a. "I have seen rape victims from 6 months to 90 years old." b. "I noticed that most rapes are impulsive acts of the rapists." c. "I feel that patients get severe injuries when they try to escape." d. "I overlook my feelings toward sexual assault before caring for the patient."
b
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 a. say, "You may not leave until you receive 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 infectious disease and pregnancy tests. d. give verbal information about legal resources in the community.
a
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
a
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."
d
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
b
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? a. Decreased motor activity b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias
abcde
Arrange the steps of the medical exam of a rape victim based on best practice guidelines. a. Head-to-toe physical assessment b. Genital examination c. Collection of evidence d. Documentation of biological and physical findings e. Treatment, discharge planning, and follow-up care
d
Before a victim of sexual assault is discharged from the emergency department, the nurse should a. notify the victim's family to provide emotional support. 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.
d
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."
revictimization
The nurse is explaining the forensic exam to a patient who was just sexually assaulted. The patient does not want to be examined and says, "I feel like my body just keeps getting violated more and more." Which is the best term used to describe this feeling?
b
The nurse is providing discharge teaching to a patient who was recently raped. What should the nurse say regarding the psychological effects of the assault? a. "You may feel hyperactive and notice an increased surge of energy." b. "It is normal to experience depression after being sexually assaulted." c. "People often report the need to be social after a sexual assault incident." d. "Let the healthcare provider know immediately if you feel scared or worried."
cde
The nurse meets with a patient who was a victim of sexual assault. Which statements made by the patient indicate recovery? Select all that apply. a. "I try not to think about the night that I was raped." b. "I realize that I am hopeless about trusting others." c. "I feel comfortable hanging out with my male friends." d. "I manage the really dark days by going to a gym class." e. "All of my bruises have healed, and I can wear tank tops again."
d
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. a. The memory of the rape will be less vivid and less frightening. b. The patient is able to describe feelings of safety and relaxation. c. Symptoms of pain, discomfort, and anxiety are no longer present. d. The patient agrees to a follow-up appointment with a rape victim advocate.
acd
When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur 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
a
When the nurse finishes addressing a group of college women about rape, the following comments are heard during the discussion period. Which comment calls for additional teaching by the nurse? a. "So if you dress conservatively, your risk of being raped is small." b. "Who would have guessed that most rape victims know the rapist?" c. "It makes sense that rape is a crime of violence, not a crime of sex." d. "I always thought rapes happened at night, but now I know that isn't true."
ade
Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? (Select all that apply.) a. Coping mechanisms the patient is using b. The patient's previous sexual experiences c. The patient's history of sexually transmitted diseases d. Signs and symptoms of emotional and physical trauma e. Adequacy and availability of the patient's support system
b
Which nursing action has priority for a patient immediately following a reported rape? a. Provide written follow-up instructions. b. Document the debris and dirt on the patient's clothing. c. Give the patient alone time to recover after the incident. d. Give the patient prophylactic analgesics after the incident.
acd
Which scenarios describe completed rape? (Select all that apply.) 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 later 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. e. A perpetrator grabs a potential victim, tears off most of her clothing, and fondles her breasts before she escapes.
ade
Which statement is true regarding the nursing care of a forensic patient? Select all that apply. a. A victim of a sexual assault meets the criteria of a forensic patient. b. Nurses should pose questions asking "why" certain events occurred. c. All sexual assault victims require a complete suicide assessment interview initially. d. Asking about possible suicidal ideations may be an appropriate interview question. e. Sexual assault nurse examiners (SANE) are trained especially to meet the needs of a sexual assault victim.
