MH: EAQ: 29

Which comment by a patient who was raped 1 year ago indicates a successful resolution of this traumatic event? "Sometimes I wonder if I secretly wanted to be raped." "Now I realize what I did that caused this assault to happen." "I'm emotionally stable, but now I have frequent headaches and stomach pain." "Although I have a nightmare once in a while, most of the time I sleep soundly."

"Although I have a nightmare once in a while, most of the time I sleep soundly."

Which statement made by the patient of sexual assault indicates recovery? Select all that apply. One, some, or all responses may be correct. "I try not to think about the night that I was raped." "I realize that I am hopeless about trusting others." "I feel comfortable hanging out with my male friends." "I manage the really dark days by going to a gym class." "All of my bruises have healed, and I can wear tank tops again."

"I feel comfortable hanging out with my male friends." "I manage the really dark days by going to a gym class." "All of my bruises have healed, and I can wear tank tops again."

Which statement made by the patient with posttraumatic stress disorder (PTSD) related to sexual assault makes the nurse suspect the patient is experiencing dissociation? "I feel like everything in my life is a dream." "Sometimes I have a hard time making decisions." "I am starting to not like foods that I used to crave." "I would rather be alone than see any of my friends."

"I feel like everything in my life is a dream."

Which statement made by a patient who was raped a year ago and diagnosed with acute stress disorder indicates a sign of recovery? Select all that apply. One, some, or all responses may be correct. "I'm sleeping about 6 straight hours each night." "My best friend takes me out for coffee twice a week." "I really enjoy cooking and having dinner parties with my friends." "I realize now that I'm the one who needed to learn a hard lesson." "I eat several snacks throughout the day since I'm never very hungry."

"I'm sleeping about 6 straight hours each night." "My best friend takes me out for coffee twice a week." "I really enjoy cooking and having dinner parties with my friends."

Which statement regarding the psychological effects of the assault is appropriate when providing discharge teaching to a patient who was raped? "You may feel hyperactive and notice an increased surge of energy." "It is normal to experience depression after being sexually assaulted." "People often report the need to be social after a sexual assault incident." "Let the healthcare provider know immediately if you feel scared or worried."

"It is normal to experience depression after being sexually assaulted."

Which statement made by an adolescent indicates further teaching about ways to prevent rape must occur? "Women do not want to be raped." "Rape can occur in the home." "Rape is not always done for the purpose of sex." "It isn't rape if the participants are in a relationship."

"It isn't rape if the participants are in a relationship."

Which statement is true regarding the nursing care of a forensic patient? Select all that apply. One, some, or all responses may be correct. A victim of a sexual assault meets the criteria of a forensic patient. Nurses should ask "why" certain events occurred. All sexual assault victims require a complete suicide assessment interview initially. Asking about possible suicidal ideations may be an appropriate interview question. Sexual assault nurse examiners (SANE) are trained especially to meet the needs of a sexual assault victim.

A victim of a sexual assault meets the criteria of a forensic patient. Asking about possible suicidal ideations may be an appropriate interview question. Sexual assault nurse examiners (SANE) are trained especially to meet the needs of a sexual assault victim.

Which assessment is immediately completed when a patient is reported to have been "roofied"? Pulse Vision Airway Reflexes

Airway

Which sign or symptom is found in the victim diagnosed with rapetrauma syndrome? Select all that apply. One, some, or all responses may be correct. Anxiety Aggression Nightmares Low alertness Relaxed muscles

Anxiety Aggression Nightmares

Which measure would the nurse take while assessing a rape victim? Select all that apply. One, some, or all responses may be correct. Make use of "why" questions. Ask questions using descriptive terms. Ask questions in a nonjudgmental tone. Ask the patient to talk at a comfortable pace. Ask the patient to explain the assault in detail.

Ask questions using descriptive terms. Ask questions in a nonjudgmental tone. Ask the patient to talk at a comfortable pace.

Which category defines rape? Select all that apply. One, some, or all responses may be correct. Targeted Attempted Intentional Completed Unintentional

Attempted Completed

Which appropriate action would the nurse take while performing the physical examination of the child who has been sexually assaulted? Select all that apply. One, some, or all responses may be correct. Avoid palpating the patient's body. Avoid asking the patient about the injuries. Document the injuries in narrative form only. Collect and preserves hair samples and oral swabs. Instruct the patient to inform if there is pain or discomfort.

Collect and preserves hair samples and oral swabs. Instruct the patient to inform if there is pain or discomfort.

Which nursing action has priority for a patient immediately after a reported rape? Provide written follow-up instructions. Document the debris and dirt on the patient's clothing. Give the patient alone time to recover after the incident. Give the patient prophylactic analgesics after the incident.

Document the debris and dirt on the patient's clothing.

Which action does the nurse take when assessing emotional trauma in a patient that was sexually assaulted? Select all that apply. One, some, or all responses may be correct. Encourages the patient to talk at a comfortable pace Asks the patient, "Are you having any suicidal intentions?" Says to the patient, "It is very painful to be in a situation like this." Asks the family about the patient's behavior before the incident Says to the patient, "Are you considering yourself responsible for this?"

Encourages the patient to talk at a comfortable pace Asks the patient, "Are you having any suicidal intentions?"

Which indicator of sexual abuse relates to recovery in a patient? Select all that apply. One, some, or all responses may be correct. Expressions of hope Feelings of revenge Feelings of empowerment Healing of physical injuries Evidence of comfort in relationships

Expressions of hope Feelings of empowerment Healing of physical injuries Evidence of comfort in relationships

Which finding would indicate that a patient who is a victim of incest may be experiencing avoidance? Feelings of guilt Frightening thoughts Difficulty completing daily tasks A decreased ability to feel happiness

Feelings of guilt

Which information would the nurse include when teaching about sexual assault? Rape is a sexual act. Only females are raped. Most rapes are impulsive. Fifty percent of all rapes occur in the home.

Fifty percent of all rapes occur in the home.

The nurse is assessing a patient with bipolar mood disorder. The patient cries out loudly and tells the nurse, "My husband is hurting me. Please save me from him. " After assessing the patient, the nurse tells the patient, "I believe you. I am here to help you. " Which reason explains the nurse's response? To calm the patient down Wants the patient to express feelings Finds physical signs indicating sexual assault Finds signs of altered perception in the patient

Finds physical signs indicating sexual assault

Which action applies to the emergency contraceptive pill? Inhibits the process of ovulation Prevents the development of a fertilized ovum Inhibits the entry of sperm into the uterine cavity Inactivates the sperm before it reaches the fallopian tube

Inhibits the process of ovulation

Which long-term outcome is appropriate for a rape victim? Repress feelings of shame, embarrassment, and self-blame. Blame the rapist rather than blame themself for the situation. Integrate the rape event and resume an optimal level of functioning. Identify and develop coping skills necessary to reduce level of anxiety

Integrate the rape event and resume an optimal level of functioning.

Which information would the nurse include when teaching a rape victim about a common survivor problem that often develops with acute stress disorder? Intrusive thoughts Denial of the event Shock and numbness Headaches and fatigue

Intrusive thoughts

A rape victim has been admitted in the hospital. On acquiring the history from the law enforcement officials, the nurse finds that the patient was drugged before the rape. During the examination, the nurse finds that the patient is in a dreamlike state and is not responding to painful stimuli. Which drug should the nurse suspect to have been used to drug the patient? Ketamine Alprazolam Flunitrazepam γ-Hydroxybutyric acid (GHB)

Ketamine

Which drug that is associated with date rape has the shortest duration? Ketamine Clonazepam Flunitrazepam γ-Hydroxybutyric acid (GHB)

Ketamine

Which assessment information is included when performing a general assessment on a patient who was sexually assaulted? Select all that apply. One, some, or all responses may be correct. Level of anxiety Coping mechanisms History of sexual partners Available support systems List of current prescriptions

Level of anxiety Coping mechanisms Available support systems

Which information is considered a part of the general nursing assessment of a victim who has experienced a physical assault? Select all that apply. One, some, or all responses may be correct. Level of anxiety Coping mechanisms Indications of physical trauma Indications of emotional trauma The value of existing physical evidence

Level of anxiety Coping mechanisms Indications of physical trauma Indications of emotional trauma

Three weeks after being raped by a man, a college-age woman says to the nurse, "My roommate says the rape was my fault. She says I could have gotten away if I had tried." Which information would the nurse consider when responding to this comment? Select all that apply. One, some, or all responses may be correct. Most men can overpower most women because of differences in body build. This rape victim is expressing remorse regarding her failure to fight the rapist. Victims of rape often panic, resulting in decisions and actions that are ineffective. This rape victim is likely to have made a false report of a rape in an attempt to gain attention. This rape victim is healthy. If she had resisted vigorously, she could have escaped the unarmed adult male rapist.

Most men can overpower most women because of differences in body build. Victims of rape often panic, resulting in decisions and actions that are ineffective.

Which statement reflects a truth about rape? Most rapes are planned. Some women want to be raped. Most charges of rape are unfounded. Most women are raped by strangers.

Most rapes are planned.

Which statement is a myth concerning sexual assaults? Select all that apply. One, some, or all responses may be correct. Most rapes occur in the home. Most women are raped by strangers. Most rapes occur for the purpose of sex. Sexual assaults are generally impulsive, unplanned acts. Fighting back will only result in additional physical injuries.

Most women are raped by strangers. Most rapes occur for the purpose of sex. Sexual assaults are generally impulsive, unplanned acts. Fighting back will only result in additional physical injuries.

A nurse is performing an assessment of a patient who was sexually assaulted. The patient reports being unconscious 10 minutes after having a cool drink. The nurse anticipates that the patient was given flunitrazepam with the drink. Which symptom does the nurse find in the patient? Anxiety Tremors Tachycardia Muscle relaxation

Muscle relaxation

Which statement accurately describes the epidemiology of rape? Men are less likely to be raped by another man. More than 25% of women in the United States have been raped. Nearly half of female survivors have been raped by an acquaintance. Men are raped more often than women, but incidents are underreported.

Nearly half of female survivors have been raped by an acquaintance.

Which statement is currently true regarding the existence of sexual assault in the United States? Select all that apply. One, some, or all responses may be correct. Nearly one in five women has been raped within her lifetime. Nearly a third of male victims were raped by intimate partners. The male is likely to have been victimized by several assailants. Rape statistics show little variance when race and ethnicity are considered. The first rape experience in female victims happens before the age of 25 the majority of the time.

Nearly one in five women has been raped within her lifetime. Nearly a third of male victims were raped by intimate partners. The male is likely to have been victimized by several assailants. The first rape experience in female victims happens before the age of 25 the majority of the time.

Which sample must be collected as legal evidence for sexual assault? Select all that apply. One, some, or all responses may be correct. Oral swabs Urine sample Blood sample Vaginal swabs Facial skin scrapings

Oral swabs Blood sample Vaginal swabs

Which description defines completed rape? Sexual desire satisfied inappropriately An act prompted by early childhood neglect Penetration without the consent of the victim Assault by a stranger on an unsuspecting victim

Penetration without the consent of the victim

Which role of the advanced practice nurse assists in the management of a rape victim? Provide legal consultation. Be an expert witness in court. Conduct the medical evaluation. Provide individual psychotherapy.

Provide individual psychotherapy.

Which nursing intervention helps reduce severe anxiety in a patient who has been physically abused? Conducting a head-to-toe physical assessment Providing compassionate support for the patient Asking the patient to verbalize their thoughts Asking the patient's relatives for details regarding the assault

Providing compassionate support for the patient

Which statement about rape is accurate? Select all that apply. One, some, or all responses may be correct. Women usually are raped by a stranger. Rape is an expression of aggression and anger. Women do not "ask" to be raped by their behavior or dress. Rape is usually an impulsive, spur-of-the-moment decision by the rapist. Most rapes occur away from home areas such as alleys and behind buildings. Male victims are more likely to experience physical trauma and to have been victimized by several assailants.

Rape is an expression of aggression and anger. Women do not "ask" to be raped by their behavior or dress. Male victims are more likely to experience physical trauma and to have been victimized by several assailants.

The nurse is teaching a group of adolescents about sexual violence. During the discussion, an adolescent states, "My parents tell me to avoid going out with my friends. They ask me to come home directly after school. When I ask the reason, they say that they fear that someone would hurt me." Which myth related to rape do the parents believe according to the adolescent's statement? Only females are raped. Rape is usually an impulsive act. Rapes usually occur in dark alleys. Many women really want to be raped.

Rapes usually occur in dark alleys.

Which nursing intervention helps avoid rape-trauma syndrome in the patient who was sexually assaulted? Select all that apply. One, some, or all responses may be correct. Administer contraceptive pills to the patient. Refer the patient to a rape advocacy program. Arrange for a person to stay with the patient. Leave the patient alone at the patient's request. Educate the patient about human immunodeficiency virus (HIV) testing.

Refer the patient to a rape advocacy program. Arrange for a person to stay with the patient. Educate the patient about human immunodeficiency virus (HIV) testing.

Which assessment finding would the nurse expect in a patient who needs further treatment for posttraumatic stress disorder (PTSD)? Restlessness Mild fearfulness Fewer episodic nightmares Mild instances of somatic reactions

Restlessness

The nurse is explaining the forensic examination 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 term best describes this feeling? Revictimization Acute stress disorder Sexual abuse trauma Posttraumatic stress disorder (PTSD)

Revictimization

Which intervention is appropriate when caring for a sexual assault victim who is being examined initially? Select all that apply. One, some, or all responses may be correct. Secure samples for legal evidence. Leave the patient alone until family members arrive. Provide detailed explanations concerning the procedures. Obtain consent for the rape protocol to be implemented. Perform a physical assessment to identify bruises and lacerations.

Secure samples for legal evidence. Provide detailed explanations concerning the procedures. Obtain consent for the rape protocol to be implemented. Perform a physical assessment to identify bruises and lacerations.

Which psychological effect might be observed in a patient that is frequently raped by her husband? Fear Anxiety Aggression Sexual distress

Sexual distress

Which development related to the common sequelae of acquaintance rape would the nurse realize when providing discharge treatment and support to a victim? An eating disorder A paranoid psychosis Anxiety and fear of men Symptoms of sexual distress

Symptoms of sexual distress

Which action made by the student nurse assisting with the discharge of a patient who was raped requires the nurse to intervene? Select all that apply. One, some, or all responses may be correct. Asking the patient if a support person is available to help them in times of distress or anxiety Printing a variety of resource materials for the patient to take home and read when anxiety has subsided Telling the patient to call the hospital in a few days to receive a list of support groups in the community Verbally telling the patient about legal matters, online resources, and potential physical concerns that the patient will experience Calling the patient's primary care provider to inform them about the discharge date and helping to schedule a follow-up appointment for the patient

Telling the patient to call the hospital in a few days to receive a list of support groups in the community Verbally telling the patient about legal matters, online resources, and potential physical concerns that the patient will experience

Which information regarding statistics about sexual violence in the United States is accurate? They are unreliable because rape is underreported. More men than women are victimized by rape. White women are the most common racial group victimized by rape. Male rape victims experience more psychological trauma than physical trauma.

They are unreliable because rape is underreported.

Which term identifies a patient of sexual assault in the legal system? Victim Client Patient Survivor

Victim

Which method of giving follow-up instructions is most appropriate for a victim of rape discharged home after initial treatment? Oral instructions Written instructions Instruction to friends Instruction to the family

Written instructions

The nurse finds that the patient who was sexually abused has reduced blood pressure, hypothermia, and respiratory depression. Which "date rape " drug would the nurse expect to find in the patient' s blood sample report? Black hole Flunitrazepam Forget me pills γ-Hydroxybutyric acid (GHB)

γ-Hydroxybutyric acid (GHB)

Which common drug is illegally used for victims of date rape and also used to treat narcolepsy? Ketamine Clonazepam Flunitrazepam γ-Hydroxybutyric acid (GHB)

γ-Hydroxybutyric acid (GHB)