sexual assault
The nurse is providing care to a client who experienced a rape 1 year ago. Which assessment finding should the nurse expect? (Select all that apply.) A. Anxiety B. Confusion C. Sexual dysfunction D. Anger E. Eating disorders
Anxiety Sexual dysfunction D. Anger E. Eating disorders Rationale: Anger, anxiety, eating disorders, and sexual dysfunction are all long-term effects of rape. Confusion is an immediate response to rape.
The nurse is providing care to a client who is the victim of rape. Which action by the nurse offers the client emotional support during the assessment process? (Select all that apply.) A. Providing access to a rape advocate B. Calling a friend or family member C. Assuming that pregnancy prevention medication is wanted D. Inquiring about current sexually transmitted infections E. Offering counseling services
Providing access to a rape advocate B. Calling a friend or family member E. Offering counseling services Rationale: Nursing actions that provide the client with emotional support during the assessment process include offering counseling services, calling a friend or family member, and providing access to a rape advocate. Inquiring about current sexually transmitted infections and assuming that pregnancy prevention is wanted are not supportive nursing behaviors.
The nurse is caring for a victim of rape who is indecisive about taking emergency contraception. The nurse understands that emergency contraception is more likely to be successful in which time frame following the attack? A. 1 week B. 1 month C. 3 days D. 10 days
3 days Rationale: Emergency contraception is more likely to be successful within 3 days after the attack. After 3 days, emergency contraception is not effective
The nurse is preparing to provide instructions for a client who is prescribed treatment for the prevention of chlamydia following a sexual assault. Which prescription should the nurse anticipate? A. Azithromycin B. Ceftriaxone C. Penicillin D. Metronidazole
Azithromycin Rationale: Chlamydia can be treated with a single dose of azithromycin or a week of doxycycline. Penicillin is used to treat syphilis. Ceftriaxone is used for the treatment of gonorrhea. Metronidazole is used to treat trichomoniasis.
The nurse is preparing to perform a physical examination on a client who is the victim of rape. Which injury should the nurse identify as an indication of the client being restrained? (Select all that apply.) A. Bruising around the neck B. Broken fingers C. Bruising on the ankles D. Burns on the wrists E. Internal injuries
Bruising around the neck Bruising on the ankles D. Burns on the wrists Rationale: Burns on the wrists and bruising around the ankles and neck are all indications that the client was restrained. Broken fingers and internal injuries may be defensive wounds or the result of physical attack.
The nurse is caring for an older adult who was sexually assaulted by a caregiver. Which intervention should the nurse implement into the plan of care? A. Contact a family member. B. Obtain a consult for a therapist. C. Address the caregiver. D. Create a postdischarge safety plan.
Create a postdischarge safety plan. Rationale: The nurse caring for an older adult who was sexually assaulted by a caregiver will create a postdischarge safety plan. It may be unsafe for the client to return home. Addressing the caregiver is inappropriate and may result in violence. Contacting a family member is a HIPAA violation. Obtaining a consult for a therapist without discussing it with the client first is inappropriate.
The nurse is caring for a client who has been raped. Which emotions should the nurse expect the client to experience initially? (Select all that apply.) A. Disbelief B. Shock C. Denial D. Suicidal ideation E. Posttraumatic stress disorder
Disbelief B. Shock C. Denial Rationale: Immediate responses to rape generally include feelings of denial, shock, and disbelief. Suicidal ideation and posttraumatic stress disorder may appear later in rape-trauma syndrome.
The community health nurse is conducting a presentation for the prevention of rape. Which information should the nurse include? A. When going out alone carry pepper spray. B. Avoid crowded places. C. Avoid going out at night. D. Enroll in self-defense classes.
Enroll in self-defense classes. Rationale: The information the nurse will include about the prevention of rape is to enroll in self-defense classes. Self-defense classes and training aid in fighting off an individual attempting to commit a sexual assault. It is not necessary to avoid crowded places or going out at night. Knowledge and awareness, as well as traveling with another, are important in the prevention of sexual assault. It is not advised to go out alone. Pepper spray may not be immediately accessible if attacked.
The nurse is teaching colleagues about the risk factors for sexual violence. Which community risk factor should the nurse include? A. High levels of crime and other forms of violence B. Alcohol and drug abuse C. Lack of employment opportunities D. Emotionally unsupportive family
Lack of employment opportunities Rationale: Lack of employment opportunities is a community risk factor for sexual violence. Alcohol and drug abuse is a personal risk factor. An emotionally unsupportive family is a relationship factor that increases the risk of sexual violence. High levels of crime and other forms of violence are societal risk factors.
The nurse is caring for an adolescent female client who has experienced a sexual assault. Which should the nurse initially include in the client's plan of care? A. Antidepressant therapy B. Information about a support group C. Antianxiety medication D. Offering emergency contraception
Offering emergency contraception Rationale: The nurse caring for the adolescent who has experienced a sexual assault will initially offer emergency contraception. Antidepressant therapy, antianxiety medication, and information about a support group may be appropriate for this client, but offering emergency contraception is the highest priority.
The nurse is creating a plan of care for a client who is the victim of rape. Which nursing diagnosis addresses the client's psychosocial needs? (Select all that apply.) A. Pain, Acute B. Powerlessness C. Coping, Ineffective D. Self-esteem, Situational Low E. Infection, Risk for
Powerlessness C. Coping, Ineffective D. Self-esteem, Situational Low Rationale: Powerlessness, Coping, Ineffective, and Self-esteem, Situational Low are all diagnoses that address the client's psychosocial needs. Physical pain and risk for infection are biophysical diagnoses. (NANDA-I ©2014)
The emergency department nurse is preparing to discharge a client who was raped. Which client statement indicates a need for additional teaching prior to discharge? A. "I live alone and will get my locks changed before I return." B. "I have an appointment to get my stitches removed in 1 week." C. "I don't need to go to the counselor—I feel fine." D. "My mom is coming to stay with me for a few weeks."
"I don't need to go to the counselor—I feel fine." Rationale: Denial of the possibility of needing to speak with a counselor indicates the client requires additional teaching. Staying with family or friends, changing the locks, and getting follow-up care indicate that the client understands the teaching that was presented.
The nurse is caring for a client who is in the acute phase of rape-trauma syndrome. Which statement from the client reflects a clinical manifestation of the acute phase? A. "I'm ready to talk about how I'm feeling about what happened to me." B. "It's been months since I was raped, and I'm still having flashbacks." C. "I'm doing fine. There's really nothing for me to talk about." D. "I'm so angry at the person who raped me, and I doubt he's going to get charged with anything."
"I'm doing fine. There's really nothing for me to talk about." Rationale: Expressive styles of the acute phase of rape-trauma syndrome vary. Some clients openly express their feelings, while others may have an outward appearance of adjustment as indicated by the client in this scenario who states, "I'm doing fine." Anger at the assailant and the judicial system and the need to talk to resolve feelings are characteristics of the reorganization phase of rape-trauma system. Flashbacks occurring months after the event are characteristics of PTSD
The nurse is caring for a client who has been raped. Which prescribed intervention should the nurse anticipate being incorporated into the plan of care? A. Collection of specimens for legal purposes B. Pregnancy testing C. Administration of emergency contraception D. Prophylactic treatment for HIV
Collection of specimens for legal purposes Rationale: The prescribed intervention the nurse anticipates is the collection of specimens for legal purposes. The specimens collected are assigned a special rape kit number that will only be processed if the victim chooses to make a report to the police. Pregnancy testing related to the rape cannot be accurately performed until the woman has missed her first period. HIV testing is offered, but prophylactic treatment is not administered. Emergency contraception is only provided with the client's permission.
The nurse is assisting in the physical examination of a client who is the victim of rape. Which action by the nurse involves collecting evidence that can be used in a criminal case to convict the attacker? (Select all that apply.) A. Combing the pubic area for stray hairs B. Collecting semen from the vagina C. Administering a prophylactic antibiotic D. Gathering a swab from the throat E. Drawing blood for a compete blood count (CBC)
Combing the pubic area for stray hairs B. Collecting semen from the vagina Gathering a swab from the throat Rationale: Semen, a swab of the throat, and stray hairs may contain DNA that can be used to identify the attacker. A CBC is a diagnostic test; is not used to identify the attacker. Administering a prophylactic antibiotic is an action to help prevent a sexually transmitted infection
The nurse is assisting with the initial physical examination for a victim of rape. Which action should the nurse perform when assisting with the collection of evidence during the examination? (Select all that apply.) A. Drawing blood for a complete blood count B. Examining the client's vagina, anus, and throat C. Collecting skin scrapings from fingernails D. Collecting the client's clothing E. Drawing blood for an electrolyte panel
Examining the client's vagina, anus, and throat C. Collecting skin scrapings from fingernails D. Collecting the client's clothing Rationale: During the initial physical examination for a client who is the victim of a rape, the nurse assists in collecting the clothes the client was wearing when the attack occurred and skin scrapings from the fingernails, as well as examining and swabbing the vagina, anus, and throat. An electrolyte panel and CBC are diagnostic tools but are not used for collecting evidence during the initial examination.
The nurse is preparing to swab a client for a DNA analysis after a sexual assault. Which is a priority nursing action? A. Obtain cultures for sexually transmitted infections and administer emergency contraception. B. Initiate prophylactic treatment for sexually transmitted infections. C. Inquire about any consensual sexual relations over the past 5 days. D. Ensure all evidence obtained is placed in a single designated envelope.
Inquire about any consensual sexual relations over the past 5 days. Rationale: The priority nursing action when preparing to swab a client for DNA analysis after a sexual assault is to inquire about any consensual sexual relations over the past 5 days. It is important to be able to differentiate the perpetrator from a consensual partner. Cultures for sexually transmitted infections will be obtained prior to prophylactic treatment. Emergency contraception can be administered within 3 days of the attack. Each piece of evidence obtained is placed in its own special envelope with the same rape kit number.
The nurse is discussing the use of a victims' advocate with a client who has been raped. Which client statement indicates an understanding of the role of the advocate? A. "The advocate assigned to me will accompany me to the court proceedings." B. "I understand the advocate assigned to me will be able to provide legal advice." C. "I can call my advocate anytime that I feel the need to talk about what happened." D. "My advocate will help guide me through the process of prosecution."
My advocate will help guide me through the process of prosecution." Rationale: The primary purpose of a victims' advocate is to help guide the victim through the process of prosecuting the attacker. The primary purpose of the advocate is not to accompany the victim to the court proceedings, provide legal advice, or be available to speak to the victim anytime that the individual feels the need to talk about what has happened.
The nurse is preparing to speak with a client who is in the reorganization phase of rape-trauma syndrome. Which clinical manifestation should the nurse anticipate? A. Somatic reactions B. Anxiety C. An outward period of adjustment D. The need to talk to resolve feelings
The need to talk to resolve feelings Rationale: The nurse can anticipate the client in the reorganization phase of rape-trauma syndrome will express a need to talk to resolve feelings. Anxiety is a characteristic of posttraumatic stress disorder (PTSD). Somatic reactions and an outward period of adjustment are clinical manifestations of the acute phase of the rape-trauma syndrome.
The nurse is discussing protective risk factors for the perpetration of sexual violence with colleagues. Which statement by a colleague indicates an understanding of the information? A. "Optimal physical health decreases the risk for sexual violence." B. "Exposure to sexually explicit material creates an awareness of sexual perpetrators." C. "An individual's empathy and concern for others is a protective factor for perpetration." D. "Participation in community crime watch is a protective factor from sexual violence."
"An individual's empathy and concern for others is a protective factor for perpetration." Rationale: Having empathetic deficits is a characteristic of a sexual perpetrator. Therefore, an individual's empathy and concern for others is a protective factor for perpetration. Optimal physical health and participation in community crime watch are not protective factors for perpetration. Exposure to sexually explicit material is a risk factor for perpetration.