Chapter 22 - Sexual Violence

19. An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on: a. maintaining the airway. b. preserving rape evidence. c. obtaining a description of the rape. d. determining what drug was ingested.

ANS: A Because the patient is unconscious, the risk for airway obstruction is present. The incorrect options are of lower priority than preserving physiologic functioning.

5. A child was abducted and raped. In the emergency department, this victim is confused and crying. Which personal reaction by the nurse could interfere with this victim's care? a. Anger b. Concern c. Empathy d. Compassion

ANS: A Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

8. A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."

ANS: C A reflective communication technique is helpful. Looking at one's role in the event serves to explain events that the victim would otherwise find incomprehensible. The incorrect options discount the victim's perceived role and interfere with further discussion.

6. Which assessment has priority when a nurse interviews a rape victim in the emergency department? a. Coping mechanisms the patient is using b. Patient's previous sexual experience c. Adequacy of interpersonal relationships d. Patient's history of sexually transmitted diseases

ANS: A Of the options listed, the priority assessment is the victim's coping mechanisms. The other options have little relevance.

3. A patient was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the patient is in the acute phase of rape trauma syndrome? a. Confusion and disbelief b. Decreased motor activity c. Flashbacks and dreams d. Fears and phobias

ANS: A Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase.

20. A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the patient says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response. a. "Are you thinking of suicide?" b. "It will take time, but you will feel the same as before." c. "Your friends will understand when you tell them." d. "You will be able to find meaning in this experience as time goes on."

ANS: A The patient's words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the patient. The other options attempt to offer reassurance before making an assessment.

1. A woman was grabbed by an attacker as she walked home from work. The attacker put a gun to her head, taped her mouth, tied her hands, took her to a remote location, and raped her. Which aspect of this crisis produced the greatest amount of psychologic trauma? a. Threat to her life b. Memory of the event c. Being in a remote location d. Physical pain experienced

ANS: A The psychologic trauma associated with rape is produced by a number of factors. Of the options given, the threat to life is by far the most traumatic aspect of the crisis. The other options may, however, add significantly to the trauma.

16. A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome? a. Acute phase b. Outward adjustment phase c. Long-term reorganization phase d. Anger phase

ANS: A The victim's response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term, or anger phase.

10. The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention? a. Use accepting, nurturing, and empathetic communication techniques. b. Educate the victim about strategies to avoid attacks in the future. c. Discourage the expression of feelings until the victim stabilizes. d. Maintain a matter-of-fact manner and objectivity.

ANS: A Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victim's needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust.

2. A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply. a. Allow the patient to talk at a comfortable pace. b. Pose questions in nonjudgmental, empathic ways. c. Place the patient in a private room with a caregiver. d. Reassure the patient that a family member will arrive as soon as possible. e. Invite family members to the examination room and involve them in taking the history. f. Put an arm around the patient to offer reassurance that the nurse is caring and compassionate.

ANS: A, B, C Neutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patient's privacy may be compromised by the presence of family. The rape victim's anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse.

1. When an emergency department nurse teaches a victim of the rape trauma syndrome about reactions that may occur during the long-term reorganization 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

ANS: A, C, D 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 are not expected.

18. A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should: a. tell the patient, "You may not leave until you receive prophylactic treatment for sexually transmitted diseases." b. provide written information concerning the physical and emotional reactions that may be experienced. c. explain the need and importance of human immunodeficiency virus (HIV) testing. d. offer verbal information about legal resources.

ANS: B 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 at later times. Patients cannot be kept against their will or coerced into receiving medication as a condition of being allowed to leave. This constitutes false imprisonment.

15. When a victim of sexual assault is discharged from the emergency department, the nurse should: a. arrange support from the victim's family. b. provide referral information verbally and in writing. c. advise the victim to try not to think about the assault. d. offer to stay with the victim until stability is regained.

ANS: B Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The incorrect options violate the patient's right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

13. A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should: a. arrange for the patient to shower. b. explain that washing would destroy evidence. c. give the patient a basin of hot water and towels. d. instruct the victim to wash above the waist only.

ANS: B No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue.

14. Which situation constitutes consensual sex rather than rape? a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects. b. A person's lover pleads to have oral sex. The person gives in but then regrets the decision. c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant. d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.

ANS: B Only the correct answer describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are, at least, the age of majority.

17. A patient in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates the patient has made improvement? The patient: a. temporarily withdraws from social situations. b. plans coping strategies for fearful situations. c. uses increased activity to reduce fear. d. expresses a desire to be with others.

ANS: B The correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.

4. After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply. a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

ANS: B, C, F The nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. "Reported" should be used instead of "alleged." "Penetration" should be used instead of "intercourse." "Declined" should be used instead of "refused."

3. Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply. a. Requiring HIV testing of a victim b. Collecting and preserving evidence c. Providing long-term counseling for rape victims d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis

ANS: B, D, E HIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within this practice role.

22. When working with rape victims, immediate care focuses first on: a. collecting evidence. b. notifying law enforcement. c. helping the victim feel safe. d. documenting the victim's comments.

ANS: C The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might refuse to have evidence collected or to involve law enforcement.

12. A nurse working a rape telephone hotline should focus communication to: a. arrange long-term patient counseling. b. provide callers with a sympathetic listener. c. explain immediate steps that a victim of rape should take. d. obtain information to relay to the local police.

ANS: C 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. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

9. The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge? a. Patient states, "I feel safe and entirely relaxed." b. Memory of the rape is less vivid and frightening. c. Physical symptoms of pain and discomfort are no longer present. d. Patient agrees to keep a follow-up appointment with the rape victim advocate.

ANS: D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

7. A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame.

ANS: D Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident.

2. A person was abducted and raped at gunpoint. The nurse observes this victim is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the patient's level of anxiety? a. Weak b. Mild c. Moderate d. Severe

ANS: D Anxiety is the result of a personal threat to the victim's safety and security. In this case, the patient's symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. "Weak" is not a level of anxiety. Mild and moderate levels of anxiety allow the patient to function at a higher level.

21. A nurse cares for a rape victim who received flunitrazepam (Rohypnol) from the assailant. Which intervention has priority? Monitoring for: a. coma. b. seizures. c. hypotonia. d. respiratory depression.

ANS: D Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma in this situation.

11. What is the primary motivator for most rapists? a. Anxiety b. Need for humiliation c. Overwhelming sexual desires d. Desire to humiliate or control others

ANS: D Rape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

4. A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial

ANS: D The patient's statements reflect the use of the ego defense mechanism denial. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patient's statements do not reflect somatic symptoms, repression, or projection.