Nursing 275 Exam 4 Rape and PTSD
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.
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.
c
A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with PTSD? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis
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."
abce
A 10-year-old child was placed in a foster home after being removed from parental contact because of abuse. The child has apprehension, tremulousness, and impaired concentration. The foster parent also reports the child has an upset stomach, urinates frequently, and does not understand what has happened. What helpful measures should the nurse suggest to the foster parents? The nurse should recommend (Select all that apply) a. conveying empathy and acknowledging the child's distress. b. explaining and reinforcing reality to avoid distortions. c. using a calm manner and low, comforting voice. d. avoiding repetition in what is said to the child. e. staying with the child until the anxiety decreases. f. minimizing opportunities for exercise and play.
d
A 35-year-old army combat veteran is being treated for migraines and hypertension. The nurse is particularly interested in the individual's response to which mental health-focused question? a. "Are you worried about anything in particular? b. "Is there any history of suicide in your family?" c. "Have you ever experienced a hallucination?" d. "How would you describe posttraumatic stress disorder?"
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.
a
A nurse conducts an initial interview with a veteran of two tours in the war with Iraq. The veteran says, "The war was years ago, but I still remember my friends who were killed. I don't know why I lived and they died." What is the nurse's priority response? a. "Are you having any thoughts of harming yourself?" b. "It's important to think about how good your life is now." c. "Are you saying you have some guilt about being a survivor?" d. "The outcomes of war are tragic and stay with us for many years."
bce
A nurse has been caring for a patient with posttraumatic stress disorder. Which patient behaviors indicate an improved ability to cope? Select all that apply. a. The patient has improved eye contact. b. The patient asks for help when required. c. The patient has fewer physical complaints. d. The patient shows improved grooming skills. e. The patient tries to find information about treatment.
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
ace
A nurse is assessing a child who has witnessed violence at home. What should the nurse document when completing an admission genogram of the child? Select all that apply. a. Relationships b. Investigations c. Family history d. Laboratory testing e. Family composition
abdc
A nurse is caring for a child who needs treatment for mental trauma. Place the stages of the staged treatment protocol in the correct order. a. Provide safety. b. Reduce arousal. c. Nurture self-awareness. d. Teach coping skills.
b
A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care? a. Trigger flashbacks intentionally in order to help the patient learn to cope with them. b. Explain that the physical symptoms are related to the psychological state. c. Encourage repression of memories associated with the traumatic event. d. Support "numbing" as a temporary way to manage intolerable feelings.
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 patient who is a victim of sexual assault has insomnia, reduced concentration, anxiety, and recurring thoughts of the event. Which medication does the nurse anticipate being prescribed for the patient? a. Clonidine b. Citalopram c. Propranolol d. Desipramine
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 soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with PTSD is the soldier describing? a. Reexperiencing b. Hyperarousal c. Avoidance d. Psychosis
d
A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which social event would be most disturbing for this soldier? a. Halloween festival with neighborhood children b. Singing carols around a Christmas tree c. A family outing to the seashore d. Fireworks display on July 4th
b
A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described? a. Illusion b. Flashback c. Nightmare d. Auditory hallucination
d
A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family, but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response. a. "Posttraumatic stress disorder (PTSD) often changes a person's sexual functioning." b. "I encourage you to continue to participate in social activities where children are present." c. "Have you talked with your spouse about these reactions? Sometimes we just need to confront behavior." d. "Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."
c
A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with PTSD. The nurse's highest priority is to screen this soldier for a. bipolar disorder. b. schizophrenia. c. depression. d. dementia.
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
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
abd
A young adult says, "I was sexually abused by my older brother. During those assaults, I went somewhere else in my mind. I don't remember the details. Now, I often feel numb or unreal in romantic relationships, so I just avoid them." Which disorders should the nurse suspect based on this history? (Select all that apply.) a. Acute stress disorder b. Depersonalization disorder c. Generalized anxiety disorder d. PTSD e. Reactive attachment disorder f. Disinhibited social engagement disorder
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
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.
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.
a
Relaxation techniques help patients who have experienced major traumas because they a. engage the parasympathetic nervous system. b. increase sympathetic stimulation. c. increase the metabolic rate. d. release hormones.
An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists?
Situational (Adventitious) Situation crisis arises from events that are extraordinary, external rather than internal and often unanticipated. An adventitious crisis is a crisis of disaster that is not a part of everyday life. It is unplanned or accidental. Adventitious crises include natural disasters, national disasters, and crimes of violence. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. Situational crisis arises from an external source such as a job loss, divorce, or other loss affecting self-concept or self-esteem. "Organic" is not a type of crisis.
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."
abcef
The nurse interviewing a patient with suspected PTSD should be alert to findings indicating the patient (Select all that apply) a. avoids people and places that arouse painful memories. b. experiences flashbacks or re-experiences the trauma. c. experiences symptoms suggestive of a heart attack. d. feels compelled to repeat selected ritualistic behaviors. e. demonstrates hypervigilance or distrusts others. f. feels detached, estranged, or empty inside.
bdef
The nurse is assessing a young child for posttraumatic stress disorder (PTSD). What does the nurse include in the assessment? Select all that apply. a. Bowel habits b. Motor function c. Blood pressure d. Speech patterns e. General appearance f. Characteristics of play
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.
b
Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse's immediate attention? a. "It's good to be home. I missed my home, family, and friends." b. "I saw my best friend get killed by a roadside bomb. I don't understand why it wasn't me." c. "Sometimes I think I hear bombs exploding, but it's just the noise of traffic in my hometown." d. "I want to continue my education, but I'm not sure how I will fit in with other college students."
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
c
When caring for a child with posttraumatic stress disorder, which intervention should the nurse include in the patient plan of care? a. Provide changeable environment. b. Help patient learn positive avoidance. c. Reduce stimulation of traumatic memories. d. Promote arousal to build tolerance to stress.
a
When discussing the symptoms of posttraumatic stress disorder (PTSD), the nurse correctly states: a. "The symptoms can occur almost immediately or can take years to manifest." b. "PTSD causes agitation and hypervigilance, but rarely chronic depression." c. "PTSD is an emotional response that does not cause significant changes in brain chemistry." d. "When experiencing a flashback, the patient generally experiences a slowing of responses."
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
bcd
Which behavior would support a diagnosis of posttraumatic stress disorder (PTSD) in a preschool child? Select all that apply. a. Engages in specific, ritual behaviors b. Frequent displays of irritability and negativity c. Reluctant to engage in previously enjoyed activities d. Expresses concern that "something bad is going to happen" e. Shares that he or she "hears voices when there is no one there"
bcde
Which child should be assessed for possible posttraumatic stress disorder (PTSD) as a result of exposure to major trauma in his or her life? Select all that apply. a. A 3-year-old whose older sibling was born with both physical and cognitive impairments. b. A 4-year-old who was hospitalized for two months after being injured in an automobile accident. c. An 8-year-old child who has a medical history that includes several broken bones and a dislocated shoulder. d. A 5-year-old child who lives with grandparents since his or her single parent was deployed by the military 10 months ago. e. A 12-year-old who has been in cancer remission for three years since finishing both chemotherapy and radiation treatments.
cde
Which experiences are most likely to precipitate PTSD? (Select all that apply). a. A young adult bungee jumped from a bridge with a best friend. b. An 8-year-old child watched an R-rated movie with both parents. c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator. d. A passenger was in a bus that overturned on a sharp curve and tumbled down an embankment. e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks
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.
