Psych Ch. 29

Which statement indicates that a victim of a sexual assault is showing signs of recovery? Select all that apply.

"I'm getting 6 to 8 hours of uninterrupted sleep most nights." "My parents and friends have been very supportive through it all." "I'm looking forward to going back to school right after spring break." Sexual assault survivors are considered to be in recovery if they are relatively free of any signs or symptoms of acute stress disorder and posttraumatic stress disorder (PTSD). Signs of recovery include sleeping well with few instances of episodic nightmares or broken sleep, getting support from family and friends, returning to prerape sexual functioning, and returning to interests such as work and school. The remaining options infer that calmness and interest in hobbies have yet to return.

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?

"So if you dress conservatively, your risk of being raped is small."

Three weeks after a patient was raped she tells the nurse, "I am going crazy. I have nightmares and wake up screaming. Then during the day all sorts of thoughts about the rape intrude into whatever I am concentrating on. I can't get anything done at work." The nurse should reply

"These are normal responses to stress and will decrease with time and therapy."

The nurse is assessing an adolescent patient who has been raped by a stranger. What question should the nurse ask the patient to assess the likelihood of pregnancy?

"What is the date of your last menstrual period?"

The nurse assesses a victim of incest who is receiving psychiatric therapy. Which finding could indicate that the patient may be experiencing avoidance?

Feelings of guilt The patient experiences guilt and depression and exhibits avoidance. This is demonstrated when the patient avoids going to certain places that will remind him or her about the traumatic event. Recurring frightening thoughts related to the abuse indicate that the patient is reexperiencing. Hyperarousal is suspected when the patient has difficulty in completing daily tasks. In the avoidance phase of posttraumatic stress disorder (PTSD), some patients have a decreased ability to experience emotions such as happiness.

Which statement is a myth concerning sexual assaults? Select all that apply.

Most women are raped by strangers. The woman's home is the location of most rapes. Sexual assaults are generally impulsive, unplanned acts. Fighting back will only result in additional physical injuries. The majority (69%) of rape victims are raped by someone they know. Sex is used as an instrument of violence in rape. Rape is an act of aggression, anger, or power. Most rapes are planned; over 50% involve a weapon. There are no verifiable data to substantiate the theory that a victim will be injured if he or she tries to get away. Over 50% of all rapes occur in the home. (some answers here are wrong btw.... home should not be selected, hypersexual SHOULD be selected....but it is not)

What interventions should be included during a rape examination? Select all that apply.

Palpating for signs of invisible injury Recording injuries in written and photographic form Conducting a superficial genital examination and speculum exam

Which nursing intervention helps reduce severe anxiety in a patient who has been physically abused?

Providing compassionate support for the patient

A victim of rape who is unconscious has been admitted to the hospital. The blood tests revealed that the patient has consumed a high dose of Gamma-hydroxy-butyric acid (GHB). What should the nurse anticipate in this situation? Select all that apply.

The patient will undergo endotracheal intubation. The patient will be given a benzodiazepine injection. The complications related to GHB overdose include severe respiratory distress, bradycardia, and seizures. Immediate endotracheal intubation would be required since the patient is in severe respiratory distress. Benzodiazepines should be given to the patient for controlling seizures. Tracheostomy is done in cases of upper airway obstruction where endotracheal intubation cannot be done for the patient. Upper airway obstruction is not associated with GHB overdose. Therefore, the patient need not undergo tracheostomy. The patient has bradycardia; therefore administering β-blocker drug is not desirable as it would further reduce the heart rate. The patient should be administered an anticholinergic drug such as atropine to increase the heart rate. GHB overdose does not cause hypovolemic shock; therefore the patient does not need fluid resuscitation.

A patient who was raped one year ago talks with the nurse. Which comment by the patient indicates a successful resolution of this traumatic event?

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

It has been six months since a patient who was raped began counseling. Which statement by the patient would indicate that an important outcome has been met?

"I am not going to let that rapist be in control of my life. I know things will keep getting better."

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?

"I have seen rape victims from 6 months to 90 years old."

Which interview question will support the possible ingestion of the date rape drug flunitrazepam (Rohypnol)? Select all that apply.

"Is it possible something was added to your drink?" "How much, if any, alcohol did you have to drink?"

A nurse is caring for a patient who was sexually assaulted at a party. The nurse teaches cognitive coping skills to the patient. Which response by the patient indicates effective teaching by the nurse?

"It is now my turn to support my parents and take care of them."

A nurse is teaching a group of nursing students about emergency nursing interventions for sexual assault victims. Which statement made by the student indicates effective learning? Select all that apply.

"The emergency nurse should identify and assess the victims of sexual assault." "It is mandatory to have a sexual assault nurse examiner in the hospital." "A specially trained advocate must be present while assessing the victim of sexual assault."

A sexual assault victim tells the nurse, "I should have tried to fight him off! But I was so terrified that I could not move. I should have tried harder." A supportive response for the nurse to make would be

"The way you behaved was the right thing to do at the time."

Which statement is true regarding the nursing care of a forensic patient? Select all that apply.

A victim of a sexual assault meets the criteria of a forensic patient. Nurses interface with assault victims most frequently soon after the rape occurs. Sexual assault nurse examiners (SANE) are trained especially to meet the needs of a sexual assault victim. Asking about possible suicidal ideations may be an appropriate interview question.

A rape victim experiences vivid dreams, flashbacks, and recurring images of the incident since it occurred three weeks ago. What is the possible nursing diagnosis of the rape victim?

Acute stress disorder

A victim of date rape is hospitalized with agitation, bradycardia, and hypothermia. Laboratory reports reveal γ-hydroxy-butyric acid (GHB) in the patient's blood. Which nursing intervention helps manage bradycardia?

Administering atropine to the patient

What measures should the nurse take while assessing a rape victim? Select all that apply.

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

Which nursing intervention is most appropriate during the follow-up visit of a rape survivor after discharge from the hospital?

Assessing for pregnancy

Which nursing intervention is consistent with the protocol for a sexual assault medical examination? Select all that apply.

Assessing the patient's current emotional status. Collecting and preserving any existing physical evidence. Performing a complete examination to identify physical trauma. Conducting an initial assessment interview concerning the assault.

Which clinical behavior demonstrates a main category of posttraumatic stress disorder (PTSD) symptoms? Select all that apply.

Difficulty keeping full-time employment because of frequent reliving of combat trauma. Inability to cross bridges, especially those that span water since being involved in an automobile accident. Hypervigilance makes it very traumatic to be in noisy, crowded environments since being abducted from a large, busy mall.

The nurse responding to the hotline call of a rape victim advises her to go to the nearest emergency department for treatment. When the woman states, "I'll think it over while I take a shower," the nurse

Explains that doing so could destroy evidence

Which findings in a patient who was raped six weeks ago at a local shopping mall parking lot indicate the patient is now in the long-term phase of rape-trauma syndrome? Select all that apply.

Fear of parking lots Frequent nightmares Common reactions experienced by people in long-term reorganization phase include phobias, flashbacks, insomnia, and increased motor activity. Fear of parking lots is a form of a phobia. Nightmares interrupt sleep. Lethargy shows decreased motor activity and suggests depression. Numbness, shock, and disbelief are findings in the acute phase.

A nurse is teaching a group of nursing students about sexual assault. Which information should the nurse include in the teaching?

Fifty percent of all rapes occur in the home.

Which is a common drug that is illegally used for victims of date rape and also used to treat narcolepsy?

Gamma-hydroxy-butyric acid (GHB)

A patient who is a rape victim has severe anxiety. The nurse teaches few relaxation techniques to the patient. What is the purpose for this intervention in this patient?

To facilitate problem-solving

Twelve months after an unreported rape by a stranger, a patient says, "I don't have any energy." The nurse notes the patient has jaundiced sclera and has lost eight pounds since the assault. The nurse should refer the patient for further evaluation related to possible development of:

Hepatitis

Arrange the steps of the medical exam of a rape victim based on the National Protocol for Sexual Assault Medical/Forensic Examination.

Information from the patient Examination Documentation of biological and physical findings Collection of evidence Following up for additional evidence

Which drug associated with date rape has the shortest duration?

Ketamine (Ketalar) The duration of ketamine is only 30 to 60 minutes. The duration of clonazepam, flunitrazepam, and GHB is up to 12 hours.

Three weeks after being raped by an adult male, a petite college female says to the nurse, "My roommate says the rape was my fault. She says I could have gotten away if I had tried." What information will the nurse consider when responding to this comment? Select all that apply.

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.

Which sample must be collected as legal evidence for sexual assault? Select all that apply.

Oral swabs Vaginal swabs Blood sample While collecting evidence for sexual assault, the nurse should collect samples such as oral swabs, vaginal swabs, and blood samples. These samples provide information on whether a sexual assault has taken place and also about the perpetrator. The urine sample and the skin scrapings are not used as evidence in cases of sexual violence. These samples are of no use to provide information about the incident of sexual assault and about the perpetrator.

Which factors have resulted in the reduction of the incidence of sexual violence in the United States? Select all that apply.

Policies supporting longer prison term for perpetrators Increased willingness by victims to report sexual violence

Care planning for the rape victim is facilitated if the nurse understands that rape trauma syndrome is actually a variant of

Posttraumatic stress disorder

What is the role of the advanced practice nurse in the management of a rape victim?

Provide individual psychotherapy

A rape victim is discharged home after initial treatment. Which method of giving follow-up instructions is most appropriate?

Provide written instructions

To provide discharge treatment and support, the nurse should realize that the most common sequelae of acquaintance rape is the development of

Symptoms of sexual distress

A police officer brings a person who has just been raped to the emergency department. What is the nurse's best first action?

Tell the person, "You are in a safe place."

A nurse is performing the clinical assessment of a patient who was sexually abused during a date. What appropriate actions does the nurse take during assessment?

The nurse assesses the usefulness of the patient's social support system.

A nurse is assessing emotional trauma in a patient who was sexually assaulted. What action does the nurse take while performing the assessment? Select all that apply.

The nurse encourages the patient to talk at a comfortable pace. The nurse asks the patient, "Are you having any suicidal intentions?"

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." What is the reason for the nurse's response?

The nurse finds physical signs indicating sexual assault.

A nurse is performing a physical assessment of a female patient who was sexually abused. Which steps does the nurse follow while performing the assessment?

The nurse inquires about the date of the patient's last menstrual cycle. The nurse explains the examination procedure to the patient. The nurse encourages the patient to participate in all the decisions of the assessment.

A nurse is performing a physical examination of a child who was sexually assaulted. What appropriate actions does the nurse take while performing the physical examination of the child? Select all that apply.

The nurse instructs the patient to inform if there is pain or discomfort. The nurse collects and preserves hair samples and oral swabs.

A nurse is caring for a patient who was sexually assaulted. Which nursing interventions does the nurse follow to avoid rape-trauma syndrome in the patient? Select all that apply.

The nurse refers the patient to a rape advocacy program. The nurse arranges for a person to stay with the patient. The nurse educates the patient about human immunodeficiency virus testing.

A nurse caring for a patient who was sexually assaulted reports to the primary health care 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.

The patient expresses the right to be protected. The patient expresses anger in a nondestructive way. The patient starts interacting with family members. The outcomes of effective treatment include the patient expresses the right to be protected from the sexual assault and avoids blaming herself, and the patient doesn't have destructive thoughts, such as suicidal intention and intentions to harm others. The patient learns to express anger in a nondestructive way, like deep breathing, and remains calm. The patient seems comfortable in relationships and interacts well with family members. The patient who is a victim of sexual assault is able to identify her emotions before and after the incident. The patient might have been aware of her own emotions and feelings before the traumatic event, so identifying emotions is not indicative of effective treatment. The patient uses both verbal and nonverbal communication after the incident, so it does not indicate the effectiveness of treatment.

After long-term treatment, the nurse is evaluating a patient who was sexually assaulted. The nurse reports to the primary health care provider that the patient has recovered. Based on which action of the patient does the nurse give the report? Select all that apply.

The patient finishes meals. The patient has reduced vaginal discharge.