CH 29 SXAL Assualt Flashcards
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. Confusion and disbelief
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
b. Self-blame
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
b. Consent signed by the patient
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.”
d. “You feel as though this would not have happened if you had not been alone.”
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.
d. The patient agrees to a follow-up appointment with a rape victim advocate.
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.”
c. “I’m sleeping better although I still have an occasional nightmare.”
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. “Male victims of sexual assault often experience physical injuries and are
assaulted by more than one person.”
A nurse works at rape telephone hotline. What should be the focus of communication with
potential victims?
a. explaining immediate steps victims should take.
b. providing callers with a sympathetic listener.
c. obtaining information for law enforcement.
d. arranging counseling.
a. explaining immediate steps victims should take
A nurse cares for a rape victim who was given a drink that contained flunitrazepam by an assailant. Monitoring for which outcome has priority?
a. coma.
b. seizures.
c. hypotonia.
d. respiratory depression.
d. respiratory depression.
Before a victim of sexual assault is discharged from the emergency department, what intervention should the nurse implement?
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.
d. provide referral information verbally and in writing.
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
a. The acute phase reaction
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 take what action?
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.
b. provide written information about physical and emotional reactions the person may experience.
An unconscious teenager is treated in the emergency department. The teenager’s friends suspect the teenager was drugged and raped at a party. What is the priority action 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.
b. maintaining physiological stability.
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
a. Development of fears and phobias
c. Feelings of numbness
d. Flashbacks,
An emergency department nurse prepares to assist with examination of a sexual assault client. 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
a. Camera
b. Body map
c. DNA swabs
