Chapter 29 - Sexual Assault Flashcards
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.” What is 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.”
d. “Sexual assaults are more often perpetrated by acquaintances. Let’s discuss ways to prevent that.”
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
d. Severe
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 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. “Has the victim consumed any alcohol?”
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.
a. Support the victim to separate issues of vulnerability from blame.
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
