Exam 28: Sexual Assault

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?

When an emergency department nurse teaches a victim of rape-trauma syndrome about reactions that may occur during the long-term phase of reorganization, which symptoms should be included? Select all that apply.

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?

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?

Which aspects of assessment have priority when a nurse interviews a rape victim in an acute setting? Select all that apply.

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 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 behaviour is characteristic of which stage of rape-trauma syndrome?

Which situation describes consensual sex rather than rape?

A rape victim tells the nurse, "I should not have been out on the street alone." Select the nurse's most therapeutic response.

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 rape victim visited a rape crisis counsellor weekly for 8 weeks. At the end of this counselling period, which comment by the victim best demonstrates that reorganization was successful?

A nurse interviews a patient who was abducted and raped at gunpoint by an unknown assailant. The patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's present coping strategy?

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.

An unconscious teenager is treated in the emergency department. The teenager's friends suspect a rape occurred at a party and tell the nurse the teenager received ketamine. Priority action by the nurse should focus on which of the following?

A rape victim tells the emergency nurse, "I feel so dirty. Help me take a shower before I get examined." Which of the following should the nurse do? Select all that apply.

Where do the majority of sexual assaults occur?

The nurse at a university health centre 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.

Before a victim of sexual assault is discharged from the emergency department, which of the following should the nurse do?

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 nurse cares for a rape victim who was given a drink that contained GHB (?-hydroxybutyric acid) by an assailant. Which intervention has priority?