Question 1

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?

Accepted Answer

A)   Weak
B)   Mild
C)   Moderate
D)   Severe D

Question 2

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.

Accepted Answer

A)   Development of fears and phobias
B)   Decreased motor activity
C)   Feelings of numbness
D)   Flashbacks, dreams
E)   Syncopal episodes A, C, D

Question 3

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?

Accepted Answer

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

Question 4

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?

Accepted Answer

A)   Decreased motor activity
B)   Confusion and disorientation
C)   Flashbacks and dreams
D)   Fears and phobias

Question 5

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

Accepted Answer

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

Question 6

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.

Accepted Answer

A)   The memory of the rape is 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.

Question 7

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?

Accepted Answer

A)   The acute phase
B)   The long-term phase
C)   A delayed reaction
D)   The angry stage

Question 8

Which situation describes consensual sex rather than rape?

Accepted Answer

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.

Question 9

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

Accepted Answer

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."

Question 10

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?

Accepted Answer

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?"

Question 11

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?

Accepted Answer

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."

Question 12

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?

Accepted Answer

A)   Compensation
B)   Somatization
C)   Projection
D)   Denial

Question 13

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.

Accepted Answer

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 nonjudgemental, 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.

Question 14

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?

Accepted Answer

A)   Preserving rape evidence
B)   Maintaining physiologic stability
C)   Determining what drugs were ingested
D)   Obtaining a description of the rape from a friend

Question 15

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.

Accepted Answer

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.

Question 16

Where do the majority of sexual assaults occur?

Accepted Answer

A)   Private home
B)   City street at night
C)   Commercial establishment
D)   Person's own motor vehicle

Question 17

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.

Accepted Answer

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."

Question 18

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

Accepted Answer

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

Question 19

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?

Accepted Answer

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?"

Question 20

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

Accepted Answer

A)   Monitoring for coma
B)   Monitoring for seizures
C)   Monitoring for hypotonia
D)   Monitoring for respiratory depression

Exam 28: Sexual Assault