Chapter 22: Sexual Violence

Question 1

Pt asks that friend wait with her while waiting for SANE. Pt anxious, states, "I don't want to be alone" Best response?

Accepted Answer

Certainly, whatever makes you feel safe.

Question 2

Victim violent rape, "Will never be the same. Can't face my friends. No sense trying to go on." Most important response.

Accepted Answer

Are you thinking of suicide?

Question 3

Client seeking txt in ED after sexual assault. Notation by nurse demonstrates appropriate nonjudgmental documentation?

Accepted Answer

Physical evidence supports the vaginal penetration occurred.

Question 4

Nurse cares for victim of violent sexual assault. Most therapeutic intervention?

Accepted Answer

Use accepting, nurturing, and empathetic communication techniques.

Question 5

Nursing diagnosis rape trauma syndrome applies. Outcome occurs before pts discharge from ED?

Accepted Answer

Pt agrees to keep a follow-up appt with rape crisis center.

Question 6

Client receiving txt for PTSD after sexual assault. Statement supports client able to resume pre-trauma function?

Accepted Answer

I'm being considered for a promotion at work

Question 7

Rape victim, "Feel so dirty. Please let me take a shower before doctor examines me." How should nurse respond?

Accepted Answer

Explain that washing would destroy evidence

Question 8

Rape victim was given flunitrazepam by assailant. For which condition has priority?

Accepted Answer

Signs and symptoms of respiratory depression

Question 9

After traumatic incident pt states, "Can't talk about it. Nothing happened. I have to forget abt it!" Coping strategy?

Accepted Answer

Denial

Question 10

Nurse working rape telephone hotline should focus communication with callers toward what intervention?

Accepted Answer

Explaining immediate steps that a victim of rape should take

Question 11

What is primary motivator for most rapists.

Accepted Answer

Desire to inflect violence or control others

Question 12

Victim sexual assault, sits in ED, rocking back and forth, "Can't believe I've been raped." Phase rape trauma syndrome?

Accepted Answer

Acute phase

Question 13

Intervention should nurse use while caring for person abducted and raped at gunpoint by unknown assailant? (SATA)

Accepted Answer

Pose questions in nonjudgmental, empathic ways., Place person in private room with a caregiver., All person to talk at comfortable pace.

Question 14

Which symptoms may be included r/t reactions that may occur during the long-term organization (delayed) phase? (SATA)

Accepted Answer

Development of fears and phobias, Flashbacks, dreams, Feelings of numbness

Question 15

Which activities are in the scope of practice of a sexual assault nurse examiner (SANE)? (SATA)

Accepted Answer

Obtaining signed consents for photographs and examinations, Providing pregnancy and sexually transmitted disease prophylaxis, Collecting and preserving evidence

Question 16

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? (SATA)

Accepted Answer

Declined, Reported, Penetration

Question 17

Person confused, talks rapidly in disconnected phrases, unable concentrate, can't make simple decisions. Level anxiety?

Accepted Answer

High

Question 18

Intervention implemented to confirm suspicion client unknowingly ingested flunitrazepam prior to sexual assault?

Accepted Answer

Obtain urine sample

Question 19

Rape victim, " Maybe I caused this attack, was it my fault?" Response most therapeutic?

Accepted Answer

Support victim to separate issues of vulnerability from blame.

Question 20

Child was abducted and raped. Personal reaction by nurse could interfere with child's care?

Accepted Answer

Disgust

Question 21

Rape victim, "Should not have been out on street alone." Most therapeutic response?

Accepted Answer

You believe this would not have happened if you had not been alone?

Question 22

Pt, "Feel like I'm going crazy". Experiencing anxiety, depression, nightmares after sexual assault. Initial response?

Accepted Answer

What you're experiencing must be frightening. Symptoms shared by many.

Question 23

Survivor, (delayed) phase rape trauma syndrome, intrusive thoughts rape, fear being alone. Finding has made improvement?

Accepted Answer

Describes personal coping strategies for fearful situations

Question 24

Man recently committed violent sexual assault against a woman. Comment from perpetrator most likely?

Accepted Answer

She wanted the sex

Question 25

Pt comes to hosp txt injuries r/t rape. Abruptly declines txt, wants return home. Before leaves, what support provided?

Accepted Answer

Provide written information re: physical/emotional reactions may experience

Question 26

Which situation constitutes consensual sex rather than rape?

Accepted Answer

Person's lover pleads have oral sex. Person gives in, then regrets decision

Question 27

Assessment finding best indicates person in acute phase rape trauma syndrome?

Accepted Answer

Confusion and disbelief

Question 28

When victim of sexual assault discharged from ED nurse should arrange for which intervention?

Accepted Answer

Provide referral information verbally and in writing.

Question 29

Unconscious person brought to ED. Semen observed on underclothes. Priority action staff members focus on?

Accepted Answer

Maintaining effective gas exchange

Question 30

When working with rape victims, what is the focus of initial care?

Accepted Answer

Helping the victim feel safe

Question 31

Nurse works with person raped 4 yrs ago. "Took me long time to recover". Term used when referring to this person?

Accepted Answer

Survivor

Chapter 22: Sexual Violence

Questions 31

Chapter 22: Sexual Violence

Questions 31