Nursing > Exam Review > Chapter 29: Sexual Assault Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A (All)
1. 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 ni... ght, I‘ll be safe from sexual attacks.‖ Choose 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.‖ ANS: D Almost half of female victims have been raped by an acquaintance. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 29-4, 5 | Pages 29-18 (Case Study and Nursing Care Plan), 30 (Table 29-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2. 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 ANS: D Acute anxiety results from the personal threat to the victim‘s safety and security. In this case, the patient‘s symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 29-10, 18 (Case Study and Nursing Care Plan) + learning from Chapter 15 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3. 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 testbanks_and_xanax b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias ANS: B Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 29-14, 15, 33 (Table 29-4), 34 (Box 29-1) | Page 29-18 (Case Study and Nursing Care Plan) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. 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 ANS: B The patient‘s statements reflect self-blame, an unhealthy coping mechanism. The patient‘s statements do not reflect rationalization, suppression, or projection. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 29-10, 11 (Table 29-2) + learning from Chapter 15 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. 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 ANS: B Patients have the right to refuse legal and medical examination. Consent forms are required to proceed with these steps. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 29-13, 14, 35 (Box 29-2) | Page 29-18 (Case Study and Nursing Care Plan) TOP: Nursing Process: Implementation MSC: Client Needs: Safe, Effective Care Environment 6. 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 testbanks_and_xanax 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?‖ ANS: B Salty water is a slang/street name for GHB (γ -hydroxy-butyric acid), a Schedule III central nervous system depressant associated with rape. Use of alcohol would produce an increased risk for respiratory depression. GHB has a duration of 1 to 12 hours, but the duration is less important than the potential for respiratory depression. Seeking evidence is less important than the victim‘s physiologic stability. PTS: 1 DIF: Cognitive Level: Analyze (Analysis) REF: Pages 29-6, 31 (Table 29-3) TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 7. 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. ANS: A Although the victim may have made choices that made her vulnerable, she is not to blame for the rape. Correcting this distortion in thinking allows the victim to begin to restore a sense of control. This is a positive response to victimization. The distracters do not permit the victim to begin to restore a sense of control or offer use of nontherapeutic communication techniques. In this interaction, the victim needs to talk about feelings rather than prevention. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 29-10, 11, 16 to 18 (Case Study and Nursing Care Plan) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 8. 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.‖ ANS: D A reflective communication technique is most helpful. Looking at one‘s role in the event serves to explain events that the victim would otherwise find incomprehensible. The distracters discount the victim‘s perceived role and interfere with further discussion. testbanks_and_xanax PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 29-17, 18 (Case Study and Nursing Care Plan) TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 9. 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. ANS: D Agreeing to keep a follow-up appointment is a realistic short-term outcome. The victim is in the acute phase; the distracters are unlikely to be achieved during the limited time the victim is in an emergency department. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 29-15, 16, 18 (Case Study and Nursing Care Plan) TOP: Nursing Process: Planning/Outcomes Identification MSC: Client Needs: Psychosocial Integrity 10. 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.‖ ANS: C Rape-trauma syndrome is a variant of posttraumatic stress disorder. The absence of signs and symptoms of posttraumatic stress disorder suggest that the long-term reorganization phase was successfully completed. The victim‘s sleep has stabilized; occasional nightmares occur, even in reorganization. The distracters suggest somatic symptoms, appetite disturbances, and self-blame, all of which are indicators that the process is ongoing. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 29-18 (Case Study and Nursing Care Plan), 23, 24 TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity 11. 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.‖ testbanks_and_xanax 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?‖ ANS: B Few rape survivors seek help, even with serious injury; so, it is important for the nurse to help the victim discuss the experience. The correct response therapeutically gives information to this victim. A male rape victim is more likely to experience physical trauma and to have been victimized by several assailants. Males experience the same devastation, physical injury, and emotional consequences as females. Although they may cover their responses, they too benefit from care and treatment. ―Why‖ questions represent probing, which is a nontherapeutic communication technique. The victim may or may not have friends who have had this experience, but it is important to talk about his feelings rather than theirs. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 29-5 TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity [Show More]
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