Nokea
A nurse cares for a rape victim who was given flunitrazepam by the assailant. Which condition has priority?
- A. Decreased consciousness
- B. Seizure activity of any kind
- C. Hypotonia of voluntary muscles
- D. Signs and symptoms of respiratory depression
Correct Answer: D
Rationale: Monitoring for respiratory depression is the priority, as flunitrazepam can cause severe respiratory issues, which are life-threatening. Other conditions are secondary.
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The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge?
- A. Patient states, 'I feel safe and entirely relaxed.'
- B. Memory of the rape is less vivid and frightening.
- C. Physical symptoms of pain and discomfort are no longer present.
- D. Patient agrees to keep a follow-up appointment with the rape crisis center.
Correct Answer: D
Rationale: Agreeing to keep a follow-up appointment is a realistic short-term outcome achievable in the emergency department. The other outcomes are unlikely to occur during the limited time in the emergency department.
A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care?
- A. Disgust
- B. Concern
- C. Empathy
- D. Compassion
Correct Answer: A
Rationale: Feelings of empathy, concern, and compassion are helpful. Disgust may make objectivity impossible and can increase the child's anxiety and shame.
An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. What is the priority action the staff members should focus on?
- A. Maintaining effective gas exchange
- B. Preserving all rape evidence
- C. Interviewing the friend for additional information
- D. Determining whether any alcohol or drugs were ingested
Correct Answer: A
Rationale: The unconscious patient is at risk for respiratory depression and airway obstruction, making gas exchange the priority. Other actions are secondary to preserving physiological functioning.
A rape victim asks an emergency department nurse, 'Maybe I did something to cause this attack. Was it my fault?' Which response by the nurse is the most therapeutic?
- A. Pose questions about the rape, helping the patient explore why it happened.
- B. Reassure the victim that the outcome of the situation will be positive.
- C. Make decisions for the victim because of the temporary confusion.
- D. Support the victim to separate issues of vulnerability from blame.
Correct Answer: D
Rationale: The victim is not to blame for the rape, though they may have made choices that increased vulnerability. Supporting the victim to separate vulnerability from blame is therapeutic. The other options suggest nontherapeutic communication, assume outcomes, or do not address control restoration.
When a victim of sexual assault is discharged from the emergency department, the nurse should arrange for which intervention?
- A. Secure support from the victim's family.
- B. Provide referral information verbally and in writing.
- C. Advise the victim to try not to think about the assault.
- D. Offer to stay with the victim until stability is regained.
Correct Answer: B
Rationale: Written referral information accounts for the victim's disorganized state and inability to retain verbal information. The other options violate privacy, offer nontherapeutic advice, or suggest a rescue fantasy.