Nokea
A nurse is caring for a patient who has been the victim of sexual assault. The nurse documents that the patient appears to be in a state of shock, verbalizing fear, guilt, and humiliation. What phase of rape trauma syndrome is this patient most likely experiencing?
- A. Reorganization phase
- B. Denial phase
- C. Heightened anxiety phase
- D. Acute disorganization phase
Correct Answer: D
Rationale: The acute disorganization phase of rape trauma syndrome involves shock, fear, guilt, and humiliation. Denial, heightened anxiety, and reorganization occur in different stages.
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A patient is admitted to the ED complaining of abdominal pain. Further assessment of the abdomen reveals signs of peritoneal irritation. What assessment findings would corroborate this diagnosis? Select all that apply.
- A. Ascites
- B. Rebound tenderness
- C. Changes in bowel sounds
- D. Muscular rigidity
- E. Copious diarrhea
Correct Answer: B,C,D
Rationale: Rebound tenderness, altered bowel sounds, and muscular rigidity indicate peritoneal irritation. Ascites and diarrhea are not specific to this condition.
A patient is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The patient is alert and oriented. What is the care team's most appropriate treatment?
- A. Administering syrup of ipecac
- B. Performing a gastric lavage
- C. Giving milk to drink
- D. Referring to psychiatry
Correct Answer: C
Rationale: Diluting an acidic ingestion with milk or water is appropriate after 2 hours, as gastric lavage is ineffective beyond 1 hour. Ipecac is obsolete, and psychiatric referral follows physical stabilization.
An ED nurse is triaging patients according to the Emergency Severity Index (ESI). When assigning patients to a triage level, the nurse will consider the patient's acuity as well as what other variable?
- A. The likelihood of a repeat visit to the ED in the next 7 days
- B. The resources that the patient is likely to require
- C. The patient's or insurer's ability to pay for care
- D. Whether the patient is known to ED staff from previous visits
Correct Answer: B
Rationale: ESI triage considers acuity and anticipated resource needs, such as diagnostics or consultations. Repeat visits, payment ability, or prior ED history are not triage factors.
A male patient with multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own. The ED nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?
- A. Absence of bruising at contusion sites
- B. Rapid pulse and decreased capillary refill
- C. Increased BP with narrowed pulse pressure
- D. Sudden diaphoresis
Correct Answer: B
Rationale: Rapid pulse and poor capillary refill suggest hypovolemia from internal hemorrhage. Increased BP or diaphoresis alone are less specific, and bruising absence doesn't rule it out.
The ED nurse is planning the care of a patient who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal?
- A. Encouraging the patient to gain a sense of control over his or her life
- B. Collecting sufficient evidence to secure a criminal conviction
- C. Helping the patient understand that this will not happen again
- D. Encouraging the patient to verbalize what happened during the assault
Correct Answer: A
Rationale: Nursing interventions post-sexual assault focus on empowering the patient to regain control, prioritizing emotional recovery over legal outcomes, future safety guarantees, or forced verbalization.