Nokea
A nurse works with a person who was raped 4 years ago. This person says, 'It took a long time for me to recover from that horrible experience.' Which term should the nurse use when referring to this person?
- A. Victim
- B. Survivor
- C. Plaintiff
- D. Perpetrator
Correct Answer: B
Rationale: A survivor is an individual who has experienced sexual assault, participated in interventions, and is moving forward in life. Victim refers to a person who experienced a recent sexual assault. Plaintiff refers to a person bringing a civil complaint to the court system. Perpetrator refers to a person who commits a crime.
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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.
After assessing a victim of sexual assault, which terms could the nurse use in the documentation? (Select all that apply.)
- A. Alleged
- B. Reported
- C. Penetration
- D. Intercourse
- E. Refused
- F. Declined
Correct Answer: B,C,F
Rationale: Reported,' 'penetration,' and 'declined' are appropriate, avoiding pejorative language. 'Alleged,' 'intercourse,' and 'refused' are not recommended.
When working with rape victims, what is the focus of initial care?
- A. Collecting forensic evidence
- B. Notifying law enforcement
- C. Helping the victim feel safe
- D. Documenting the victim's comments
Correct Answer: C
Rationale: Helping the victim feel safe is the first focus, as the vulnerable individual may perceive assessments as intrusive or threatening. Other actions are secondary and may depend on the victim's decisions.
A nurse working a rape telephone hotline should focus communication with callers toward what intervention?
- A. Arranging long-term counseling
- B. Serving as a sympathetic listener
- C. Obtaining information to relay to the local police
- D. Explaining immediate steps that a victim of rape should take
Correct Answer: D
Rationale: The counselor should provide information to help the victim decide immediate steps. Long-term counseling is addressed later, and empathy, not sympathy, is appropriate. Obtaining police information is inappropriate due to anonymity.
A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, 'I can't believe I've been raped.' This behavior is characteristic of which phase of the rape trauma syndrome?
- A. Anger phase
- B. Acute phase
- C. Outward adjustment phase
- D. Long-term reorganization phase
Correct Answer: B
Rationale: The victim's response, showing cognitive, affective, and behavioral disruptions, is typical of the acute phase. It does not reflect behaviors of the anger, outward adjustment, or long-term reorganization phases.