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A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before theå?? patient leaves, the nurse should provide what support?
- A. Assure the patient, 'Before you leave you receive prophylactic treatment for sexually transmitted infections (STIs).'
- B. Provide written information concerning the physical and emotional reactions that may be experienced.
- C. Explain the need and importance of human immunodeficiency virus (HIV) testing in this situation.
- D. Offer to stay with the victim until stability is regained.
Correct Answer: B
Rationale: Providing written information about physical and emotional reactions helps the anxious patient who cannot retain verbal information. The other options are premature, violate privacy, or suggest a rescue fantasy.
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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.
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 person was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the person is in the acute phase of rape trauma syndrome?
- A. Confusion and disbelief
- B. Decreased motor activity
- C. Flashbacks and dreams
- D. Fears and phobias
Correct Answer: A
Rationale: Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase. Decreased motor activity is not specific to any phase.
A rape victim tells the emergency department nurse, 'I feel so dirty. Please let me take a shower before the doctor examines me.' How should the nurse respond to the request?
- A. Arrange for the patient to shower.
- B. Explain that washing would destroy evidence.
- C. Give the patient a basin of hot water and towels.
- D. Instruct the victim to wash above the waist only.
Correct Answer: B
Rationale: The patient should not bathe until the forensic examination is complete to preserve evidence critical for court proceedings. The other options would destroy evidence or are inappropriate.