Nokea
A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? (Select all that apply.)
- A. Allow the person to talk at a comfortable pace.
- B. Pose questions in nonjudgmental, empathic ways.
- C. Place the person in a private room with a caregiver.
- D. Reassure the person that a family member will arrive as soon as possible.
- E. Invite family members to the examination room and involve them in taking the history.
- F. Put an arm around the person to offer reassurance that the nurse is caring and compassionate.
Correct Answer: A,B,C
Rationale: Neutral, nonjudgmental care, empathetic questions, and privacy with a caregiver are critical for crisis management. Family involvement may compromise privacy, and touching may escalate anxiety.
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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.
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 rape victim tells the nurse, 'I should not have been out on the street alone.' Which is the nurse's most therapeutic response?
- A. Rape can happen anywhere.'
- B. Blaming yourself only increases your anxiety and discomfort.'
- C. You believe this would not have happened if you had not been alone?'
- D. You are right. You should not have been alone on the street at night.'
Correct Answer: C
Rationale: A reflective communication technique helps the victim explore their role in the event, aiding understanding. The other options discount the victim's perceived role or interfere with further discussion.
When an emergency department nurse teaches a victim of rape about reactions that may occur during the long-term organization (delayed) phase, which symptoms should be included? (Select all that apply.)
- A. Development of fears and phobias
- B. Decreased motor activity
- C. Feelings of numbness
- D. Flashbacks, dreams
- E. Syncopal episodes
Correct Answer: A,C,D
Rationale: Fears, phobias, numbness, flashbacks, and dreams are common in the long-term reorganization phase. Decreased motor activity and syncopal episodes are not expected.
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.