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A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the person's level of anxiety?
- A. Minimal
- B. Mild
- C. Moderate
- D. High
Correct Answer: D
Rationale: Anxiety is the result of a personal threat to the victim's safety and security. The person's symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. 'Minimal' is not a level of anxiety. Mild and moderate levels allow the person to function at a higher level.
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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.
The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention?
- A. Use accepting, nurturing, and empathetic communication techniques.
- B. Educate the victim about strategies to avoid attacks in the future.
- C. Discourage the expression of feelings until the victim stabilizes.
- D. Maintain a matter-of-fact manner and objectivity.
Correct Answer: A
Rationale: Victims require unconditional acceptance, nurturing, and empathy to meet their needs and build trust. Focusing on avoidance strategies is premature, and the other options do not promote acceptance.
A nurse working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely?
- A. She was very beautiful.'
- B. She wanted the sex.'
- C. I have issues with my mother.'
- D. I've been depressed for a long time.'
Correct Answer: B
Rationale: Rape involves a need for control, power, degradation, and dominance. The correct response shows a lack of remorse or guilt, common in antisocial personality. The other responses suggest appreciation, psychological conflict, or self-disclosure, not expected from a perpetrator.
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.
Which activities are in the scope of practice of a sexual assault nurse examiner (SANE)? (Select all that apply.)
- A. Requiring HIV testing of a victim
- B. Collecting and preserving evidence
- C. Providing long-term counseling for rape victims
- D. Obtaining signed consents for photographs and examinations
- E. Providing pregnancy and sexually transmitted disease prophylaxis
Correct Answer: B,D,E
Rationale: SANEs collect evidence, obtain consents, and provide prophylaxis. HIV testing is not mandatory, and long-term counseling is provided by other team members.