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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.
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A rape victim asks an emergency department nurse, 'Maybe I did something to cause this attack. Was it my fault?' Which response by the nurse is the most therapeutic?
- A. Pose questions about the rape, helping the patient explore why it happened.
- B. Reassure the victim that the outcome of the situation will be positive.
- C. Make decisions for the victim because of the temporary confusion.
- D. Support the victim to separate issues of vulnerability from blame.
Correct Answer: D
Rationale: The victim is not to blame for the rape, though they may have made choices that increased vulnerability. Supporting the victim to separate vulnerability from blame is therapeutic. The other options suggest nontherapeutic communication, assume outcomes, or do not address control restoration.
A nurse cares for a rape victim who was given flunitrazepam by the assailant. Which condition has priority?
- A. Decreased consciousness
- B. Seizure activity of any kind
- C. Hypotonia of voluntary muscles
- D. Signs and symptoms of respiratory depression
Correct Answer: D
Rationale: Monitoring for respiratory depression is the priority, as flunitrazepam can cause severe respiratory issues, which are life-threatening. Other conditions are secondary.
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.
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.
When a victim of sexual assault is discharged from the emergency department, the nurse should arrange for which intervention?
- A. Secure support from the victim's family.
- B. Provide referral information verbally and in writing.
- C. Advise the victim to try not to think about the assault.
- D. Offer to stay with the victim until stability is regained.
Correct Answer: B
Rationale: Written referral information accounts for the victim's disorganized state and inability to retain verbal information. The other options violate privacy, offer nontherapeutic advice, or suggest a rescue fantasy.