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A survivor in the long-term organization (delayed) phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement?
- A. The survivor expresses a need to regularly withdraw from social situations.
- B. The survivor describes personal coping strategies for fearful situations.
- C. The survivor uses increased activity to reduce feelings of fear.
- D. The survivor expresses a deep desire to be with others.
Correct Answer: B
Rationale: Describing personal coping strategies shows a willingness and ability to address fear effectively. The other options demonstrate continued ineffective coping.
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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 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.
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.
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 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.