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A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the victim says softly, 'I will never be the same again. I can't face my friends. There is no sense of trying to go on.' Select the nurse's most important response.
- A. Are you thinking of suicide?'
- B. It will take time, but you will feel the same as before.'
- C. Your friends will understand when you tell them.'
- D. You will be able to find meaning in this experience as time goes on.'
Correct Answer: A
Rationale: The victim's words suggest hopelessness, indicating a risk for suicide. Directly addressing suicidal ideation is critical. The other options offer reassurance without assessing the risk.
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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.
What is the primary motivator for most rapists?
- A. Anxiety
- B. Need for humiliation
- C. Overwhelming sexual desires
- D. Desire to inflict violence or control others
Correct Answer: D
Rationale: Rape is a crime of power, control, and violence, not sex. The perpetrator aims to subjugate the victim. The other options are not the primary motivators for rape.
Which situation constitutes consensual sex rather than rape?
- A. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects.
- B. A person's lover pleads to have oral sex. The person gives in but then regrets the decision.
- C. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant.
- D. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.
Correct Answer: B
Rationale: Only the scenario where the person gives in to oral sex describes consensual sex, as it involves agreement, even if later regretted. The other scenarios involve force or lack of consent.
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 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.