NCLEX RN Free Practice Questions Related

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As a nurse in the emergency room, you receive an outside call from an elderly woman who states she has just been raped. She states, 'I know I must come to the hospital, but what do I do next?' You advise her to call the police, then come to the hospital emergency room. What action by the nurse would indicate an understanding of the examination process once the victim enters the emergency room?

  • A. Inform the victim not to wash, change clothes, douche, brush teeth, or eat or drink anything.
  • B. Inform the victim to bring insurance information with her to the hospital so she can be properly cared for.
  • C. Phone a rape counselor to begin working with the victim as soon as she enters the hospital.
  • D. Do not leave the victim alone to collect her thoughts.
Correct Answer: A

Rationale: Providing the victim with these instructions will aid in the determination of physical evidence of rape. Victims frequently feel 'dirty' after rape, and their first instinct is to take care of personal hygiene before facing anyone. This action is of lesser importance at this time. Although this is a nursing measure appropriate in this situation, contacting a counselor can be done once the victim enters the hospital. Frequently victims call but do not follow up with the visit. Once the victim enters the emergency room, it is important not to leave her alone.