Nokea
The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge?
- A. Patient states, 'I feel safe and entirely relaxed.'
- B. Memory of the rape is less vivid and frightening.
- C. Physical symptoms of pain and discomfort are no longer present.
- D. Patient agrees to keep a follow-up appointment with the rape crisis center.
Correct Answer: D
Rationale: Agreeing to keep a follow-up appointment is a realistic short-term outcome achievable in the emergency department. The other outcomes are unlikely to occur during the limited time in the emergency department.
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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.
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.
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.
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 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.