Nokea
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.
You may also like to solve these questions
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 working in the county jail interviews a man who recently committed a violent sexual assault against a woman. Which comment from this perpetrator is most likely?
- A. She was very beautiful.'
- B. She wanted the sex.'
- C. I have issues with my mother.'
- D. I've been depressed for a long time.'
Correct Answer: B
Rationale: Rape involves a need for control, power, degradation, and dominance. The correct response shows a lack of remorse or guilt, common in antisocial personality. The other responses suggest appreciation, psychological conflict, or self-disclosure, not expected from a perpetrator.
A person was abducted and raped at gunpoint. The nurse observes this person is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the person's level of anxiety?
- A. Minimal
- B. Mild
- C. Moderate
- D. High
Correct Answer: D
Rationale: Anxiety is the result of a personal threat to the victim's safety and security. The person's symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. 'Minimal' is not a level of anxiety. Mild and moderate levels allow the person to function at a higher level.
A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, 'I can't believe I've been raped.' This behavior is characteristic of which phase of the rape trauma syndrome?
- A. Anger phase
- B. Acute phase
- C. Outward adjustment phase
- D. Long-term reorganization phase
Correct Answer: B
Rationale: The victim's response, showing cognitive, affective, and behavioral disruptions, is typical of the acute phase. It does not reflect behaviors of the anger, outward adjustment, or long-term reorganization phases.
An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. What is the priority action the staff members should focus on?
- A. Maintaining effective gas exchange
- B. Preserving all rape evidence
- C. Interviewing the friend for additional information
- D. Determining whether any alcohol or drugs were ingested
Correct Answer: A
Rationale: The unconscious patient is at risk for respiratory depression and airway obstruction, making gas exchange the priority. Other actions are secondary to preserving physiological functioning.