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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.
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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.
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.
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 assessment finding best indicates the person is in the acute phase of rape trauma syndrome?
- A. Confusion and disbelief
- B. Decreased motor activity
- C. Flashbacks and dreams
- D. Fears and phobias
Correct Answer: A
Rationale: Shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity depict the acute phase of rape trauma syndrome. Flashbacks, dreams, fears, and phobias occur in the long-term reorganization phase. Decreased motor activity is not specific to any phase.
A patient comes to the hospital for treatment of injuries sustained during a rape. The patient abruptly decides to decline treatment and return home. Before theå?? patient leaves, the nurse should provide what support?
- A. Assure the patient, 'Before you leave you receive prophylactic treatment for sexually transmitted infections (STIs).'
- B. Provide written information concerning the physical and emotional reactions that may be experienced.
- C. Explain the need and importance of human immunodeficiency virus (HIV) testing in this situation.
- D. Offer to stay with the victim until stability is regained.
Correct Answer: B
Rationale: Providing written information about physical and emotional reactions helps the anxious patient who cannot retain verbal information. The other options are premature, violate privacy, or suggest a rescue fantasy.