TEST BANK CHAPTER 22 SEXUAL VIOLENCE VARCAROLIS ESSENTIALS OF PSYCHIATRIC MENTAL HEALTH, Exams of Advanced Education

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TEST BANK CHAPTER 22 SEXUAL

VIOLENCE VARCAROLIS ESSENTIALS OF

PSYCHIATRIC MENTAL HEALTH NURSING

A COMMUNICATION APPROACH TO

EVIDENCE-BASED CARE

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 d. High We have an expert-written solution to this problem! 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 a. Confusion and disbelief A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy? a. Somatic reaction b. Repression c. Projection d. Denial d. Denial Disbelief is a common finding during the acute stage following sexual assault. Denial is evidence of the

disbelief. This mechanism may be unconsciously used to protect the person from the emotionally overwhelming reality of rape. The patient's statements do not reflect somatic symptoms, repression, or projection. A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care? a. Disgust b. Concern c. Empathy d. Compassion a. Disgust A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic? a. Pose questions about the rape, helping the patient explore why it happened. b. Reassure the victim that the outcome of the situation will be positive. c. Make decisions for the victim because of the temporary confusion. d. Support the victim to separate issues of vulnerability from blame. d. Support the victim to separate issues of vulnerability from blame. A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response? a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night." c. "You believe this would not have happened if you had not been alone?" 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. d. Patient agrees to keep a follow-up appointment with the rape crisis center. 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 d. Explaining immediate steps that a victim of rape should take

A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." How should the nurse respond to the request? a. Arrange for the patient to shower. b. Explain that washing would destroy evidence. c. Give the patient a basin of hot water and towels. d. Instruct the victim to wash above the waist only. b. Explain that washing would destroy evidence. 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. b. Provide referral information verbally and in writing. 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 b. Acute phase A survivor in the long-term organization (delayed) phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates this survivor has made improvement? a. The survivor expresses a need to regularly withdraw from social situations. b. The survivor describes personal coping strategies for fearful situations. c. The survivor uses increased activity to reduce feelings of fear. d. The survivor expresses a deep desire to be with others. b. The survivor describes personal coping strategies for fearful situations. 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 the 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 both verbal and written information about locally available legal resources.

b. Provide written information concerning the physical and emotional reactions that may be experienced. 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 they 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 of drug were ingested a. Maintaining effective gas exchange 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." a. "Are you thinking of suicide?" A nurse cares for a rape victim who was given flunitrazepam by the assailant. Which for 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 d. Signs and symptoms of respiratory depression 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 c. Helping the victim feel safe

1. When an emergency department nurse teaches a victim of rape about reactions that may occur during the long-term organization (delayed) phase, which symptoms should be included? (Select all that apply.) a. Development of fears and phobias b. Decreased motor activity c. Feelings of numbness d. Flashbacks, dreams

a. Development of fears and phobias c. Feelings of numbness d. Flashbacks, dreams We have an expert-written solution to this problem! 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. 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. 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 b. Collecting and preserving evidence d. Obtaining signed consents for photographs and examinations e. Providing pregnancy and sexually transmitted disease prophylaxis After assessing a victim of sexual assault, which terms could the nurse use in the documentation? (Select all that apply.) a. Alleged b. Reported c. Penetration d. Intercourse e. Refused f. Declined

b. Reported c. Penetration f. Declined