Chapter 29: Sexual Assault Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

MULTIPLE CHOICE 1. The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, ―If I avoid strangers or situations where I am alone outside at night, I‘ll be safe from sexual attacks.‖ Choose the nurse‘s best response. a. Your plan is not adequate. You could still be raped or sexually assaulted.‖ b. I am glad you have this excellent safety plan. Would others like to comment?‖ c. It‘s better to walk with someone or call security when you enter or leave a building.‖ d. Sexual assaults are more often perpetrated by acquaintances. Let‘s discuss ways to prevent that.‖ ANS: D Almost half of female victims have been raped by an acquaintance. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion. PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 29-4, 5 | Pages 29-18 (Case Study and Nursing Care Plan), 30 (Table 29-2) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 2. A woman was found confused and disoriented after being abducted and raped at gunpoint by an unknown assailant. The emergency department nurse makes these observations about the woman: talking rapidly in disjointed phrases, unable to concentrate, indecisive when asked to make simple decisions. What is the woman‘s level of anxiety? a. Weak b. Mild c. Moderate d. Severe ANS: D Acute anxiety results from the personal threat to the victim‘s safety and security. In this case, the patient‘s symptoms of rapid, dissociated speech, inability to concentrate, and indecisiveness indicate severe anxiety. Weak is not a level of anxiety. Mild and moderate levels of anxiety would allow the patient to function at a higher level. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 29-10, 18 (Case Study and Nursing Care Plan) + learning from Chapter 15 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 3. After an abduction and rape at gunpoint by an unknown assailant, which assessment finding best indicates that a patient is in the acute phase of the rape-trauma syndrome? a. Decreased motor activity b. Confusion and disbelief c. Flashbacks and dreams d. Fears and phobias ANS: B Reactions of the acute phase of the rape-trauma syndrome are shock, emotional numbness, confusion, disbelief, restlessness, and agitated motor activity. Flashbacks, dreams, fears, and phobias are seen in the long-term reorganization phase of the rape-trauma syndrome. Decreased motor activity by itself is not indicative of any particular phase. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 29-14, 15, 33 (Table 29-4), 34 (Box 29-1) | Page 29-18 (Case Study and Nursing Care Plan) TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The patient says, ―I shouldn‘t have been there alone. I knew it was a dangerous area.‖ What is the patient‘s present coping strategy? a. Projection b. Self-blame c. Suppression d. Rationalization ANS: B The patient‘s statements reflect self-blame, an unhealthy coping mechanism. The patient‘s statements do not reflect rationalization, suppression, or projection. PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 29-10, 11 (Table 29-2) + learning from Chapter 15 TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. An emergency department nurse prepares to assist with evidence collection for a sexual assault victim. Prior to photographs and pelvic examination, what documentation is important? a. The patient‘s vital signs b. Consent signed by the patient c. Supervision and credentials of the examiner d. Storage location of the patient‘s personal effects