VARCAROLIS Chapter 29: Sexual
Assault
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." - ANSD
Females know their offenders in almost 70% of all violent crimes committed against them,
including rape. 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: Page 553-554 | Page 560 (Nursing Care Plan 29-1)
TOP: Nursing Process: Assessment
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
c.
Moderate
b.
Mild
d.
Severe - ANSD
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: Page 560 (Nursing Care Plan 29-1) + learning from Chapter 15
TOP: Nursing Process: Assessment
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
c.
Flashbacks and dreams
b.
Confusion and disbelief
d.
Fears and phobias - ANSB
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: Page 554 | Page 558 (Table 29-2) | Page 560 (Nursing Care Plan 29-1)
TOP: Nursing Process: Assessment
4. A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The
patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's
present coping strategy?
a.
Compensation
c.
Projection
b.
Somatization
d.
Denial - ANSD
The patient's statements reflect use of denial, an ego defense mechanism. This mechanism
may be used unconsciously to protect the person from the emotionally overwhelming reality of
the rape. The patient's statements do not reflect somatization, compensation, or projection.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 558 (Table 29 - 2) + learning from Chapter 15
TOP: Nursing Process: Assessment
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?
Assault
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." - ANSD
Females know their offenders in almost 70% of all violent crimes committed against them,
including rape. 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: Page 553-554 | Page 560 (Nursing Care Plan 29-1)
TOP: Nursing Process: Assessment
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
c.
Moderate
b.
Mild
d.
Severe - ANSD
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: Page 560 (Nursing Care Plan 29-1) + learning from Chapter 15
TOP: Nursing Process: Assessment
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
c.
Flashbacks and dreams
b.
Confusion and disbelief
d.
Fears and phobias - ANSB
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: Page 554 | Page 558 (Table 29-2) | Page 560 (Nursing Care Plan 29-1)
TOP: Nursing Process: Assessment
4. A nurse interviews a patient abducted and raped at gunpoint by an unknown assailant. The
patient says, "I can't talk about it. Nothing happened. I have to forget." What is the patient's
present coping strategy?
a.
Compensation
c.
Projection
b.
Somatization
d.
Denial - ANSD
The patient's statements reflect use of denial, an ego defense mechanism. This mechanism
may be used unconsciously to protect the person from the emotionally overwhelming reality of
the rape. The patient's statements do not reflect somatization, compensation, or projection.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension)
REF: Page 558 (Table 29 - 2) + learning from Chapter 15
TOP: Nursing Process: Assessment
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?
