Sexual Violence

MULTIPLE CHOICE

1. A nurse works with a person who was raped four years ago. This person says, “It took a long time for me to recover from that horrible experience.” Which term should the nurse use when referring to this person?
a. Victim
b. Survivor
c. Plaintiff
d. Perpetrator
ANS: B
A survivor is an individual who has experience sexual assault, participated in interventions, and is moving forward in life. Victim refers to a person who experienced a recent sexual assault. Plaintiff refers to a person bringing a civil complaint to the court system. Perpetrator refers to a person who commits a crime.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 431
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

2. 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. Weak
b. Mild
c. Moderate
d. Severe
ANS: D
Anxiety is the result of a personal threat to the victim’s safety and security. In this case, the person’s symptoms of rapid, dissociated speech, confusion, and indecisiveness indicate severe anxiety. “Weak” is not a level of anxiety. Mild and moderate levels of anxiety allow the person to function at a higher level.

DIF: Cognitive Level: Application (Applying) REF: Page: 431 | Pages: 438-439
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. 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
ANS: A
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 of rape trauma syndrome. Decreased motor activity, by itself, is not indicative of any particular phase.

DIF: Cognitive Level: Application (Applying) REF: Page: 438
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

4. 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
ANS: D
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.

DIF: Cognitive Level: Application (Applying) REF: Page: 438
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

5. A child was abducted and raped. Which personal reaction by the nurse could interfere with the child’s care?
a. Anger
b. Concern
c. Empathy
d. Compassion
ANS: A
Feelings of empathy, concern, and compassion are helpful. Anger, on the other hand, may make objectivity impossible.

DIF: Cognitive Level: Application (Applying) REF: Page: 439 | Pages: 441-442
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

6. 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. “I gave her what she wanted.”
c. “I have issues with my mother.”
d. “I’ve been depressed for a long time.”
ANS: B
Rape involves a need for control, power, degradation, and dominance over others. The correct response shows a lack of remorse or guilt, which is a common characteristic of an antisocial personality. The incorrect responses show an appreciation for women, psychological conflict, and self-disclosure, which are not expected from a perpetrator of sexual assault.

DIF: Cognitive Level: Application (Applying) REF: Pages: 436-437
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

7. 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.
ANS: D
Although the victim may have made choices that increased vulnerability, the victim is not to blame for the rape. The incorrect options either suggest the use of a nontherapeutic communication technique or do not permit the victim to restore control. No confusion is evident.

DIF: Cognitive Level: Application (Applying) REF: Page: 437 | Pages: 441-442
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

8. 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.”
ANS: C
A reflective communication technique is helpful. Looking at one’s role in the event serves to explain events that the victim would otherwise find incomprehensible. The incorrect options discount the victim’s perceived role and interfere with further discussion.

DIF: Cognitive Level: Application (Applying) REF: Page: 437 | Pages: 441-442
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

9. 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.
ANS: D
Agreeing to keep a follow-up appointment is a realistic short-term outcome. The incorrect options are unlikely to occur during the limited time the victim is in the emergency department.

DIF: Cognitive Level: Application (Applying) REF: Pages: 439-440
TOP: Nursing Process: Outcomes Identification
MSC: NCLEX: Psychosocial Integrity

10. The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention?
a. Use accepting, nurturing, and empathetic communication techniques.
b. Educate the victim about strategies to avoid attacks in the future.
c. Discourage the expression of feelings until the victim stabilizes.
d. Maintain a matter-of-fact manner and objectivity.
ANS: A
Victims require the nurse to provide unconditional acceptance of them as individuals, because they often feel guilty and engage in self-blame. The nurse must be nurturing if the victim’s needs are to be met and must be empathetic to convey understanding and to promote an establishment of trust.

DIF: Cognitive Level: Application (Applying) REF: Page: 437 | Pages: 441-442
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

11. What is the primary motivator for most rapists?
a. Anxiety
b. Need for humiliation
c. Overwhelming sexual desires
d. Desire to humiliate or control others
ANS: D
Rape is not a crime of sex; rather, it is a crime of power, control, and humiliation. The perpetrator wishes to subjugate the victim. The dynamics listed in the other options are not the major motivating factors for rape.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 436-437
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

12. A nurse working a rape telephone hotline should focus communication with callers to:
a. arrange long-term counseling.
b. serve as a sympathetic listener.
c. obtain information to relay to the local police.
d. explain immediate steps that a victim of rape should take.
ANS: D
The telephone counselor establishes where the victim is and what has happened and provides the necessary information to enable the victim to decide what steps to take immediately. Long-term aftercare is not the focus until immediate problems are resolved. The victim remains anonymous. The incorrect options are inappropriate or incorrect because counselors should be empathic rather than sympathetic.

DIF: Cognitive Level: Application (Applying) REF: Page: 437
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

13. A rape victim tells the emergency department nurse, “I feel so dirty. Please let me take a shower before the doctor examines me.” The nurse should:
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.
ANS: B
No matter how uncomfortable, the patient should not bathe until the forensic examination is completed. The collection of evidence is critical if the patient is to be successful in court. The incorrect options would result in the destruction of evidence or are untrue.

DIF: Cognitive Level: Application (Applying) REF: Pages: 437-439
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

14. Which situation constitutes consensual sex rather than rape?
a. After coming home intoxicated from a party, a person forces the spouse to have sex. The spouse objects.
b. A person’s lover pleads to have oral sex. The person gives in but then regrets the decision.
c. A person is beaten, robbed, and forcibly subjected to anal penetration by an assailant.
d. A physician gives anesthesia for a procedure and has intercourse with an unconscious patient.
ANS: B
Only the correct answer describes a scenario in which the sexual contact is consensual. Consensual sex is not considered rape if the participants are, at least, the age of majority.

DIF: Cognitive Level: Application (Applying) REF: Pages: 432-433
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

15. When a victim of sexual assault is discharged from the emergency department, the nurse should:
a. arrange 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.
ANS: B
Immediately after the assault, rape victims are often disorganized and unable to think well or remember what they have been told. Written information acknowledges this fact and provides a solution. The incorrect options violate the patient’s right to privacy, evidence a rescue fantasy, and offer a platitude that is neither therapeutic nor effective.

DIF: Cognitive Level: Application (Applying) REF: Pages: 437-440
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

16. 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
ANS: B
The victim’s response is typical of the acute phase and evidences cognitive, affective, and behavioral disruptions. The response is immediate and does not include a display of behaviors suggestive of the outward adjustment, long-term reorganization, or anger phases.

DIF: Cognitive Level: Application (Applying) REF: Page: 438
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

17. A survivor in the long-term reorganization 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? The survivor:
a. temporarily withdraws from social situations.
b. plans coping strategies for fearful situations.
c. uses increased activity to reduce fear.
d. expresses a desire to be with others.
ANS: B
The correct response shows a willingness and ability to take personal action to reduce the disabling fear. The incorrect responses demonstrate continued ineffective coping.

DIF: Cognitive Level: Application (Applying) REF: Pages: 438-439
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

18. 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:
a. tell the patient, “You may not leave until you receive prophylactic treatment for sexually transmitted diseases.”
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.
d. offer verbal information about legal resources.
ANS: B
All information given to a patient before he or she leaves the emergency department should be in writing. Patients who are anxious are unable to concentrate and therefore cannot retain much of what is verbally imparted. Written information can be read and referred to at later times. Patients cannot be kept against their will or coerced into receiving medication as a condition of being allowed to leave. This constitutes false imprisonment.

DIF: Cognitive Level: Application (Applying) REF: Pages: 439-440
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

19. 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. The priority actions of staff members should focus on:
a. maintaining the airway.
b. preserving rape evidence.
c. obtaining a description of the rape.
d. determining what drug was ingested.
ANS: A
Because the patient is unconscious, the risk for airway obstruction is present. The incorrect options are of lower priority than preserving physiologic functioning.

DIF: Cognitive Level: Application (Applying) REF: Pages: 433-434 | Page: 438
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

20. 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.”
ANS: A
The victim’s words suggest hopelessness. Whenever hopelessness is present, so is the risk for suicide. The nurse should directly address the possibility of suicidal ideation with the victim. The other options attempt to offer reassurance before making an assessment.

DIF: Cognitive Level: Application (Applying) REF: Pages: 438-442
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

21. A nurse cares for a rape victim who was given flunitrazepam (Rohypnol) by the assailant. Which intervention has priority? Monitoring for:
a. coma.
b. seizures.
c. hypotonia.
d. respiratory depression.
ANS: D
Monitoring for respiratory depression takes priority over hypotonia, seizures, or coma in this situation.

DIF: Cognitive Level: Application (Applying) REF: Pages: 433-434 | Page: 438
TOP: Nursing Process: Intervention MSC: NCLEX: Physiological Integrity

22. When working with rape victims, immediate care focuses first on:
a. collecting evidence.
b. notifying law enforcement.
c. helping the victim feel safe.
d. documenting the victim’s comments.
ANS: C
The first focus of care is helping the victim feel safe. An already vulnerable individual may view assessment questions and the physical procedures as intrusive violations of privacy and even physically threatening. The patient might decline to have evidence collected or to involve law enforcement.

DIF: Cognitive Level: Application (Applying) REF: Pages: 439-440
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

1. When an emergency department nurse teaches a victim of the rape about reactions that may occur during the long-term reorganization 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
e. Syncopal episodes
ANS: A, C, D
These reactions are common to the long-term reorganization phase. Victims of rape frequently have a period of increased motor activity rather than decreased motor activity during the long-term reorganization phase. Syncopal episodes are not expected.

DIF: Cognitive Level: Application (Applying) REF: Pages: 438-440
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

2. 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.
ANS: A, B, C
Neutral, nonjudgmental care and emotional support are critical to crisis management for the victim of rape. The rape victim should have privacy but not be left alone. Some rape victims prefer not to have family members involved. The patient’s privacy may be compromised by the presence of family. The rape victim’s anxiety may escalate when he or she is touched by a stranger, even when the stranger is a nurse.

DIF: Cognitive Level: Application (Applying) REF: Pages: 439-440
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

3. Which activities are in the scope of practice of a sexual assault nurse examiner? 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
ANS: B, D, E
HIV testing is not mandatory for a victim of sexual assault. Long-term counseling would be provided by other members of the team. The other activities would be included within this practice role.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 437
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. 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
ANS: B, C, F
The nurse should refrain from using pejorative language when documenting assessments of victims of sexual assault. “Reported” should be used instead of “alleged.” “Penetration” should be used instead of “intercourse.” “Declined” should be used instead of “refused.”

DIF: Cognitive Level: Application (Applying) REF: Pages: 437-440
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment