Answer Choices:
a. Repeated middle ear infections
b. Severe colic
c. Bite marks
d. Croup
Answer:
C
Question: 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?
Answer Choices:
a. Anger phase
b. Acute phase
c. Outward adjustment phase
d. Long-term reorganization phase
Answer:
B
Question: 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 that emergency staff members should focus on?
Answer Choices:
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
Answer:
A
Question: An adult tells the nurse, “My partner abuses me only when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I’ve considered leaving but haven’t been able to bring myself to actually do it.” Which phase in the cycle of violence prevents the patient from leaving?
Answer Choices:
a. Tension building
b. Acute battering
c. Honeymoon
d. Recovery
Answer:
C
Question: 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?
Answer Choices:
a. Assure the patient, “Before you leave you receive prophylactic treatment for sexually transmitted infections (STIs).”
b. Explain the need and importance of human immunodeficiency virus (HIV) testing.
c. Insist the patient wait to receive counseling about the assault.
d. Offer both verbal and written information about locally available legal resources.
Answer:
B
Question: A nurse assists a victim of intimate partner violence to create a plan for escape if it becomes necessary. The plan should include which components? (Select all that apply.)
Answer Choices:
a. Keep a cell phone fully charged.
b. Hide money with which to buy new clothes.
c. Have the telephone number for the nearest shelter.
d. Take enough toys to amuse the children for 2 days.
e. Secure a supply of current medications for self and children.
f. Determine a code word to signal children that it is time to leave.
g. Assemble birth certificates, Social Security cards, and licenses.
Answer:
A, C, E, F, G
Question: When working with rape victims, what is the focus of initial care?
Answer Choices:
a. Collecting forensic evidence
b. Notifying law enforcement
c. Helping the victim feel safe
d. Documenting the victim’s comments
Answer:
C
Question: A patient at the emergency department is diagnosed with a concussion. The patient is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority?
Answer Choices:
a. Risk of intimate partner violence
b. Phobia of crowded places
c. Migraine headaches
d. Depressive symptoms
Answer:
A
Question: A child was abducted and raped. Which personal reaction by the nurse could interfere with the child’s care?
Answer Choices:
a. Disgust
b. Concern
c. Empathy
d. Compassion
Answer:
A
Question: What is a nurse’s legal responsibility if child abuse or neglect is suspected?
Answer Choices:
a. Discuss the findings with the child’s teacher, principal, and school psychologist.
b. Report the suspected abuse or neglect according to state regulations.
c. Document the observations and speculations in the medical record.
d. Continue the assessment.
Answer:
B
Question: Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources?
Answer Choices:
a. Support group
b. Law enforcement
c. Women’s shelter
d. Vocational counseling
Answer:
C
Question: A nurse working a rape telephone hotline should focus communication efforts toward what intervention?
Answer Choices:
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
Answer:
D
Question: A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, “I want to go to school but we can’t afford a babysitter. It doesn’t matter; I’m too dumb to learn.” What preliminary assessment is evident?
Answer Choices:
a. Insufficient data are present to make an assessment.
b. Child and siblings are experiencing neglect.
c. Children are at high risk for sexual abuse.
d. Children are experiencing physical abuse.
Answer:
B
Question: The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient’s discharge?
Answer Choices:
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.
Answer:
D
Question: An adult has recently been absent from work for 3-day periods on several occasions. Each time, this person returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse’s priority assessment question?
Answer Choices:
a. “Do you drink excessively?”
b. “Did your partner beat you?”
c. “How did this happen to you?”
d. “What did you do to deserve this?”
Answer:
C
Question: A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. The patient attends anger management classes. Which finding indicates success in this plan of care?
Answer Choices:
a. The patient expresses frustration verbally instead of physically.
b. The patient explains the rationale for behaviors to the victim.
c. The patient identifies three personal strengths.
d. The patient agrees to seek counseling.
Answer:
A
Question: Which situation constitutes consensual sex rather than rape?
Answer Choices:
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.
Answer:
A
Question: A nurse cares for a rape victim who was given flunitrazepam by the assailant. The nurse should conduct a history to:
Answer Choices:
a. Determine reasons that person receiving flunitrazepam cannot remember.
b. Collect evidence of voluntary muscles
c. Hypnotize the patient to recall any memory.
d. Signs and symptoms of respiratory depression
Answer:
D
Question: 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.)
Answer Choices:
a. Allow the person to talk at a comfortable pace.
b. Pose questions in nonjudgmental, empathetic ways.
c. Insist the person provide a written report and involve them in assembling the rape kit.
d. Reassure the person that a family reunion with an adult is possible.
e. Activate family members to the emergency department as soon as possible.
f. Put an arm around the person to offer reassurance that the nurse is caring and compassionate.
Answer:
A, B