ATI LPN
Test Bank for Essentials of Psychiatric Mental Health Nursing: A Communication Approach to Evidence-Based Care, 4e 4th Edition
Chapter 22 Questions
Question 1 of 5
After assessing a victim of sexual assault, which terms could the nurse use in the documentation? (Select all that apply.)
Correct Answer: B,C,F
Rationale: Reported,' 'penetration,' and 'declined' are appropriate, avoiding pejorative language. 'Alleged,' 'intercourse,' and 'refused' are not recommended.
Question 2 of 5
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?
Correct Answer: B
Rationale: The patient should not bathe until the forensic examination is complete to preserve evidence critical for court proceedings. The other options would destroy evidence or are inappropriate.
Question 3 of 5
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.
Correct Answer: A
Rationale: The victim's words suggest hopelessness, indicating a risk for suicide. Directly addressing suicidal ideation is critical. The other options offer reassurance without assessing the risk.
Question 4 of 5
A nurse cares for a rape victim who was given flunitrazepam by the assailant. Which condition has priority?
Correct Answer: D
Rationale: Monitoring for respiratory depression is the priority, as flunitrazepam can cause severe respiratory issues, which are life-threatening. Other conditions are secondary.
Question 5 of 5
A child was abducted and raped. Which personal reaction by the nurse could interfere with the child's care?
Correct Answer: A
Rationale: Feelings of empathy, concern, and compassion are helpful. Disgust may make objectivity impossible and can increase the child's anxiety and shame.