TownsendPMHN, 10eChapter 34 - ETBis collected.4.This is incorrect. Providing cues is not an appropriate nursing action.CON: Violence5. In the emergency department, a client who was raped appears calm and exhibits a blunt affect.The client answers the nurse’s questions in a monotone using single words. Which statementindicates the nurse interpretation of this client’s responses?
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ANS: 3Chapter: Chapter 34, Survivors of Abuse or NeglectObjective: Describe physical and psychological effects on the survivors of intimate partnerviolence, child abuse, and sexual assault.Page: 770Heading: Sexual Violence > The VictimIntegrated Processes: Nursing ProcessNursing Process: AssessmentClient Need: Psychosocial IntegrityCognitive Level: Analysis [Analyzing]Concept: ViolenceDifficulty: ModerateFeedback1.This is incorrect. The client’s response is not indicative of lying but of a controlledresponse pattern.2.This is incorrect. The silent rape reaction is evident when the survivor tells no oneabout the assault. Anxiety is suppressed, and the emotional burden may becomeoverwhelming.3.This is correct. This client’s responses reflect a controlled response pattern, in whicha rape victim’s affect is calm, controlled, or subdued, and feelings are masked orhidden.4.This is incorrect. In a compounded rape reaction,additional symptoms such asdepression and suicide, substance abuse, and psychotic behaviors may occur.CON: Violence
