Module 3 (Spiritual and Cultural Nursing Practices) 225

A surgeon tells a patient who is a Jehovah's Witness that they need emergency surgery to repair an aortic aneurysm, which will require blood transfusions. The patient states, "If I receive blood, I will not go to paradise. It is against my religion." What nursing response to the patient is appropriate? a. "I understand you will not receive blood products, even if it means you will die." b. "Please listen to the surgeon; I've seen many aneurysms successfully repaired" c. "Have you discussed your decision to refuse surgery with your family?" d. "What can I say to help you through this difficult decision?"

c. "Have you discussed your decision to refuse surgery with your family?" (Patients who practice the Jehovah's Witness faith believe blood transfusions violate God's laws and do not allow them. The nurse supports the patient's beliefs. It is disrespectful of the nurse to attempt to coerce a decision or impose their beliefs on the patient.)

A nurse in a long-term care facility is performing spirituality assessments of residents on their unit. What is the best question the nurse could use to assess for spiritual needs? a. "Can you describe your usual spiritual practices and how you maintain them daily?" b. "Are your spiritual beliefs causing you any concern?" c. "How can I and the other nurses help you maintain your spiritual practices?" d. "How do your religious beliefs help you to feel at peace?"

c. "How can I and the other nurses help you maintain your spiritual practices?" (Questioning how the staff can meet patients' spiritual practices assesses spiritual needs. Asking the patient to describe spiritual practices is an assessment of spiritual practices. Asking about concerns assesses spiritual distress, and asking about feeling at peace assesses the need for forgiveness.)

A nurse is interviewing a newly admitted patient from another culture. What question best displays cultural sensitivity? a. "Do you think you'll be able to eat the food we have here?" b. "You do understand that we can't prepare special meals?" c. "What types of food do you typically prepare for meals?" d. "Could you make an exception on what food you eat while you are here?"

c. "What types of food do you typically prepare for meals?" (Asking patients what types of foods they eat for meals is culturally sensitive. The other questions are culturally insensitive.)

A hospice nurse is caring for a patient who is dying of pancreatic cancer. The patient tells the nurse, "I feel no connection to God" and "I'm worried that I've found no real meaning in life." What is the nurse's best response to this patient? a. Give the patient a hug and tell them that their life still has meaning. b. Arrange for a spiritual advisor to visit the patient. c. Ask if the patient would like to talk about their feelings. d. Call in a close friend or relative to talk to the patient.

c. Ask if the patient would like to talk about their feelings. (When caring for a patient who is in spiritual distress, the nurse should listen to the patient first, then ask whether the patient would like to visit with a spiritual advisor. Arranging for a spiritual advisor first may not be respectful of the patient's wishes. A hug and false reassurances do not address the problem of spiritual distress. Talking to friends or relatives may be helpful, but only if the patient agrees.)

A parish nurse is speaking to a congregant whose adolescent child was arrested for shoplifting. The congregant is very angry, stating they cannot face the child, let alone discuss the situation: "I just will not tolerate a thief." What nursing action will best assist the congregant at this time? a. Assuring the congregant that many parents feel the same way b. Reassuring the congregant that many teenagers act rebelliously and that it will pass c. Assisting the congregant to identify how withholding forgiveness hurts them d. Asking the congregant if they have spent sufficient time with their child

c. Assisting the congregant to identify how withholding forgiveness hurts them (Helping the congregant identify how their unforgiving feelings may be harmful to themselves is the only intervention that directly addresses forgiveness, a universal spiritual need. Assuring the congregant that many parents would feel the same way or that many teenagers shoplift out of rebelliousness may make them feel better initially, but this does not address the benefits of forgiveness. Suggesting the congregant may not have spent enough time with their child may be untrue and could promote guilty feelings, when they may be unwarranted.)

A patient who lost their home, spouse, and children in a fire is depressed and states that they have no reason to live. The patient states, "My family was my life." The nurse documents a health problem of Spiritual Distress based on the patient's inability to find meaning and purpose in their current situation. What is the priority nursing action for this patient? a. Asking the patient which spiritual advisor they would like you to call b. Recommending that the patient engage in spiritual or religious readings c. Determining what has given the patient meaning and purpose in the past d. Reminding the patient that God is a loving and personal God

c. Determining what has given the patient meaning and purpose in the past (The nurse prioritizes determining what, in addition to their family, has given the patient's life meaning and purpose in the past. This helps the patient focus on their strengths. This assessment data can be used to further plan individualized spiritual care.)

A nurse who was raised as a strict Roman Catholic but is no longer practicing stated they could not assist patients with spiritual distress because they recognize only a "field of power" in each person. The nurse says to her colleague, "My parents and I hardly talk because I've deserted my faith. Sometimes I feel really isolated from them and God—if there is a God." These statements reveal which unmet spiritual need? a. Meaning and purpose b. Forgiveness c. Love and relatedness d. Strength for everyday living

c. Love and relatedness (The data point to an unmet spiritual need to experience love and belonging, given the nurse's estrangement from their family and God after leaving the church. The other options may represent other needs this nurse has, but the nurse's statements do not support them.)

clinical judgment

visible or observed outcome of the elements of critical thinking and decision making that considers nursing knowledge, client situations and prioritization of client problems and concerns, while utilizing evidence-based practice.

Four common skills that can be delegated to an AP by either an RN or a PN

vital signs collection, activities of daily living assistance and measurement of height and weight are skills commonly delegated to APs.

Holistic nursing care

which is based on considering all human dimensions affecting how the patient's basic human needs are met in health and in illness, allows the nurse to provide thoughtful, person-centered, health-oriented care.

Five steps of the nursing process (RN)

!. Assessment 2. Analysis 3. Planning 4. Implementation 5. Evaluation

The hierarchy is based on the theory that something is a basic need if it has the following characteristics: (6)

- Lacks fulfillment results in illness - Fulfillment helps prevent illness or signals health - Meeting it restores health - Priority over other desires & needs when unmet - Person feels something is missing when the need is unmet - Person feels satisfaction when the need is met

Consider the client experiencing pain. 5 questions to ask.

1. "Are you having pain?" 2. "How would you rate your pain on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine?" 3. "Where are you having pain?" 4. "How would you describe your pain?" 5. "Is there anything that makes your pain better? Worse?"

When providing culturally respectful care to a client from a different cultural background, which question is appropriate to begin a pain assessment? A. "Can you tell me what you think might be causing your pain?" B. "Have you tried anything to help stop the pain?" C. "Is there something you are not telling me about the pain?" D. "Do you have any tingling that comes with the pain?"

A. "Can you tell me what you think might be causing your pain?"

A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process? A. Evaluation B. Implementation C. Analysis D. Planning

D. Plannings

The National Council of State Boards of Nursing (NCSBN) has developed a :

Clinical Judgment Action Model (CJAM) that represents the process of making clinical judgments.

nursing process

A framework that guides nurses in delivering client-focused care that takes the entire person into consideration. A five-step sequential process that guides nurses in assessing and prioritizing care for clients. The five steps are assessment, analysis, planning, implementation, and evaluation.

interprofessional health care team

A group including members from different disciplines who work collaboratively with the client to make decisions and set goals.

plan of care

A plan including the client problem (analysis), plans and goals, implementation, and responses; it is used by the interprofessional health care team.

A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make? A. "Critical thinking is the foundation for clinical decision making." B. "Critical thinking takes into consideration nursing, scientific, and technological knowledge in client situations." C. "Critical thinking is the visible or observed outcome while using evidence-based practice." D. "Critical thinking is necessary for the nurse to collect objective client data."

A. "Critical thinking is the foundation for clinical decision making." (Critical thinking is considered a higher order of thinking that is the foundation for clinical decision making. It is a critical component of nursing care and is used in each step of the nursing process to enhance client care.)

A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the clients care requires clinical reason when it is complicated by which of the following factors? A. Complex clinical situations B. Ongoing client and family concerns C. Cost of health care D. Decreased need for advanced health care practitioner intervention E. Availability of computerized medical records

A. Complex clinical situations (For example, clients who have broken bones as well as a compromised airway need their airway to be stabilized prior to setting broken bones. Correct prioritization is a key part of clinical reasoning in complex care settings.) B. Ongoing client and family concerns (The nurse needs to carefully listen to everything that clients and their families say to collect information that might be useful in providing optimal care to the client.)

It is a religious holy day. The hospitalized client is withdrawn, occasionally tearful, and requests that a minister visit. Family is at the bedside. What action will the nurse take to address the client's spiritual distress on this day? A. Contact the chaplain to request to see the client today. B. Ask the client, "Can we pray together?" C. Provide religious material for the client to read. D. Encourage the family to talk to the client.

A. Contact the chaplain to request to see the client today.

A nurse asked the client to write the current level of pain using a scale of 0 to 10 after administering a pain medication 30 minutes ago. Which of the following steps of the nursing process is the nurse performing? A. Evaluation B. Implementation C. Analysis D. Planning

A. Evaluation (The nurse is using the evaluation step of the nursing process by collecting subjective data from the client using an established pain scale to compare the client's current pain level to their original level of pain.)

A 2-year-old child arrives at the emergency department of a local hospital with difficulty breathing from an asthmatic attack. What is the priority nursing intervention? A. assessing respirations and administering oxygen B. giving the child a favorite stuffed animal to hold C. asking the child's parent about favorite foods D. raising the side rails and restraining the child's arms

A. assessing respirations and administering oxygen

Developed a Hierarchy of Basic Human Needs

Abraham Maslow

delegation

Assigning a nursing task or procedure to another person who has the training appropriate for that task or procedure.

A nurse returns to a client's room 25 minutes after administering morphine 2 mg IV. How should the nurse evaluate the effectiveness of the intervention? A. Ask the client to walk down the hallway. B. Ask the client to rate the pain level. C. Observe the client for 10 minutes. D. Ask the client's family member if the morphine has helped.

B. Ask the client to rate the pain level.

A nurse is caring for a client who has been wheezing. The nurse asked an assistive personnel do use a stethoscope and listen to the clients lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts? A. Delegation of the right circumstance B. Delegation of the wrong task C. Delegation to the right person D. Delegation of the wrong time

B. Delegation of the wrong task (Delegating an AP to use a stethoscope and listen to lung sounds is inappropriate as it is not within the range of function of an AP. This action involves clinical reasoning and should be delegated to a nurse.)

A nurse caring for a client in isolation with tuberculosis is aware that the client's love and belonging needs may not be properly met. Which nursing action would help to meet these needs? A. Focusing on the client's strengths rather than problems B. Encouraging family to visit and help in the care of the client C. Using hand hygiene and sterile technique to prevent infection D. Respecting the client's values and beliefs

B. Encouraging family to visit and help in the care of the client

A nurse is caring for a client who constantly requests pain medication. What should the nurse consider when assessing the client's pain? A. Most people react to pain in the same way. B. Pain is what the client says it is. C. The client has a low pain tolerance. D. Pain in adults is less intense than pain in children.

B. Pain is what the client says it is.

A client states, "I have successfully raised my family and had a good life." This statement illustrates meeting which basic human need? A. Love and belonging B. Self-actualization C. Self-esteem D. Safety and security

B. Self-actualization

A nurse in a large metropolitan city has been working in a health clinic that has primarily served Middle Eastern clients for several years. The nurse is well-respected and effective in providing care to this population. Given this information, what can be inferred about the nurse? A. The nurse is attempting to overcompensate for cultural blindness and ethnocentrism within the community. B. The nurse is knowledgeable about Middle Eastern culture and respects and values providing culturally competent care. C. The nurse's knowledge and skills provide expected care for clients in this demographic. D. his employment has allowed the nurse to demonstrate ethnic identity and cultural bias to a specific group of people.

B. The nurse is knowledgeable about Middle Eastern culture and respects and values providing culturally competent care.

A client scheduled for complex heart surgery has been reading their religious text for hours each day, cries often, and is not sleeping well. What might these observations cue the nurse about the client? A. The client is naturally emotional and reactive. B. These behaviors are signs of spiritual distress. C. Family members live far away and the client is lonely. D. These behaviors are expected before major surgery.

B. These behaviors are signs of spiritual distress.

An immigrant lives with relatives in a community with many households from the country of origin. The client is taken to the emergency department following a fall at work and is admitted to the hospital for observation. The nurse is aware that this client is at risk for: A. cultural blindness. B. culture shock. C. cultural assimilation. D. cultural imposition.

B. culture shock.

objective data

Data that can be observed by the nurse through the senses. (seeing, hearing, smelling, touching). Not based on opinions. Ex: facial expressions, dry skin and respiratory rate.

Which statement by a nurse would nurture spirituality by promoting love and relatedness? A. "How often do you read your religious text each day?" B. "Tell me about what you do in your job." C. "Tell me about how you get along with others." D. "I know you are angry about your diagnosis."

C. "Tell me about how you get along with others."

A charge nurse is planning to discuss factors that can influence the clinical decision making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include? A. Appropriate delegation B. Cost of client care C. Available resources D. Awareness of client status E. Support from other staff

C. Available resources (Resources are factors that can influence the decision-making process, which is used as the framework for developing the plan of care.) D. Awareness of client status (The nurse's awareness of the client's status is a factor that can influence the decision-making process, which is used as the framework for developing the plan of care.) E. Support from other staff (The availability of support from other staff is a factor that can influence the decision-making process, which is used as the framework for developing the plan of care.)

A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion? A. Inspection B. Implementation C. Inference D. Creativity E. Inductive reasoning

C. Inference D. Creativity E. Inductive reasoning

According to Maslow's basic human needs hierarchy, which needs are the most basic? A. Love and belonging B. Self-esteem C. Physiologic D. Safety and security

C. Physiologic

What factor is necessary to express and experience spirituality? A. quiet time in isolation from others B. membership in an organized religion C. connectedness with other people D. long-term suffering and pain

C. connectedness with other people

Physical wellbeing

Caring for a client's ___________ means that the nurse helps maintain and improve the client's physical health. The nurse can promote physical well-being by providing the client with a nutritious diet, assisting the client to be physically active, and educating the client about recommended health screenings.

Spiritual wellbeing

Caring for a client's ______________ means something different for each client. The nurse can promote spiritual well-being by assisting a client to observe a religious practice, providing a client time for meditation, or praying with a client.

Mental wellbeing

Caring for a client's ______________ means that the nurse helps maintain and promote the client's mental health. The nurse can promote mental well-being by teaching the client relaxation techniques, taking the client for a walk outdoors, and assisting the client to maintain relationships with friends and family.

subjective data

Data that is based upon the client's feelings, perception and assumptions. Self-report. Ex: pain level, description of pain and other statements of clients experience.

An older adult client is brought to the emergency department via ambulance due to a fall. The client does not speak the area's dominant language. Shortly after the client arrives, several family members and a neighbor who called the ambulance arrive, all of whom speak the area's dominant language. When attempting to gather information about what happened, which action by the nurse is appropriate? A. Ask the client to explain as best as possible what occurred. B. Enlist the aid of a family member to answer the nurse's questions. C. Have the neighbor who called the ambulance explain what happened. D. Arrange for an interpreter to be present to translate.

D. Arrange for an interpreter to be present to translate.

A nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using? A. Evaluation B. Implementation C. Analysis D. Assessment

D. Assessment (The nurse should identify auscultating a client's lungs as being part of the assessment step of the nursing process because the nurse is collecting data from the client. Auscultating the client's lung sounds is part of a physical assessment.)

The nurse who is caring for a child admitted after an automobile accident recognizes the importance of including the child's family in the plan of care. Inclusion of the family meets which of Maslow's basic human needs? A. Self-actualization B. Physiologic C. Self-esteem D. Love and belonging

D. Love and belonging

Place the following levels of needs in the correct ascending order (starting with the most basic as 1) according to Maslow's hierarchy of basic human needs. A. Love and belonging needs B. Safety and security needs C. Self-esteem needs D. Physiologic needs E. Self-actualization needs

D. Physiologic needs B. Safety and security needs A. Love and belonging needs C. Self-esteem needs E. Self-actualization needs

Objective or Subjective ? 20mL of amber-colored urine

Objective

Objective or Subjective ? Cool and clammy skin

Objective

Objective or Subjective ? Crackles in the posterior left lung

Objective

Objective or Subjective ? Raised red rash on the left arm

Objective

Objective or Subjective ? Systolic heart murmur

Objective

Objective or Subjective ? Dull pain in the right knee

Subjective

Objective or Subjective ? Nausea for 2 days

Subjective

Objective or Subjective ? Report of difficulty breathing

Subjective

planning (Generate Solutions)

The _________ step of the nursing process involves the nurse s ability to make decisions and problem solve. The nurse uses a clients assessment data to develop measureable client goals/outcomes and identify nursing interventions. The nurse uses evidenced based practice to set client goals, establish priorities of care, and identify nursing interventions to assist the client to achieve their goals.

analysis (Analyze/Prioritize Hypotheses Cues)

The ____________ of assessment data to identify health problems/risks and a client s needs for health intervention. The nurse identifies patterns or trends, compares the data with expected standards or reference ranges and draws conclusions to direct nursing care.

evaluation (Evaluate Outcomes)

The _____________ of a client s response to nursing interventions and to reach a nursing judgment regarding the extent to which the client has met the goals and outcomes. During this step the nurse will also assess client/staff understanding of instruction, the effectiveness of interventions, and identify the need for further intervention or the need to alter the plan.

implementation (Take Actions)

The application of nursing knowledge to _______________ interventions to assist a client to promote, maintain, or restore their health. The nurse uses problem-solving skills, clinical judgment, and critical thinking when using interpersonal and technical skills to provide client care. During this step the nurse will also delegate and supervise care and document the care and the clients response.

assessment (Recognize Cues)

The application of nursing knowledge to the collection, organization, validation and documentation of data about a client's health status. The nurse thinks critically to perform a comprehensive ____________ of subjective and objective information.

critical thinking

Thought process that is systematic and logical in reviewing information and data, that is open to reflection, inquiry and exploration in order to make informed decisions. To make decisions or judgments.

At the last staff meeting, the nurse manager discussed the organizational initiative to improve provision of culturally competent care. During rounds, which behaviors inconsistent with this goal require the manager to intervene? Select all that apply. a. A staff nurse tells the AP that patients should not be given a choice, but should shower or bathe daily. b. A nurse asks the family of a patient who has died if they would like to wash their loved one's body. c. A nurse tells another nurse that Jewish dietary restrictions are just a way for them to get special foods. d. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. e. A nurse obtains a translator to speak to the patient in their native language. f. A nurse refuses to care for a married gay patient who is HIV positive because the nurse is against same-sex marriage.

a. A staff nurse tells the AP that patients should not be given a choice, but should shower or bathe daily. d. A Catholic nurse insists that a patient diagnosed with terminal bladder cancer see the chaplain in residence. (Cultural imposition occurs when someone believes others should conform to their beliefs, such as whether or not to shower or bathe daily, when a Catholic nurse insists that a terminally ill patient see a chaplain. Cultural blindness occurs when a nurse treats all patients the same regardless of culture. Culture conflict occurs when a nurse judges a patient's dietary restrictions as a way to get their favorite foods. When a nurse refuses to respect an older adult's ability to speak for themselves, or refuses to treat a patient based on their sexual orientation, stereotyping has occurred.)

A nurse is caring for patients in a long-term care facility. Which nursing actions are appropriate based on the religious beliefs of these patients? Select all that apply. a. Asking a Buddhist if they have any diet restrictions related to the observance of holy days b. Asking a Christian Scientist who is in traction if they would like to try nonpharmacologic pain measures c. Administering medications to a Muslim patient and avoiding touching the patient's lips d. Asking a Roman Catholic patient if they would like to attend Mass in the common room on Sunday e. Avoiding scheduling treatment and procedures on Saturday for a Hindu patient f. Consulting with the medicine man of a Native American patient and incorporating their suggestions into the care plan

a. Asking a Buddhist if they have any diet restrictions related to the observance of holy days b. Asking a Christian Scientist who is in traction if they would like to try nonpharmacologic pain measures d. Asking a Roman Catholic patient if they would like to attend Mass in the common room on Sunday f. Consulting with the medicine man of a Native American patient and incorporating their suggestions into the care plan (The nurse should ask a Buddhist if they have any diet restrictions related to the observance of holy days. Since Christian Scientists avoid the use of pain medications, the nurse should offer nonpharmacologic pain relief measures. A nurse administering medications to a Hindu patient avoids touching the patient's lips. A nurse should ask a Roman Catholic if they would like to attend Mass on Sunday. The nurse is careful not to schedule treatment and procedures on Saturday for a Jewish patient who observes the Sabbath. The nurse would appropriately consult with the medicine man of a Native American patient and incorporate their suggestions into the care plan.)

A nurse is practicing community-based nursing in a mobile health clinic. Which example best demonstrates community-based nursing? a. Caring for a mother and her child who have diabetes b. Providing shelter for vulnerable populations within the community c. Providing local same-day surgery facilities d. Assisting families in crisis and overseeing the crisis hotline

a. Caring for a mother and her child who have diabetes (Community health nursing focuses on whole populations within a community, and community-based nursing is centered on the health care needs of individuals and families. Nurses practicing community-based nursing provide interventions to manage acute or chronic health problems, promote health, and facilitate self-care.)

A nurse tells a patient, "tonight's menu selection is pork. I understand many people in your culture do not eat pork; may I order something else for you?" When the patient states they no longer observe this dietary practice, the nurse understands that the patient has experienced what transition? a. Cultural assimilation b. Cultural imposition c. Culture shock d. Ethnocentrism

a. Cultural assimilation (Assimilation occurs when minority groups living within a dominant group lose the cultural characteristics that make them different. Cultural imposition occurs when one person believes that everyone should conform to their own belief system. Culture shock occurs when a person is placed in a different culture perceived as strange, and ethnocentrism is the belief that the ideas, beliefs, and practices of one's own cultural group are best, superior, or most preferred to those of other groups.)

A nurse tells a new mother from Africa that she should not carry her infant in a sling because bassinets are safer. The charge nurse suggests the nurse is displaying which behavior? a. Cultural imposition b. Clustering c. Cultural competency d. Stereotyping

a. Cultural imposition (The nurse is trying to impose her belief that bassinets are preferable to baby slings on the African mother—in spite of the fact that African women have safely carried babies in these slings for years.)

After terminating a pregnancy, a patient tells the nurse, "I shouldn't have had that abortion because I'm Catholic, but what else could I do? I'm afraid I'll never get close to my mother or back in the Church again." They then talk with their priest about this feeling of guilt. Which evaluation statement shows a solution to the problem? a. Patient stated, "I wish I had talked with the priest sooner. I now know God has forgiven me, and my mother is beginning to understand." b. Patient has slept from 10 pm to 6 am for 3 consecutive nights without medication. c. Patient has developed mutually caring relationships with others. d. Patient has identified several spiritual beliefs that give purpose to their life.

a. Patient stated, "I wish I had talked with the priest sooner. I now know God has forgiven me, and my mother is beginning to understand." (The patient's statements indicate feelings of guilt, which has caused spiritual distress. Only option a clearly evaluates whether the patient's feelings of guilt have resolved after speaking to the priest.)

A nurse performs an assessment of a family consisting of a single parent, a grandparent, and two children. What interview questions will the nurse direct toward the mother to best determine the family's affective and coping functions? Select all that apply. a. Who is the person you depend on for emotional support? b. Who is the person you depend on for financial support in your family? c. Do you plan on having any more children? d. Who keeps your family together in times of stress? e. What family traditions do you pass on to your children?

a. Who is the person you depend on for emotional support? d. Who keeps your family together in times of stress? (The five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. Affective areas of function include feelings and coping, assessed by determining who provides emotional support in times of stress. Assessing the financially responsible individual focuses on the economic function. Inquiring about having more children assesses the reproductive function, asking about family traditions assesses the socialization function, and checking the environment assesses the physical function.)

A nurse is prioritizing nursing care for patients on a medical-surgical unit. Which nursing interventions address patients' physiologic needs? Select all that apply. a. Preventing falls during admission b. Administering oxygen to a patient with shortness of breath c. Providing a magazine for a patient without visitors d. Assisting a patient who had a stroke eat their dinner e. Facilitating a visit from the patient's significant other f. Referring a patient to a cancer support group

b. Administering oxygen to a patient with shortness of breath d. Assisting a patient who had a stroke eat their dinner (Physiologic needs—oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. Providing food and oxygen are examples of interventions to meet these needs. Preventing falls helps meet safety and security needs; providing art supplies may help meet self-actualization needs; facilitating visits from loved ones helps meet self-esteem needs; and referring a patient to a support group helps meet love and belonging needs.)

An ambulatory care nurse serving a large, culturally diverse population is planning a free blood pressure screening clinic. Based on the nurse's understanding of racial differences in health and illness, which groups will the nurse target for screening? Select all that apply. a. Native American people b. African American people c. Alaska Native people d. Asian people e. White people f. Hispanic people

b. African American people c. Alaska Native people e. White people (African American people, Asian people, and White people are more prone to developing hypertension. Alaska Native individuals and Native American individuals are prone to heart disease, diabetes, cirrhosis, and fetal alcohol syndrome.)

A nurse who is comfortable with spirituality is caring for a patient who needs spiritual counseling. What action will the nurse take first? a. Calling the patient's own spiritual advisor b. Asking if the patient has a spiritual advisor they wish to consult c. Counseling the patient and, if unsuccessful, making a referral to a spiritual advisor d. Explaining the best health options for the patient to the spiritual advisor

b. Asking if the patient has a spiritual advisor they wish to consult (Even when a nurse feels comfortable discussing spiritual concerns, they should always determine whether the patient has a spiritual advisor they would like to consult. Calling the patient's spiritual advisor may be premature if it is a matter the nurse can handle. The other two options deny the patient's right to speak privately with their spiritual advisor from the outset, if that is their preference.)

A nurse caring for families in a free health care clinic assesses for psychosocial risk factors for altered family health. Which example best describes one of these risk factors? a. The family does not have dental care insurance or resources to pay for it. b. Both parents work and leave a 12-year-old child to care for his younger brother. c. Both parents and their children are considerably overweight. d. The youngest member of the family has cerebral palsy and needs assistance from community services.

b. Both parents work and leave a 12-year-old child to care for his younger brother. (Inadequate childcare resources are a psychosocial risk factor. Not having access to dental care and obese family members are lifestyle risk factors. Having a family member with birth defects is a biologic factor.)

Nurses in a long-term care facility use Maslow's hierarchy of basic human needs to plan care for their patients. What is the expected outcome when using this hierarchy ? a. Accurate nursing diagnoses b. Clear priorities of care c. Concerns communicated concisely d. Integration of science into nursing care

b. Clear priorities of care (Maslow's hierarchy of basic human needs is useful for establishing priorities of care.)

A nurse is using the Explanatory Model of Health and Illness (ESFT) model to assess how a patient from another culture views their diagnosis of chronic obstructive pulmonary disease (COPD). What interview question is most appropriate to assess the E aspect of this model? a. How do you get your medications? b. How does having COPD affect your lifestyle? c. Are you concerned about the side effects of your medications? d. Can you describe how you will take your medications?

b. How does having COPD affect your lifestyle? (The ESFT model, a cross-cultural communication tool, guides providers in understanding a patient's explanatory model (a patient's conception of their illness), social and environmental factors, and fears and concerns and also guides providers in contracting for therapeutic approaches. Asking the questions: "How does having COPD affect your lifestyle?" explores the explanatory model, "How do you get your medications?" refers to the social and environmental factor, "Are you concerned about the side effects of your medications?" addresses fears and concerns, and "Can you describe how you will take your medications?" involves therapeutic contracting.)

A hospice nurse who provides pastoral care is teaching nursing students about the three spiritual needs believed to be common to all people. Which of these will the nurse include in the discussion? Select all that apply. a. Food, clothing, and shelter b. Meaning and purpose c. Family d. Love and relatedness e. Forgiveness f. Rules to live by

b. Meaning and purpose d. Love and relatedness e. Forgiveness (Meaning and purpose, love and relatedness, and forgiveness are the three spiritual needs believed to be common to all people. Option a is a human need as described by Maslow, as is family (love and belonging). Many people live by a set of rules, but this is not a common spiritual need.)

A young Hispanic mother comes to the local clinic because her baby is sick. She speaks only Spanish, and the nurse speaks only English. Which action should the nurse take next? a. Use short words and speak loudly b. Obtain a medical interpreter c. Explain why care cannot be provided d. Provide instructions in writing

b. Obtain a medical interpreter (Requesting an interpreter reflects best practice. Qualified interpreters, available in many facilities or via video or phone, have knowledge of health care and can provide assistance. Using short words, talking loudly, and providing instructions in writing will not aid communication. Explaining why care cannot be provided will not meet the patient's health needs; the nurse is required to provide care. Since the patient doesn't speak English, this will not be understood.)

A nurse provides care for postoperative patients using meticulous hand hygiene and aseptic technique. Which of Maslow's basic human needs is the nurse addressing? a. Physiologic b. Safety and security c. Self-esteem d. Love and belonging

b. Safety and security (By using meticulous hand hygiene and aseptic technique, nurses prevent infection, which falls under safety. An example of a physiologic need is clearing a patient's airway. Self-esteem needs may be met by allowing an older adult to talk about a past career. An example of helping meet a love and belonging need is contacting a hospitalized patient's family to arrange a visit.)

A nurse caring for patients in a long-term care facility develops strategies to help patients achieve Maslow's highest level of needs: self-actualization. Which concepts will the nurse incorporate when planning care? Select all that apply. a. Humans are born with a fully developed sense of self-actualization. b. Self-actualization needs are met by depending on family, friends, and others for help. c. No matter the patient's age, the self-actualization process continues throughout life. d. Loneliness and isolation occur when self-actualization needs are unmet. e. A person achieves self-actualization by focusing on problems outside self. f. Self-actualization needs may be met by creatively solving problems.

c. No matter the patient's age, the self-actualization process continues throughout life. e. A person achieves self-actualization by focusing on problems outside self. f. Self-actualization needs may be met by creatively solving problems. (Self-actualization, or reaching your full potential, is a process that continues throughout life. A person achieves self-actualization by focusing on their unique capabilities, being creative, and demonstrating the capacity for happiness and affection for others. Humans are not born with a fully developed sense of self-actualization, and self-actualization needs are not met specifically by depending on others for help. Loneliness and isolation are not always the result of unmet self-actualization needs.)

A nurse working in a new community performs an assessment to determine the health of the community. What finding indicates a healthy community? a. Meets all the needs of its inhabitants b. Mixes residential and industrial areas c. Offers access to health care services d. Consists of modern housing and condominiums

c. Offers access to health care services (A healthy community offers access to health care services to treat illness and to promote health. A healthy community cannot usually meet all the needs of its residents, but should be able to help with health issues such as nutrition, education, recreation, safety, and zoning regulations to separate residential sections from industrial areas. The age of housing is irrelevant as long as residences are maintained according to code.)

After receiving a change-of-shift report, the nurse on a medical-surgical unit sets initial priorities for care. According to Maslow's hierarchy of needs, which patient requires immediate assessment? a. Patient requesting help to phone family to ask them to visit b. Patient who needs education on changing their wound dressing prior to discharge c. Patient who calls for assistance because they are breathing fast and feel faint d. Patient who needs assistance to walk to the bathroom to void

c. Patient who calls for assistance because they are breathing fast and feel faint (The nurse prioritizes the patient with rapid breathing who feels faint, who may need oxygen or additional assistance with physiologic needs. Family visits help meet love and belonging needs, while assisting the patient to prevent falls and proper dressing change technique meets safety and security needs.)

A nurse who is caring for patients on a pediatric unit is assessing children's spiritual needs. Which is the most important source of learning for a child's own spirituality? a. Child's church or religious organization b. What their parents say about God and religion c. Their parents' behavior in relationship to the family, others, and to God d. Family's spiritual advisor

c. Their parents' behavior in relationship to the family, others, and to God (Children learn most about their own spirituality from how their parents behave in relationship to one another, their children, others, and God (or a higher being). What parents say about God and religion, the family's spiritual advisor, and the child's church or religious organization are less important sources of learning.)

A community organization includes provision of culturally competent care in their mission. Which action has the organization set as a priority? a. Learning the predominant language of the community b. Obtaining significant information about the community c. Treating each patient at the clinic as an individual d. Recognizing the importance of the patient's family

c. Treating each patient at the clinic as an individual (In all aspects of nursing, patients should be treated as individuals; this remains true when providing culturally competent care. Additional ways to provide culturally competent care include learning the predominant language in the community, researching the patient's culture, and recognizing the influence of family on the patient's life.)

The charge nurse overhears a nurse state, "That patient is 78 years old—too old to learn how to change a dressing." How should the charge nurse respond? a. "Please don't impose your view of the patient's culture on them." b. "I wish you would try to demonstrate more cultural sensitivity." c. "Try to be open to your patient's culture, to make the biggest impact." d. "Grouping all older adults as having trouble learning is a form of stereotyping."

d. "Grouping all older adults as having trouble learning is a form of stereotyping." (Stereotyping is assuming that all members of a group are alike. This is not an example of cultural competence nor is the nurse imposing her culture on the patient. The information in this scenario does not suggest the nurse is not open to her patient's culture.)

A patient who stated their religion as Jewish at the intake interview was served a kosher meal ordered from a restaurant on a paper plate because the hospital had no provision for kosher food or dishes. The patient became angry and accused the nurse of insulting him, emphatically stating, "I want to eat what everyone else does—and give me decent dishes." After analyzing the data, the nurse returns to the patient and makes which of these statements? a. "I'm terribly sorry, I should have ordered kosher food and dishes as well." b. "Did someone on the staff behave condescendingly or critically?" c. "It seems difficult to please you today." d. "We did not ask about your dietary preferences; tell me what you usually eat."

d. "We did not ask about your dietary preferences; tell me what you usually eat." (On the basis of the patient's stated religion, the nurse assumed they would want a kosher diet. This is a form of stereotyping. When evaluating the outcome of the situation, the nurse returns to the first step of the nursing process and assesses the patient's dietary practices and preferences.)

A nurse working in an "Aging in Place" facility interviews a married couple in their late 70s. Based on Duvall's Developmental Tasks of Families, what developmental task is most appropriate for the nurse to assess? a. Maintenance of a supportive home base b. Strength of the marital relationship c. Ability to cope with loss of energy and privacy d. Adjustment to retirement years

d. Adjustment to retirement years (The developmental tasks of the family with older adults are to adjust to retirement and possibly to adjust to the loss of a spouse and loss of independent living. Maintaining a supportive home base and strengthening marital relationships are tasks of the family with adolescents and young adults. Coping with loss of energy and privacy is a task of the family with children.)

A nursing student is caring for a patient admitted with chest pain related to aortic valve stenosis. The student notes the patient, who had been calm and cooperative the day before, has become contemplative and withdrawn, stating, "I've never thought much about dying, but my chances of making it through tomorrow's surgery are 50-50." How does the student best respond when the clinical professor asks the student why this behavior likely surfaced later in the patient's admission? a. Patients usually want to maintain privacy about their spiritual needs. b. People are better able to focus on spiritual needs after their spiritual advisor visits. c. Family members and close friends often initiate spiritual concerns. d. Illness increases spiritual concerns, which may initially be difficult to verbalize.

d. Illness increases spiritual concerns, which may initially be difficult to verbalize. (Illness may increase spiritual concerns, which many patients find difficult to initially express. The other options presume patients are purposefully secretive or must speak with a spiritual advisor, friends, or family to promote discussion of spiritual concerns. Spirituality is anything that pertains to a person's relationship with a nonmaterial life force or higher power; there is no universal definition, as the experience is individual and personal.)

A nurse in a family-centered health clinic is assessing a new family composed of two parents and three preschool children. Which value does the nurse include in a family-centered approach to health care? a. Each person in the family will be evaluated and treated independently of the others. b. Time will be saved as there is only one clinic to contact for health problems. c. All members of the family can be part of health-related decisions. d. Interdependence of family members affects them in illness and health.

d. Interdependence of family members affects them in illness and health. (Families likely share beliefs and values about health and illness. The nurse can help reduce risk for all family members at any level of development and recognizes interdependence of families affect one another in illness and health promotion.)

A surgeon will not attempt a life-saving repair of a ruptured aneurysm unless the patient agrees to receive blood transfusions. Although receiving blood products is against the patient's religious beliefs, the surgeon ordered four units of packed red blood cells. What action will the nurse take first? a. Administer the blood transfusion b. Call the patient's family and ask them to reason with the patient c. Discuss obtaining a court order to save the patient's life d. Maintain the patient's comfort and support their decision

d. Maintain the patient's comfort and support their decision (The nurse does not force patients to participate in care that conflicts with their values. Imposing such care may engender feelings of guilt and alienation from a religious or cultural group and create a threat to the patient's well-being.)

The Roman Catholic family of an infant born with hydrocephalus requests a baptism for their infant. The nurse advocates for the family's wishes to be honored for which reason? a. Baptism frequently helps postpone or prevent death or suffering. b. It is legally required that the nurse provide for this care when requested. c. It is a nursing function to assure the salvation of the infant. d. Not facilitating the baptism may increase the family's sorrow and suffering.

d. Not facilitating the baptism may increase the family's sorrow and suffering. (Failure to ensure that an infant baptism is performed when parents desire it may greatly increase the family's sorrow and suffering. Whether baptism postpones or prevents death and suffering is a religious belief that is insufficient to bind all nurses. There is no legal requirement regarding baptism, and although some nurses may believe part of their role is to ensure the salvation of the infant, this function could be rejected by many.)

A nurse is caring for patients of diverse cultures in a community health clinic. Which concepts will the nurse incorporate to guide the plan of care? Select all that apply. a. The United States has become less inclusive of same-sex couples. b. Cultural diversity is limited to people of varying cultures and races. c. Cultural diversity is separate and distinct from health and illness. d. People may be members of multiple cultural groups at one time. e. Culture guides what is acceptable behavior for people in a specific group. f. Cultural practices may evolve over time but mainly remain constant.

d. People may be members of multiple cultural groups at one time. e. Culture guides what is acceptable behavior for people in a specific group. f. Cultural practices may evolve over time but mainly remain constant. (A person may belong to multiple cultural, ethnic, and racial groups at one time. Culture guides what is acceptable behavior for people in a specific group. Cultural practices and beliefs may evolve over time, mainly remaining constant as long as they satisfy a group's needs. The United States has become more inclusive of same-sex couples. The definition of cultural diversity includes, but is not limited to, people of varying cultures, racial and ethnic origin, religion, language, physical size, biologic sex, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural diversity, an integral component of health and illness, includes culture, ethnicity, and race.)

A patient states they feel very isolated from their family and church, and even from God, "in this huge medical center so far from home." When preparing expected outcomes for this patient, which most appropriately measures relief of the patient's spiritual distress? a. The patient will express satisfaction with the compatibility of their spiritual beliefs and everyday living. b. The patient will identify spiritual beliefs that meet their need for meaning and purpose. c. The patient will express peaceful acceptance of limitations and failings. d. The patient will identify spiritual supports available to them in this medical center.

d. The patient will identify spiritual supports available to them in this medical center. (Each of the four options represents appropriate spiritual goals, but identifying spiritual supports available to this patient in this medical center at this point in time, is the most appropriate and realistics.)

clinical reasoning

requires nurses to have critical thinking abilities that are then applied to the practice setting. (client care)