270 week 2 spirituality

A client has been admitted with depression and asks to speak with the hospital chaplain. What is your most therapeutic nursing intervention?

"I will try my best to have the chaplain visit you as soon as possible." All patients have spiritual needs, regardless of diagnosis. If the patient indicates a need for spiritual care, it should be provided.

Which client statement most clearly suggests the potential of a nursing diagnosis of Spiritual Anxiety?

"Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." Worry about one's spiritual condition is indicative of the nursing diagnosis of Spiritual Anxiety. Unfamiliarity with the religious character of a care setting suggests Spiritual Alienation, while questions of suffering often indicate Spiritual Pain or Spiritual Despair. Regrets over previous religious or spiritual apathy may suggest a nursing diagnosis of Spiritual Guilt.

The nurse is collecting the health history of a client and notes the client is apprehensive in answering questions. The client states, "My spiritual healer will be here soon." What is the best response by the nurse?

"We can wait until your spiritual healer arrives and work together to answer these questions" The culturally sensitive nurse understands that some cultures rely on a spiritual healer to restore harmony and health. If the client requests the spiritual healer to be present, the nurse should respect the client's beliefs and decision. Leaving the questionnaire with the client is not acceptable because the nurse needs to make sure the questionnaire is completed with the client. Telling the client that he or she is the only one who can fill out the questionnaire is not necessary and rude. Telling the client that the questions need to be answered so the health care team can provide the best care is important, but recognizing and supporting the client and his or her beliefs is the priority.

A nurse identifies a nursing diagnosis of spiritual distress for a patient based on assessment of which of the following? Select all that apply.

- anger - despair - ambivalence Spiritually distressed patients may show despair, discouragement, ambivalence, detachment, anger, resentment, or fear. They may question the meaning of suffering or life and express a sense of emptiness.

The nurse is caring for an adolescent client. What is the best way for the nurse to obtain data related to the client's spirituality?

Ask the client if there are aspects of the client's life they consider to be spiritual In a spiritual assessment, the nurse may ask if there are any aspects of the client's life they feel are of a spiritual nature. Limiting the discussion to religion does not capture all person's definition of spirituality. This client is old enough to respond to such questions independently. Asking the client's parents if the client attends services does not give the client an opportunity to discuss the client's own spirituality. Observing whether the client reads religious material does not provide adequate information about the client's spirituality. Asking about spiritual leaders makes the assumption the client has these in their life, which may not be the case

It is a religious holy day. The hospitalized client is withdrawn, occasionally tearful, and requests a minister to see him. Family is at the bedside. What action would the nurse take to address the client's spiritual distress on this day?

Contact the chaplain to request to see the client today The client has asked for a minister to see him. To best address the client's need, the nurse would refer to the chaplain. Even on a holy day, there is usually a spiritual caregiver on call for the hospital. Encouraging the family to talk to the client ignores the client's request. The other options may bring some relief to the client, but they still ignore his request for a spiritual caregiver.

A client, age 22, is admitted in a psychotic episode. The client's frequent requests to speak with the hospital chaplain are interspersed with profanities regarding God and the devil. The most therapeutic nursing intervention would be to

Continue providing safe, effective care and give anti-psychotic medications as ordered to reduce symptoms of psychosis Safety is the nurse's first priority. The client is experiencing altered thought processes and is unlikely to be able to distinguish his spiritual beliefs at this time.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?

Discuss possible alternatives to a blood transfusion with the physician As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants?

Encourage parents to be present during the treatment When caring for infants and newborns, the best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child.

The nurse is caring for a client whose treatment has been based on the Ayurveda medical system. Which nursing intervention incorporates this client's beliefs into the nursing plan?

Helping the client to balance his or her dosha Central to Ayurvedic medicine is an understanding of the client's basic constitution, or dosha. The three doshas in Ayurvedic medicine are vata (changeable), pitta (intense), and kapha (relaxed). Yin-yang and qi are associated with traditional Chinese medicine. A shaman is associated with shamanism (involves the spirit world).

Which culturally related perspective on illness/disease involves a belief in supernatural forces or a higher power?

Magico-religious According to the magico-religious perspective, supernatural forces dominate. Examples include faith healing in some Christian faiths and voodoo or witchcraft in some Caribbean cultures. Health beliefs are a person's ideas about what causes illness, the role of the sick person, how to restore health, and how one stays healthy. The biomedical or scientific view is generally shared by Western healthcare personnel. An example is the belief that bacterial or viral organisms cause meningitis. The natural/holistic view espouses that human beings are only one part of nature. Natural balance or harmony is essential for health. Homeopathy is an alternative treatment modality. It is not a cultural view of illness/disease.

The nurse is taking care of a client who is scheduled for a mastectomy. The client tells the nurse that the client is apprehensive about the operation and asks the nurse to read a passage from the Koran to help prepare the client for surgery. Which action by the nurse is the most appropriate?

Read the Koran passage to the client According to Maslow's hierarchy, self-actualization is a need related to the spiritual and intellectual dimension of a client. Reading a religious passage to a client is not practicing a religion, and asking to call a minister or another staff member to address this spiritual need is deferring the client's needs to someone else.

A client is on a stress management program. She states that she is open to trying a guided meditation class. When helping her get started, a nurse tells her that which of the following is not important?

Soft music Music may be helpful for some but is not essential for meditation.

A nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse?

"It sounds like that offers you a sense of security" Spiritual or religious beliefs give meaning to life, illness, other crises, and death; contribute a sense of security for present and future; guide daily living habits; drive acceptance or rejection of other people; furnish psychosocial support within a group of like-minded people; provide strength in meeting life's crises; and give healing strength and support. The nurse can respond to the client by validating the client's sense of security. It is not therapeutic for the nurse to judge whether a spiritual belief is good or bad. It is false hope to tell the client that people with strong beliefs have better outcomes. It is not the nurse's place to tell the client to think about the client's spiritual leader in times of doubt.

The nurse's client states that his pastor is coming in a few hours to pray with him and offer sacrament. The nurse plans to do the following things in preparation for this. Select all that apply.

- clear the bedside table; cover with clean towel - have a chair available near the bed - clean the room of unnecessary items When expecting a visit from a client's spiritual counselor, preparations may vary, but the following are usually recommended: • The room should be orderly and free of unnecessary equipment and items. • There should be a seat for the religious counselor at the bedside or near the client so that both can be comfortable. • The bedside table should be free of items and covered with a clean, white cover if a sacrament is to be administered. • The bed curtains should be drawn for privacy if the client can't be moved to a more private setting. The nurse should not expect or plan to join a private group such as described.

A nurse working in a facility that cares for clients with Alzheimer's includes spirituality in client care. A family caregiver tells the nurse that faith has been broken and asks about help in getting through the day. What approaches can the nurse use to help the family member? Select all that apply.

- help the family member get relief so church services can be attended - contact the family church group members for assistance - give the family member some spiritual reading materials Spiritual nurturing for the client's family caregiver(s) also is important. Recent research findings support the importance and value of caregivers' spirituality, yet this resource is often overlooked. Consider using interventions that enhance a caregiver's ability to take part in spiritual activities to satisfy his or her spiritual needs and to work with religious groups to secure helpful services. Using clergy, prayer, forgiveness, and spiritual reading materials as resources for caregivers may also be helpful.

Upon assessment, the client reports that they do not belong to an organized religion. The nurse is correct to interpret this statement as the

Client is not affiliated with a specific system of belief regarding a higher power The nurse should not interpret the fact that a client does not belong to an organized religion to mean that the client has no spiritual need; a person may be highly spiritual yet not profess a religion. The client may seek spiritual counseling during hospitalization related to spiritual needs.

Nurses are responsible for delivering culturally competent care for all clients. Culturally competent care does not account for:

Client's height In partnership with the person, family, and others; the nurse develops an individualized plan considering the person's characteristics or situation including but not limited to: values, beliefs, spiritual and health practices, preferences, choices, developmental level, coping style, culture, environment, and available technology. A physical characteristic such as one's height does not contribute to cultural competence.

A nurse is of the Catholic faith and votes pro-life. This nurse is considered to have:

Personal values The only information given here tells us that this nurse has personal values on a particular issues. Personal values are ideas or beliefs a person considers important and feels strongly about. Moral agency is the ability to do the ethically right thing because one knows it is the right thing to do. Ethics is a systematic study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct and human flourishing. Legal obligations are behaviors and actions required by law.

The nurse caring for a bedridden hospitalized client who states that this will be the first time that he has missed a Methodist church service in 50 years plans care based on which of the following NANDA-I diagnoses?

Spiritual distress related to inability to attend church services evidenced by verbal states of guilt Persons suffering spiritual dysfunction or distress may verbalize such distress or express a need for help. Developing a three-part nursing diagnosis consists of data analysis, problem identification, and the formulation of the nursing diagnosis. There are four different types of nursing diagnoses: actual nursing diagnosis, wellness (or health promotion) nursing diagnosis, risk nursing diagnosis, and syndrome diagnosis. The other three statements are missing part of the nursing diagnosis.