Health Assessment Ch 12 PrepU

While completing a spiritual assessment, which question would provide the most information about a patient's sources of hope and strength? 1) "What do you think is going to happen to you?" 2) "Is prayer helpful to you?" 3) "What religious symbols are helpful to you?" 4) "Who is the most important person to you?"

4) "Who is the most important person to you?"

A nurse interviews a client with bipolar mood disorder. Which formal assessment tool for spiritual health should the nurse use? - Beck Depression Inventory_II (BDI-II) - Brief Religious Coping Questionnaire (RCOPE) - FICA - CES-D

- Brief Religious Coping Questionnaire (RCOPE) RCOPE is a formal assessment tool for spiritual health. RCOPE stands for Brief Religious Coping Questionnaire. It consists of a set of questions for which the ratings are given. FICA is a non-formal assessment tool for spiritual health. BDI-II and CES-D are depression scales.

A client is a vegetarian because it is an expectation of the client's religion. For which religions is vegetarianism a likelihood? Select all that apply. 1) Buddhism 2) Hinduism 3) Christianity 4) Judaism 5) Islam

1) Buddhism 2) Hinduism

Matters of the human soul are referred to as what? 1) Ethnicity 2) Spirituality 3) Culture 4) Values and beliefs

2) Spirituality

A client asks how long the hospitalization will be since family and friends will not be able to visit because of the distance to travel. Which nursing diagnosis should be identified for this client's concern? 1) RC: Depression 2) Hopelessness 3) Risk for social isolation 4) Anxiety

3) Risk for social isolation

The patient states, "I cannot believe I have breast cancer. I am a good person; I don't know why God is punishing me." The nurse suspects the patient is experiencing: 1) Spiritual distress 2) Social isolation 3) Impaired social interaction 4) Readiness for enhanced spiritual well-being

1) Spiritual distress

The path one pursues in the search for life's meaning and purpose. 1) Religion 2) Spirituality 3) Denomination 4) Philosophy

2) Spirituality

A nurse is using a quick reference to guide the spiritual assessment. A published acronym related to the assessment of spirituality is which of the following? 1) FICA 2) FACES 3)PIE 4) PRN

1) FICA

A nurse should assess patients for signs of spiritual distress, which include which of the following? (Select all that apply.) 1) wishing to die 2) anger 3) singing 4) crying

1) wishing to die 2) anger 4) crying

Prior to assessing the spirituality of the patient, what is important for the nurse to do? 1) Talk to a religious leader. 2) Have knowledge of his/her own spirituality. 3) Be affiliated with a house of worship. 4) Have an understanding of all religious practices.

2) Have knowledge of his/her own spirituality.

The nurse learns that a client routinely engages in spiritual practices. Which activities should the nurse document as being spiritual in nature? Select all that apply. 1) Knitting 2) Prayer 3) Baking bread 4) Attending church 5) Yoga

2) Prayer 4) Attending church 5) Yoga

While discussing care needs a client states the desire to be positive about the upcoming medical treatments and expect them to help cure the disease. Which nursing diagnosis should the nurse identify for this client? 1) Risk for spiritual distress 2) Readiness for enhanced hope 3) Hopelessness 4) Spiritual distress

2) Readiness for enhanced hope

Spirituality can best be described as 1) another way of expressing a connection to a church. 2) a part of community identification. 3) a source of inner strength. 4) necessary for healing.

3) a source of inner strength.

A nurse is aware that religion can sometimes negatively affect health. Which of the following is an example? 1) practicing yoga 2) taking multiple medications 3) failure to seek timely and proper medical care 4) receiving blood transfusions

3) failure to seek timely and proper medical care

After completing a spiritual assessment, a nurse determines that the patient has signs and symptoms requiring medical diagnosis and treatment. What should the nurse do? 1) Return to the patient to further discuss spirituality. 2) Treat the medical condition. 3) Ignore the medical problem. 4) Make a referral to a primary care provider.

4) Make a referral to a primary care provider.

The nurse reviews data collected while completing a spiritual assessment with a client. Which data should the nurse focus as the primary source of information for this assessment? 1) Secondary sources 2) Objective 3) Medical record 4) Subjective

4) Subjective

When performing a spiritual assessment, what may help the nurse to identify related nursing diagnoses, needed interventions, and improve patient care? 1) Gathering information about the patient's mental status from the patient's family. 2) Gathering current objective data. 3) Establishing a close nurse-patient relationship. 4) Gaining relevant information about the patient's spirituality.

4) Gaining relevant information about the patient's spirituality.

While preparing a Hindu client for surgery, it becomes apparent that the client's view about spirituality is entirely different from the nurse's. What is the most appropriate action by the nurse? 1) Suggest the client meet with a chaplain for spiritual support 2) Tell the client that his illness is due to his spiritual views 3) Request a nurse to continue care who shares the client's belief 4)Be respectful, open, and willing to discuss spiritual issues as appropriate

4)Be respectful, open, and willing to discuss spiritual issues as appropriate

During a spiritual assessment the nurse realizes that personal beliefs differ significantly from those of the client. What should the nurse do? - Continue with the assessment - End the assessment - Ask other nurse to continue the assessment - Discuss about the differences with patient

- Continue with the assessment The nurse must always approach a client's spirituality with sensitivity and acceptance even if not in agreement with the client's expressed beliefs. To argue or discuss the differences in beliefs would add further stress to the client. The nurse should not end the assessment or ask another nurse to complete the assessment.

Which assessment findings support the existence of a client's personal loss of self? Select all that apply. - stated, "I've given up any hope of singing professionally." - was diagnosed with schizophrenia at age 21 - lost most physical possessions when home burned - spouse of 45 years died 2 years ago. - was sexually abused as a child

- was sexually abused as a child - spouse of 45 years died 2 years ago. - was diagnosed with schizophrenia at age 21 Loss of self can occur through being sexually abused, the death of a spouse, or coping with a mental illness. The loss of one's personal possessions is considered a concrete loss while losing hope is an abstract loss.

A nursing instructor is teaching how to perform a spiritual assessment and informs students that it is best not to ask uncomfortable questions but instead observe for which of the following characteristics? (Select all that apply.) 1) patient's concept of God 2) patient's food preferences 3) patient's religious practices 4) patient's sexual preference

1) patient's concept of God 3) patient's religious practices

The nurse is meeting with a client for the first time and begins to assess the client's perspective of spirituality. Which questions are appropriate when focusing on the establishment of a trusting nurse-client relationship? Select all that apply. 1) "Would you like me to pray with you?" 2) "Are you aware of the research that confirms a connection between physical health and spiritual comfort?" 3) "What do you believe happens when a person dies?" 4) "Do you belong to any formal religion?" 5) "Are you interested in having a member of the clergy visit during your hospitalization?"

2) "Are you aware of the research that confirms a connection between physical health and spiritual comfort?" 4) "Do you belong to any formal religion?" 5) "Are you interested in having a member of the clergy visit during your hospitalization?"

The nurse wants to support a patient's spirituality. To do so, what must the nurse do first? 1) Give the patient a Bible to read. 2) Tell the patient that religion is important to you and you are happy to discuss it. 3) Keep an objective perspective and meet the patient at his or her level. 4) Ask the on-call chaplain to come see the patient.

3) Keep an objective perspective and meet the patient at his or her level.

After completing an admission assessment the client asks if the room door can be closed so that the client can have silence when reading the Bible. What does this indicate to the nurse about the client's spirituality? 1) Noise interrupts the client's ability to concentrate when reading 2) The client has limited reading material 3) Reading the Bible provides comfort to the client 4) The client reads the Bible instead of praying

3) Reading the Bible provides comfort to the client

In the assessment of a client, the nurse is having her complete a daily spiritual experiences self-assessment scale. Which of the following should the nurse mention to the client before giving her this assessment tool? 1) She should base her answers on whether she feels that she should have the indicated experiences. 2) She should confirm all of her answers with a spiritual leader whom she trusts. 3) She may substitute another word for God in the scale, if she would like. 4) She should not complete the scale if she is a member of an organized religion.

3) She may substitute another word for God in the scale, if she would like.

The nurse begins an assessment of a client's religion and spirituality. Which statement indicates that the client is spiritual? 1) "I attend church every Sunday." 2) "I attend an adult education class at my synagogue every Friday." 3) "I am responsible for myself since there is no God." 4) "I am at peace when I spend time out of doors."

4) "I am at peace when I spend time out of doors." Spirituality is defined as a search for meaning and purpose in life which seeks to understand life's ultimate questions in relation to the sacred. The client finding peace when out of doors is an expression of spirituality. Attending church and synagogue are group actions consistent with religion. Saying that there is no God is an expression of atheism.

A nursing instructor is teaching about spirituality, major world religions, and common beliefs. The instructor realizes that a student understands the differences based on which of the following statements? 1) Jews believe that prayer and meditation are used for cleansing and healing. 2) Buddhists believe that Allah is in control of the beginning and end of life. 3) Christians believe that restrictions related to work on holy days are removed to save a life. 4) Hindus believe that illness is the result of past and current life actions.

4) Hindus believe that illness is the result of past and current life actions.

The nurse is informed about a new client being admitted to the care area. When should the nurse plan to complete the spiritual assessment? 1) With the admission assessment 2) When having consent forms signed 3) Prior to discharge 4) It depends upon the situation

4) It depends upon the situation

A patient just died, and the nurse is preparing the body for the funeral home. The patient practiced Judaism and a rabbi was present at the time of death. The nurse is careful to do which of the following to honor the patient's religious beliefs concerning death? A) Burn all bandages with the patient's blood. B) Place a medal with the patient. C) Do not cross the patient's arms. D) Discard all clothes of the patient.

C) Do not cross the patient's arms.

A patient in the hospice unit has fewer than 3 months to live. The patient states, "I have been good all my life ... I do not know why God is punishing me like this." What is the most appropriate action for the nurse? - telling the patient not to feel that way - give anti-anxiety medication - stay with the patient and provide presence.

Stay with the patient and provide presence. When considering illness, some people view illness as punishment for living outside God's laws. With time, they may learn to accept their diagnosis and rely on faith. When this happens the nurse needs to stay with the patient, provide presence, and allow the patient to express true feelings. Ignoring what the patient says or making a judgmental statement (ie, telling the patient not to feel that way) is not appropriate. The patient does not need an anti-anxiety medication but needs someone to listen.

The nurse plans time to sit with a client to help address the client's spiritual needs. Why is this important? 1) Clients feel more comfortable talking with nurses 2) Clients are holistic beings consisting of body, mind, and spirit 3) Nurses have the most time to address a client's spiritual needs 4) Nurses are easier to talk to than spiritual advisors or chaplains

2) Clients are holistic beings consisting of body, mind, and spirit

When performing an assessment of a patient, the nurse observes that the patient begins to cry when asked if she has a religious preference. What part of the care plan would the nurse document this assessment finding? 1) Evaluation 2) Subjective data 3) Outcomes 4) Objective data

4) Objective data

When assessing the client, the nurse finds that verbal responses are minimal, with little eye contact and he states he does not "get out much." Which nursing diagnosis would be most appropriate? - Social isolation - Spiritual destress - Social interaction, impaired - Depression

Social interaction, impaired With impaired social interaction, there is little engagement with other, poor eye contact and minimal communication. Social isolation occurs when the client experiences loneliness; can be hostile and uncommunicative. The client expresses concern with meaning of life and death with spiritual distress. Depression is a medical diagnosis.

Spirituality is the same thing as religion. - true - false

false

A nursing instructor is teaching the importance of religion and spirituality to patients. The instructor identifies which of the following as the first step in promoting the spiritual aspect of holistic care?

reflect on one's own spiritual dimension Nurses aware of their own spirituality are more comfortable discussing potential spiritual needs with patients. Introspective reflections on one's own beliefs and biases about the relationship between spirituality and health can be undertaken through writing in journals, meditation, or discussions with interested people.

A client on hospice care tells his nurse that he is not afraid of death. He explains that this is because he believes he has lived a very good life and therefore his next life should be even better than this one, as all of his life actions will be carried into the next. The nurse recognizes this belief as which of the following? 1) Kosher 2) Holy Trinity 3) Karma 4) Ramadan

3) Karma

Shared practices and rituals used to express one's faith can be called 1) spirituality. 2) religion. 3) denomination. 4) philosophy.

2) religion.

To give spiritual care to a client, it is not necessary for the nurse to 1) prepare to help clients seek a source of strength and hope from their own (clients') religion and spiritual beliefs. 2) share the same religious beliefs as the client to provide effective spiritual care. 3) recognize that depression may result from unmet religious group expectations. 4) be aware of personal religious beliefs and biases in order to provide effective spiritual care.

2) share the same religious beliefs as the client to provide effective spiritual care.

What outcome should the nurse prioritize when addressing a patient's social, cultural, and spiritual issues? 1) The patient will express a sense of oneness with self and others. 2) The patient will express meaning and purpose in life. 3) The patient will engage in worship weekly. 4) The patient will engage in interactions with others.

2) The patient will express meaning and purpose in life.

The most useful spiritual assessment techniques should have specific introductory questions and be specific to a particular religious denomination to guide precise questions. 1) False 2) True

1) False

What are some of the general recommendations when the nurse is taking a spiritual history? (Select all that apply) 1) Respect a patient's privacy and do not impose your beliefs on them. 2) Spirituality is an important component of physical well-being and mental health 3) If you do not have the same spiritual beliefs as the patient, you should have someone else do the assessment. 4) Inform the patient that you will be happy to call your spiritual adviser to come and talk with the patient. 5) Make referrals to chaplains, spiritual directors, or community resources as appropriate.

1) Respect a patient's privacy and do not impose your beliefs on them. 2) Spirituality is an important component of physical well-being and mental health 5) Make referrals to chaplains, spiritual directors, or community resources as appropriate.

During an interview, a patient tells the nurse about spending time out of doors and hiking to connect with the earth and observe the activities of small animals. The nurse would document this patient's hiking behavior as supporting: 1) Spirituality 2) Relaxation 3) Religious activities 4) Exercise needs

1) Spirituality

A Muslim teenager is in the hospital for surgical repair of a severe fracture in the leg during the month of Ramadan, which the client says he would like to observe during his stay. Which of the following interventions should the nurse be prepared for in caring for this client? 1) Do not mix dairy and meats together on the client's tray 2) Withhold all food and drink between sunrise and sunset 3) Serve only kosher meats at all three meals 4) Serve meals as normal, but do not include pork

2) Withhold all food and drink between sunrise and sunset

The nurse prepares to complete a spiritual assessment with a client. What should the nurse keep in mind when completing this assessment? 1) It gives the nurse an opportunity to speak freely about personal spiritual beliefs and practices 2) It offers the nurse a chance to subjectively discuss the client's spiritual beliefs 3) The reason is for the nurse to share personal views in relation to what the client believes 4) The reason is to better understand the client's spiritual perspective related to health

4) The reason is to better understand the client's spiritual perspective related to health

The nurse identifies which of the following as risk factors for spiritual distress? (Select all that apply.) 1) natural disasters 2) ability to forgive 3) experiencing a new love life 4) chronic illnesses 5) negative life changes

1) natural disasters 4) chronic illnesses 5) negative life changes

While conducting a cultural assessment the nurse would like to include the client's spirituality. What needs to be established before this part of the assessment can be successfully completed? 1) trust 2) social boundaries 3) eye contact 4) time limits

1) trust

A child is admitted to the hospital after an injury during a school field trip. The child's parents arrive shortly afterwards and refuse to allow their child to receive needed antibiotics to fight off infection and analgesics to lessen the child's severe pain. Which of the following should the nurse do? 1) Administer the medications regardless of the parents' wishes 2) Follow the parents' wishes and try to comfort the child without use of medications 3) Try to persuade the parents to allow administration of medications 4) Consult the hospital's ethics committee

4) Consult the hospital's ethics committee

A nurse is caring for a terminally ill client. The client's family has requested that at the time of death, the client's arms not be crossed and any clothing or bandages with the client's blood be prepared for burial with the person. The nurse recognizes that this family follows the rituals of which religion? 1) Buddhism 2) Hinduism 3) Islam 4) Judaism

4) Judaism

A nurse cares for a client who practices Hinduism. The nurse understands that Hindus believe illness is caused by which type of behavior? 1) Cured by worshipping God 2) Consumption of dirty food 3) Unhygienic habits 4) Result of past and current life actions

4) Result of past and current life actions

When the nurse is attempting to demonstrate nursing presence, which intervention would be most therapeutic?

sitting with the client as he or she shares feelings about being ill Sitting with the client and reflecting back what the nurse sees may encourage the client to express concerns and is an excellent example of the nurse being "present." While appropriate interventions, none of the remaining options demonstrates the sharing and sincere connection required of being present.

What questions should be included in a spiritual assessment? Select all that apply. 1) "I see you are Jewish, does that mean you do not eat pork?" 2) "How does your spiritual practices help you to deal with pain? 3) "Do you need a private place to pray?" 4) "What gives you meaning to your life?" 5) "Are you a practicing Catholic?"

2) "How does your spiritual practices help you to deal with pain? 3) "Do you need a private place to pray?" 4) "What gives you meaning to your life?"

The nurse observes that a patient who is Jewish and follows an Orthodox way of life. The patient is not eating the food that the dietary department is sending. What would be the best lunch to bring this patient? 1) Sliced pork, stuffing, and green peas. 2) Cottage cheese, peaches, and crackers with tea. 3) Crab cakes, french fries, and a roll. 4) Roast beef sandwich, mashed potatoes, and a cup of ice cream.

2) Cottage cheese, peaches, and crackers with tea.

A patient with cancer is talking to the primary nurse about the diagnosis and states, "I feel like it is God's will that I have this cancer. If I get out of the hospital, I want to take nature walks like I used to before I got so sick. I feel so close to God when I do this." The nurse understands that this patient is demonstrating which of the following? 1) Traumatization over this diagnosis 2) Acceptance of the diagnosis 3) Signs of depression 4) Viewing the cancer as punishment for past lifestyle

2) Acceptance of the diagnosis

The nurse is asking open-ended questions in order to establish a dialogue with a patient when talking about spirituality. This is an example of what type of approach? 1) Focused 2) Nonformal 3) Decisive 4) Formal

2) Nonformal

A nurse must perform a nonformal spiritual assessment of a client. Which tool would be most appropriate for the nurse to use? 1) Open-ended questions 2) SPIRIT assessment tool 3) Casual conversation 4) Personal interviews

2) SPIRIT assessment tool

The nurse is assessing a patient's ability to employ coping mechanisms when given a diagnosis of cancer. What type of assessment would be beneficial for the nurse to use? 1) Mini-Mental status assessment 2) Spiritual assessment 3) Physical assessment 4) Cultural assessment

2) Spiritual assessment

A patient is admitted to the oncology floor with a terminal illness diagnosis. Upon completing the spiritual assessment the nurse realizes that this patient has no connection to others such as God, nature, family, or peers.The patient has a pessimistic attitude and has not identifed any coping resources and does not want to adapt to any. The best nursing diagnosis for this patient is what? - Spiritual distress - risk for spiritual distress - readiness for enhanced spiritual well-being - risk for hypertension

Spiritual distress The best diagnosis for this patient is spiritual distress. Upon doing the spiritual assessment the nurse realizes that this patient has no coping resources and does not want to adapt to any.The patient also has no sources of strength, hope, comfort or peace. THis is an actual problem and not a potential one. Since the patient does not want to adapt to any new reources the patient is definitely not ready for an enhanced spiritual well-being.Hypertension could be a secondary problem but there is no data to support this at this time.

A nurse is in the process of selecting a spiritual assessment tool to use with clients. Which of the following characteristics should this tool possess? Select all that apply. - Containing precise questions that would guide a client's responses related to specific spiritual needs - Objectivity - General introductory questions - Ask specific question about patient's religious denomination

- General introductory questions - Objectivity Objectivity is a key component in a high-quality spiritual assessment. The most useful spiritual assessment techniques should have general introductory questions and not be specific to any religious denomination that would guide a client's responses related to specific spiritual needs.

A patient asks the nurse if there are church services in the hospital because the patient attends mass every Sunday. The nurse realizes that this patient is demonstrating: 1) Religion 2) Spirituality 3) Culture 4) Recreation

1) Religion

A patient is being educated on a new diagnosis of diabetes mellitus. The patient asks no questions during or after the session. What cultural consideration does the nurse understand may be the reason for the patient not asking questions? 1) The patient considers asking questions of the nurse a sign of mistrust in her abilities. 2) The patient has not understood enough about the education to ask a question. 3) The patient already knows everything about diabetes mellitus and has no questions. 4) The patient does not believe that they have diabetes dellitus and refuses to listen

1) The patient considers asking questions of the nurse a sign of mistrust in her abilities.

The nurse is setting an outcome with the patient experiencing spiritual distress. Which goal would be appropriate? 1) The patient will express meaning and purpose in life. 2) The patient will initiate interaction with others. 3) The patient will express feelings of connectedness with others. 4) The patient will attend a community event every week.

1) The patient will express meaning and purpose in life.

Loss of connection with one's spiritual support most often leads to 1) spiritual distress. 2) a new-found sense of liberation. 3) improved sense of health and well-being. 4) increased adherence to religious practices.

1) spiritual distress.

A nurse assesses the spirituality of a client who is terminally ill with pancreatic cancer. Which of the following is the best rationale for this action, from the nurse's perspective? 1) Searching for meaning and purpose 2) Identifying possible coping mechanisms 3) Finding common practices shared with a group 4) Defining the meaning of the afterlife

2) Identifying possible coping mechanisms

A nurse supervisor is instructing a novice nurse on methods of introspective reflection to help the novice gain an understanding of self beliefs and biases about the relationship between spirituality and health. Which of the following methods should the supervisor recommend to the novice? Select all that apply. 1) Adherence to special dietary practices 2) Journaling 3) Discussions with a spiritual leader 4) Meditation 5) Facing east while praying

2) Journaling 3) Discussions with a spiritual leader 4) Meditation

Which nursing intervention best demonstrates the nurse's attempt to provide effective spiritual care to a client in spiritual distress? 1) providing intense spiritual counseling for a client who has expressed hopelessness 2) sharing a story related to one's own spiritual beliefs attending a religious service in the hospital's chapel with 3) a client who is scheduled for surgery 4) assessing the spiritual needs of a client who is critical ill

4) assessing the spiritual needs of a client who is critical ill

Because the nurse realizes that spirituality varies, information gained will assist the nurse in individualizing interventions to meet specific needs. 1) diagnosing the client with spiritual distress. 2) teaching strict adherence to rituals and practices to improve outcomes. 3)) providing an overview of widely held beliefs from the major religions. 4) individualizing interventions to meet specific needs.

4) individualizing interventions to meet specific needs.

A nurse is performing a spiritual assessment on a client that is diagnosed with aggressive form of lymphoma. What is the best intervention by the nurse to address the patient's spiritual end of life issues if she is unable to? - Make a referral to the appropriate professional. - Tell the charge nurse that you do not want to be assigned to this patient. - Do not interact with the patient in a spiritual nature. - Tell the patient that you are not able to address these issues since you are both different religions.

Make a referral to the appropriate professional. Many hospitals have staff pastoral chaplains, and community resources of different faiths and are usually available through social work professionals. While nurses can assess and support many patients' spiritual needs, some situations are beyond the scope of nursing practice and require someone with more experience and knowledge about a particular faith.