Ch.46 PrepU
A client scheduled for outpatient surgery is requesting that the operating room be sprayed with holy water. Which is an appropriate response?
"Are you concerned how the surgery will go?"
The nurse is assessing a 27-year-old Navajo male who is being admitted for surgery. The client requests a visit from the spiritual healer. Which is the best response from the nurse?
"Do you have a preference as to which spiritual leader you would like to visit?"
A nurse is conducting a spiritual assessment of a 73-year-old client who is being admitted to an assisted living center. Which factor(s) should the nurse prioritize? Select all that apply.
Client's friends or support system Best treatment to assist client in current situation Available resources to assist client
The nursing diagnosis Spiritual Distress related to crisis of illness as evidenced by loss of meaning in life and overuse of pain medication is created for a client who attempted to take his life. Which intervention is appropriate for these problems?
Plan and coordinate a multidisciplinary team conference including the chaplain.
When a nurse supports the client's spiritual needs, the nurse supports which level of the Maslow's hierarchy of needs?
Self-actualization needs
Allen is an 82-year-old retiree who recently relocated to senior apartments. The apartments are not affiliated with any religious beliefs. Allen was raised in the Roman Catholic church and has attended mass every Sunday since childhood. He has not attended mass for 3 weeks. What best describes Allen's situation?
Separation from spiritual ties
While interviewing a client, a nurse is told that the client practices Catholicism. This client is identifying:
his faith.
Individuals who are Christian Scientists may not approve of:
immunizations.
Which set of terms best reflects nursing's view of clients as holistic beings?
mind, body, spirit
A nurse is educating staff members about the importance of meeting the spiritual needs of clients on the unit. What spiritual needs should be met in the delivery of care? Select all that apply.
need for meaning and purpose need for love and relatedness need for forgiveness
An appropriate goal for the client with a nursing diagnosis of Spiritual Distress related to intense pain and suffering as verbalized by the client would be that the client will:
participate in supportive spiritual practices.
When the client tells the nurse that she believes God's reality is personal, and that God is the creator of all beings, the nurse determines the client is expressing:
theism
A new client is on the hospital unit. He was recently diagnosed with metastatic pancreatic cancer and was told that any treatment would be palliative. He tells a nurse that there is no God that he knows of who would subject someone to this. The client's statement is most reflective of:
spiritual crisis.
Which question would be appropriate for the F in the FICA spiritual assessment tool?
"Do you consider yourself a spiritual person?"
When asked about his religious preference, the client becomes very upset with the nurse. Which response is appropriate for this situation?
"I can see that this question upsets you. Do you have any questions about this?"
A client who has suffered a debilitating stroke asks the nurse, "Why did God allow this to happen to me?" What question would the nurse ask to promote a conversation with the client about the client's spiritual needs?
"In the past, what has given you strength during a crisis?"
A nurse is conducting a spiritual assessment on a client recently admitted to the hospital unit. Which questions would be appropriate to ask the client about his religious and spiritual practices? Select all that apply.
"Is religion a significant part of your life?" "Are there any spiritual practices that you would like to continue while hospitalized?" "Does the present situation interfere with any spiritual or religious practice?"
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."
The nursing instructor has been discussing spirituality with a group of nursing students. Which statement by a student would indicate a need for further education?
"Spiritual beliefs and practices do not give strength when a person is in crisis."
Upon assessment, the client reports not belonging to an organized religion. Which assessment question would the nurse ask to assess the client's spirituality?
"Tell me about spiritual or religious beliefs that are important to you."
The nurse is performing the intake assessment for a 16-year-old adolescent in the emergency department. Which question by the nurse will assist in understanding the adolescent's spirituality?
"What are your spiritual beliefs?"
The nurse is caring for a critically ill client who informs the nurse that there is a conflict between the client's spiritual beliefs and a proposed health option. Which question does the nurse ask to begin a conversation about the conflict that the client is experiencing?
"Would you like to talk to someone to help you make an informed decision?"
A nursing instructor, after teaching about the importance of spirituality, identifies a need for further teaching when overhearing a student make which of the following statements?
"You can provide quality nursing care to clients even though you ignore the spiritual dimension of health."
Based on religious customs, for which client would the nurse administering medicines avoid touching the client's lips?
A Hindu client
The nurse is caring for a client that practices Islam in the hospital. When dietary brings the client a food tray for supper, which food on the tray should the nurse remove that is against the dietary laws for a practicing Muslim?
A pork chop
Which religious groups would the nurse anticipate to regard Saturday as the Sabbath? (Select all that apply.)
Adventist Judaism
When reviewing the history of a client admitted to the health care facility, the nurse notes that the client reported being an atheist. Which action will the nurse take to meet spiritual needs when planning nursing care for the client?
Ask the client how he or she expresses spirituality.
The nurse cares for a client of the Islamic faith. Which lunch will the nurse recommend to the client?
Broiled chicken sandwich with skimmed milk
The school nurse is concerned about the week-long absence of Jerry, a third grader. The nurse visits the home and learns that Jerry has been diagnosed with appendicitis by a local clinic doctor. The parents, who are Christian Science church members, have had several church groups in to pray over Jerry. He is not improving and is getting worse. The nurse should do which of the following?
Contact Child Protection Services
The nurse is caring for a Roman catholic client who is dying. What would be an appropriate action for the nurse?
Contact a local priest to complete the anointing of the sick ritual.
The nurse is caring for a 6-year-old child who was in a motor vehicle accident and has lost a lot of blood through an open leg wound. The parents tell inform the nurse that the child cannot have blood transfusions due to their religious beliefs. What decision does the nurse determine that the court will support regarding the child's blood transfusion?
Did not support the parents' right to refuse treatment for the child
The nurse is caring for a dying male client who practices Islam. What is the most appropriate action for the nurse after the client's death?
Ensure that a male washes the client's body.
A nurse overhears a client telling a family member that a belief in God is the only thing helping in the fight against a terminal illness. What is this client demonstrating?
Faith
The nurse is caring for a client diagnosed with human immunodeficiency virus (HIV) 10 years ago. The client states, "my relationship with God has helped me to survive this long". The nurse determines that the client's spiritual well-being is demonstrated by being at peace with which entities? Select all that apply.
God Self Community Environment
According to Shelly and Fish (1988), which of the following are spiritual needs underlying all religious traditions that are common to all people? Select all that apply.
Meaning and purpose Love and relatedness Forgiveness
A nurse is preparing a presentation for a group of staff nurses about spirituality and the importance of meeting clients' spiritual needs. As part the presentation, the nurse plans to address the major religious groups. Which characteristic would the nurse identify as being common to the major religions? Select all that apply.
Involvement of a sacred word or scripture Ideas related to after death Ethical code for right and wrong An identity as a group
A client who is admitted to the ER with severe right-sided abdominal pain is diagnosed with appendicitis. The surgeon is called and proceeds to explain the procedure to the client and asks her to sign the consent. The client refuses and informs the doctor that her husband needs to be called to do this. Which of the following religions does this client likely practice?
Islam
Which nursing title is being recognized by the American Association of Nursing that aids and assists the clients with spiritual needs in the community setting?
Parish nursing
An older adult client who is very sick but very spiritual and has a deep faith asks the nurse to say a prayer for her. The nurse, who is not very comfortable praying out loud, wants to honor the client's request. What would be the best action by the nurse?
Read a passage from the Bible to the client
A nurse interviews a client and finds that, because of religious beliefs, the client's view on health care does not involve blood transfusions. How can the nurse best handle this client situation?
Record this information in the client's chart.
While studying religion and spirituality, the nursing student exhibits an understanding of the concepts when making which of the following statements?
Religion is a collection of spiritual beliefs and practices.
The home care nurse visits a client with asthma and observes several lighted candles by the client's bedside. Which action should the nurse take?
Replace the lighted candles with battery operated candles.
The nurse is assisting a client with his meal selection for the next day. The client states, "I can't have meat tomorrow, it's a Holy Day." The nurse recognizes that the client is a member of which religious organization?
Roman Catholic
A bedridden hospitalized client expresses a belief that missing weekly church service is a failure to live by the church's rules. The notes not missing a service in the past 50 years. Which is an appropriate nursing diagnosis for this client?
Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt
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
The nurse enters a client's room as the client and family are praying. Which is the most appropriate action of the nurse?
Step outside the door until the prayer is finished.
A nurse is developing a plan of care to meet a client's spiritual needs. When identifying appropriate interventions, which concept would the nurse need to integrate as the foundation for all the interventions?
Supportive presence
A client is in the late stages of lung cancer with bone metastases. Since receiving the terminal diagnosis, the client has often made mentioned an estranged child and being a "miserable parent." Which conversation will the nurse have with the client to attend to unfinished business?
The need for forgiveness
The client is being discharged home with hospice due to a terminal disease. The nurse is arranging visitations of the spiritual leader for the next 3 months. Which of the outcomes identified supports this intervention? Select all that apply.
The client identifies support provided by the spiritual leader. The client demonstrates spiritual practices such as praying. The client expresses satisfaction with spiritual relationships. The client expresses satisfaction with life.
A new nurse observes a priest visiting the clients every Saturday afternoon and praying with them. This activity supports which of the nursing outcomes?
The client uses a type of spiritual experience that provides comfort.
The nurse understands that spiritual care is dynamic and embodies some of the basic tenets of nursing. What is a factor supporting this concept? Select all that apply.
Therapeutic use of self Client centeredness Spiritual nurturing environment Nurse's availability for the client
After being informed that his wife only has a few hours to live, the nurse hears the husband say; "If you take my wife now. I will never pray to you!" What should be the nurse's reply?
Use silence and allow the husband to express his emotions.
Mr. V. is recovering from pneumonia. The nurse understands that a well-balanced diet will help him to recover. However, Mr. V. informs the nurse that it is Ramadan and he must fast from sunrise to sunset. What is the nurse's most appropriate nursing action?
Work with the nutrition staff to provide nutritious meals at off hours.
A terminally ill client tells the nurse that he does not belong to an organized religion. It is safe for the nurse to assume:
the client may still be deeply spiritual.
A nurse is caring for Mr. Glanden, who recently underwent a lung resection. As the nurse is completing the physical assessment, he asks to have the elders from his church perform a "laying on of hands". The nurse interprets this as a healing process associated which of the following religions?
Mormon
A nursing student is studying spirituality and completing a report on the Mormon faith. Which fact about Mormonism should the student include in the report?
Mormons are not allowed to use tobacco or alcohol.
When conducting a spiritual assessment, the nurse must be sensitive to the client's personal beliefs. Which questions should the nurse ask? Select all that apply.
"Is religion or God significant to you?" "Do you feel your faith is helpful to you?" "Is there anyone from your church you would like to talk to?"
The nurse overhears a client, who is scheduled to begin chemotherapy, tell a family member that everything will eventually be okay and the cancer will be in remission. Which question will the nurse ask to begin a conversation about hope with the client?
"What provides you with strength to deal with this health situation?"
A nurse is caring for a client who is upset after being told about a diagnosis of cancer. The client asks the nurse to stay a minute to pray. Which is the nurse's most respectful and appropriate behavior?
Agree to pray with the client and stand in silence by the bed.
The nurse is performing the initial assessment on a client admitted with pneumonia. The client tells the nurse, "Last time I was here, the nurse gave me the wrong medication!" Which statement by the nurse will help establish trust with the client?
Actively listen to the client and allow expression of negative feelings.
An older adult client who identifies as a devout Catholic has recently relocated to an assisted living facility. The client is pleased with most aspects of the living situation but laments the fact that the church is not nearby, so attending daily mass is not an option. The client is quite upset by this restriction and states, "Going to daily mass was my life." Which action would the nurse take to address the client's spiritual distress?
Actively listen to the client to explore the client's feelings.
A client who is admitted with severe back pain rates it a 10 on a scale of 1 to 10. After assessing the client for pain, the nurse tells the client that the physician had ordered pain medication and its effect should be felt 10 to 15 minutes after its administration. However, the client refuses the pain medication and informs the nurse that narcotics are contrary to his religion. Which religion does this client practice?
Adventist
The nurse admits a new client to the unit for elective surgery. What would be the best way for the nurse to facilitate the practice of religion for this client? Choose all that apply.
Arrange for the client's pastor to visit if desired. Attempt to meet religious dietary restrictions. Respect the need for privacy during periods of prayer.
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
While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion?
Islam
The nurse is on the third day of caring for a client who recently underwent a colectomy. During the physical assessment, a discussion about spirituality develops. The client reports feeling some guilt about being in the hospital because her religion opposes modern science, including medicine. The nurse recognizes this as a belief of which of the following groups?
Jehovah's Witnesses
A client who is admitted for a debilitating disease is talking to the nurse. The client relates that family is the only thing that matters, stating that family helps fulfill all the spiritual needs by first fulfilling the most basic of all needs. What is this basic need?
Love
A nurse is conducting online research for information related to spiritual needs and religious traditions. The nurse demonstrates understanding of the information by identifying which need as common to all? Select all that apply.
Love Meaning Forgiveness
A client in a long-term care facility has recently begun to refuse to cooperate with the staff, is having difficulty agreeing with the treatment goals suggested by the nurse, and is showing more stress when the family goes home. What is the best response from the nurse?
Question the client concerning spiritual concerns
Mr. J. is a 78-year-old man, who is actively dying of unknown causes. Mr. J. is a practicing Muslim. His wife, children, and grandchildren are present. The physician in charge of Mr. J.'s care plans to discuss Mr. J.'s impending death with the family. Based on the nurse's knowledge of the Muslim faith, which of the following is not true?
The family will likely want an autopsy.
A dying client requests that the nurse pray with him. The nurse is not accustomed to praying aloud but is comfortable praying silently. What is the best approach for this nurse to follow to pray with this client?
The nurse should select a formal prayer or Bible passage to use to pray aloud.
A client recently diagnosed with cancer informs the nurse that they value faith and finds comfort in their faith. The nurse is aware that faith is best defined as:
a belief in something for which there is no proof or material evidence.
The nurse is caring for a client who states, "No one can understand God." The nurse would document the client's spiritual belief as:
agnostic.
The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. The nurse informs the parents that the development of a child's spirituality is best accomplished by:
educating through parental behaviors.
The best definition of a spiritual need is:
expression of a person's inner being and meaning.
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. Clear the room of unnecessary items.
