Health Assessment Chapter 12

What questions should be included in a spiritual assessment? Select all that apply.

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

The client states his pain is "intolerable" and requests pain medication. The nurse observes the client to be talking and laughing with visitors as they help to provide care to him. How should the nurse best respond?

"I will be back with your pain medication." Some cultures encourage those that are sick to express pain freely and will be pampered by family. Pain is what the client states and he nurse needs to address the pain. The other statements demonstrate a judgmental attitude by the nurse.

A hospice nurse performs spiritual assessments on four of her clients one afternoon. The nurse knows that, based on recent statistics, which of the following clients is most likely to express nonbelief in God?

A 22-year-old woman A Gallup poll in 2011 and updates from the Pew Forum have found a slight decrease in belief and slight rise in those reporting nonbelief in God, especially in young Americans, those living in the eastern United States, and those identifying themselves as liberals.

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?

Acceptance of the diagnosis\When doing a spiritual assessment on patients with cancer, the nurse understands that a normal finding is for a spiritual person to believe the situation is God's will. Stating this fact is not indicating depression, a view of cancer as punishment, or traumatization from the diagnosis.

The nurse is working with a client in the hospital who is Muslim. Which of the following considerations that is unique to a client of this faith should the nurse be prepared to address in this situation?

Assisting the client in turning in his bed to face east during his prayer time In Islam, prayer occurs five times a day: dawn, sunrise, noon, afternoon, sunset, and evening. Prayers are done facing east toward the sacred place in Mecca. Muslims abstain from pork and alcohol, but other meats are allowed. Buddhists and many Hindus, on the other hand, are strict vegetarians. Keeping meat and dairy separate is a practice of the Jewish faith. Karma, or the moral consequences of one's past life that are carried into future lives, is a Hindu belief, not a Muslim belief.

A child whose parents are Christian Scientists 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?

Consult the hospital's ethics committee Christian Scientists frequently rely on prayer alone to heal illnesses, rarely seek mainstream medical care, and have higher rates of mortality than the general population. The U.S. Supreme Court has generally sided against parents' withholding medical therapies for religious reasons. The hospital's ethics committee should be consulted immediately to assist in this complex decision.

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?

Cottage cheese, peaches, and crackers with tea. Orthodox or Kosher involves no mixing of meat with dairy; separate cooking and eating utensils are used for food preparation and consumption. Kosher laws include special slaughter and food handling. "Keeping Kosher" is predominantly an Orthodox practice. No pork products or shellfish are allowed in the dietary restrictions. The cottage cheese, peaches, and crackers are permissible.

A patient reports wanting to practice yoga while hospitalized. The nurse understands that yoga is a form of spiritual practice proven to:

Encourage greater mental and physical health Spiritual practices include yoga and meditation, which have the potential to encourage greater mental and physical health. Yoga does not protect one from death, make illness go away, or clean or heal the patient.

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?

FICA The acronym related to the assessment of spirituality is FICA, which stands for faith and beliefs, importance and influence, community, and address. FACES is a pain scale frequently used with children. PIE refers to the charting format that includes problem, intervention, and evaluation. PRN is a common abbreviation used in healthcare that stands for as needed.

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.

General introductory questions Objectivity

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?

Hindus believe that illness is the result of past and current life actions. Hindus believe that illness is the result of past and current life actions. People who practice Islam believe that Allah is in control of the beginning and end of life. Buddhists believe that prayer and meditation are used for cleaning and healing. Jews believe that restrictions related to work on holy days are removed to save a life.

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?

Identifying possible coping mechanisms Religion and spirituality have been related to a client's well-being in the face or illness and disease. They can be powerful coping mechanisms when a client is facing end-of-life issues. The definition of spirituality is a search for meaning and purpose in life. Common practice shared by a group of persons defines a religion. Religion also helps to define the meaning of the afterlife.

hospitalized patient is found on the floor of the room, kneeling on a small rug praying. The nurse understands that this ritualistic behavior is common in which religious practice?

Islam

A nurse cares for a terminally ill client. The client's family has requested that at the time of death, the client's arms are not crossed and any clothing or bandages with the client's blood should be prepared for burial with the person. The nurse recognizes that this family follows the rituals of which religion?

Judaism In Judaism, the Psalms and the last prayer of confession are held at bedside. At death, arms are not crossed; any clothing or bandages with the client's blood should be prepared for burial with the person. It is important that the whole person be buried together. Hinduism, Buddhism, and Islam do not follow this ritual.

A Hindu 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?

Karma In Hinduism, death marks a passage because the soul has no beginning or end. At death the soul may be reborn as another person and one's karma, or life actions, is carried forward. It is important for karma to leave this life with as little negativity as possible to ensure a better life next birth. Ramadan is a Muslim holy month that involves fasting from food and drink between sunrise and sunset. The Holy Trinity is the Christian belief that God exists in three persons simultaneously: the Father, the Son, and the Holy Spirit. In Judaism, kosher laws govern methods of slaughter and food handling.

A Jewish nurse is performing a spiritual assessment on a Muslim patient that is diagnosed with aggressive form of lymphoma. What is the best intervention by the nurse to address the patient's end of life issues if she is unable to?

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.

A nurse realizes the importance of being aware of the patient's spiritual needs. Some cues for which the nurse should look are what? (Select all that apply.)

Patient referring to God Patient praying the rosary Patient reading the Bible

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:

Religion Religion can be described as a system of beliefs or a practice of worship. The patient requesting information about church services is demonstrating religion. Desiring to attend church services may or may not be an activity within the patient's culture. Spirituality is a behavior that gives meaning to life. Attending church may or may not help the patient give meaning to life. Attending church services is not typically viewed as being a recreational activity.

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?

Spiritual assessment

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:

Spirituality

Matters of the human soul are referred to as what?

Spirituality

The client states "What does it matter? I have no purpose in this life." This client is questioning what?

Spirituality

What are some of the general recommendations when the nurse is taking a spiritual history? (Select all that apply)

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

The path one pursues in the search for life's meaning and purpose.

Spirituality. Spirituality is defined as a search for meaning and purpose in life; it seeks to understand life's ultimate questions in relation to the sacred.

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?

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 is preparing to complete a spiritual assessment on a patient. There are many friends and family members at the patients bedside that are volunteering information for the patient. Who should be the focus of the spiritual assessment?

The patient

A patient of Islamic faith is being educated on a new diagnosis of diabetes mellitus. The patient asks no questions during or after the session. What does the nurse understand may be the reason for the patient not asking questions?

The patient considers asking questions of the nurse a sign of mistrust in her abilities. To question or ask questions of health care providers is considered a sign of mistrust, so patients and family are less likely to ask question.

A patient who practices Hinduism has been admitted to the hospital for dehydration. The nurse is putting in an IV and the patient says to be sure to put it in the right hand. What does the nurse understand is the purpose for this request?

The right hand is considered holy and the IV goes in the right hand to promote healing. Illness is the result of past and current life actions (Karma). The right hand is seen as holy, and eating and intervention (IV) needs to be with the right hand to promote clean healing.

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?

Withhold all food and drink between sunrise and sunset During the holy days of Ramadan (29 days in December and/or January), neither food nor drink is taken between sunrise and sunset, though frail, ill, and young children are exempt. At all times, consumption of pork or alcohol is prohibited. Other meats must meet ritual requirements and many use kosher (Jewish ritual) foods because these meet the requirements of Islamic believers as well. Not mixing dairy and meats is a Jewish dietary practice, not Muslim.

Spirituality can best be described as

a source of inner strength. Spirituality, in the most fundamental sense, pertains to matters of the human soul, be it a state of mind, a state of being in the world, a journey of self-discovery, or a place outside the five senses. Having faith in God and participating in organized religious life are important to people of diverse cultures and ethnicities and are often seen as a source of inner strength and spirituality.

The previous week a client from a non-English speaking culture desired time to say prayers before eating breakfast. Another client from the same culture is currently being admitted. What should the nurse do to support the new client's spiritual needs?

assess if the client would like time for prayers before breakfast Spirituality is a dimension of culture, and it is culture-specific in how it is viewed. The nurse provides spiritual care by supporting the client's practice of spirituality such as prayer or meditation. The nurse should assess if the client wants time for prayers before having breakfast and not assume that this is to be done. Spirituality is an important health dimension and should not be minimized over physical concerns or needs. Explaining that there is no control over the time for breakfast does not support the client's cultural or spiritual needs.

Because the nurse realizes that spirituality varies, information gained will assist the nurse in

individualizing interventions to meet specific needs. After collecting subjective and objective data pertaining to the client's spiritual assessment, identify abnormal findings and client strengths using diagnostic reasoning. Then, cluster the data to reveal any significant patterns or abnormalities.

The nurse identifies which of the following as risk factors for spiritual distress? (Select all that apply.)

negative life changes natural disasters chronic illnesses Negative data signify distress and would include natural disasters, chronic illnesses, and negative life changes. Experiencing a new love and the ability to forgive indicate a positive spirituality state.

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.

Shared practices and rituals used to express one's faith can be called

religion. Religion is defined as the rituals, practices, and experiences shared within a group that involve a search for the sacred.

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?

trust Clients will not discuss deep spiritual concerns until a trusting relationship has been built with the nurse. Time limits, eye contact, and social boundaries may impact the completion of an assessment however do not need to be established before completing a spiritual assessment.