Test 11

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."

***Patient is dying from cancer and family is there. They are expressing sorrow over the fourth coming lost, what would be the nursing diagnoses?

Anticipating

***Pt diagnosed with sleep apnea, what do you do to promote sleep?

Avoid sedatives for sleeping

What factor has been hypothesized by researchers regarding current thoughts on sleep?

Chronic sleep deprivation is present.

Church of Jesus Christ of Latter Day Saints (Mormons)

Devout adherents believe in divine healing through the "laying on of hands," though many do not prohibit medical therapy. The Church maintains an extensive and well-funded welfare system, including financial support for the sick. Disapprove of alcohol, tobacco, and caffeinated beverages. • A special undergarment worn by some members should be removed only in an emergency.

***A son is named to make decisions for his mother in the event he cant speak for herself

Durable power of attorney

***Middle aged male starting exercise, what would you teach them about timing and sleep?

Exercising within 2 hours of sleep can hinder the sleep

***Patient has naps after lunch, extends to 3 hours and is difficult to arise? what condition is this referred to?

Hypersomia

***What patient is at risk for disturbed sleep pattern with difficulty remaining asleep? 1216

IV antibiotics every 3 hours Noise of hospital environment and need for periodic treatments

***Expected outcome demonstrating the effectiveness of the plan of care to promote resting sleep, what would be the expected outcome?

Identify factors that interfere with sleep

The client is a young mother whose spouse died 3 months ago. The client is tearful and unkempt, eats a poor diet, and has lost 50 lb (22.6 kg) since the death of the spouse. The client states, "I can't do this anymore." The nursing diagnosis best supported by these data is:

Ineffective coping related to failure of previously used coping mechanisms

***Patient is actively dying and they are DNR. Mouth breathing with noisy respirations, they are incontinent and their family is at the bedside. What will you do for that patient?

Insert a catheter Elevate HOB to semi fowler Encourage family to reminisce Cleanse mouth every shift and PRN

***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

***When is a death certificate is necessary?

Prepared for each person who dies Mortician is responsible for handling and filing

The nurse is assisting a client and family with the death and dying process. Which is the first thing the nurse does to prepare to provide culturally competent care?

Understand the client's beliefs.

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.

***Assisted suicide is opposed by

a lethal dose of meds

***Terminal weening

gradual withdrawal of mechanical ventilation from a PT with terminal illness or an irreversible condition with poor prognosis

A nursing instructor has finished presenting information to a group of nursing students on the factors that influence the grieving process. Which statement by a student would indicate a need for further education?

"A death that occurs as a result of natural causes is just as stressful as a death from homicide or suicide."

The nursing student is learning how to care for clients whose death is expected within a limited period of time. Which statement makes the faculty member believe the student has mastered this topic?

"Many clients know they have a terminal illness by picking up on nonverbal communication."

Baha'i International Community

- Believe in a basic harmony between religion and science - Seek out competent medical care and pray for health - Obligatory prayers, holy days, and the 19 day fast - Permanent sterilization is prohibited and abortion is discouraged

***How much sleep does an infant get?

12-15 hours

***PT with planned procedure but it is against their spiritual belief, and patient asks for help, what is your role as nurse?

Advocate Talk to DR. about other options Ask open ended questions to get as much information

A client is dying and the nurse has developed a strong rapport with the client and spouse. The spouse states to the nurse, "I just don't know how I am going to deal with the process. It makes me nervous to think I can't deal with it." What is the priority concern with the spouse of the client?

Anxiety related to unknown reaction to stages of death

***Its a religious holiday and PT that is withdrawn, tearful, request minister and family is at bedside, what do you do?

Contact spiritual advisor

When planning care for a 55-year-old male client with newly diagnosed terminal pancreatic cancer, which nursing diagnosis would be most appropriate?

Death Anxiety

***A hospitalized 9yo, information considered when planning spiritual assessment with them

Definite perception of god

***Obstructive sleep apnea, day time sleepiness, fatigue, and excessive snoring. What do you think the diagnoses would be?

Disturbed sleep as evidence of excessive snoring

Hinduism

Doctrine of Transmigration. Moral factors, linked with the all-embracing doctrine of "karma," are believed to be significant in promoting health or causing disease. Hindu medicine shows a surprising openness to new ideas, at least in respect to practical treatment. • Many Hindu dietary restrictions conform to individual sect doctrine. • The nurse administering medications should avoid touching the patient's lips. • Certain prescribed rites are followed after death; disposal of the body is by cremation.

An older adult client reports insomnia. Which interventions can the nurse implement to promote quality sleep for the client?

Encourage the client to empty the bladder at bedtime.

***A young patient is diagnosed with chronic renal failure, effective strategy to help coping with this diagnoses?

Encourage to join support group with people with same disorder

***Each of the major religions have several characteristics in common, what is one of them?

Ethical code defines right and wrong

***Confidence in traditional healer to relieve symptom of stress/illness

Faith

A client comes to the hospital because of complications related to newly diagnosed terminal cancer. The client is concerned about how his wife is coping with the diagnosis. Which information is important for the nurse to obtain to assess factors that may affect the family member's grief? Select all that apply.

Financial concerns Cultural practices Religious beliefs Social support

*** Why do you need a CPAP? 1209

Forces oxygen into lungs, keeping it open

***Patient is terminal and has unrelieved and retractable pain. He just wants more meds to die. What is the nurse response?

Give them what they can get

***Patient diagnosed with HIV 10 years ago, my relationship with god allowed me to survive, spiritual well being

God Self Community Environment

***Resolving conflicts between spiritual beliefs and treatments

Help obtain the information needed to make an informed decision and to support the patients decision making maintain objectivity

The hospice nurse is caring for a group of clients with terminal illness. Which is the highest care priority for a client in the process of dying?

Hygiene

***Patient wants to make health care decisions while consulting the social worker, what would put in the request to social worker?

Information about advance directives to guide choices and leads to referral to social worker

After the death of a terminally ill spouse, a client reports frequent headaches and loss of appetite. The client states, "How am I going to live without him?" What type of grief is the client experiencing?

Inhibited grief

A nurse is explaining to an insomniac client the effect of a prescribed medication and the different phases of sleep. Which statement is true for nonrapid eye movement (NREM) sleep?

It is called slow wave sleep.

***Which set of terms best reflects the nurses view of clients as a holistic being?

Mind Body Spirit

***Signs of impending death

Nausea, flatus, abdominal distention Cheyne-Stokes respirations Loss of movement, sensation, and reflexes

***Which signs assessed in a dying client would the nurse recognize as signs of death? Select all that apply.

Nausea, flatus, abdominal distention Cheyne-Stokes respirations Loss of movement, sensation, and reflexes

***Patient has trouble falling and staying asleep, what recommendation for insomnia?

No napping Warm caffeine free drink before bed Reduce stress, talk to someone Regular excerise Have a routine

***Hypothyroidism, suffering from fatigue and depression and difficulty with everyday tasks, what type of deprivation would this be?

Non REM

The nurse is admitting a client that has obesity and is diagnosed with obstructive sleep apnea (OSA). The client states, "I just wake up a lot and don't feel rested but it's not a big deal." What eductation should the nurse provide about the complications related to OSA?

OSA contributes to hypertension and heart disease.

***The nurse is implementing comfort measures to promote sleep for a client. Which intervention is the best choice for the client?

Offer client a small carbohydrate and protein snack before bedtime.

***What is an example of a perceived lost?

Older patient grieves from lost of independence

Steps for being a healing presence

Open yourself: Become present to yourself in a way that is honest, insightful, and accepting .Intend to Be a Healing Presence: Be aware that the healing presence doesn't just occur out of the blue, you intentionally decide to be such a presence with another. Prepare a Space for Healing Presence to Take Place: Clear a space to interact with the other or others, assuring as much privacy as possible and creating an atmosphere of calm. Honor the One in Your Care: Approach those you accompany as people with dignity and worth. Offer What You Have to Give: Freely and simply make available what you have to offer, realizing it is up to the other or others to accept or not. Receive the Gifts That Come: Accept with a grateful heart what is yours to receive. Live a Life of Wholeness and Balance: There is more to life than being a healing presence.

***Ordering sleep meds, how would you order it?

PRN

***Most important goal when caring for a PT receiving comfort care?

Pain free dignity

***Living will

Provides specific instructions about what medical treatment the client chooses to omit or refuse in the event that the client is unable to make those decisions.

The nurse is attempting to wake a client from sleep and is having a difficult time arousing them. What stage of sleep does the nurse identify the client is experiencing?

REM sleep

***Whats the goal of palliative care?

Relief of symptoms, pain, and stress of serious illness, and improve quality of life of patient and family.

***Life is meaningless since divorce and no longer want to live, what ND is resulting from spiritual distress?

Risk for self directed violence

***What do you need to do for a spiritual counselor visit?

Room should be orderly and free of unnecessary equipment Should be a seat at bedside or near PT Bedside table should be free of items and covered with clean white cover Bed curtains should be drawn for privacy

***Patient with restless leg and complains of sleepiness. The nursing diagnosed MOST appropriate for this pt is?

Sleep deprivation

***Patient is scheduled for testing, and they arousal easily from sleep, which sleep stage is the PT in?

Stage 2

***Patient on ventilator after stroke and they know they aren't going to recover, they are going to extubate. What do you think will happen? What will you tell the family?

Terminal weening, and explaining what to expect

***Patient has DNR order, what is the responsibility of the nurse?

Uphold that order, make no attempt to resuscitate, let nature takes it course

The nurse is performing assessments on several clients at the clinic. Which client condition indicates the presence of a parasomnia?

a child who wets the bed each night

***God if you let me live to see my daughter marry, I will go to church

bargaining

***Patient with insomnia, insomnia is increasing, what do you think you would ask during assessment?

bed time routine caffeine stress smoking meds

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

coping strategies

Which physiologic change occurs during non-rapid eye movement (NREM) sleep?

decreased brain activity from wakefulness

Kubler-Ross stages of dying

denial, anger, bargaining, depression, acceptance

***How can religious life affirming influences be compared with basic human needs?

enhance life, give meaning and purpose to existence, strengthen a persons feelings of self worth, encourage self actualization, and hare health health giving and life sustaining

***Patient is sleeping abnormally long periods of time is a result of injury to which body structure? 1201

hypothalamus

***Spiritual Health

is the condition that exists when the persons universal spiritual needs for meaning, purpose, love and belonging, and forgiveness are met.

When the newly admitted client with chronic obstructive pulmonary disease informs the nurse that she frequently awakens during the night, the nurse may notify the physician for which intervention?

low-flow oxygen

***PT fears being alone and nurse knows this is related to which spiritual needs?

need for love and relatedness

***What would you eat to help you fall asleep?

peanut butter toast cheese and crackers

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?

pork chop

***Factor necessary to express and experience spirituality

relationship with non material life force or higher power love and god

The client is sleeping, and arousal is easy. Occasionally, the client exhibits involuntary muscle jerking, which appears to startle the client. Vital signs are unchanged from 1 hour ago. The nurse assesses the stage of nonrapid eye movement (NREM) sleep, which the client exhibits as Stage:

stage 1

A client begins snoring and is sleeping lightly. The stage of sleep is:

stage 2

The nurse is completing a sleep history on a client who reports sleeping problems. Which of the client's regular behaviors will cause the client to have difficulty with sleep?

taking a diuretic at 9 a.m. and 5 p.m. daily

The nurse is caring for a client who is having difficulty sleeping. Which medication does the nurse anticipate will be prescribed by the health care provider?

temazepam

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.

***Which factor has the most influence on an individual's sleep-wake patterns?

the inner biologic clock

Buddhism

the teaching of Buddha that life is permeated with suffering caused by desire, that suffering ceases when desire ceases, and that enlightenment obtained through right conduct and wisdom and meditation releases one from desire and suffering and rebirth Buddhists do not outwardly proclaim healing through faith. However, spiritual peace and liberation from anxiety attained through the awakening to Buddha's wisdom may be an important factor in expediting healing and the recovery process. • Accepts modern science. The doctrine of avoidance of extremes is applied to the use of drugs, blood, vaccines. • Buddhism does not condone taking lives of any form. • Check with the patient about any special diet restrictions and the observance of holy days.

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