Chapter 10
What questions should be included in a spiritual assessment? Select all that apply. "I see you are Jewish, does that mean you do not eat pork?" "Are you a practicing Catholic?" "Do you need a private place to pray?" "How does your spiritual practices help you to deal with pain? "What gives you meaning to your life?"
"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? Explanation: It is important to ask about spiritual practices and what the client needs to perform those practices such as a private area for prayer. It is also important to understand how the client's spiritual beliefs help them to deal with pain and how the view life. Asking if the client eats pork and if they are a practicing Catholic provides no information that the nurse can use to establish a plan of care.
The client states his pain is "intolerable" and requests pain medication. The nurse observes the client to be talking and laughing with visitors. How should the nurse best respond? "If we can get some visitors out of your room, you might rest better." "I will be back with your pain medication." "You do not look like you are in pain." "I cannot imagine you are having pain the way you are laughing in here."
"I will be back with your pain medication." Explanation: Some cultures encourage those that are sick to express pain freely and will be pampered by family. Pain is what the client states and the nurse needs to address the pain. The other statements demonstrate a judgmental attitude by the nurse.
A nurse is completing a comprehensive assessment of a client who has been referred to the clinic. Which of the following would be most appropriate for the nurse to ask when beginning to assess the client's spirituality? "Would you like to speak to a chaplain?" "Do you believe in God?" "What religion are you?" "What gives you hope or peace?"
"What gives you hope or peace?" Explanation: When beginning a spiritual assessment, the nurse needs to initiate the interaction by opening up a general dialogue about global concepts such as hope, peace, comfort, strength, love, and connection. The most useful techniques typically have general introductory questions, which then lead to more focused questions such as beliefs, formalized religion, and eventually questions about the client's desires related to accessing resources such as a chaplain or spiritual leader.
The nurse is performing a community health assessment. When performing data collection, the nurse should seek out what informants? A combination of educational leaders and political leaders The residents who use health services most often The residents who work in the health care industry A combination of community leaders and "typical" residents
A combination of community leaders and "typical" residents Explanation: The nurse should consult key members or leaders of the community, as well as "typical" residents, to provide further information and insight about the community. Informants should not be limited to the heaviest users of health services or to health care professionals.
A nurse has a regular client who is an immigrant from China and who follows the traditional medical system of that culture. To improve the ability to understand and work with this client, the nurse researches this client's cultural view of health. Which of the following would the nurse most likely discover? Prayers to God and saints for spiritual reparations for sins Use of herbs, roots, talismans, and amulets A focus on maintaining balance between yin and yang Respect for nature and use of masks and sand paintings
A focus on maintaining balance between yin and yang Explanation: Asian traditions of medicine include Chinese medical practitioners and herbalists who focus on maintaining balance between yin and yang. Native American and Alaska Native traditions include respect for nature and avoidance of evil spirits, along with use of masks, herbs, sand paintings, and amulets. Hispanic traditions include prayers to God and saints for spiritual reparations for sins. African traditions include use of magic, herbs, roots, rituals, talismans, and amulets.
A nurse has a regular client who is an immigrant from China and who follows the traditional medical system of that culture. To improve the ability to understand and work with this client, the nurse researches this client's cultural view of health. Which of the following would the nurse most likely discover? Respect for nature and use of masks and sand paintings Use of herbs, roots, talismans, and amulets Prayers to God and saints for spiritual reparations for sins A focus on maintaining balance between yin and yang
A focus on maintaining balance between yin and yang Explanation: Asian traditions of medicine include Chinese medical practitioners and herbalists who focus on maintaining balance between yin and yang. Native American and Alaska Native traditions include respect for nature and avoidance of evil spirits, along with use of masks, herbs, sand paintings, and amulets. Hispanic traditions include prayers to God and saints for spiritual reparations for sins. African traditions include use of magic, herbs, roots, rituals, talismans, and amulets.
Which of the following would be the best indication that a community's police department is inadequate? High unemployment Increases in loss of life and property due to fires Low graduation rate A high rate of homicides
A high rate of homicides Explanation: A high rate of violent crimes—such as homicide, rape, robbery, and assault—would indicate that a community's police department is inadequate. An increase in the loss of life and property due to fires would indicate that a community's fire protection services are inadequate. High unemployment would indicate economic instability. A low graduation rate would indicate an inadequate educational system.
A nurse is planning a program to address measures to reduce the leading cause of mortality in children age 1 to 14 years. Which of the following would the nurse include? Accident prevention Substance abuse Prenatal care Gun control
Accident prevention Explanation: According to the National Center for Health Statistics, accidental injuries are the leading cause of death in children from ages 1 to 4 and from ages 5 to 14. The most appropriate program would be accident prevention. Homicide, which might benefit from gun control programs, is the fourth leading cause for both age groups. Prenatal care programs would be important to help reduce the risk of neonatal mortality. Substance abuse/use is not listed among the top five causes of mortality for any age group.
A nurse knows that the most important risk factor for assessing health related problems is what demographic information? Age Occupation Gender Race
Age Explanation: Age is the most important risk factor for health-related problems. Gender is another important factor.
In preparing to assess a client from a different culture, a nurse is aware that one needs to assess both factors that affect the client's approach to providers and factors that affect the client's disease, illness, and health state. Which of the following is a factor the nurse should consider that primarily affects the client's approach to providers? Pregnancy and childbearing Pain Death rituals Body language
Body language Explanation: Elements of communication—including time, space, eye contact and face positioning, body language and hand gestures, silence, and touch—are all examples of factors that affect the client's approach to providers. Health care beliefs—such as causes of illness, culture-bound syndromes, culture-based treatments, death rituals, pregnancy and child-bearing, pain, and blood products and transfusions—are examples of factors that primarily affect the client's disease, illness, or health state.
The nurse learns that there is a lack of resources to support the learning needs of students in a community grade and middle school. Where should the nurse obtain information about school district funding? Select all that apply. State education agencies Telephone directories Census reports Local school districts Chamber of Commerce
Census reports Local school districts State education agencies Explanation: Information about school districts and funding can be obtained from census reports, local school districts, and state education agencies. This information cannot be obtained from telephone directories or the Chamber of Commerce.
A nurse is caring for a 70-year-old client from a different culture whose breast cancer has metastasized. The nurse observes that the client tends to defer responsibility for decision making around treatment options to her eldest son. How should the nurse respond to this? Attempt to dialogue with the client when her son is not present. Confirm that the client wants her son to make these decisions. Explain the disconnect between the client's practice and the principle of client autonomy. Request a referral for a social worker.
Confirm that the client wants her son to make these decisions. Explanation: A client has the right to appoint another person to make decisions, provided there is no evidence of coercion. This is considered an application of the principle of autonomy, not necessarily a violation of it. Social work may not be warranted, and circumventing the client's wishes is inappropriate.
A nurse is assigned to care for a client who practices a religion different from her own. After reading the client's medical record, the nurse takes time to talk with the client about how to make his hospital stay more comfortable. The nurse admits to the client that she is not familiar with his religion but would like to learn more. The nurse is in which stage of cultural awareness? Conscious incompetence Unconscious competence Unconscious incompetence Conscious competence
Conscious incompetence Explanation: The nurse is aware of the lack of knowledge about the client's religion. Unconscious incompetence is not being aware that one lacks cultural knowledge. Conscious competence involves learning about the differences and providing culturally relevant interventions. Unconscious competence is the ability to automatically provide culturally competent care.
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? Follow the parents' wishes and try to comfort the child without use of medications Consult the hospital's ethics committee Administer the medications regardless of the parents' wishes Try to persuade the parents to allow administration of medications
Consult the hospital's ethics committee Explanation: 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.
A nurse is assessing a client from India who complains of panic, sexual dysfunction, fatigue, weakness, and loss of appetite. Which culture-bound syndrome should the nurse suspect in this client? Wind illness Koro Latah Dhat
Dhat Explanation: Dhat is a culture-bound syndrome of India and includes symptoms of panic, sexual complaints, fatigue, weakness, loss of appetite, guilt, and sexual dysfunction with no physical findings. Latah is a culture-bound syndrome of Malaysia that occurs after a traumatic episode or surprise. Symptoms include an exaggerated startle response (usually in women), screaming, cursing, dancing, hysterical laughter, imitation of people, and hyper-suggestibility. Wind illness is a culture-bound syndrome of Asia that features symptoms including fear of wind or cold exposure causing a loss of yang energy. Koro is a culture-bound syndrome of Malaysia and Southeast Asia that features a fear that genitalia will retract into the body, possibly leading to death.
After assessing the health care needs of a Native American community, what health care problem would most likely need addressing? Diabetes mellitus Tuberculosis Hypertension Cardiovascular
Diabetes mellitus Explanation: A large percentage of ethnic or racial minorities may indicate that certain health concerns exist within these groups of individuals. For Native Americans, there is a higher incidence of diabetes or alcohol-related health problems.
A client requests to be cared for by a nurse who is a member of his own culture. The nurse recognizes that which barrier exists in regards to this client's nursing care? Prejudice Ethnocentrism Stereotype Ethnicity
Ethnocentrism Explanation: Ethnocentrism is the barrier that the nurse identifies in this client's nursing care. The perception that one's beliefs, values, and sanctioned behaviors are superior to all others is termed as ethnocentrism. Ethnicity refers to a socially, culturally, and politically constructed group of individuals that holds a common set of characteristics not shared by others with whom they come in contact. Prejudice is based on preconceived notions about certain groups of people. Stereotype refers to accepting that there are people from other cultures, having different beliefs and values, but not recognizing the variation that can exist within any cultural group.
A nurse recognizes that the belief that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others is called what? Egocentrism Ethnocentrism Ethnicity Stereotyping
Ethnocentrism Explanation: Ethnocentrism is the belief that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others. Stereotyping is expecting group members to hold the same beliefs and behave in the same way. Egocentrism is the tendency to perceive, understand, and interpret the world in terms of the self and the inability to see other people's viewpoints. Ethnicity describes subgroups that have a common history, ancestry, or other cultural identity and may relate to geographic origin.
A nurse is admitting a client who is from another culture. Prior to caring for a client from another culture, the nurse should place primary importance on which action? Developing awareness of the culture's health practices Researching characteristics of the specific culture Examining personal biases and prejudices Asking colleagues about ways to approach the client
Examining personal biases and prejudices Explanation: Examining one's biases, prejudices, and stereotypes assists the nurse in being more sensitive to possible communication barriers that may impede competent care. This self-examination is the first step in developing cultural awareness. This is followed by consciously learning about the client's culture and providing culturally relevant interventions, gaining cultural knowledge, and developing cultural skills.
A group of students is reviewing material related to the role of religion and spirituality in health care choices. The students demonstrate understanding when they identify which situation as the most prominent ethical dilemma that involves religion? Providing life-saving therapy Failure to seek timely medical care Implementing spiritual care Treating clients' psychological needs
Failure to seek timely medical care Explanation: Although providing life-saving therapy, implementing spiritual care, and treating associated psychological needs may present ethical dilemmas, failure to seek timely medical care and withholding proper medical care are the two most prominent religion-based ethical dilemmas facing health care providers.
A nursing instructor is describing formal and informal channels of communication that occur within a community. The instructor determines that the teaching was successful when the students identify which of the following as an example of informal communication? Newspaper Radio Television Fliers SUBMIT ANSWER
Fliers Explanation: Informal communications include word of mouth, newsletters, bulletin board notices, and fliers. Newspaper, television, and radio are formal methods of communication
If a client does not speak English, when is a trained interpreter required? For any meaningful communication, including pain assessment or client teaching When a family member is not available When there is no one on staff who speaks the person's language For legal purposes such as obtaining informed consent
For any meaningful communication, including pain assessment or client teaching Explanation: When clients do not understand or speak English, an interpreter is essential for conducting an accurate health assessment and capturing clients' health concerns and priorities. Any significant communication, including assessing the client's pain, performing client teaching, as well as discussing legal matters, would necessitate the use of a trained interpreter. Family members or staff members should not be used as interpreters whenever possible.
When performing a spiritual assessment, what may help the nurse to identify related nursing diagnoses, needed interventions, and improve client care? Gathering information about the client's mental status from the client's family. Gaining relevant information about the client's spirituality. Establishing a close nurse-client relationship. Gathering current objective data.
Gaining relevant information about the client's spirituality. Explanation: A spiritual assessment is similar to the many other assessments nurses perform on a daily basis. Gaining relevant information about the client's spirituality helps to identify related nursing diagnoses and needed interventions and can improve client care.
A nurse is gathering health information about a community that is economically unstable. Which of the following should she expect to find? Low unemployment rates Reduced incidence of lung diseases Higher morbidity and morality A large tax base
Higher morbidity and morality Explanation: Economic instability in a community can lead to a number of health-related concerns. Poverty is associated with higher morbidity and mortality rates. High unemployment creates a stressful environment and a threat to the psychological well-being of the community. Occupationally related death and injuries cost the nation billions of dollars a year, with lung diseases and musculoskeletal injuries being the most frequent causes.
A nurse is assessing the level of social services available in a rural community. Which of the following is such a community most likely to be lacking in? Medicare Homeless shelters Medicaid Salvation Army
Homeless shelters Explanation: Availability of programs may be limited in rural areas. For example, homeless shelters and shelters for abused women are nonexistent in many rural areas. Medicare and Medicaid are typically available everywhere, and the Salvation Army is present in most areas.
A nurse is preparing to conduct a community assessment. Upon completing the assessment, which of the following would the nurse expect as the primary outcome? Creation of a health partnership Development of a common bond Increase in the number of services provided Identification of health-related concerns
Identification of health-related concerns Explanation: The purpose of a community assessment is to determine the health-related concerns of its members, regardless of the type of community being assessed. Throughout the process, the nurse may develop common bonds with the community members. Once the health-related concerns are identified, then the nurse can work with the community to increase services where needed. A positive relationship with the community may lead to health partnership.
A nurse has just learned that a community recreation league for youth has just been eliminated due to lack of funding. Which of the following results should the nurse suspect? Increased sports injuries Increased unemployment Increased standardized testing scores Increased gang activity
Increased gang activity Explanation: In a community where there are no programs available for young people, gang activity and alcohol/drug abuse may develop. In communities where activities such as water sports or snow sports are common, lack of programs related to safety issues could result in serious injury or even death. Increased unemployment is not a likely result, nor is increased standardized testing scores.
A nurse demonstrates cultural skill by which of the following? Examining his or her own biases about other cultural groups Being aware of cultural differences among groups Interacting in a face-to-face manner with someone from another culture Interpreting data accurately based on a client's culture
Interpreting data accurately based on a client's culture Explanation: Cultural skill involves learning how to complete cultural assessments and culturally based physical assessments and to interpret the data accurately. Interacting face-to-face with someone from another culture refers to a cultural encounter. Examining one's own biases, and being aware of cultural differences, reflects cultural awareness.
An instructor is describing culture and minority. Which statement would be most accurate for the instructor to include related to minority? The members fail to act in appropriate ways. It means that a group has smaller population numbers. It refers to a group with less power or prestige in society. The group does not hold the accepted primary values.
It means that a group has smaller population numbers. Explanation: Minority commonly refers to a group that has less power or prestige within the society. However, the most accurate description is that minority actually means a group with smaller population numbers. The term has a negative meaning in most uses, indicating a group that does not hold the "majority" values or does not behave in "appropriate" ways.
A nurse is working with a client who has received a terminal diagnosis. To help the nurse identify the client's possible coping responses, what would be most important for the nurse to understand about spirituality? It remains static throughout the lifespan. It decreases in importance with age. It varies in different situations. It increases in significance with illness.
It varies in different situations. Explanation: Spirituality is highly variable and differs from one client to the next and in one individual in different contexts. Knowing how spirituality can vary helps a nurse to identify possible coping responses. Illness does not necessarily increase a person's focus on spirituality.
A client who followed Judaism has died. What should the nurse do to ensure for this client's end-of-life care and burial? Place the client to face the East Straighten the arms Ensure a calm environment Keep all bandages with the client's blood
Keep all bandages with the client's blood Explanation: In Judaism, all clothing or bandages with blood should be prepared for burial with the person because the whole person needs to be buried. The arms are straightened after death in Hinduism. A calm environment is necessary in Buddhism. The client needs to face the East in Islam.
The nurse is concerned that a community is at risk for tornadoes and other weather-related events. Where should the nurse obtain information about this community's geographic terrain? Select all that apply. Local library Chamber of Commerce Government agencies Census bureau Direct observation
Local library Direct observation Government agencies Explanation: Information about a community's geographic terrain can be obtained from the local library, government agencies, and direct observation. This information is not available from the census bureau or the Chamber of Commerce.
Participating in the community allows the nurse to be accepted as a member of it. This method of data collection allows the nurse to participate in the daily life of the community, obtain information about the structures and influences of the community, and also do which of the following? Make observations. Form judgements. Facilitate immediate changes. Tell people what to do.
Make observations. Explanation: Through the process of participant observation, the nurse hopes to become accepted as a member of the community. This method of data collection allows the nurse to participate in the daily life of the community, make observations, and obtain information about the structures and influences that affect the community. It does not intend to allow for the nurse to make quick changes or to make judgements, nor does it imply that the nurse tells people what to do. The nurse can, however, after time make suggestions for the better of the community.
The nurse is assessing a client and notices that when being asked questions, the client does not make eye contact. The nurse should include what in the plan of care? Fear of authority Minimal eye contact due to culture Uncomfortable answering questions. History of abuse
Minimal eye contact due to culture Explanation: Some cultures make minimal eye contact out of respect. There is no indication the client is fearful of authority, uncomfortable answering questions or has been abused.
After teaching a group of students about spirituality and religion, the instructor determines that the students need additional teaching when a student states which of the following? Religion and spirituality are separate and distinct, but interrelated concepts. Nursing has only recently begun to incorporate spirituality into client care. There has been a tremendous growth in the understanding of spirituality in the past 20 years. Spirituality and religion are important factors that can affect health decisions and outcomes.
Nursing has only recently begun to incorporate spirituality into client care. Explanation: Nursing has a history of incorporating spirituality into client care, as evidenced by the writings of Florence Nightingale denoting an inner strength. Spirituality and religion are important factors that can affect health decisions and outcomes. They are separate and distinct concepts that are interrelated. Spirituality has undergone tremendous growth in its conceptual understanding during the past 20 years.
When performing an assessment of a client, the nurse observes that the client begins to cry when asked if she has a religious preference. What part of the care plan would the nurse document this assessment finding? Objective data Subjective data Outcomes Evaluation
Objective data Explanation: The subjective data is the primary source of information from the client, and the objective data is the data that is observed by the nurse.
The city police department has had to make significant budget cutbacks and have been forced to decrease their workforce. The nurse has seen in increase in injuries caused by violent crimes in the emergency department. What would be a priority nursing diagnosis for this issue? Risk for Social Isolation related to insufficient police protection Risk for Impaired Community Processes related to subgroup of ethnic people Risk for Ineffective Community Therapeutic Regimen Management Other-Directed Violence related to insufficient police protection
Other-Directed Violence related to insufficient police protection Explanation: The problem related to the decrease in the police workforce is actually creating a problem, the increase in injuries related to violent crime. The other nursing diagnosis are risks which are lower on the priority list for nursing diagnosis.
As a novice nurse caring for a client from a different culture, what may the nurse find confusing or upsetting? Patient's level of motivation Patient's family members Patient's nonverbal communication Patient's ethnicity SUBMIT ANSWER
Patient's nonverbal communication Explanation: A client's nonverbal communication may confuse or upset a novice nurse when it is different from the nurse's culture.
A nurse is assessing a client and observes several reddened and bruised areas on the skin. Further assessment reveals that the client was using cupping to treat back pain. The nurse understands this as which of the following? Placing warm burning herbs directly on the skin Attaching smoldering herbs to acupuncture needles Rubbing ointment into the skin with a spoon Placing heated glass jars on the skin that are allowed to cool
Placing heated glass jars on the skin that are allowed to cool Explanation: Cupping, often used to treat back pain, involves placing heated glass jars on the skin. Cooling causes suction, which leaves redness and bruising. Coining involves rubbing ointment into the skin with a spoon or coin. It leaves bruises or red marks but does not cause pain. It is used for "wind illness" (a fear of being cold or of wind, which causes loss of yang), fever, and for stress-related illnesses such as headache. Moxibustion is the attachment of smoldering herbs to the end of acupuncture needles or placing the herbs on the skin; this causes scars that look like cigarette burns.
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? Spiritual distress Hopelessness Risk for spiritual distress Readiness for enhanced hope
Readiness for enhanced hope Explanation: The client wants to be positive about the upcoming treatment. The most appropriate diagnosis would be Readiness for enhanced hope. The client is not demonstrating Hopelessness, Spiritual distress, or is at Risk for spiritual distress.
A nurse is assessing a community's environmental protection. What would the nurse address? Local law enforcement agencies Sewage treatment facilities Major local employers Educational facilities
Sewage treatment facilities Explanation: Environmental protection includes a wide range of programs, such as water and air quality, solid and hazardous waste disposal, sewage treatment, food/restaurant inspection, and monitoring of public swimming pools, motels, and other facilities. Law enforcement agencies, educational institutions, and employers may or may not be able to inform the nurse about environmental concerns.
The client 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 client is experiencing: Readiness for enhanced spiritual well-being Impaired social interaction Social isolation Spiritual distress
Spiritual distress Explanation: The client is experiencing spiritual distress, as evidenced by the statement of feeling punished by God. Readiness for enhanced spiritual well-being is appropriate for the individual who is comfortable with their spirituality but wishes to attain a higher level. Impaired social interaction is characterized by decreased interaction or interaction that lacks quality with others. The person with a nursing diagnosis of social isolation experiences loneliness and often withdraws from others.
What are some of the general recommendations when the nurse is taking a spiritual history? (Select all that apply) Inform the client that you will be happy to call your spiritual adviser to come and talk with the client. Respect a client's privacy and do not impose your beliefs on them. If you do not have the same spiritual beliefs as the client, you should have someone else do the assessment. Spirituality is an important component of physical well-being and mental health Make referrals to chaplains, spiritual directors, or community resources as appropriate
Spirituality is an important component of physical well-being and mental health Respect a client's privacy and do not impose your beliefs on them. Make referrals to chaplains, spiritual directors, or community resources as appropriate. Explanation: General recommendations when taking a spiritual history: Consider spirituality as a potentially important component of every client's physical well-being and mental health. Address spirituality at each complete physical examination and continue addressing it at follow-up visits if appropriate. In client care, spirituality is an ongoing issue. Respect a client's privacy regarding spiritual beliefs; do not impose your beliefs on others. Make referrals to chaplains, spiritual directors, or community resources as appropriate. Be aware that your own spiritual beliefs will help you personally and will overflow in your encounters with those for whom you are to make the encounter a more humanistic one.
A nurse is preparing to begin a community assessment. The nurse would begin with which activity? Enlist the help of nurses in the community. Draft preliminary health goals for the community. Visit the hospitals in the community. Study the history of the community.
Study the history of the community. Explanation: Studying the community's history near the beginning of a community assessment provides valuable context and background. This should precede the other listed activities.
The school nurse is in the talking to a group of students about sexually transmitted diseases. One of the students says, "I know that most of the 10th grade has already had sex. There's drinking and parties, and this is where a lot of it happens." What type of data is the nurse collecting? Summative Subjective Formulative Objective
Subjective Explanation: Subjective data collection includes perceptions of the community by the nurse as well as by members of the community.
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? Subjective Secondary sources Medical record Objective
Subjective Explanation: Subjective data will be the primary source of information during a spiritual assessment with objective data used to validate the information. The medical record and secondary sources are not the primary sources of information for a spiritual assessment.
The nurse assesses a client's spiritual dimension, documenting the primary source of information at which location? Implementation Objective data Nursing diagnosis Subjective data
Subjective data Explanation: Subjective and objective data will be collected during assessment. However, the subjective data will be the primary source of information during a spiritual assessment. Objective data can validate or call into question information presented to the nurse. Possible conclusions or clustering the data would lead to nursing diagnoses. Interventions would be documented in implementation.
Long-term care facilities in a community would be deemed adequate if which situation exists? Residents are admitted to inpatient hospital units during exacerbations of symptoms. Sufficiently specialized care is available for local residents who cannot live independently. Older adults are able to live in structured settings without having to pay. Older adults are able to live in their own homes regardless of health status.
Sufficiently specialized care is available for local residents who cannot live independently. Explanation: A community should provide services for long-term care assistance in the home, as well as extended care for those who can no longer function in their homes. This is not normally provided free-of-charge, however. Home settings are preferred but not always possible. Excessive hospital admission by older adults may suggest inadequate long-term care services.
The nurse is educating a client from another country about the medications they will be taking. The client continually interrupts the nurse during the conversation. When the nurse considers the many ways cultural differences can affect communication, how should the nurse interpret the client's interruptions? This client is impolite and does not know good manners. The client believes that what they have to say is more important than what the nurse is saying. The client believes that they know more about the medications than the nurse does. The client is deeply engaged in the conversation.
The client is deeply engaged in the conversation. Explanation: In some cultures, it is common for speakers to interrupt one another in conversation. This provides for overlap in speech. In such cultures, this indicates that the persons are deeply engaged in the conversation. In other cultures this practice is perceived to be rude by other cultures. By practicing cultural awareness the nurse can prevent herself from perceiving negativity in this situation.
A clinic nurse is conducting a comprehensive assessment of a client. The nurse observes that the client rarely makes eye contact and holds his head low during the assessment. Using knowledge of cultural practices how should the nurse best interpret this practice? The client may not understand the purpose of the assessment. The client may be a victim of intimate partner violence. The client may be showing the nurse respect. The client may not trust the nurse's expertise.
The client may be showing the nurse respect. Explanation: Members of certain cultures tend to look down to show respect to the person talking. This does not necessarily rule out the other possible explanations, but is a cultural factor the nurse should consider.
What outcome should the nurse prioritize when addressing a client's social, cultural, and spiritual issues? The client will engage in interactions with others. The client will express a sense of oneness with self and others. The client will express meaning and purpose in life. The client will engage in worship weekly.
The client will express meaning and purpose in life. Explanation: An outcome related to social, cultural, and spiritual issues includes the client will express meaning and purpose in life.
The nurse is setting an outcome with the client experiencing social isolation. Which goal would be appropriate? The client will express feelings of connectedness with God. The client will attend a church event every week. The client will express meaning and purpose in life. The client will initiate interaction with others.
The client will initiate interaction with others. Explanation: An outcome appropriate for the client experiencing social isolation would be for the client to initiate interaction with others. The other options would be appropriate for the client experiencing spiritual distress.
What must occur before a client will be willing to teach the nurse about her culture? The nurse needs to establish a value-based partnership The nurse needs to hide her biases The client's family must allow it The nurse needs to establish rapport and trust
The nurse needs to establish rapport and trust Explanation: If the nurse has established rapport and trust, clients will be willing to teach about their cultures.
A nurse has completed a community assessment and is analyzing the availability of agency services. What assessment finding would suggest that agencies provide sufficient services in the community? Primary care facilities do the functions performed by agencies in other jurisdictions. There is a combination of several different public agencies and volunteer agencies. Agencies are limited to tasks that cannot be performed in a hospital or institutional setting. The agencies in the community are primarily faith-based.
There is a combination of several different public agencies and volunteer agencies. Explanation: A healthy community has a variety of agencies, some of which are volunteer-based and others which are publicly funded. Faith-based agencies perform valuable roles but should not be the sole type of agency available. Agencies should perform roles that are not performed efficiently or appropriately in primary care settings.
A community nurse's assessment of a rural community reveals the presence of more cultural diversity than was previously thought. The presence of differences between cultures may have what effect on the health of the community? There may be worse health outcomes than in a homogenous community. There may be an unwillingness to change. There may be a lack of health services. There may be a potential for conflicting views.
There may be a potential for conflicting views. Explanation: Difference between cultural groups may have the potential for conflict, although this is not always the case. Diverse regions do not necessarily have poorer health outcomes than more homogeneous communities. Culture may or may not affect willingness to change.
A health care organization is preparing posters about childhood mortality for a community health fair. What should be identified as the leading cause of mortality for children of all ages? Malignant neoplasms Unintentional injuries Homicide Suicide
Unintentional injuries Explanation: The leading cause of childhood mortality for ages 1 through 14 is unintentional injuries. Suicide is the 2nd cause of death for children ages 10 to 14. Homicide is the 3rd leading cause of death for children aged 1 through 4, 4th leading cause of death for children aged 5 through 9, and 5th leading cause of death for children aged 10 through 14. Malignant neoplasms are considered the 4th leading cause of death for children aged 1 through 4, 2nd leading cause of death for children aged 5 through 9, and 3rd leading cause of death for children aged 10 through 14.
Within all age groups from 1 to 44 years, a nurse knows that the most common cause of mortality is from what source? Malignant neoplasms Lower respiratory diseases Suicide Unintentional injuries
Unintentional injuries Explanation: Unintentional injuries are the most common cause of death among age groups 1-4, 5-14, 15-24, and 25-44 years of age. In the 45- to 64-year-old age group, the most common cause of mortality is from malignant neoplasms.
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 explain that there is no control over the time when breakfast arrives schedule breakfast after time for prayers emphasize the importance of physical health as a priority
assess if the client would like time for prayers before breakfast Explanation: 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.
Which nursing intervention best demonstrates the nurse's attempt to provide effective spiritual care to a client in spiritual distress? Sharing a story related to one's own spiritual beliefs Assessing the spiritual needs of a client who is critical ill Attending a religious service in the hospital's chapel with a client who is scheduled for surgery Providing intense spiritual counseling for a client who has expressed hopelessness
assessing the spiritual needs of a client who is critical ill Explanation: When an individual's sense of purpose or meaning of life is threatened, spiritual distress may result. Nursing care includes assessment of the client's spiritual needs and implementation of care related to these needs. The generalist nurse is not prepared to provide intense spiritual counseling. The remaining options are nurse focused rather than client focused.
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? Searching for meaning and purpose Defining the meaning of the afterlife Finding common practices shared with a group Identifying possible coping mechanisms
dentifying possible coping mechanisms Explanation: 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.
A nurse has just completed a community assessment for a small rural town. Some data collected include the following: 11.8% unemployment, lack of medical care services, median income below the national average. Based on the limited data given, which of the following is the best nursing diagnosis? social isolation risk for trauma related to high crime areas readiness for enhanced community coping ineffective community coping related to unemploymen
ineffective community coping related to unemployment Explanation: After grouping the limited data given, the correct diagnosis is ineffective community coping related to unemployment. No data support that the community is ready to learn how to better cope with its problem of unemployment, nor is there any mention about citizens feeling socially isolated. High crime areas also are not part of the data collected.
To give spiritual care to a client, it is not necessary for the nurse to share the same religious beliefs as the client to provide effective spiritual care. be aware of personal religious beliefs and biases in order to provide effective spiritual care. recognize that depression may result from unmet religious group expectations. prepare to help clients seek a source of strength and hope from their own (clients') religion and spiritual beliefs. SUBMIT ANSWER
share the same religious beliefs as the client to provide effective spiritual care. Explanation: Nurses who are more aware of their spirituality are more comfortable discussing the potential spiritual needs of the client. Introspective reflection on one's own beliefs and biases about the relationship between spirituality and health can be undertaken through journaling, meditation, or discussions with interested persons. These reflections help to provide a deeper understanding of one's spiritual dimension and build confidence for future discussions on spirituality. While many nurses view spiritual assessment and care as an important part of nursing practice, training levels vary from institution to institution. However, nurses can educate themselves to meet this vital need of the client. The nurse who understands the content of a spiritual assessment can use this knowledge also to increase self-understanding.
What aspects of culture are relevant when conducting a health assessment on a foreign-born client admitted for surgery? Select all that apply. age when immigration to the United States occurred alternative medicine practices whether there are any existing language barriers nutritional or dietary considerations reasons for immigrating to the United States
whether there are any existing language barriers nutritional or dietary considerations alternative medicine practices Explanation: Aspects of culture relevance to a health assessment include communication and language, nutrition, and health care beliefs and practices. The remaining questions relate to the social aspects of a cultural assessment.