NU270 Week 2 PrepU: Spirituality
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 room of unnecessary items. Clear the bedside table; cover with clean towel. Have a chair available near the bed. Keep the bed curtains open so as to allow others to join in prayer Complete your work so you may join them.
Clear the bedside table; cover with clean towel. Have a chair available near the bed. Clear the room of unnecessary items. Explanation: When expecting a visit from a client's spiritual counselor, preparations may vary, but the following are usually recommended:• The room should be orderly and free of unnecessary equipment and items.• There should be a seat for the religious counselor at the bedside or near the client so that both can be comfortable.• The bedside table should be free of items and covered with a clean, white cover if a sacrament is to be administered. • The bed curtains should be drawn for privacy if the client can't be moved to a more private setting.The nurse should not expect or plan to join a private group such as described. Reference: Chapter 46: Spirituality - Page 1811
nurse is giving a bed bath to a terminally ill client. The client tells the nurse that the client has great respect and faith in a particular spiritual leader. Which is the best response by the nurse? "It's good to have something to believe in." "People with strong beliefs have better outcomes." "It sounds like that offers you a sense of security." "Think about your leader when you have moments of doubt."
It sounds like that offers you a sense of security." Explanation: Spiritual or religious beliefs give meaning to life, illness, other crises, and death; contribute a sense of security for present and future; guide daily living habits; drive acceptance or rejection of other people; furnish psychosocial support within a group of like-minded people; provide strength in meeting life's crises; and give healing strength and support. The nurse can respond to the client by validating the client's sense of security. It is not therapeutic for the nurse to judge whether a spiritual belief is good or bad. It is false hope to tell the client that people with strong beliefs have better outcomes. It is not the nurse's place to tell the client to think about the client's spiritual leader in times of doubt.
Mrs. Dopson is a 75-year-old widow who lost her last offspring to cancer last month. She shares with the nurse that she fears being alone. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people? Need for forgiveness Need for love and relatedness Need basic necessities of life Need for meaning and purpose
Need for love and relatedness Explanation: According to Shelly and Fish (1988), the three spiritual needs underlying all religious traditions and common to all people are the need for meaning and purpose, the need for love and relatedness, and the need for forgiveness. The client is experiencing a loss of love and relatedness. A need for meaning and purpose can be related to loss of a job or function. Need for forgiveness is reconciling differences with other persons. Basic necessities are something necessary or indispensable such as food, water, and shelter. Reference: Chapter 46: Spirituality - Page 1807
Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family? Reproductive Physical Affective and coping Socialization
Socialization Explanation: Through socialization, the family teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback; and guides problem solving. Incorporating religious beliefs, values, and attitudes is an example of socialization. Physical functions of the family include providing a safe, comfortable environment necessary for growth and development, rest, and recuperation. The reproductive function of the family is raising children. The affective and coping function of the family involves providing emotional comfort to family members. Reference: Chapter 4: Health of the Individual, Family, and Community - Page 72
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 Spiritual Need as evidenced by verbalizations and distress at missing Methodist church services Dysfunctional Grieving related to inability to attend church services as a result of his medical condition Potential for Enhanced Spiritual Well-Being related to distress at missing Methodist church services
Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt Explanation: Persons suffering spiritual dysfunction or distress may verbalize such distress or express a need for help. Developing a three-part nursing diagnosis consists of data analysis, problem identification, and the formulation of the nursing diagnosis. There are four different types of nursing diagnoses: actual nursing diagnosis, wellness (or health promotion) nursing diagnosis, risk nursing diagnosis, and syndrome diagnosis. The other three statements are missing part of the nursing diagnosis. Reference: Chapter 46: Spirituality - Page 1807
A nurse is employed by a community organization engaged in health promotion. In this role, the nurse teaches clients steps they can take toward achieving wellness. The nurse would explain "wellness" to a client as: a state of complete physical, mental, and social well-being. an ongoing and intentional effort to achieve the highest potential for total well-being. the absence of disease. viewing one's health in terms of a balance of body, mind, and spirit, which means being open to alternative treatment options.
an ongoing and intentional effort to achieve the highest potential for total well-being. Explanation: Wellness involves lifestyle choices that result in a balance in the physical, mental, spiritual, emotional, and social aspects of a person's life. Wellness is a state of being that goes beyond the mere absence of disease. This is the definition of health. Viewing one's health in terms of a balance of body, mind, and spirit is the definition of holism. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 1: Health Care Delivery and Evidence-Based Nursing Practice, p. 6. Chapter 1: Health Care Delivery and Evidence-Based Nursing Practice - Page 6
Mrs. Jones is an 81-year-old client who can no longer live alone safely and is being admitted to a long-term-care facility. She had to leave her elderly cat, Baby, with neighbors. She tells the nurse that her cat was the only family she had and that she misses her. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people? need for basic necessities of life need for meaning and purpose need for love and relatedness need for forgiveness
need for love and relatedness Explanation: According to Shelly and Fish (1988), the three spiritual needs underlying all religious traditions and common to all people are the need for meaning and purpose, the need for love and relatedness, and the need for forgiveness. The client is experiencing the need for love for her cat. The need for forgiveness is reconciliation for past relationship issues. The need for meaning and purpose is finding connectiveness with jobs or people. Basic needs are something necessary or indispensable such as food, water, and shelter. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1699. Chapter 46: Spirituality - Page 1699
A nurse cares for a client who believes in Hinduism. The nurse understands that Hindus believe illness is caused by which type of behavior? consumption of dirty food past and current life actions poor worship of God unhygienic habits
past and current life actions Explanation: According to Hinduism, illness is the result of past and current life actions. The right hand is seen as holy, and eating and intervention need to be done with the right hand to promote clean healing. The spiritual health belief in Hinduism is not that illness is from consumption of dirty food, unhygienic habits, or poor worship of God.
A nurse is developing a plan of care for a client who recently lost his spouse. Which of the following would be most appropriate for the nurse to suggest to help the client cope with his loss? validating his needs maintaining nutritional intake remaining active in the community seeking support from his faith
seeking support from his faith Explanation: Seeking support from the client's faith is an adaptive means of coping with loss. Social support and therapy are other methods of adaptive coping. Although remaining active in the community fosters social connection, the client may find it difficult to do so. Remaining active does aid in addressing loneliness. Maintaining nutrition promotes the health of the older adult but does not affect coping. Validating his needs is a treatment strategy used with clients experiencing dementia. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 433. Chapter 23: The Older Adult - Page 433
A nurse identifies a nursing diagnosis of spiritual distress for a patient based on assessment of which of the following? Select all that apply. Acceptance Ambivalence Peacefulness Anger Despair
Anger Ambivalence Despair Explanation: Spiritually distressed patients may show despair, discouragement, ambivalence, detachment, anger, resentment, or fear. They may question the meaning of suffering or life and express a sense of emptiness.
A client diagnosed with terminal lung cancer expresses a desire to seek spiritual advice. Which intervention by the nurse best provides spiritual support for this client? Ask who the client's spiritual advisor is and make the contact. Ask if the client would like to speak to the nurse. Identify the name of the spiritual advisor from the client's admission history. Contact the most available spiritual advisor, even if of another faith.
Ask who the client's spiritual advisor is and make the contact. Explanation: The nurse may contact the client's spiritual advisor if the client so desires. The nurse can listen to the client, but spiritual support is best provided by someone proficient in that field, such as a spiritual advisor. It would be appropriate for the nurse to contact the clergy of another faith only if no other resources were available and if the client consented. The nurse should speak with the client and get the information firsthand, researching the admission history only if that is not possible.
When comparing the theories of mental illness popular in ancient Greece with those popular in the Middle Ages, which is more applicable to the Middle Ages? Mental illness was considered a disturbance of the four body fluids, or "humors." Emotional disorders were believed to be an organic dysfunction. Belief in demonic possession and exorcism was common. Treatment included sedation, good nutrition and hygiene, and music and recreation.
Belief in demonic possession and exorcism was common. Explanation: While some of these answers are true of both ancient Greece and the Middle Ages, belief in demonic possession and exorcism was more common in the Middle Ages. Reference: Chapter 1: Foundations of Psychiatric-Mental Health Nursing - Page 3
Members of which religious tradition are likely to have the most stringent restrictions and parameters placed on their medical care? Hinduism Buddhism Protestantism Christian Scientist
Christian Scientist Explanation: Christian Science places significant restrictions of the use of drugs, medical procedures, therapies, and surgeries. Hindu religious belief begins with the assumption that all living things have a soul, which passes through successive cycles of birth and rebirth. Hinduism includes ideas of karma and rebirth, collective versus individual identity, an emphasis on purity and a preference for sons. Buddhism and Protestants have very few if any health care restrictions. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1704. Chapter 46: Spirituality - Page 1704
Members of which religious tradition are likely to have the most stringent restrictions and parameters placed on their medical care? Protestantism Hinduism Buddhism Christian Scientist
Christian Scientist Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1704. Chapter 46: Spirituality - Page 1704
The son of a dying female client is surprised at his mother's adamant request to meet with the hospital chaplain and has taken the nurse aside and said, "I don't think that's what she really wants. She's never been a religious person in the least." What is the nurse's best action in this situation? Contact the chaplain to arrange a visit with the client. Perform a detailed spiritual assessment of the client. Organize a meeting between the chaplain, the son, and the client to achieve a resolution. Document the client's request and wait to see if the client reiterates the request.
Contact the chaplain to arrange a visit with the client. Explanation: The nurse's primary responsibility is to honor the client's request for a meeting with a spiritual advisor. Completing a spiritual assessment is not necessary at this time. Organizing a meeting between the chaplain, the son, and the client is not an accurate intervention at this time unless requested by the client. Documentation of the conversation with the client and calling for a spiritual advisor should be recorded in the client's health record. It is not necessary to document and wait for the client to ask again before the nurse considers the request. Afterall, she is dying and waiting for her to ask again is not warranted. Reference: Chapter 46: Spirituality - Page 1807
A nurse is reading a journal article about complementary health approaches that specifically describes mind-body practices. The nurse demonstrates understanding of the article by identifying which type as an example? Select all that apply. Homeopathy Ayurveda Traditional Chinese Medicine Meditation Tai Chi
Meditation Tai Chi Explanation: According to the National Center for Complementary and Integrative Health, mind-body practices include meditation and Tai Chi. Traditional Chinese medicine, homeopathy, and Ayurveda are classified as other complementary health approaches. Reference: Chapter 28: Complementary and Alternative Therapies - Page 805
While interviewing a client, a nurse is told that the client practices Catholicism. This client is identifying: his culture. his faith. his values. his spirituality.
his faith. Explanation: Faith is a term also used to describe a cultural or institutional religion such as Judaism, Islam, Catholicism, or Confucianism. Spirituality refers to anything that pertains to a person's relationship with a higher power or force. Values refer to those beliefs most meaningful to a person. Culture pertains to a person's background. Reference: Chapter 46: Spirituality - Page 1795
When providing care to Aboriginal clients, it may be important for the nurse to elicit help from the preacher. rabbi. priestess. spiritual healer.
spiritual healer. Explanation: Shamans and spiritual leaders are found among Aboriginal and many Southeast Asian groups
A nurse is updating the care plan for a client to integrate spirituality into the client's care. What assessment question would the nurse use in an effort to update the care plan accordingly? "Do you prefer a health care provider who shares your beliefs?" "What does the word 'spiritual' mean to you?" "Are there any spiritual practices that are important to you?" "Why do you have these particular spiritual beliefs?"
Are there any spiritual practices that are important to you?" Explanation: An open-ended yet clear question about a person's spiritual beliefs is most likely to elicit information about the client in a thoughtful manner. Asking the client about the meaning of the word 'spiritual' is not a direct way of assessing spirituality for a care plan. Asking if the client would like a health care provider who shares the same spiritual beliefs is unrealistic. Asking the client why the client has particular spiritual beliefs does not assess the client's spirituality in a practical way that can be used for a care plan.
A nurse is caring for a client who suffered a fall while on vacation. He is from another state and has no visitors except his spouse, who seems lonely without any friends or family nearby. The nurse invites the spouse to attend services with her at the nurse's church, which is a denomination different from the spouse's. This could be construed as which of the following? Cultural blindness Cultural imposition Cultural taboo Acculturation
Cultural imposition Explanation: A cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 7: Overview of Transcultural Nursing, p. 104. Chapter 7: Overview of Transcultural Nursing - Page 104
A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention? Discuss the client's options with other church members. Discuss the risks and benefits of a blood transfusion with the client. Discuss possible alternatives to a blood transfusion with the physician. Discuss the client's refusal with hospital risk managers.
Discuss possible alternatives to a blood transfusion with the physician. Explanation: As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority. Reference: Chapter 17: Implementing - Page 416
A client with posttraumatic stress disorder (PTSD) holds strong Christian beliefs. The nurse refers the client to an individual from the clergy as a part of treatment. What would be the most appropriate reason for the nurse to take this action? It fosters resilience through allegiance to religious beliefs. It helps the client concentrate on the therapy. It helps the client sleep in peace. It helps the client forget the traumatic incident.
It fosters resilience through allegiance to religious beliefs. Explanation: Strong cultural, spiritual, and/or religious identity and allegiance contribute to resilience and, therefore, are highly positive factors in the lives of people with PTSD. As this client is inclined toward spiritual and religious orientation, referring the client to a clergy person would help build resilience in the client. Talking to a member of the clergy would not directly treat concentration issues or insomnia. This intervention will not be directly helpful for the client to forget the traumatic incident. Reference: Chapter 13: Trauma and Stressor-Related Disorders - Page 210
Which client statement most clearly suggests the potential of a nursing diagnosis of Spiritual Anxiety? "I always tried to do the right thing, so I don't understand why I have to suffer so much now." "I've never been a religious man, and all these Catholic crosses and pictures in the hospital make me a bit uncomfortable." "Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." "I guess I should have taken a lot more time to go to church when I was younger."
Now that I'm nearing the end, I'm worried that God won't think I lived a good enough life." Explanation: Worry about one's spiritual condition is indicative of the nursing diagnosis of Spiritual Anxiety. Unfamiliarity with the religious character of a care setting suggests Spiritual Alienation, while questions of suffering often indicate Spiritual Pain or Spiritual Despair. Regrets over previous religious or spiritual apathy may suggest a nursing diagnosis of Spiritual Guilt. Reference: Chapter 46: Spirituality - Page 1806
The family members of a dying client have asked for the hospital chaplain's help in having a member of the clergy come to the client's bedside to perform the anointing of the sick. The nurse who is providing care for the client should recognize that the family is likely which religion? Jehovah's Witnesses Jewish Christian Scientist Roman Catholic
Roman Catholic Explanation: Among the sacraments of the Roman Catholic Church is the anointing of the sick or the sacramental anointing with blessed oil. This specific rite is not a component of Jehovah's Witnesses, Christian Science, or Judaism. Reference: Chapter 46: Spirituality - Page 1797
A client who has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count. She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong? She should place her three fingers just below the wrist on the outside of the arm with the palm up. She needs to take her pulse after her medication so that her pulse is stronger. She should stand when taking her pulse to increase blood flow. She needs to press harder until she feels a pulse.
She should place her three fingers just below the wrist on the outside of the arm with the palm up. Explanation: A client is taught to take his or her own pulse before certain medications or after exercise, depending on the individual client's needs. When teaching a client to take his or her own pulse, the nurse should teach the client to sit down and place an arm on a hard service with the palm upward. Using three fingers, the client should feel just below the wrist on the outer side of the arm for the pulse. The client should be taught not to press too hard or the pulse can be obliterated. Reference: Chapter 25: Vital Signs - Page 669
A client with a fetal demise at 40 weeks asks the nurse, "How could God let this happen?" An appropriate goal for the client with a nursing diagnosis of Spiritual distress related to infant lossas verbalized by the client would be that the client will meet with a minister daily. participate in supportive spiritual practices. express feelings of anger and despair to God. reflect on positive accomplishments in life.
participate in supportive spiritual practices. Explanation: The goal for the client should focus on supporting the client's strengths and utilizing what techniques have worked in the past.
When preparing for a spiritual counselor to visit a hospitalized client, the nurse should ask to be present during the visit to explain any medical information or answer questions about the client's care. take measures to ensure privacy during the counselor's visit. ask the spiritual counselor to summarize the visit in the client's medical record. ensure that the hospital administration approves the counselor.
take measures to ensure privacy during the counselor's visit. Explanation: Visits between a client and a spiritual counselor require privacy. The details of the meeting are not typically documented in the client's chart, though the fact that the visit took place is often noted. The nurse may be present during the meeting but this should take place at the client's request. Spiritual counselors do not require administrative approval; clients and their families are normally able to seek spiritual help from whomever they prefer.
Nurses are aware that culture links a wide variety of behaviors and events uniquely. For Westerners, which is a culturally linked behavior to autopsy? rebirth is made impossible body ultimately decomposes into dust the cause of death can be discovered the continuation of society is prevented
the cause of death can be discovered Explanation: Westerners believe that autopsy is used to discover the causes of death. Hmong who have not converted to Christianity believe that autopsy prevents continuation of society and rebirth. Judeo-Christians believe that the body ultimately decomposes into dust.
The nurse teaches a client about the use of yoga as a stress management intervention. Which client statement indicates to the nurse that learning has taken place? "It reduces physical and emotional tension through postural changes and focused concentration." "It eases tense muscles by clearing the mind of stressful thoughts." "It alters a negative physiologic response through the power of suggestion." "It uses the mind to visualize calming, pleasurable, and positive experiences."
"It reduces physical and emotional tension through postural changes and focused concentration." Explanation: Stating that yoga reduces physical and emotional tension through postural changes and focused concentration is correct, because yoga reduces stress, increases relaxation, and promotes greater flexibility. Stating that yoga eases tense muscles by clearing the mind of stressful thoughts refers to progressive relaxation, not yoga. Stating that yoga alters a negative physiologic response through the power of suggestion is incorrect, as this is referring to the placebo effect. Using the mind to visualize calming, pleasurable, and positive experiences is called imagery, not yoga. Reference: Chapter 42: Stress and Adaptation - Page 1676
The nurse is collecting the health history of a client and notes the client is apprehensive in answering questions. The client states, "My spiritual healer will be here soon." What is the bestresponse by the nurse? "I can wait until your spiritual healer arrives, but you are the only one who can answer these questions." "These questions need to be answered so we can provide you with the best care." "I will leave the questionnaire here. Please fill it out when your spiritual healer arrives." "We can wait until your spiritual healer arrives and work together to answer these questions."
"We can wait until your spiritual healer arrives and work together to answer these questions." Explanation: The culturally sensitive nurse understands that some cultures rely on a spiritual healer to restore harmony and health. If the client requests the spiritual healer to be present, the nurse should respect the client's beliefs and decision. Leaving the questionnaire with the client is not acceptable because the nurse needs to make sure the questionnaire is completed with the client. Telling the client that he or she is the only one who can fill out the questionnaire is not necessary and rude. Telling the client that the questions need to be answered so the health care team can provide the best care is important, but recognizing and supporting the client and his or her beliefs is the priority. Reference: Chapter 5: Cultural Diversity - Page 88-91
A nurse is caring for a client who is upset after being told about a diagnosis of cancer. The client asks the nurse to take a minute to pray, but the nurse is not a very religious person. What is the best action for this nurse? Tell the client that there are medications to be passed and maybe later. Inform the client that someone else of the same religion would be better to pray with the client. Agree to pray with the client and stand in silence by the bed. Tell the client that praying will not help the cancer go away.
Agree to pray with the client and stand in silence by the bed. Explanation: Nurses can assist clients to meet spiritual needs by offering a compassionate presence. Standing quietly at the bedside while the client prays will help do this. Although nurses may differ in their beliefs about how involved they should become in meeting spiritual needs, it is impossible to nurse clients well while ignoring this dimension of health. A nurse does not have to hold the same beliefs to pray with the client. The other options are not therapeutic responses and should never be used. Reference: Chapter 46: Spirituality - Page 1791
The nurse who is preparing a Native American client for surgery notes that the client is wearing a medicine bag. What intervention should the nurse implement to best address the client's spiritual needs with respect to presurgical care needs? Ask the client to provide information about his or her personal spiritual belief system. Explain to the client that the medicine bag must be removed in order to minimize the risk of infection during the surgical procedure. Remove the medicine bag and give it to a family member for safe keeping. Ask the client how the medicine bag can be respected while preparing for surgery.
Ask the client how the medicine bag can be respected while preparing for surgery. Explanation: Nurses who are unsure of a person's social or cultural preferences need to ask the client directly during the initial encounter about preferred terms of address and ways the nurse can help support the client's spiritual, religious, or health practices. None of the remaining options demonstrates respect and interest in the client's spiritual needs related to the medicine bag. Reference: Chapter 7: Client's Response to Illness - Page 123
The nurse is caring for a terminally ill client who immigrated from Mexico. Which nursing intervention regarding spiritual care is appropriate? Ask the client if a spiritual leader is desired. Inquire if the client desires the Sacrament of the Sick. Do nothing unless the client requests spiritual assistance. Call a Roman Catholic priest to visit the client.
Ask the client if a spiritual leader is desired. Explanation: The appropriate response is to ask the client if a spiritual leader is desired, which is observant of the client's preferences. The nurse should not generalize that a Latino client is Roman Catholic, nor should the nurse refrain from inquiring about spiritual needs. Reference: Chapter 5: Cultural Diversity - Page 91-92
The nurse is caring for a 55-year-old client admitted to the hospital for liver failure. The client states being an active member of The Church of Jesus Christ of Latter-day Saints. The client tells the nurse about strictly adhering to the religious practices that are condoned by the Church. However, the nurse overhears two health care providers discussing that the client's liver failure is likely due to chronic alcohol use. The nurse suspects that the health care providers are incorrect. Which nursing nursing action is appropriate? Order several laboratory tests looking for genetic defects that affect the liver. Engage the client in a discussion about past and present religious practices. Know that the health care providers are incorrect; the restored gospel of Jesus Christ does not permit alcohol use. Accuse the client of lying and find out why the client lied.
Engage the client in a discussion about past and present religious practices. Explanation: A client's current religious practice is not necessarily indicative of lifelong practices. The nurse should talk with the client about lifelong religious practice. As a result, useful information may be uncovered that will help to guide the plan of care. Reference: Chapter 46: Spirituality - Page 1796
The nurse is caring for a client whose treatment has been based on the Ayurveda medical system. Which nursing intervention incorporates this client's beliefs into the nursing plan? Helping the client to balance his or her dosha Including the client's shaman in the plan of care Preparing the client for exercises that help him or her regulate qi Basing practice on the yin-yang theory
Helping the client to balance his or her dosha Explanation: Central to Ayurvedic medicine is an understanding of the client's basic constitution, or dosha. The three doshas in Ayurvedic medicine are vata (changeable), pitta (intense), and kapha (relaxed). Yin-yang and qi are associated with traditional Chinese medicine. A shaman is associated with shamanism (involves the spirit world). Reference: Chapter 28: Complementary and Alternative Therapies - Page 810
The yin/yang theory of harmony and illness is rooted in which paradigm of health and illness? Scientific Holistic Biomedical Religious
Holistic Explanation: One example of a naturalistic or holistic belief, held by many Asian groups, is the yin/yang theory, in which health is believed to exist when all aspects of a person are in perfect balance or harmony. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 7: Overview of Transcultural Nursing, p. 109. Chapter 7: Overview of Transcultural Nursing - Page 109
A college foreign exchange student is living with a family in England and is confused about the daily Catholic prayers and rituals of the family. The student longs for the comfort of her fundamentalist Protestant practices and reports to the campus nurse for direction. The nurse recognizes the student is experiencing which type of spiritual distress? Spiritual loss Spiritual anger Spiritual guilt Spiritual alienation
Spiritual alienation Explanation: Spiritual alienation occurs when an individual is separated from one's faith community. Spiritual guilt is the failure to live according to religious rules. Spiritual anger is the inability to accept illness. Spiritual loss occurs when one is not able to find comfort in religion. Reference: Chapter 46: Spirituality - Page 1806
A student nurse walks into a client's room and observes the client chanting and holding his rosary. The client pauses and asks the student nurse to join hands while he prays. What is the best action for the student nurse to take? Call the chaplain on duty to come pray with the client. Carefully explain to the client that she is of a different faith and excuse herself from the room. Join hands with the client and remain at the bedside until the patient finishes the prayer. Join hands with the client and lead a prayer of behalf of the client.
Join hands with the client and remain at the bedside until the patient finishes the prayer. Explanation: It is important that the spiritual beliefs of people and families be acknowledged, valued, and respected for the comfort and guidance they provide. It is within the scope of the nurse to support the client's request for prayer and conveys respect for the client's spirituality. Leaving the room based on the nurse's spiritual beliefs does not convey respect for the client. The client needs to remain in control of the prayer, speaking it as he or she is accustomed to doing it. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia: Wolters Kluwer, 2018, Chapter 5: Adult Health and Nutritional Assessment, p. 67-68.
When performing a spiritual assessment on a child, the nurse and child discuss church attendance and practices that are most important to the child. Which domain is the nurse addressing when doing this assessment? All of the above Psychological Social Biologic
Social Explanation: Spiritual assessment is an important part of a mental health assessment. It is part of the social domain. Growing research suggests that religious and spiritual practices may promote both physical and mental health. Reference: Videbeck, S. Psychiatric-Mental Health Nursing, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 19: Neurodevelopmental Disorders, p. 369. Chapter 22: Neurodevelopmental Disorders - Page 369
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 Strength Religion Prayer
Supportive presence Explanation: A nurse's supportive presence must underlie all other types of intervention to meet the client's spiritual needs. The aim of this intervention is to create a hospitable and sacred space ("holy ground") in which clients can share their vulnerabilities without fear. Supportive presence communicates value and respect. Prayer, strength and religion are not foundational to spiritual interventions. Reference: Chapter 46: Spirituality - Page 1808
A nurse is caring for a Jewish client with a terminal illness who is on a ventilator. The spouse of the client intends to stay near the client when the ventilator is removed. What is the reason for such a request, according to the Jewish culture? Choose the best answer. The soul of the deceased should comfortably be able to travel into the afterlife. The soul of the deceased should not be disturbed by the other spirits. The soul of the deceased should not be alone while leaving the body. The soul of the deceased should pass through the body of a close family member.
The soul of the deceased should not be alone while leaving the body. Explanation: The Orthodox Jewish people believe that the soul should not leave the body while the person is alone. Thus a close relative is supposed to be there with a person who is dying. The purpose of this custom is not to prevent disturbance from the other spirits, to help the soul travel comfortably to the afterlife, or to make the soul of the deceased pass through the body of a close family member. Reference: Chapter 10: Grief and Loss - Page 158
A nurse is learning about religious dietary restrictions at a nursing conference. Which religious meal selection should the nurse understand is appropriate? toast with coffee for a client who practices the restored gospel of Jesus Christ grilled pork chop for a client who practices Orthodox Judaism grilled shrimp for a client who practices Orthodox Judaism vegetable plate for a client who practice Hinduism
Vegetable plate for a client who practice Hinduism Explanation: Dietary restrictions associated with religions are extremely important to provide culturally competent nursing care. Clients who practice Hinduism do not consume beef, because cows are considered a sacred creature. They are typically vegetarians; therefore, a vegetable plate is appropriate for this client. Clients who practice Orthodox Judaism eat have kosher foods. Shrimp and pork are prohibited in a kosher diet. Members of The Church of Jesus Christ of Latter-day Saints do not drink coffee, tea, or alcohol and they limit their meat consumption. Reference: Chapter 36: Nutrition - Page 1292
A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? physician, so he can provide education about HELLP syndrome human resource director, so she can arrange vacation time for the staff social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff chaplain, because his educational background includes strategies for handling grief
chaplain, because his educational background includes strategies for handling grief Explanation: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation time isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.
Upon assessment, the client reports that they do not belong to an organized religion. The nurse is correct to interpret this statement as the client will not request to see the hospital chaplain or seek spiritual counseling. client will experience conflicts between religious beliefs and healthcare options. client is not affiliated with a specific system of belief regarding a higher power. client's spiritual needs are met.
client is not affiliated with a specific system of belief regarding a higher power. Explanation: The nurse should not interpret the fact that a client does not belong to an organized religion to mean that the client has no spiritual need; a person may be highly spiritual yet not profess a religion. The client may seek spiritual counseling during hospitalization related to spiritual needs.
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 the child about God. educating through religious-based schools. educating the child about religion. educating through parental behaviors.
educating through parental behaviors. Explanation: A child's parents play a key role in the development of the child's spirituality. What is important is not so much what parents teach a child about God and religion, but rather what the child learns about God, life, and self from the parents' behavior. Reference: Chapter 46: Spirituality - Page 1794
A nurse is assisting a terminally ill female client with bathing. The client tells the nurse that she has great respect and faith in a particular spiritual leader. The nurse interprets this information as fulfilling which need for the client? sense of security for present and future living a longer life power to perform miracles financial strength and support
sense of security for present and future Explanation: Whatever the spiritual or religious beliefs the person holds and practices, these beliefs contribute to a sense of security for the present and future; give meaning to life, illness, other crises, and death; guide daily living habits; drive acceptance or rejection of other people; furnish psychosocial support within a group of like-minded people; provide strength in meeting life's crises; and give healing strength and support. However, spiritual beliefs do not guarantee that a person gains financial power and strength, the power to perform miracles, or the ability to live longer. Reference: Chapter 46: Spirituality - Page 1812
