NUR 108 Ch 46: Spirituality
A client scheduled for outpatient surgery is requesting that the operating room be sprayed with holy water. Which is an appropriate response? "This is not possible since not everyone in the room will allow to it." "The operating room must be kept free of any infection." "Are you concerned how the surgery will go?" "Surgical aseptic technique requires that fluids used must be sealed from the manufacturer."
"Are you concerned how the surgery will go?" Explanation: When providing spiritual care, nurses should listen to for cues either verbally or nonverbally. In this situation, the client is expressing a verbal cue about spirituality. The nurse should address the behavior with an open ended statement to allow for a flow of communication and feelings. Telling the client that the operating room personnel will not adhere to the request and stating about surgical aseptic technique requires fluids to be sealed are all correct, but nontherapeutic.
Based on religious practices, which client would be most likely to defer to her husband when making health care decisions? An Islamic woman A Jewish woman A Roman Catholic woman A Protestant woman
An Islamic woman Explanation: Some Muslim (Islamic religion) women are not allowed to make independent decisions; husbands may need to be present when consent is sought. This practice does not apply to Jewish, Catholic, or Protestant religions.
The school nurse is concerned about the week-long absence of Jerry, a third grader. The nurse visits the home and learns that Jerry has been diagnosed with appendicitis by a local clinic doctor. The parents, who are Christian Science church members, have had several church groups in to pray over Jerry. He is not improving and is getting worse. The nurse should do which of the following? Allow the parents their religious rights Insist that the parents take Jerry to the hospital Threaten the parents with a lawsuit Contact Child Protection Services
Contact Child Protection Services Explanation: Child Protective Services can intervene immediately, and have the child hospitalized and treated against the parents' wishes. Allowing the parents to make life/death decisions about their minor child could place the child in harm's way. Insisting the parents take the child to a hospital or threatening them will a lawsuit will only cause ill feelings toward you and will not likely change the parents' minds.
The nurse is caring for Mr. Z., a 55-year-old man admitted to the hospital for liver failure. He is an active member in the Latter-Day Saints (Mormon) church. Mr. Z. tells the nurse that he strictly adheres to the religious practices that are condoned by the church. However, the nurse overhears two of his physicians discussing that Mr. Z.'s liver failure is likely due to chronic alcohol use. The nurse suspects that they are wrong. Which of the following is an appropriate nursing activity? Know that the physicians are wrong; the Mormon faith does not permit alcohol use. Engage Mr. Z. in a discussion about past and present religious practices. Accuse Mr. Z. of lying and find out why he lied. Order several laboratory tests looking for genetic defects that affect the liver.
Engage Mr. Z. in a discussion about past and present religious practices. Explanation: A client's current religious practice is not necessarily indicative of lifelong practices. Talk with Mr. Z about his lifelong religious practice. As a result, useful information may be uncovered that will help to guide the plan of care.
A new client is on the hospital unit. He was recently diagnosed with metastatic pancreatic cancer and was told that any treatment would be palliative. He tells a nurse that there is no God that he knows of who would subject someone to this. The client's statement is most reflective of: spiritual crisis. change in beliefs. separation from spiritual ties. depression.
spiritual crisis. Explanation: A spiritual crisis can occur with an acute illness, sudden loss, or a new challenging diagnosis. These turning points often result in the questioning of one's beliefs.
The nurse is caring for a client who states, "No one can understand God." The nurse would document the client's spiritual belief as: atheist. agnostic. theist. holistic.
agnostic. Explanation: Beliefs may range from atheism (denial of God's existence) to agnosticism (belief that God's reality is unknown and unknowable) to theism (belief that God's reality is personal, without a body, perfect in all things, and creator and sustainer of the universe).
A nurse is conducting online research for information related to spritiual needs and religious traditions. The nurse demonstrates understanding of the information by identifying which need as common to all? Select all that apply. Love Meaning Punishment Ritual Forgiveness
Love Meaning Forgiveness Explanation: Three spiritual needs underlie all religious traditions and are common to all people: need for meaning and purpose; need for love and relatedness; and the need for forgiveness.
A nursing instructor, after teaching about the importance of spirituality, identifies a need for further teaching when overhearing a student make which of the following statements? "Nurses can meet spiritual needs by offering a compassionate presence." "You can provide quality nursing care to clients even though you ignore the spiritual dimension of health." "You can help clients meet spiritual needs by assisting in their struggle to find meaning in suffering." "Nurses can better assist clients by meeting their spiritual needs."
"You can provide quality nursing care to clients even though you ignore the spiritual dimension of health." Explanation: It is impossible to provide quality nursing care to clients while ignoring the spiritual dimensions of health. Nurses can assist clients to meet spiritual needs by offering a compassionate presence; assisting in the struggle to find meaning and purpose in the face of suffering, illness, and death; and fostering relationships with a higher being that nurture their spirit.
To obtain subjective data related to a 16-year-old client's spirituality, the nurse should: ask the client's parents if the client attends services. observe whether the client reads religious material. ask the client if religion or a higher being is significant. document the number of times a minister visits.
ask the client if religion or a higher being is significant. Explanation: In a spiritual assessment, the nurse may ask if religion or God is significant to the client.
Based on religious customs, for which client would the nurse administering medicines avoid touching the client's lips? A Hindu client An Islamic client A client who is a member of the Baha'i International Community A Roman Catholic client
A Hindu client Explanation: The nurse caring for a client with Hindu beliefs should avoid touching the client's lips when administering medicines. This is not a belief practiced by Islamic, Baha'i, or Catholics.
The nurse receives a "do not resuscitate" (DNR) order for a dying client. What should the nurse do next? Assess the client's spiritual needs Inform the client that a priest will be in to see her very soon. Avoid talking about suicide and its effects. Inform the family that this order does not keep the nurse from doing her job.
Assess the client's spiritual needs Explanation: Conducting a spiritual assessment is an essential aspect of maintaining health and providing holistic and sensitive nursing care especially in a DNR. Following the spirituality assessment, if the client has additional questions or concerns related to spirituality, the nurse may suggest follow-up with a chaplain or a priest, but there is no indication the client requested spiritual guidance. A nurse should not discuss suicide and its affects as that is inappropriate. The order may impact the nurse's interventions but this is not the priority at this point.
The nurse is caring for a 6-year-old child who was in a motor vehicle accident and has lost a lot of blood through an open leg wound. The parents tell inform the nurse that the child cannot have blood transfusions due to their religious beliefs. What decision does the nurse determine that the court will support regarding the child's blood transfusion? Supported the parents' right to refuse treatment for the child Allowed the child to accept treatment or not Did not support the parents' right to refuse treatment for the child Allowed the church pastor to accept or refuse treatment for the child
Did not support the parents' right to refuse treatment for the child Explanation: The courts have not supported the right of Jehovah Witness parents to refuse life-saving treatment for their children such as in traumatic accidents. The courts do not allow child to make health care decisions nor allow the church pastor to accept or refuse treatment over the parents.
After being informed that his wife only has a few hours to live, the nurse hears the husband say; "If you take my wife now. I will never pray to you!" What should be the nurse's reply? Tell the husband to think before saying anything negative. Call the pastor into the room to speak with the husband. Leave the room and do not be part of this situation. Use silence and allow the husband to express his emotions.
Use silence and allow the husband to express his emotions. Explanation: During times of grief, a nurse should exhibit a sensitive and non-intrusive approach in caring for the client and client's family. Therefore the nurse should use silence and allow the husband to express his emotions. Telling the client's husband to think before he speaks or leaving the room is inappropriate and rude. However, assisting clients to reconnect to their faith community or to utilize the resources of a faith community such as a pastor has health benefits but is not the priority in this situation.
While interviewing a client, a nurse is told that the client practices Catholicism. This client is identifying: his spirituality. his faith. his values. his culture.
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.
Which question would be appropriate for the F in the FICA spiritual assessment tool? "Do you consider yourself a spiritual person?" "Are you actively involved with a church community? "Do you use your church family for support? "How would you like me to address this issue in your health care?"
"Do you consider yourself a spiritual person?" Explanation: "F" is for questions of faith. Some examples of questions to ask would include the following: Do you consider yourself a spiritual person? What gives your life meaning? "I" represents the importance of this resource in the client's life. Assessment questions might include asking how often the client attends worship services. Do your beliefs strongly influence your decisions with regards to your medical practices? "C" is for community. Are you actively involved with a church community, and do you use this as a support? "A" is for the practitioner to address these concerns with the client, such as to ask, how would you like me to address these issues in your health care?
When asked about his religious preference, the client becomes very upset with the nurse. Which response is appropriate for this situation? "There is nothing to be upset about. This is part of my assessment." "I can see that this upsets you. Let me come back later when you are feeling better." "You need to understand that I am just doing my job here." "I can see that this question upsets you. Do you have any questions about this?"
"I can see that this question upsets you. Do you have any questions about this?" Explanation: The nurse should assist the client in understanding that his nursing history is a review of the whole human being and that questions will be wide ranging, including spiritual health, physical health, and emotional health. A client who appears angry, anxious, depressed, or defensive when asked spiritual questions may need to hear something like, "I can see from your response that you might not have expected these questions; however, they do let you know that we are interested in how you are experiencing your current situation. Do you have a question or concern in this area?" Telling the client that the nurse is just completing his or her job or telling the client that it is part of the assessment is not appropriate or therapeutic.
A nurse is conducting a spiritual assessment on a client recently admitted to the hospital unit. Which questions would be appropriate to ask the client about his religious and spiritual practices? Select all that apply. "Is religion a significant part of your life?" "Are there any spiritual practices that you would like to continue while hospitalized?" "You would like the priest to come and visit you, right?" "Does the present situation interfere with any spiritual or religious practice?"
"Is religion a significant part of your life?" "Are there any spiritual practices that you would like to continue while hospitalized?" "Does the present situation interfere with any spiritual or religious practice?" Explanation: A spiritual and religious assessment attempts to identify and document any practices or beliefs that are important for the client to maintain or that may alter medical or nursing treatment.
When conducting a spiritual assessment, the nurse must be sensitive to the client's personal beliefs. Which questions should the nurse ask? Select all that apply. "Is religion or God significant to you?" "Why do you still not believe in God?" "Do you feel your faith is helpful to you?" "Why can't you share your feelings with me? I am your nurse." "Is there anyone from your church you would like to talk to?"
"Is religion or God significant to you?" "Do you feel your faith is helpful to you?" "Is there anyone from your church you would like to talk to?" Explanation: Several nurses have developed spiritual assessment tools. Stoll's (1979) Guidelines for Spiritual Assessment is an early widely recognized spiritual assessment tool. This tool is built around a definition of spirituality that encompasses religion and belief in a higher power. It identifies four areas and suggests questions for each: (a) concept of God or deity, (b) source of hope and strength, (c) religious practices and rituals, and (d) relationship between spiritual beliefs and state of health. "Is religion or God significant to you?" is a question asking about the concept of God or deity. "Do you feel your faith is helpful to you?" focuses on the relationship between spiritual beliefs and state of health. "Is there anyone from your church you would like to talk to?" asks about their source of hope and strength. Asking the client why they do not believe in God and why they will not share their belief are questions focusing on belittling and degrading the client.
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." "I've never been a religious man, and all these Catholic crosses and pictures in the hospital make me a bit uncomfortable." "I always tried to do the right thing, so I don't understand why I have to suffer so much now." "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.
A recently graduated nurse is talking to the charge nurse about spirituality and tells the charge nurse that it is difficult to understand why people have a hard time giving spiritual care to clients. The charge nurse identifies the new nurse's lack of understanding when the new nurse makes which statement? "Spirituality and religion are the same thing." "Spirituality and religion have distinctions." "Spirituality is anything that pertains to a person's relationship with a higher power." "Spirituality and faith are the same thing."
"Spirituality and religion are the same thing." Explanation: Although some people use the words spirituality, faith, and religion interchangeably, there are distinctions. Spirituality is anything that pertains to a person's relationship with a higher power. Religion may be defined as a cultural system of designated behaviors and practices, worldviews, texts, sanctified places, prophecies, ethics, or organizations, that relates humanity to supernatural, transcendental, or spiritual elements. Faith is a strong belief in God or in the doctrines of a religion, based on spiritual apprehension rather than proof.
The nurse admits a new client to the unit for elective surgery. What would be the best way for the nurse to facilitate the practice of religion for this client? Choose all that apply. Offer to pray with the client whenever she likes. Discuss similarities and differences between the nurse's religion and the client's religion. Arrange for the client's pastor to visit if desired. Attempt to meet religious dietary restrictions. Respect the need for privacy during periods of prayer.
Arrange for the client's pastor to visit if desired. Attempt to meet religious dietary restrictions. Respect the need for privacy during periods of prayer. Explanation: The following are means the nurse can use to help the client continue normal spiritual practices in the unfamiliar environment of the hospital or care center:• Familiarize the client with the religious services and materials available within the institution.• Respect the client's need for privacy or quiet during periods of prayer.• Assist the client to obtain devotional objects and protect them from loss or damage.• Arrange for the client wishing to receive the sacraments to do so.• Attempt to meet the client's religious dietary restrictions.• Arrange for the client's minister, priest, or rabbi to visit if the client so wishes.Proselytizing is never acceptable in professional settings. Addressing spiritual issues should not be coercive. Praying with clients should not be initiated by the nurse unless there is no pastoral care available and the client requests it. Comparing and contrasting religious beliefs is not likely to benefit the client.
The nurse's client states that his pastor is coming in a few hours to pray with him and offer sacrament. The nurse plans to do the following things in preparation for this. Select all that apply. Clear the bedside table; cover with clean towel. Complete your work so you may join them. Have a chair available near the bed. Clear the room of unnecessary items. Keep the bed curtains open so as to allow others to join in prayer
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.
The nurse is caring for a Roman catholic client who is dying. What would be an appropriate action for the nurse? Contact a local priest to complete the anointing of the sick ritual. Contact a local priest to provide special care to the body after death. After death, place the client's body on the floor to facilitate the soul's journey. Ensure that a person of the same sex as the deceased clean the body.
Contact a local priest to complete the anointing of the sick ritual. Explanation: Roman Catholics believe that people should have the anointing of the sick, as well as the Eucharist and penance, by a priest before death. There are no special care rituals for the body after death.
The nurse is caring for a dying male client who practices Islam. What is the most appropriate action for the nurse after the client's death? Ensure that a male washes the client's body. Place the body on the floor to facilitate the soul's journey. Ensure that no one is in the room when the client dies. Ensure that someone performs the anointing of the sick sacrament prior to the client's death.
Ensure that a male washes the client's body. Explanation: Islamic beliefs about death are that the family should be with the dying person so they can read the Koran and pray. There are also special procedures for care of the body after death; men wash male bodies and women wash female bodies and a variety of other rituals are performed. Hinduism beliefs include placing the body on the floor to facilitate the soul's journey. The anointing of the sick sacrament is part of the Roman Catholic faith.
A nurse overhears a client telling a family member that a belief in God is the only thing helping in the fight against a terminal illness. What is this client demonstrating? Faith Hope Love Religion
Faith Explanation: Faith refers to a confident belief in something for which there is no proof or material evidence. It can involve a person, idea, or thing, and it is usually followed by action related to the ideals or values of that belief. Hope is a feeling of expectation and desire for a certain thing to happen. Love is an intense feeling of deep affection. Religion is a particular system of faith and worship.
While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion? Christianity Judaism Islam Hinduism
Islam Explanation: According to the Islamic religion, neither food nor drink is taken between sunrise and sunset during the holy days of Ramadan. There are no special or universal food beliefs common to Christianity. According to Judaism, Kosher food is eaten, meat cannot be mixed with dairy, and separate cooking and eating utensils are used for food preparation and consumption. According to Hinduism, pork and alcohol are forbidden and other meats must meet ritual requirements.
A client who is admitted to the ER with severe right-sided abdominal pain is diagnosed with appendicitis. The surgeon is called and proceeds to explain the procedure to the client and asks her to sign the consent. The client refuses and informs the doctor that her husband needs to be called to do this. Which of the following religions does this client likely practice? Hinduism Catholicism Islam Judaism
Islam Explanation: Some Muslim women are not allowed to make independent decisions; husbands may need to be present when consent is sought. The other religions, Hinduism, Catholism, and Judaism, do not restrictions on women to make independent health care decisions.
The nurse is on the third day of caring for a client who recently underwent a colectomy. During the physical assessment, a discussion about spirituality develops. The client reports feeling some guilt about being in the hospital because her religion opposes modern science, including medicine. The nurse recognizes this as a belief of which of the following groups? Buddhism Baha'i International Community Mormon Jehovah's Witnesses
Jehovah's Witnesses Explanation: Jehovah's Witnesses oppose the "false teachings" of other sects; opposition often extends to modern science, including medicine. The Baha'i International Community believes in a basic harmony between religion and science. Buddhists believe in the Four Noble Truths and the Noble Eightfold Path. Mormons believe in divine healing through the "laying on of hands".
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? Autonomy Love Self-reliance Belonging
Love Explanation: Love develops from the basic human need to love and be loved, and we cannot be spiritually whole, spiritually healthy, unless this need is met. Autonomy is freedom from external control or influence. Self reliance is reliance on one's own powers and resources rather than those of others. Autonomy and self reliance are higher level of needs. A sense of belonging is a human need, just like the need for food and shelter but love is more important.
According to Shelly and Fish (1988), which of the following are spiritual needs underlying all religious traditions that are common to all people? Select all that apply. Meaning and purpose Power Formal religion Love and relatedness Forgiveness
Meaning and purpose Love and relatedness Forgiveness Explanation: According to Shelly and Fish (1988), there are three spiritual needs underlying all religious traditions and common to all people: need for meaning and purpose, need for love and relatedness, and need for forgiveness.
The nurse is caring for a client who asks that his special undergarments not be removed for an upcoming procedure. The nurse is aware that these undergarments are related to the client's religion. This religion is: Mormon. Christian Scientist. Adventist. Muslim.
Mormon. Explanation: Members of the Church of Jesus Christ of Latter-Day Saints (Mormons) wear a special undergarment that should only be removed in emergencies, or when absolutely necessary. The other religions have no special undergarments related to their beliefs.
Mr. Baker is an 81-year-old patient who can no longer live alone safely and is being admitted to a long-term-care facility. He grew a large garden every summer and took pleasure in sharing the produce with neighbors. He now tells the nurse that he feels he is of no use to anyone. The nurse knows that this is related to which of the following spiritual needs believed to be common to all people? Need for meaning and purpose Need for love and relatedness Need for basic necessities of life Need for forgiveness
Need for meaning and purpose 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 meaning and purpose. The garden provided a needed element for the client to provide for others. The need for love and relatedness is have a sense of companionship. The need for forgiveness is reconciling with others. Basic necessities are something necessary or indispensable such as food, water, and shelter.
The nurse is assessing a client for spirituality using the HOPE acronym. Which statement describes an element of this tool? H = sources of help O = organized religion P = persons important in the person's life E = external stressors affecting spirituality
O = organized religion Explanation: The HOPE assessment tool asses the client's spirituality. The acronym stands for:H—Sources of hope, meaning, comfort, strength, peace, love, and connectionO—Organized religionP—Personal spirituality and practiceE—Effects on medical care and end-of-life issue
The nursing diagnosis Spiritual Distress related to crisis of illness as evidenced by loss of meaning in life and overuse of pain medication is created for a client who attempted to take his life. Which intervention is appropriate for these problems? Plan and coordinate a multidisciplinary team conference including the chaplain. Provide client education on negative spiritual implications on suicide. Encourage the client to watch movies when alone. Explore past negative coping mechanisms used.
Plan and coordinate a multidisciplinary team conference including the chaplain. Explanation: The nurse should facilitate a care-planning conference involving the social support network including family and friends. Initiating a multidisciplinary social network of conferences facilitates a sense of acceptance, love, and belonging. The nurse should work with the client to explore and build on past positive coping mechanisms, which helps enhance a sense of self-control and self-esteem. Encouraging the client to watch movies when alone does not allow the client to interact and find positive elements of his or her life. Although spiritual review can be helpful, the nurse should not "scare" the client away from action by mentioning negative spiritual outcomes.
A nurse is caring for a terminally ill client who believes that death and reincarnation are the ultimate gifts from God to mankind. What would be most appropriate to integrate into this client's plan of care when providing spiritual support? Subtly attempt to change the client's belief. Provide support that builds on the client's faith. Provide literature to the client that says otherwise. Request the client refrain from talking about death.
Provide support that builds on the client's faith. Explanation: The nurse should support and build on the client's faith. Nurses should not attempt to change faith that clients already possess. If faith is lost, clients will lose hope; without the will to live, many people are beyond the help of the most potent medical powers. The nurse should not attempt to change the client's belief or provide literature that says otherwise. Conversations regarding faith, however, must not pass judgment or present controversy. Clients need to feel accepted in their beliefs and encouraged to remain open in expressing and learning.
An older adult client who is very sick but very spiritual and has a deep faith asks the nurse to say a prayer for her. The nurse, who is not very comfortable praying out loud, wants to honor the client's request. What would be the best action by the nurse? Tell the client that they are not comfortable praying out loud Read a passage from the Bible to the client Inform the client that they will try to get another nurse to pray with the client Tell the client the nurse is busy at the moment and hope the client will forget
Read a passage from the Bible to the client Explanation: A nurse unaccustomed to praying aloud or in public may find it helpful to have a Bible passage or formal prayer readily available. The other options are not therapeutic.
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? Roman Catholic Christian Scientist Jehovah's Witnesses Jewish
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 Judiasm.
The nurse is assisting a client with his meal selection for the next day. The client states, "I can't have meat tomorrow, it's a Holy Day." The nurse recognizes that the client is a member of which religious organization? Orthodox Jewish Reform Jewish Roman Catholic Islamic
Roman Catholic Explanation: Roman Catholics observe fasting and abstinence from meat on certain Holy Days.
When a nurse supports the client's spiritual needs, the nurse supports which level of the Maslow's hierarchy of needs? Physiologic needs Security needs Ego needs Self-actualization needs
Self-actualization needs Explanation: In the hierarchy of human needs, spiritual well-being appears to connote fulfillment of needs beyond the self-actualization level. Spiritual well-being has been associated with health and general well-being. Safety needs in Maslow's hierarchy refer to the need for security and protection. When we have our physiological needs for food and water met, our safety needs dominate our behavior. Physiological needs deal with the maintenance of the human body. This lowest category includes the most basic needs that are vital to survival, such as the need for water, air, food, and sleep. There are no ego needs in the hierarchy.
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
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.
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 alienation Spiritual guilt Spiritual anger Spiritual loss
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.
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? Prayer Supportive presence Strength Religion
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.
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? Prayer Supportive presence Strength Religion
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.
A dying client requests that the nurse pray with him. The nurse is not accustomed to praying aloud but is comfortable praying silently. What is the best approach for this nurse to follow to pray with this client? The nurse should select a formal prayer or Bible passage to use to pray aloud. The nurse should defer the client's request to pray. The nurse should inform the client that she will pray for the client but not with him. The nurse should ask the client's roommate to pray with the client.
The nurse should select a formal prayer or Bible passage to use to pray aloud. Explanation: A nurse unaccustomed to praying aloud or in public may find it helpful to have a Bible passage or formal prayer readily available for praying. If the nurse is not comfortable praying with the client, they should call the hospital chaplain or find another individual who is comfortable.
Mr. J. is a 78-year-old man, who is actively dying of unknown causes. Mr. J. is a practicing Muslim. His wife, children, and grandchildren are present. The physician in charge of Mr. J.'s care plans to discuss Mr. J.'s impending death with the family. Based on the nurse's knowledge of the Muslim faith, which of the following is not true? The body is washed and cared for by the family. The family will likely want an autopsy. The family will want to read from the Koran at the time of death. Organ donation is generally not permitted.
The family will likely want an autopsy. Explanation: Ritualistic care of the body following death is an important piece of the Muslim culture.
A nurse is caring for a client who practices Daoism. Which religious beliefs would the nurse keep in mind when planning care for this client? Select all that apply. Allah, who is all-seeing, all-hearing, all-speaking, all-knowing, all-willing, and all-powerful, is their one God. They oppose the "false teachings" of other sects. They worship one God revealed to the world through Jesus Christ. They believe that health is a manifestation of the harmony of the universe, obtained through the proper balancing of internal and external forces. The universal principle is the mysterious biologic and spiritual life rhythm or order of nature. Inherent in Daoism is knowing and living a natural life is the secret of health and sagehood
They believe that health is a manifestation of the harmony of the universe, obtained through the proper balancing of internal and external forces. The universal principle is the mysterious biologic and spiritual life rhythm or order of nature. Inherent in Daoism is knowing and living a natural life is the secret of health and sagehood Explanation: Daoism (Taoism) beliefs include that there is a "medicinal" concern for maintaining and prolonging human health and life (sheng); knowing and living a natural life—following the Tao—is the secret of both health and sagehood; and long tradition of seeking pragmatic medical techniques, along with its religious techniques of meditation and ritual for establishing a harmony of body and spirit, humanity, and nature (holistic approach). Allah is a belief of Islam religion. The concept of "false teachings" is a part of the Jehovah's Witnesses faith. Inherent in Daoism is knowing and living a natural life is the secret of health and sagehood.
Mr. V. is recovering from pneumonia. The nurse understands that a well-balanced diet will help him to recover. However, Mr. V. informs the nurse that it is Ramadan and he must fast from sunrise to sunset. What is the nurse's most appropriate nursing action? Work with the nutrition staff to provide nutritious meals at off hours. Encourage Mr. V. to speak with a religious leader to grant a medical exception. Provide liquid nutrition only as this does not interfere with religious practice. Tell Mr. V. he must eat to maintain his health.
Work with the nutrition staff to provide nutritious meals at off hours. Explanation: The most appropriate action is to work with Mr. V to maintain practice that is important to him. If Mr. V decided to suspend religious practice for medical reasons, it would be appropriate to support this decision. Asking to speak with a religious leader to grant a medical exception disregards Mr. V's religious practice. Liquid nutrition may interfere with the fasting rules. Telling Mr. V to eat despite his religious convictions is inappropriate and not empathetic.
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. a positive outlook even in the bleakest moments. an organized belief system about a higher power. practices associated with all aspects of a person's life.
a belief in something for which there is no proof or material evidence. Explanation: Faith is a belief in something for which there is no proof or material evidence. The client is expressing a sense of faith to the nurse. Hope is a positive outlook even in the bleakest moments. Religion is an organized belief system about a higher power. Spiritual beliefs are practices associated with all aspects of a person's life.
When a client informs the nurse that he is a Jehovah's Witness, the nurse must recognize and validate that the client will not accept: blood transfusions. traditional health practices. pain medication. disease causation from germs.
blood transfusions. Explanation: Jehovah's Witnesses do not accept blood transfusions.
The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. The nurse informs the parents that the development of a child's spirituality is best accomplished by: educating through parental behaviors. educating the child about religion. educating the child about God. educating through religious-based schools.
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.
The client states "I have lifted my cancer to God and am accepting of God's plan for me." This is an example of an adaptive expression of spiritual needs labeled: trust. forgiveness. love and relatedness. faith.
faith. Explanation: The nurse should be aware of adaptive behaviors of faith. These include: Faith depends on divine wisdom/God; faith is motivated toward growth; faith expresses satisfaction with explanation of life after death; faith expresses a need to enter into and/or understand the larger drama of human history; faith expresses a need for the symbolic, or ritual; faith expresses a need for sense of a shared faith/community. In this case, the client believes that he will depend on the divine wisdom of God for guidance. Trust is believing in the truth. Forgiveness is seeking out peace between two people. Love and relatedness is to support and cherish the relationship between two.
A man age 79 years is in the late stages of lung cancer with bone metastases. Since receiving his terminal diagnosis, the client has often made mention of the fact that he has a long-estranged daughter and that he was a "miserable father." The client has recently asked for the social worker's assistance in locating his daughter before his death. What spiritual need likely underlies the client's request? need for forgiveness need for purpose need for meaning need for love
need for forgiveness Explanation: While a need for love may be a factor in the man's request, the fact that he admits his parental failings and wishes to rekindle a relationship with his child suggests that he may feel a need for forgiveness and repair past behavior. The need for meaning also has focus in the past while the need for purpose looks to the future. The purpose of a person is often related to their values, which may well be social in nature. The need for love is the need for togetherness with another person.
According to Shelly and Fish, which of the following is a spiritual need underlying all religious traditions? need for formal ceremony need for power in relationship with God need for justice need for meaning and purpose
need for meaning and purpose Explanation: Shelly and Fish recognized that all religious traditions have the spiritual need for meaning and purpose, the need for love and relatedness, and the need for forgiveness.
An appropriate goal for the client with a nursing diagnosis of Spiritual Distress related to intense pain and suffering as verbalized by the client would be that the client will: express feelings of anger and despair to God. meet with a minister daily. reflect on past accomplishments in life. participate in supportive spiritual practices.
participate in supportive spiritual practices. Explanation: The goal for the client should focus on supporting the client's strengths.
A recently graduated nurse is working with a client who is suffering from excruciating pain with no relief. The client tells the nurse that religion and spirituality are a big part of her life. The nurse wants to help nurture this client's spirituality and can do so in which of the following ways? Select all that apply. promoting meaning and purpose promoting love and relatedness promoting pain relief promoting forgiveness promoting independence
promoting meaning and purpose promoting love and relatedness promoting forgiveness Explanation: The nurse can help the client to nurture her own spirituality by promoting meaning and purpose, promoting love and relatedness, and promoting forgiveness. Although promoting pain relief and independence are both good nursing actions, they do not help in nurturing one's spirituality.
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 is an atheist. the client has no belief system. the client is an agnostic. the client may still be deeply spiritual.
the client may still be deeply spiritual. Explanation: The nurse should not interpret the fact that a client does not belong to an organized religion to mean that he or she has no spiritual needs; a person may be deeply spiritual yet not profess to belong to an organized religion. An atheist is a person who denies the existence of a higher power; an agnostic is one who holds that nothing can be known about the existence of a higher power.
