Deck 3 Module 30

Question 1

The nurse is assessing a client’s spirituality. Which of the following findings would suggest that the client experiences spirituality as a source of strength? Select all that apply.
A) The client uses the telephone to inform family members of an unwanted diagnosis.
B) The client reads spiritual material every evening.
C) The client asks to watch a religious service on television.
D) The client says she has no desire to meet with a chaplain.
E) The client tells the nurse she is convinced she will be punished in the afterlife.

Answer 1

B) The client reads spiritual material every evening.
C) The client asks to watch a religious service on television.

Rationale:

Regularly reading spiritual material and asking to watch a religious service on television are actions that suggest the client views spirituality as a source of strength. In contrast, focusing on possible punishment in the afterlife would suggest that the client is experiencing spiritual distress. Lack of interest in meeting with a chaplain might indicate spiritual distress, or it might indicate that the client either places little emphasis on spirituality or feels that his or her spirituality is a private matter. Discussing an unwanted diagnosis on the phone is unrelated to spirituality.

Question 2

While hospitalized, a client learns that a close friend has died suddenly. The client is crying and asking, "Why, God?" The nurse should correctly identify that the client is demonstrating which type of spiritual distress?
A) Physiologic
B) Psychologic
C) Treatment-related
D) Situational

Answer 2

D) Situational

Rationale:

Factors that may be associated with or contribute to an individual’s spiritual distress include situational concerns, physiologic problems, and treatment-related concerns. Situational factors include the death or illness of a significant other, inability to practice one’s spiritual rituals, or feelings of embarrassment when practicing them. Physiologic problems include having a medical diagnosis of a terminal or debilitating disease. Treatment-related factors include recommendation for treatment, surgery, dietary restrictions, or isolation. Psychologic is not a factor that contributes to spiritual distress.

Question 3

The nurse is providing care to a client diagnosed with type 2 diabetes mellitus. The client wishes to take Communion but must fast for 1 hour prior to receiving it. Which action by the nurse is most appropriate?
A) Contact the healthcare provider to suggest an alternative form of nutrition because the client is refusing to eat or drink.
B) Provide the client with breakfast and morning medication and encourage the client to eat and take Communion some other time.
C) Find out when the hospital clergy will be distributing Communion and adjust the client’s medications and breakfast accordingly.
D) Suggest that because the client is hospitalized, eating and drinking will not affect the Communion.

Answer 3

C) Find out when the hospital clergy will be distributing Communion and adjust the client’s medications and breakfast accordingly.

Rationale:

The nurse should follow the client’s expressed wishes regarding spiritual care and should not pressure them to relinquish any of their beliefs or practices. To support the client’s spiritual needs, the nurse should find out when Communion will be distributed and adjust the medications and breakfast accordingly. The nurse should not suggest that eating and drinking will not affect Communion. The nurse should not ignore the client’s needs by providing medication and breakfast. The nurse should also not contact the healthcare provider to suggest alternative forms of nutrition, because the client is not refusing to eat or drink but wants to delay eating and drinking until after Communion.

Question 4

While assessing a client's spiritual needs, the nurse asks, "What spiritual beliefs are important to you?" This question represents which step of the FICA assessment model?
A) Community
B) Address
C) Implication
D) Faith

Answer 4

D) Faith

Rationale:

Within the FICA assessment model for spirituality, faith is assessed by asking the question “What spiritual beliefs are important to you?” Implication is assessed by asking the client, “How is your faith affecting the way you cope?” Community is assessed by asking, “Is there is a community of like-minded believers with which you routinely meet?” Address is assessed by asking the client, “How can the healthcare team support your spiritual needs?”

Question 5

When receiving nursing care, the client states, “I drink a small glass of warm water mixed with the juice of one lemon every morning because it helps to heal my body.” Which action by the nurse is appropriate when providing care to this client?
A) Tell the client that cold water is better metabolized by the body.
B) Instruct the client that lemon juice is really a dose of vitamin C that helps with healing.
C) Provide the warm water and juice of a lemon.
D) Suggest the client delay the water and lemon until after morning medications.

Answer 5

C) Provide the warm water and juice of a lemon.

Rationale:

The nurse should follow the client’s expressed wishes regarding spiritual care. To support the client’s beliefs about healing, the nurse should provide the client with the warm water and lemon juice. The nurse should not instruct the client about the benefits of lemon juice being vitamin C. The nurse should also not suggest that cold water be used instead. Asking the client to delay drinking the water and lemon juice will not support the client’s spiritual needs.

Question 6

Which questions are appropriate for the nurse to ask when assessing the spiritual beliefs of a client? Select all that apply.
A) “How will being sick interfere with your religious practices?”
B) “Would you like a visit from your spiritual counselor or the hospital chaplain?”
C) “Are any particular religious practices important to you?”
D) “How is your faith helpful to you?”
E) “Because you indicated you are Catholic, I suppose you fast every Friday?”

Answer 6

A) “How will being sick interfere with your religious practices?”
B) “Would you like a visit from your spiritual counselor or the hospital chaplain?”
C) “Are any particular religious practices important to you?”
D) “How is your faith helpful to you?”

Rationale:

The question related to fasting on Friday is inappropriate because it assumes that a client follows all the practices of the client’s stated religion. All other questions are appropriate for the nursing student to ask a client during an admission assessment while assessing spiritual and religious beliefs.

Question 7

A nurse is admitting a client to the oncology unit. During the admission assessment, when the nurse asks the client about religious preference, the client states, “I am an atheist.” The nurse should recognize that the client holds which belief?
A) The client believes that there is one God.
B) The client believes that there is more than one god.
C) The client believes that the existence of God has not been proven.
D) The client does not believe in any god.

Answer 7

D) The client does not believe in any god.

Rationale:

An atheist is an individual who does not believe in any god. Monotheism is the belief in the existence of one God. Polytheism is the belief in more than one god. An agnostic is an individual who doubts the existence of God or a supreme being or who believes that the existence of God has not been proven.

Question 8

The family members of a critically ill client tell the nurse, "We believe in the power of prayer. Prayer connects us all and makes us stronger. We will continue to pray that our loved one recovers." This statement suggests that the family is demonstrating which of the following characteristics?
A) Good family support system
B) Spiritual well-being
C) Denial
D) Spiritual distress

Answer 8

B) Spiritual well-being

Rationale:

Through their statement, the family members express the belief that they are connected by a higher power. They also say they draw strength from this belief. This is evidence of spiritual well-being, not spiritual distress. The family may or may not be denying the client’s health status. Although this statement indicates that the family turns to a higher power for support, it does not reveal anything about the family’s overall support system.

Question 9

Prior to being discharged, a client tells the nurse, "I trust you and the rest of the medical team, and I think the prescribed treatment is going to work. I'm ready to embrace life, and I'm looking forward to celebrating the holiday season in a few months." This statement suggests that the client is experiencing which of the following?
A) Spiritual well-being
B) Denial
C) Conflict
D) Apprehension

Answer 9

A) Spiritual well-being

Rationale:

The client speaks of trusting relationships, hope, and a feeling of being alive and ready to embrace what the future brings. This suggests the client is in a state of spiritual well-being. The client’s statement is not suggestive of denial, apprehension, or conflict about the future.

Question 10

A client was recently diagnosed with alcoholic liver cirrhosis. During a regular checkup, the client tells the nurse, "This is God's punishment for all those parties I went to when I was younger." The nurse should recognize that this religious view could have a negative effect on what other nursing concept?
A) Addiction
B) Legal Issues
C) Stress and Coping
D) Digestion

Answer 10

C) Stress and Coping

Rationale:

Clients can use religion as either a positive or a negative coping strategy. Negative expressions of religious coping include statements like “God is punishing me.” If the client is addicted to alcohol, the diagnosis and religious belief may stimulate the client to give up alcohol, which would not be a negative effect. There are no legal issues present due to this client’s statement. This religious view is unlikely to affect the client’s digestive processes, although the disease itself may reduce metabolism associated with digestion.

Question 11

The nurse is caring for a devout Muslim client who is near death. The nurse should be prepared for which request from the client related to religious beliefs?
A) Turn the client’s head or body toward Mecca.
B) Have a spiritual leader perform the Anointing of the Sick.
C) Read the client the Tibetan Book of the Dead.
D) Perform a ritualistic bath for cleansing the body.

Answer 11

A) Turn the client’s head or body toward Mecca.

Rationale:

Muslims who are dying often want their body or head turned toward Mecca, and they are encouraged to say the prayer recognizing their loyalty to Allah. Roman Catholics may request having a spiritual leader perform the sacrament of Anointing of the Sick. Tibetan Buddhists may read the Tibetan Book of the Dead within 7 days after death, but not before death. Ritualistic bathing of the body is usually performed by some religions, including Muslims, after death, not before death.

Question 12

The nurse is caring for an 8-year-old client who has been in the hospital repeatedly due to complications from leukemia. The nurse understands that the family is very religious, and the client often speaks about God’s care for her. Which age-appropriate nursing intervention should the nurse implement that can help the child express her spirituality?
A) Help the child reminisce about fun experiences earlier in life.
B) Provide the child with tools to draw and color pictures.
C) Provide the child with tools to produce a music video.
D) Support parent-child bonding to encourage attachment.

Answer 12

B) Provide the child with tools to draw and color pictures.

Rationale:

Nurses can support the spiritual well-being of the child by age-appropriate activities that allow nonverbal expression of faith, including drawing, coloring, painting, play, or music, depending on the child’s interests or energy level. Producing a music video is more appropriate for adolescent clients. Supporting parent-child bonding is more appropriate for infants. Reminiscing about the past is more appropriate for older adults.

Question 13

The nurse is caring for an older adult client with advanced dementia. The family often mentions that the client was very spiritual earlier in life and loved to sing. What could the nurse suggest to the family to help support the client’s religious needs?
A) They should help the client reminisce about spiritual events early in life.
B) They should encourage the client to compose lyrics or write music to a new spiritual song.
C) They should sing some of their favorite songs to the client.
D) They should bring in a recording of some of the client’s favorite spiritual songs for him to listen to.

Answer 13

D) They should bring in a recording of some of the client’s favorite spiritual songs for him to listen to.

Rationale:

One way that clients with dementia can worship is through various art forms, including music. This is an especially appropriate option for this client, given his history of spirituality and a love of singing. Letting the client listen to some favorite of his spiritual songs will give him an opportunity to enjoy an enriching spiritual experience without being pressured to participate, generate new ideas, or remember events from the past.

Question 14

The nurse is providing care to a client who has just received a diagnosis of cancer. Which findings would suggest that the client is experiencing spiritual distress? Select all that apply.
A) Client is observed crying with children.
B) Client tells the nurse that he feels hopeless.
C) Client discusses possible outcomes with healthcare provider.
D) Client turns off a religious show on the TV and stares out the window.
E) Client is talking quietly with spouse.

Answer 14

B) Client tells the nurse that he feels hopeless.
B) Client tells the nurse that he feels hopeless.

Rationale:

Spiritual distress may be characterized by expressions of a deficit in meaning, purpose, hope, forgiveness, or intimacy with the divine, or by anger or a lack of interest about previously spiritually nurturing persons or resources. Telling the nurse he feels hopeless and turning off a religious TV show indicates spiritual distress. The other actions are normal responses to a cancer diagnosis.

Question 15

The nurse is planning care for a hospitalized client. Which activities should the nurse identify as appropriate to support the client’s spiritual needs through presencing? Select all that apply.
A) Being available to the client
B) Sharing about a time when the nurse overcame a similar situation
C) Reading a newspaper at the nurse’s station
D) Stating personal religious beliefs
E) Listening to the client

Answer 15

A) Being available to the client
E) Listening to the client

Rationale:

Features of presencing include being available to the client and listening. Stating personal religious beliefs, reading a newspaper, and sharing about a time when the nurse overcame a similar situation are not characteristics of presencing.

Question 16

A nurse is caring for a client who was recently diagnosed with a terminal illness. Which statement made by the client would indicate to the nurse that the client is in spiritual distress?
A) “I am not sure why this is happening but I believe God has a plan for me.”
B) “I wish I did not have cancer but I believe that it is happening for a reason.”
C) “My children don’t go to church and they are having a difficult time dealing with my diagnosis.”
D) “People tell me things happen for a reason, but why is God doing this to me?”

Answer 16

D) “People tell me things happen for a reason, but why is God doing this to me?”

Rationale:

The statement “But why is God doing this to me?” is reflective of spiritual distress. The client is not demonstrating being able to find a purpose and is also demonstrating a disconnect between herself and her higher spirit. The other answers do not indicate spiritual distress of the client.

Question 17

A nurse enters a client’s room to assess why the alarm on an IV infusion has sounded. As the nurse checks the IV equipment, the client says he would like someone to pray with. How should the nurse address the client’s spiritual needs while providing necessary IV care?
A) The nurse should focus her attention solely on the infusion, because it is more important at this time than the client’s prayer request.
B) The nurse should nod in response to the client’s request while taking care of the infusion.
C) While taking care of the infusion, the nurse should offer to call a clergy member.
D) After assessing that the alarm is not an emergency, the nurse should offer to pray with the client.

Answer 17

D) After assessing that the alarm is not an emergency, the nurse should offer to pray with the client.

Rationale:

The nurse can best address this client’s spiritual needs by being fully present with the patient and not being distracted by other tasks such as assessing the IV infusion. Although the nurse’s first priority is to assess that the alarm is not an emergency, she can then stop and be fully present by listening to the client’s request and offering to pray with the client. The other options do not indicate that the nurse is fully present with the client.

Question 18

The nurse is performing a holistic assessment of a client. Which observations indicate that the client is experiencing spiritual distress? Select all that apply.
A) The client is sitting in a chair before breakfast reading the Bible.
B) The client states he has lost his faith in God since he’s gotten ill.
C) The client is watching a religious program on the television.
D) The client is crying, pacing, and mumbling about God being angry with him.
E) The client is overheard arguing with clergy about the existence of God.

Answer 18

B) The client states he has lost his faith in God since he’s gotten ill.
D) The client is crying, pacing, and mumbling about God being angry with him.
E) The client is overheard arguing with clergy about the existence of God.

Rationale:

The client who states a loss of faith in God after getting ill, the client who is crying, pacing and mumbling about God being angry with him, and the client who is overheard arguing with clergy about the existence of God may all be experiencing spiritual distress. The client who is observed sitting in a chair before breakfast reading the Bible or who is watching a religious program on the television is demonstrating a behavior of spiritual health.

Question 19

The nurse recognizes that a client is experiencing spiritual distress due to the need to receive a blood transfusion. The nurse should also identify the need to provide interventions for what other nursing diagnosis?
A) Decisional Conflict
B) Chronic Confusion
C) Acute Pain
D) Self Neglect

Answer 19

A) Decisional Conflict

Rationale:

Some clients have religious beliefs that prevent them from receiving any blood products. If a client has a life-threatening condition that requires a blood transfusion, the client may have spiritual distress related to the conflict between religious beliefs and lifesaving medical treatments. This causes Decisional Conflict for the client. This conflict between beliefs and treatments would not likely cause Chronic Confusion, Acute Pain, or Self Neglect.

Question 20

The nurse is caring for a client in spiritual distress. The client has met with the hospital chaplain but did not find it beneficial. The nurse recognizes that outside assistance from the client’s own spiritual advisor may be helpful. What should the nurse do before making an appointment with the advisor?
A) Consult with the primary care provider to find an available counselor.
B) Ask the client’s permission to contact the counselor.
C) Call the hospital chaplain to come speak with the client.
D) Advocate with the primary care provider to offer spiritual care to the client.

Answer 20

B) Ask the client’s permission to contact the counselor.

Rationale:

The client’s permission is needed before seeking an outside counselor in order to protect the client’s right to confidentiality. Therefore, the nurse should ask the client’s permission before contacting the counselor. The nurse does not need to consult with the primary care provider to find an available counselor, nor should the nurse ask the primary care provider to offer spiritual care to the client. Although the nurse could call the hospital chaplain to come speak with the client, this is not required before scheduling an appointment with an outside counselor.

Question 21

While helping a client with the evening meal, the nurse observes the client close his eyes, bow his head, and murmur words of thanks and praise. What should this behavior suggest to the nurse?
A) The client did not want the nurse to leave.
B) The client was asking that the meal be better than the last.
C) The client is confused.
D) The client was praying before eating.

Answer 21

D) The client was praying before eating.

Rationale:

The client’s behavior of bowing the head, closing the eyes, and murmuring words of thanks and praise are indications that the client was praying. The client was not demonstrating confusion. The nurse has no way of knowing if the client was asking that the meal be better than the last. The client was not delaying the nurse so that she did not leave.

Question 22

A client requests that surgery be delayed for several days until after a period of Holy Days has concluded. Which action by the nurse supports this client’s request?
A) Remind the client that one’s health is more important than following Holy Days.
B) Provide the client with alternative forms of treatment to replace having surgery.
C) Suggest the client think about whether having the surgery is the right decision, as the client is willing to delay it now.
D) Communicate the client’s request to the surgeon.

Answer 22

D) Communicate the client’s request to the surgeon.

Rationale:

To support the client’s need to avoid surgery during Holy Days, the nurse should communicate the client’s request to the surgeon. The nurse should not remind the client that health is more important than following Holy Days or suggest that the client consider not having surgery. The nurse should also not provide the client with alternative forms of treatment to replace having surgery, as this is outside the nurse’s scope of practice.

Question 23

A client who is scheduled for surgery wants to continue to wear a religious medallion. Which actions by the nurse support the client’s religious needs? Select all that apply.
A) Keep the medallion on the client but remove it once anesthesia is provided.
B) Ask the client if wearing a medallion is going to ensure a successful surgery.
C) Document that the medallion is being worn by the client.
D) Suggest the client not wear the medallion because it will most likely be lost.
E) Explain that the medallion can be safety pinned to the client’s gown.

Answer 23

C) Document that the medallion is being worn by the client.
E) Explain that the medallion can be safety pinned to the client’s gown.

Rationale:

The nurse should explain that the medallion can be safety pinned to the client’s gown. This approach would ensure compliance with the client’s religious needs as well as safety for any surgical intervention planned for the client. The nurse should also document that the medallion is being worn by the client. The nurse should not remove the medallion after anesthesia is provided. The nurse should not tell the client that the medallion will be lost if worn or confront the client by asking if the medallion is going to ensure successful surgery.

Question 24

A client is abstaining from meat and dairy products during Lent and refuses to select these items when making meal choices. Which actions by the nurse support the client’s nutritional and religious needs? Select all that apply.
A) Ask the healthcare provider to discuss the impact of the restricted diet on the client’s health.
B) Provide soy milk products as supplements.
C) Add protein powder supplements to the client’s water pitcher.
D) Ask the client what foods are typically consumed during this period of time.
E) Consult with a dietitian for food choices to meet the client’s needs.

Answer 24

D) Ask the client what foods are typically consumed during this period of time.
E) Consult with a dietitian for food choices to meet the client’s needs.

Rationale:

The best interventions would be for the nurse to consult with a dietitian for food choices to meet the client’s health and religious needs and ask the client what foods are typically consumed during this period of time. The nurse should not provide soy milk products as supplements because the client may not like them. The nurse should not ask the physician to talk about the restricted diet with the client. The nurse should also not provide protein powder supplements in the client’s water pitcher.

Question 25

The nurse is preparing to discharge a client from the hospital. Which actions by the client indicate that her religious needs were met during the hospitalization? Select all that apply.
A) Requesting and attending religious services in the hospital chapel
B) Thanking the nurse for contacting a priest to visit while hospitalized
C) Asking nurse for additional supplies to change dressings while at home
D) Refusing home care services because the client’s daughter is a nurse and a Sunday school teacher
E) Asking the nurse whom to call if problems occur after surgery

Answer 25

A) Requesting and attending religious services in the hospital chapel
B) Thanking the nurse for contacting a priest to visit while hospitalized

Rationale:

Evidence that a client’s religious needs were met while hospitalized would be the client thanking the nurse for contacting her priest and the client requesting and attending religious services in the hospital chapel. Asking for additional supplies to change dressings at home, asking whom to call if she has any problems at home, or telling the nurse that she will not need home care are unrelated to spiritual care.

Question 26

The nurse is developing a plan of care for a devout Muslim client. Which intervention should the nurse anticipate being a priority for this client?
A) The client will be able to participate in observing Sabbath.
B) The client will be able to participate in daily prayer with a rosary.
C) The client will be able to participate in reading the Torah.
D) The client will be able to participate in prayer at specific times without interruption.

Answer 26

D) The client will be able to participate in prayer at specific times without interruption.

Rationale:

Nurses working with Muslim clients should be aware that many Muslims pray five times a day, and when developing the plan of care they should take prayer times into consideration if this is important to the client. Observing the Sabbath is common to Christianity and Judaism. Daily prayer with a rosary is common to Catholicism. Reading the Torah is specific to Judaism.

Question 27

The nurse is providing care to several clients. Which clients are most likely to request a vegetarian diet due to religious beliefs? Select all that apply.
A) A Catholic client
B) A Jewish client
C) A Hindu client
D) An Episcopalian client
E) A Seventh-Day Adventist client

Answer 27

C) A Hindu client
E) A Seventh-Day Adventist client

Rationale:

Of the individuals listed, the Hindu and Seventh-Day Adventist clients are most likely to be vegetarian because of their religious beliefs. The Jewish, Episcopalian, and Catholic clients may opt to abstain from certain types of food, but these clients are not likely to be vegetarian because of their religious beliefs.

Question 28

The nurse is providing care to a Catholic client who describes herself as "extremely devout." Which treatment option is most likely to cause spiritual distress for this client?
A) Blood transfusion for anemia
B) Specialized cardiac diet
C) Elective termination of pregnancy
D) A below-the-knee amputation

Answer 28

C) Elective termination of pregnancy

Rationale:

Elective termination of pregnancy, or abortion, is the treatment most likely to cause a devout Catholic client spiritual distress. Blood transfusion, specialized cardiac diet, and below-the-knee amputation are less likely to cause this client spiritual distress because they are not prohibited by Catholic teaching.

Question 29

The nurse is caring for a client who is actively engaged in an organized religion. Based on this statement, the nurse knows that which of the following statements is most likely true?
A) The client believes in the presence of only one god.
B) The client knows other individuals from the same religion who may be available to offer emotional and spiritual support.
C) The client lives by the moral code of the Ten Commandments.
D) The client will require time set aside for prayer several times each day, and the nurse will need to work around this schedule.

Answer 29

B) The client knows other individuals from the same religion who may be available to offer emotional and spiritual support.

Rationale:

Individuals who are actively engaged in a specific religion are usually part of a religious community. Members of this community are often called upon for emotional and spiritual support, especially during times of hardship or illness. Without knowing the client’s specific religion, the nurse cannot assume that the client believes in the presence of only one god, that the client will need to set aside specific times each day for prayer, or that the client lives by the moral code of the Ten Commandments.