Chapter 29: Spiritual Health Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

1. A nurse should be aware that adolescent clients who are discussing spirituality often:

1.

Have a good concept of a supreme being

2.

Question religious practices and/or values

3.

Fully accept the higher meaning of their faith

4.

Often give themselves over to spiritual tasks

ANS: 2

Adolescents often reconsider their childlike concept of a spiritual power, and in the search for an identity, they may either question practices and values or find the spiritual power as the motivation to seek a clearer meaning to life. Adolescents do not necessarily have a good concept of a supreme being. Adolescents do not necessarily fully accept the higher meaning of their faith. Older adults, not adolescents, often turn to important relationships and the giving of themselves to others as spiritual tasks.

DIF: A REF: 446 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

2. A nurses knowledge about spirituality begins with him or her:

1.

Researching all popular religions

2.

Looking at his or her own beliefs

3.

Sharing his or her faith with the clients

4.

Providing prayers and religious articles for clients

ANS: 2

Knowledge about spirituality begins with nurses insight about their own spirituality. This self-exploration may occur through reading, religious involvement, or activities such as meditation to understand their own beliefs and values. Researching popular religions may add to the nurses knowledge, but knowledge of spirituality begins with the nurse examining his or her own beliefs. It is essential for the nurse to be aware of his or her own beliefs so as to not impose them on others, and to be able to recognize and understand a clients spiritual needs. The nurses knowledge about spirituality does not begin with the nurse sharing his or her faith with clients. Providing prayers and religious articles for clients may be an intervention to meet a clients spiritual needs; however, it is not how the nurses knowledge about spirituality begins.

DIF: A REF: 444 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

3. The client experienced a near-death experience and was successfully resuscitated. The nurse wants to provide the opportunity for the client to discuss the near-death experience. The most appropriate response by the nurse is:

1.

This is a common experience that is easily explained.

2.

That must have been a very awful experience for you.

3.

Have you ever heard of other persons having a near-death experience?

4.

What was your experience like, and how did it make you feel?

ANS: 4

After a client has experienced a near-death experience, it is important for the nurse to remain open, such as asking about the experience and how it made the client feel, and give the client a chance to explore what happened. This is not a common experience that can be easily explained. The client should be encouraged to discuss it as he or she may find meaning from this powerful experience. The nurse should not assume this was an awful experience for the client. Many people who have had a near-death experience report positive aftereffects, including a positive attitude and spiritual development. Asking if the client had ever heard of other persons having a near-death experience would not be the most appropriate response. It does not help the client explore his or her own experience.

DIF: A REF: 447 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

4. A 76-year-old client has just been admitted to the nursing unit with terminal cancer of the liver. The nurse is assessing the clients spiritual needs and responds best by saying:

1.

I notice you have a Bible; is that a source of spiritual strength to you?

2.

What do you believe will happen to your personal spirit when you die?

3.

We would allow members of your church to visit you whenever you desire.

4.

Has hearing about your terminal condition made you lose your faith or beliefs?

ANS: 1

Stating the observation of a client having a Bible opens communication regarding the clients source of strength. Assessing a clients source of strength and faith can direct interaction with the client, including medical treatment plans. Asking what the belief about the spirit upon death is not the best response. It does not provide information that would assist the nurse in meeting the clients spiritual needs. Allowing fellow church members is not the best response. It implies the client goes to church or should go to church, and assumes that church members are a source of strength for the client. It does not provide assessment information to determine the clients spiritual needs. Asking if this has caused a loss in faith or beliefs is not the best response. It has a negative connotation, and does not assess the clients source of strength or the beliefs of the client.

DIF: A REF: 447 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

5. A client with diabetes is being cared for in the home, with the assistance of a home health nurse and a family member. The client asks you if eating a vegetarian diet will conflict with the disease. The nurse anticipates that the client will follow a vegetarian diet because he is a member of which of the following religions?

1.

Hinduism

2.

Judaism

3.

Islam

4.

Sikhism

ANS: 1

Some sects of Hindus are vegetarians. The belief is not to kill any living creature. Followers of Judaism may observe the kosher dietary restriction of avoiding pork and shellfish and not preparing and eating milk and meat at the same time. People of Islamic faith do not consume pork and alcohol. Fasting is done during the month of Ramadan. Members of the Sikhism religion do not necessarily follow a vegetarian diet.

DIF: A REF: 450 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

6. A tool that may be used effectively with clients who have terminal diseases is hope. Hope provides a:

1.

Relationship with a divinity

2.

System of organized beliefs

3.

Cultural connectedness

4.

Meaning and purpose

ANS: 4

Hope provides a sense of meaning and purpose. When a person has hope, he or she has an attitude of something to live for and look forward to. Faith is a relationship with a divinity. Religion is a system of organized beliefs. Spirituality provides a cultural connectedness.

DIF: A REF: 446 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

7. The nurse, while working with a client to support and assess spirituality should first:

1.

Refer the client to the agency chaplain

2.

Assist the client to use faith to get well

3.

Provide a variety of religious literature

4.

Determine the clients personal belief system

ANS: 4

While working with a client to assess and support spirituality, the nurse should first determine the clients perceptions and belief system. Exploring the clients spirituality may reveal responses to health problems that require nursing intervention, or it may reveal the existence of a strong set of resources that enable the client to cope effectively. Although the agency chaplain may be a source for referral, it is not the first action the nurse should take in assessing and supporting a clients spirituality. The nurse needs to first assess a clients spirituality to determine the clients perceptions and belief system before attempting to assist the client to use faith to get well. Providing a variety of religious literature may be ineffective as it does not address the client as an individual and does not assess the clients personal spiritual needs. The nurse should first assess the clients perception and belief system before implementing any intervention.

DIF: A REF: 444-445 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

8. If a client is identified as following the traditional health care beliefs of Judaism, the nurse should prepare to incorporate the following into care:

1.

Faith healing

2.

Regular fasting

3.

Ongoing group prayer

4.

Observance of the Sabbath

ANS: 4

Observance of the Sabbath is important to a client who follows the traditional health care beliefs of Judaism. This client my refuse treatments scheduled on the Sabbath. Followers of the Islamic or Christian faith may use faith healing in response to illness. Regular fasting may be seen with some Roman Catholics or with followers of the Russian Orthodox Church. Ongoing group prayer may be seen with the Islamic faith. Christians also use prayer.

DIF: A REF: 451 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

9. The nurse is conferring with the nutritionist about the needs of a Native American. The nurse anticipates that the client will:

1.

Follow a strict vegetarian diet

2.

Avoid the use of alcohol and tobacco

3.

Expect to avoid pork-related products

4.

Follow a diet according to individual tribal beliefs

ANS: 4

Food practices of Native Americans are influenced by individual tribal beliefs. Some Hindus and Buddhists are vegetarians. Buddhists, Mormons, and some Baptists, Evangelicals, and Pentecostals avoid the use of alcohol and tobacco. Members of Hinduism, Islam, and Judaism may avoid pork products.

DIF: A REF: 457 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

10. The nurse has identified the following nursing diagnoses for his assigned clients. Of the following diagnoses, which one indicates the greatest potential need to plan for the clients spiritual needs?

1.

Altered health maintenance

2.

Ineffective individual coping

3.

Impaired long-term memory

4.

Decreased adaptive capacity

ANS: 2

Ineffective individual coping is a nursing diagnosis that may apply to clients in need of spiritual care. The nursing diagnosis of altered health maintenance does not indicate the greatest potential need for spiritual care. The nursing diagnosis of impaired long-term memory does not imply the need for spiritual care. The nursing diagnosis of decreased adaptive capacity does not indicate the greatest potential need for spiritual care.

DIF: A REF: 446 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

11. The nurse is working in the labor and delivery area with parents who are members of the Shinto and Buddhist religions. The nurse expects that after the birth of the child:

1.

Baptism will be performed immediately

2.

Special prayers will be said over the child

3.

Special preparations will be made for the umbilical cord and placenta

4.

No particular rituals will usually be performed in the postpartum period

ANS: 4

No special rituals are usually performed in the immediate postpartum period with members of the Shinto, Buddhist, or Hindu religions. Many Christians will baptize their infants. Followers of Islam will say special prayers after birth over the child. Navajos make special preparations for the umbilical cord and placenta after the birth of a child.

DIF: A REF: 451 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

12. The nurse may incorporate similarities of nutritional needs into the plan of care for clients who are Mormon and Buddhist. Members of these religions both:

1.

Fast on Fridays

2.

Follow vegetarian diets

3.

Avoid alcohol and tobacco

4.

Avoid mixing dairy and meat products

ANS: 3

Both Mormons and Buddhists avoid alcohol and tobacco. Some Roman Catholics and Russian Orthodox members may fast on Fridays. Both Hindus and Buddhists may follow vegetarian diets. Followers of Judaism may avoid eating milk and meat at the same time.

DIF: A REF: 457 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

13. The nurse anticipates the gender-related needs of the clients and tries to accommodate those needs whenever possible. A female nurse is arranged for the female client who practices:

1.

Sikhism

2.

Judaism

3.

Hinduism

4.

Buddhism

ANS: 1

Females are to be examined by females according to the Sikhism religion. Followers of Judaism view visiting the sick as an obligation. They have no restrictions on gender-related care. Followers of Hinduism view illness as being caused by past sins. Prolonging life is discouraged. There are no restrictions on care related to gender. Buddhists believe in Dharma, which teaches that life is impermanent and all persons have to age and die. There are no restrictions on care related to gender.

DIF: A REF: 451 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

14. The nurse working in the labor and delivery area is aware that special care is provided for the umbilical cord after the childs birth for the clients who are:

1.

Catholic

2.

Navajo

3.

Shinto

4.

Hindu

ANS: 2

After a Navajo childs delivery, the umbilical cord is taken from the newborn, dried, and buried near a place that symbolizes what parents want for the childs future. Catholics do not have special care of the umbilical cord after delivery. They may want their newborn baptized if there is any chance of the newborn not surviving. Shintos have no special rituals related to birth, including the umbilical cord. Hindus have no special rituals related to birth, including the umbilical cord.

DIF: A REF: 451 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

15. A client diagnosed with an autoimmune disorder uses guided imagery to help control anxiety. Which of the following assessment data supports the effectiveness of the intervention on the actual management of the disease?

1.

A noticeable increase in the clients appetite

2.

A decrease in the clients HDL cholesterol level

3.

A white blood cell count at the low-normal range

4.

A blood glucose level at the low end of the normal range

ANS: 3

Current evidence has shown that relaxation exercises and guided imagery improve immune function. So a normal white cell count in a client diagnosed with an autoimmune disorder would be considered evidence of the therapeutic nature of the guided imagery. There is no known connection to these other options.

DIF: C REF: 444 OBJ: Cognitive Level: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

16. Which of the following statements made by a client diagnosed with terminal renal failure best expresses the clients sense of hope?

1.

My father lived for years with this disease.

2.

Ive had a good life, and Ill live each day as it comes.

3.

Research is always coming up with new treatments and cures.

4.

My daughter is getting married in 4 months, and Im going to walk her down the aisle.

ANS: 4

When a person has the attitude of something to live for and look forward to, hope is present. The plan to attend and participate in the daughters wedding provides the focus for living. The other options are lacking that component of focus.

DIF: C REF: 446 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

17. The wife of a client diagnosed with Alzheimers disease shares with the home health nurse that, We always went to church on Wednesday evenings. I miss that a lot. Which of the following statements made by the nurse has the greatest therapeutic value at this time?

1.

Was religion as important to your husband as well?

2.

Please tell me more about the role religion plays in your lives.

3.

May I help arrange for a sitter so you can attend church services again?

4.

Attending church services has always been very important to me as well.

ANS: 3

Encourage caregivers to participate in spiritual behaviors or practices (e.g., prayer, attending religious services) to enhance spiritual well-being when appropriate. Since the client has introduced the wish to attend services, it is appropriate for the nurse to make a suggestion to help that happen. Some of the remaining options do encourage the caregiver to discuss the couples spiritual needs but do not directly deal with the verbalized need. The final option is merely the nurses statement of religious practice.

DIF: C REF: 445-446 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

18. A client who recently required advanced cardiac life support after experiencing a myocardial infarction shares with the nurse that, I could hear voices talking about me dying and then there was this brightly lighted tunnel. Which of the following statements made by the nurse shows the best understanding of therapeutic communication regarding a clients near-death experience?

1.

Tell me more about what you saw and heard.

2.

What you are describing is called a near-death experience.

3.

Many clients who have been clinically dead have those types of memories.

4.

What you are describing is most likely a result of the drugs you were given.

ANS: 1

Clients who have a near-death experience are often reluctant to discuss it, thinking family or caregivers will not understand. However, individuals experiencing a near-death experience who discuss it with family or caregivers find acceptance and meaning from this powerful experience. By encouraging the client to discuss the experience, the nurse is providing therapeutic care in an accepting manner. The remaining options close the communication opportunity by providing a reason for the event.

DIF: C REF: 13 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

19. Which of the following statements made by a nurse regarding spiritual support provided displays an inappropriate intervention or attitude?

1.

I offer to pray with my clients as I prepare them for transport to surgery.

2.

I always try to tell my Catholic clients when Mass is being held in the chapel.

3.

When caring for a client for the first time, I always check to see their religious affiliation.

4.

Im not very comfortable interviewing a client concerning their religious beliefs or practices.

ANS: 1

It is essential to promote an environment that respects clients values, customs, and spiritual beliefs. Routinely implementing nursing interventions such as prayer or meditation is coercive and/or unethical. Therefore determine which interventions are compatible with the clients beliefs and values before selecting nursing interventions. To routinely offer to pray with a client without first establishing the appropriateness of that intervention is unethical and so requires immediate instruction of that to the nurse. Two options are not inappropriate and so require no intervention while the third reflects the nurses discomfort with a task but does not indicate any failure to provide effective, appropriate nursing care.

DIF: C REF: 448 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

20. When asked about his or her religious affiliation, a client responds, Thats personal; why do you want to know? The most appropriate nursing response is:

1.

You need not answer my question if you prefer not to share that information.

2.

All information you provide will be kept in strict confidence.

3.

By knowing your religious preferences, I can best meet your spiritual needs.

4.

I did not mean to offend you; we ask that question of all our new admissions.

ANS: 3

The Joint Commission requires health care organizations to acknowledge clients rights to spiritual care and provide for clients spiritual needs through pastoral care or others who are certified, ordained, or lay individuals. The Joint Commission requires nurses to assess their clients denomination, beliefs, and spiritual practices. Informing the client of this requirement and the purpose for which the information will be used is the most appropriate response. The remaining options fail to fully answer the clients question.

DIF: C REF: 448 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

21. Which of the following interview questions will best determine a clients readiness for enhanced spiritual well-being?

1.

Are you a religious person?

2.

Are you satisfied with your life?

3.

To whom do you turn when you have a problem to deal with?

4.

Do you tend to rely on prayer during times of personal stress?

ANS: 3

Readiness for enhanced spiritual well-being is based on defining characteristics that show a persons ability to experience and integrate meaning and purpose in life through connectedness with self and others. A client with this nursing diagnosis has potential resources to draw on when faced with illness or a threat to well-being. By asking the client to identify his or her coping strategy for times of stress, the nurse can begin to assess the clients spiritual well-being. The remaining options are more directed towards assessing faith, or life satisfaction.

DIF: C REF: 452 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

22. The nurse is caring for a terminally ill client who frequently engages in prayer with her family. The most therapeutic nursing intervention for this client regarding this practice would be to:

1.

Move the family into the units sunroom for the ritual

2.

Ask the client and her family to be allowed to pray with the group

3.

Offer to arrange for the facilitys chaplain to attend the prayer session

4.

Schedule the clients physical therapy treatments to avoid being an interruption

ANS: 4

Spiritual priorities do not need to be sacrificed for physical care priorities. For example, when a client is in acute distress, focus care to provide the client a sense of control, but when a client is terminally ill, spiritual care is possibly the most important nursing intervention. By arranging for the PT treatment at a time that will not interrupt the clients prayers, the nurse is showing attention to the clients spiritual needs most therapeutically. While the other options may be appropriate, they do not address the facilitation of the clients expressed need regarding prayer.

DIF: C REF: 444 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Safe, Effective Care Environment

23. A client who has been severely burned has been taught meditation techniques to help manage the stress of his recovery period. The nurse recognizes which of the following assessment findings as most conclusive of the effectiveness of the intervention?

1.

The client stating, I like to meditate

2.

Observing the client in a meditative pose

3.

The client heard telling his son that he has learned to meditate

4.

A 10-point drop in the clients systolic blood pressure after meditation

ANS: 1

The most conclusive evidence of the effectiveness of the intervention is the clients verbalization of its worth. The client stating his positive feelings regarding meditation is the best option. The remaining options may indicate effectiveness but not as personally as the clients statement.

DIF: C REF: 457 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Safe, Effective Care Environment

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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