A home care nurse is completing a comprehensive assessment & sees that the client has written "spiritual but no specific religious denomination". How should the nurse interpret this data? The client...

should not be asked about religion or spirituality

has abandoned religion due to illness

could be interviewed about personal experiences that guide their life

does not believe in a higher power

Answer and Explanation

The Correct Answer is C

A. The client should not be asked about religion or spirituality: This option is not appropriate. Religion and spirituality are important aspects of holistic care and should be addressed based on the client's preferences and needs. Avoiding discussions about religion or spirituality based on the client's statement may overlook opportunities for supportive care.

B. The client has abandoned religion due to illness: There is no evidence to suggest that the client has abandoned religion due to illness based solely on the statement provided. Assuming such a conclusion without further assessment would be inappropriate and potentially inaccurate.

C. The client could be interviewed about personal experiences that guide their life: This is the correct interpretation. The client's statement indicates that they identify as spiritual but do not adhere to a specific religious denomination. This suggests that the client may have personal beliefs, values, or experiences that guide their life and worldview. The nurse can explore these aspects through open-ended questions to gain insight into the client's spiritual needs and preferences.

D. The client does not believe in a higher power: There is no indication from the client's statement that they do not believe in a higher power. The statement simply suggests that the client does not affiliate with a specific religious denomination, but it does not necessarily imply atheism or disbelief in a higher power.

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Correct Answer is B

Explanation

When a client experiences increased production of antidiuretic hormone (ADH) and aldosterone due to extreme stress, the body's response is aimed at retaining fluid to maintain blood pressure and hydration. As a result, urinary output decreases because the kidneys retain more water, leading to concentrated urine production. This decrease in urinary output helps conserve fluids and contributes to maintaining blood pressure and hydration levels in response to stress.

A. Serum osmolarity: With increased ADH production, serum osmolarity tends to remain stable or may even increase slightly due to the retention of water. ADH acts on the kidneys to increase water reabsorption, which can concentrate the blood and elevate serum osmolarity.

B. Urinary output: Increased production of ADH and aldosterone leads to decreased urinary output as the kidneys retain more water. This response helps conserve fluid volume and maintain hydration during times of stress.

C. Insensible fluid loss: Insensible fluid loss, which includes water lost through respiration and skin evaporation, is not directly affected by ADH and aldosterone. These hormones primarily influence renal water retention rather than insensible fluid loss.

D. Blood pressure: Although aldosterone can indirectly affect blood pressure by increasing sodium retention and therefore influencing fluid balance, its primary role is to regulate sodium and potassium levels. Blood pressure may be influenced by various factors, including stress, hydration status, and cardiovascular health, but it is not directly decreased as a result of increased ADH and aldosterone production.

A. ask about medications the client currently takes. B. check the client's vital signs. C. notify the healthcare provider about the bleeding. D. send the urine to the lab for culture and sensitivity.

Correct Answer is A

Explanation

A. Ask about medications the client currently takes: The first nursing action should be to gather information about potential causes of the pink coloration of the urine. Certain medications, foods, and medical conditions can cause urine discoloration. Asking about the medications the client currently takes can help identify if the pink coloration is due to a medication side effect, such as certain antibiotics, laxatives, or antipsychotics, which can cause urine to appear pink or reddish.

B. Check the client's vital signs: While assessing the client's vital signs is important for obtaining baseline data and assessing the client's overall health status, it may not provide immediate insights into the cause of the pink urine. Vital signs are unlikely to reveal the underlying cause of urine discoloration.

C. Notify the healthcare provider about the bleeding: Notifying the healthcare provider about the presence of pink urine is important, but it should not be the first action taken without gathering more information. Before contacting the healthcare provider, the nurse should assess the client's medications, recent dietary intake, and medical history to identify potential causes of the urine discoloration.

D. Send the urine to the lab for culture and sensitivity: Sending the urine to the lab for culture and sensitivity is not the first action indicated in this scenario. While urine analysis may be warranted to further evaluate the pink urine, it should be done after assessing the client's medications and obtaining additional information to determine the likely cause of the urine discoloration.

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A home care nurse is completing a comprehensive assessment & sees that the client has written "spiritual but no specific religious denomination". How should the nurse interpret this data? The client...

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is under extreme stress will have an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse should expect a decrease in which clinical finding?

Correct Answer is B

Explanation

The nurse collects a urine sample from a newly admitted client. The color of the urine is slightly pink. The first nursing action would be to:

Correct Answer is A

Explanation

A client who has a terminal illness asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?

A client is prescribed isotonic IV hydration for their current fluid balance problem. Which property of isotonic fluid replacement is essential for the nurse to understand?

Nurse Z is extremely attentive to their client's emotional & spiritual needs. The nurse spends up to 45 minutes each day providing the psychosocial support. As a result, the nurse does not plan enough time to perform assessments or give medications on time. This nurse is liable for:

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