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 A

Explanation

A. The person experiencing the pain is the authority about the pain: This is the most important principle to recognize when caring for a patient in pain. Pain is a subjective experience, and the individual experiencing it is the best authority on their pain. Nurses should listen to and respect the patient's descriptions and assessments of their pain, as they are the ones experiencing it firsthand. This principle underscores the importance of patient-centered care and empowers patients to participate in decisions about pain management.

B. Administering analgesics for pain will eventually lead to addiction: While concerns about addiction are important to consider when administering analgesics, this statement is not the most important principle to recognize when caring for a patient in pain. Fear of addiction should not overshadow the patient's right to adequate pain relief. Nurses should prioritize effective pain management while also considering factors such as the patient's history of substance use and monitoring for signs of misuse or addiction.

C. Behavioral signs are always congruent with statements about pain: While behavioral signs can provide valuable information about a patient's pain experience, they may not always be congruent with verbal statements about pain. Some patients may exhibit stoic behaviors despite experiencing significant pain, while others may express distress more visibly. Nurses should consider both verbal and non-verbal cues when assessing pain and tailor interventions accordingly.

D. The extent of pain is directly related to the amount of tissue damage: While pain often accompanies tissue damage or injury, the extent of pain experienced by an individual is influenced by various factors beyond just tissue damage. Pain perception is subjective and can be influenced by factors such as psychological, emotional, cultural, and social factors. Therefore, pain intensity may not always directly correlate with the amount of tissue damage present.

A. "I shouldn't take my vitamin D pill before the stool sample is collected." B. "I should take a laxative to help me pass my stool." C. "I must avoid drinking milk before collecting the stool sample." D. "Any meat that I eat before I collect my stool sample must be fully cooked."

Correct Answer is D

Explanation

A. "I shouldn't take my vitamin D pill before the stool sample is collected." Vitamin D supplements are unlikely to interfere with the hemoccult test, as they typically do not contain substances that affect the detection of occult blood in the stool. Therefore, this statement does not demonstrate an understanding of factors relevant to the stool sample collection for the hemoccult test.

B. "I should take a laxative to help me pass my stool." Taking a laxative before collecting the stool sample is not recommended, as it can alter the consistency and composition of the stool, potentially affecting the accuracy of the hemoccult test. Laxatives may also cause diarrhea, leading to difficulty in collecting a sufficient sample. Therefore, this statement is incorrect and does not reflect effective teaching regarding stool sample collection for the hemoccult test.

C. "I must avoid drinking milk before collecting the stool sample." While certain dietary restrictions may be necessary for specific diagnostic tests, drinking milk is not typically prohibited before collecting a stool sample for a hemoccult test. Milk consumption is unlikely to interfere with the test results or the detection of occult blood in the stool. Therefore, this statement is not relevant to the hemoccult test and does not demonstrate understanding of appropriate preparation for the test.

D. "Any meat that I eat before I collect my stool sample must be fully cooked." This statement reflects an understanding of food safety and hygiene practices relevant to stool sample collection for the hemoccult test. Fully cooked meat reduces the risk of bacterial contamination in the stool sample, which could interfere with the accuracy of the test results. Therefore, this statement demonstrates effective teaching regarding the importance of food preparation in ensuring accurate test results for the hemoccult test.

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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

When caring for a patient in pain, the most important principle that the nurse must recognize is that:

Correct Answer is A

Explanation

The nurse is teaching a client who will be collecting a stool sample for a hemoccult test. The nurse determines that teaching has been effective when the client states:

Correct Answer is D

Explanation

The nurse caring for a client diagnosed with dehydration recognizes that which of the following are appropriate nursing interventions? (SELECT ALL THAT APPLY)

The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

The client's urine is cloudy, amber, and has an unpleasant odor. The nurse should make the inference that the client may have:

The nurse notes that the client's indwelling urinary catheter bag has had no urine output since being emptied 1 hour ago. What should the nurse's first action be?

The nurse is caring for a client who has kidney disease. The client has urinated 250 mL over the past 24 hours. The nurse describes this urine output as:

The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

The client reports to the nurse that their bowel movements are hard & difficult to pass. Which of the medications taken by the client most likely contributed to this problem? A/An: