A Mexican American client puts a picture of the Virgin Mary on the bedside table.
What is the nurse's best action?
Leave the picture where the client placed it.
Send the picture home with the client's family.
Send the picture to the business office safe.
Move the picture so it is beside a window.
The Correct Answer is A
Choice A rationale
Leaving the picture of the Virgin Mary on the bedside table demonstrates respect for the client's cultural and religious beliefs. This action supports a client-centered care approach, which recognizes the importance of a client's spirituality and cultural practices in their healing process. The nurse's action fosters trust and promotes a therapeutic relationship, ensuring the client feels safe, respected, and understood within the healthcare environment, which is conducive to positive health outcomes.
Choice B rationale
Removing the picture and sending it home with family disrespects the client's religious and cultural practices. This action can be perceived as dismissive and insensitive, potentially causing the client emotional distress and a feeling of alienation. Such an action could damage the nurse-client relationship, undermine trust, and negatively impact the client's willingness to adhere to their treatment plan. Cultural competence requires acknowledging and accommodating a client's spiritual needs.
Choice C rationale
Sending a personal, religious item to the business office safe is inappropriate and shows a lack of cultural sensitivity. This action implies the item is merely a valuable object to be secured, rather than a significant symbol of faith and comfort for the client. The client may interpret this as a disregard for their deeply held beliefs, leading to feelings of disrespect and a breakdown in communication with the healthcare team.
Choice D rationale
Moving the picture to a different location, such as a window, despite being well-intentioned, may still be perceived as a form of disrespect. The client placed the image in a specific spot for a reason, likely for comfort and a sense of presence. Relocating it without the client's permission or understanding can be seen as a violation of their personal space and autonomy, potentially disrupting their sense of security and trust in the care environment. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
This response minimizes the client's experience by suggesting her observations are biased. Prolonged stress and negative emotions directly impact the immune system's function. The HPA axis and sympathetic nervous system are activated, leading to the release of cortisol and catecholamines. These hormones suppress the immune system, making the body more susceptible to infections like shingles and the flu. Suggesting it's just a matter of "noticing more" disregards this established physiological link.
Choice B rationale
This statement is scientifically inaccurate. The nervous system is a complex, integrated network. The sympathetic and parasympathetic divisions, part of the autonomic nervous system, directly influence physiological responses, including the immune system. The hypothalamic-pituitary-adrenal (HPA) axis, a key component of the neuroendocrine system, is a prime example of the interconnectedness of emotions, stress, and physical health, proving that these systems do not travel on separate tracts.
Choice C rationale
This rationale is not a correct reflection of current scientific knowledge. Extensive research in psychoneuroimmunology (PNI) has demonstrated a clear and well-documented connection between psychological stressors and physiological health outcomes. The field studies how the central nervous system, endocrine system, and immune system interact, showing that chronic stress leads to a compromised immune response, increasing susceptibility to illness. The link is not unclear.
Choice D rationale
Stressors, both psychological and physical, activate the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system. This activation leads to the release of hormones such as cortisol and epinephrine. Cortisol, in particular, is a potent immunosuppressant that, when chronically elevated, reduces the number and activity of white blood cells, such as lymphocytes and natural killer cells, thereby weakening the body's ability to mount an effective immune response against pathogens.
Correct Answer is D
Explanation
Choice A rationale
Elevated blood pressure and excessive sleeping are examples of physiological responses to stress. While psychological stress is the initial trigger, these physical manifestations represent the body's physiological reaction to that stressor. Elevated blood pressure is a sympathetic nervous system response, and excessive sleeping can be a physical coping mechanism or a symptom of depression, which is a physiological state.
Choice B rationale
A racing heart rate is a classic physiological response to stress, mediated by the sympathetic nervous system's release of catecholamines like adrenaline. Avoiding others, while driven by a psychological state (fear or anxiety), is a behavioral response. Therefore, this pairing includes one physiological and one behavioral response, not two purely psychological ones. The prompt asks for a pair of psychological responses.
Choice C rationale
Headaches and tense muscles are both physiological manifestations of stress. Headaches can be tension-related due to muscle constriction, and tense muscles are a direct result of the fight-or-flight response, preparing the body for action. These are physical symptoms that occur as a result of the psychological stressor but are not psychological responses themselves, as they are changes within the body's tissues and systems.
Choice D rationale
Self-doubt and apprehension are cognitive and emotional responses, respectively, which are both classified as psychological. Self-doubt is a thought process involving uncertainty about one's abilities, while apprehension is an emotional state of anxiety or fear about a future event. This pair correctly identifies two internal, mental states that are direct psychological manifestations of stress, distinct from physiological or behavioral reactions.
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