A nurse is caring for a client who reports feeling spiritual distress because his prescribed treatment plan conflicts with his religion. Which of the following actions should the nurse take first?

Ask the client to describe his spiritual beliefs.

Provide available resources on spiritual care for the client.

Consult a dietitian to incorporate the client's religious preferences into a meal plan.

Offer to contact the local leader of the client's religious group.

Answer and Explanation

The Correct Answer is A

A. Ask the client to describe his spiritual beliefs. This is correct. Understanding the client’s spiritual beliefs is the first step in providing appropriate and individualized care.
B. Provide available resources on spiritual care for the client. Providing resources is helpful but should follow an understanding of the client’s specific needs and beliefs.
C. Consult a dietitian to incorporate the client's religious preferences into a meal plan. This is important for comprehensive care but is not the first step in addressing spiritual distress related to treatment conflicts.
D. Offer to contact the local leader of the client's religious group. Contacting a religious leader can be supportive, but the first step should be to understand the client’s specific spiritual beliefs and concerns.

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Correct Answer is A

Explanation

A. Keep the collection bag below the level of the bladder. This prevents backflow of urine, which can introduce bacteria into the bladder and cause infection.
B. Irrigate the catheter routinely with sterile water every other day. Routine irrigation is not recommended as it can introduce pathogens and increase the risk of infection.
C. Use an antiseptic to cleanse the periurethral area twice each day. Cleansing with soap and water is recommended; frequent antiseptic use can irritate the skin and is not necessary.
D. Disconnect the catheter from the drainage tubing to collect urine specimens. Disconnecting the catheter can introduce bacteria and increase the risk of infection. Specimens should be collected using a sterile technique without disconnecting the system.

A. Ask the client to tilt her head back when swallowing. B. Offer the client larger portions of food during the meal. C. Use spoons, instead of cups, when serving liquids to the client. D. Encourage the client to complete the meal within 15 min.

Correct Answer is C

Explanation

A. Ask the client to tilt her head back when swallowing. Tilting the head back can increase the risk of aspiration. Clients with dysphagia should be instructed to tuck their chin to their chest when swallowing.
B. Offer the client larger portions of food during the meal. Smaller portions are safer for clients with dysphagia to reduce the risk of choking and aspiration.
C. Use spoons, instead of cups, when serving liquids to the client. This is correct. Using spoons can help control the amount of liquid the client receives, reducing the risk of aspiration.
D. Encourage the client to complete the meal within 15 min. Rushing a meal increases the risk of choking and aspiration. Clients with dysphagia should eat slowly and take small bites.

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A nurse is caring for a client who reports feeling spiritual distress because his prescribed treatment plan conflicts with his religion. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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