client scheduled for complex heart surgery has been reading their religious text for hours each day, cries often, and is not sleeping well. What might these observations cue the nurse about the client?
Family members live far away and the client is lonely.
These behaviors are signs of spiritual distress.
These behaviors are expected before major surgery.
The client is naturally emotional and reactive
The Correct Answer is B
A. While loneliness can contribute to distress, the specific behaviors observed (excessive religious reading, crying, and poor sleep) suggest something deeper than just social isolation.
B. These behaviors are signs of spiritual distress, which may occur when a person is facing a serious illness or surgery and is struggling with questions of meaning, faith, or fear. Spiritual distress can manifest emotionally and behaviorally, as seen here.
C. While some anxiety is expected before major surgery, persistent emotional signs like excessive crying and poor sleep, along with intense religious focus, indicate more than normal preoperative nerves.
D. Labeling the client as “naturally emotional” is an assumption and dismisses the need for assessment and appropriate support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While involving a spiritual advisor may be helpful, the nurse’s priority is to ensure the client is fully informed before decisions are made.
B. Providing all relevant information allows the client to weigh risks and options and make an informed decision respecting their beliefs.
C. Forcing information or pressuring the client disregards their autonomy and beliefs.
D. Having the client sign refusal without thorough discussion does not support informed consent or shared decision-making.
Correct Answer is B
Explanation
A. While loneliness can contribute to distress, the specific behaviors observed (excessive religious reading, crying, and poor sleep) suggest something deeper than just social isolation.
B. These behaviors are signs of spiritual distress, which may occur when a person is facing a serious illness or surgery and is struggling with questions of meaning, faith, or fear. Spiritual distress can manifest emotionally and behaviorally, as seen here.
C. While some anxiety is expected before major surgery, persistent emotional signs like excessive crying and poor sleep, along with intense religious focus, indicate more than normal preoperative nerves.
D. Labeling the client as “naturally emotional” is an assumption and dismisses the need for assessment and appropriate support.
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