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 C
Explanation
A. While pain can motivate protective behaviors, it does not directly increase personal strength.
B. Acute pain is a subjective experience but serves an important biological purpose.
C. Acute pain is protective because it warns an individual of tissue damage or disease, prompting actions to avoid further harm and seek treatment.
D. Pain is subjective, not objective, and while it can aid diagnosis, its primary role is protective rather than diagnostic.
Correct Answer is C
Explanation
A. Delegation guidelines may be influenced by organizational policy but are often based on state nurse practice acts.
B. Medicare and Medicaid qualification criteria are defined at the federal level, not state.
C. Scope of practice differences between registered nurses and licensed practical nurses are established by state legislation, which regulates nursing practice within the state.
D. Medication administration processes can be guided by federal laws and facility policies but are also regulated by state laws; however, the clear differentiation of scope of practice is specifically legislated at the state level.
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