The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention?

Establish a trusting nurse-client relationship.

Identify the client's belief in a Supreme Being.

Tell the client everything will be fine when they get home.

Have the client describe the physical problem.

Answer and Explanation

The Correct Answer is A

A. Establishing a trusting relationship is crucial in nursing care, including when addressing spiritual distress. This intervention allows the nurse to create a safe space for the client to express their feelings, concerns, and spiritual beliefs. It fosters open communication and helps the nurse understand the depth of the client's distress, which is essential for providing effective support and care.

B. Understanding the client's belief system, including their beliefs in a Supreme Being or higher power, is important in addressing spiritual distress. This information helps the nurse provide culturally and spiritually sensitive care that aligns with the client's values and preferences. However, while important, this would typically follow establishing a trusting relationship as it involves a deeper understanding of the client's spiritual perspective.

C. This response may come from a well-intentioned desire to reassure the client, but it oversimplifies the client's concerns and does not address the root of spiritual distress. Spiritual distress is often complex and may involve existential questions, fears, or conflicts related to beliefs, meaning, and purpose.

Offering simplistic reassurances without addressing these deeper issues may not effectively alleviate the client's distress.

D. Spiritual distress is distinct from physical problems, although it can manifest with physical symptoms. Focusing solely on the physical aspects may overlook the spiritual and existential concerns that underlie the client's distress. While it's important to assess physical symptoms comprehensively, this approach does not directly address the spiritual distress identified by the nurse.

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Correct Answer is C

Explanation

C. This entry is factual and avoids assumptions about how the client ended up on the floor, focusing instead on the sequence of events as discovered by the recorder. It is important to avoid speculation and to document only what is directly observed or verifiable.

A. This option provides a clear description of the situation: the client was found on the floor, and it attributes the fall to getting tangled in bed linens. However, it includes an assumption of how the client fell.

B. This option indicates that the client fell out of bed and did push the call button for assistance. While it acknowledges the fall and the use of the call button, it doesn't specify who found the client on the floor or the circumstances surrounding the discovery.

D. This option suggests that the client called for assistance after falling out of bed due to being tangled in bed linens. It mentions the sequence of events (tangled in bed linens first, then called for assistance), but it doesn't specify who found the client on the floor or the action taken thereafter.

A. Reduce environmental stimuli B. Suction the oropharynx C. Assess pulse oximetry D. Administer oxygen

Correct Answer is A

Explanation

A. Restlessness and agitation in nonverbal clients can often be exacerbated by environmental factors such as noise, bright lights, or unfamiliar surroundings. By reducing environmental stimuli, such as dimming lights, minimizing noise, and providing a calm atmosphere, the nurse can help alleviate agitation and promote a more comfortable environment for the client.

B. Suctioning the oropharynx is not typically the first action unless there is a clear indication that airway obstruction or secretion management is contributing to the client's agitation. It is important to first assess whether there are signs of respiratory distress or airway compromise before performing suctioning.

C. Assessing pulse oximetry is important for monitoring oxygen saturation levels, especially if there are concerns about respiratory distress or inadequate oxygenation. However, it is not typically the first action when a client is restless and agitated unless there are specific indications or signs suggesting respiratory compromise.

D. Administering oxygen may be necessary if there are signs of hypoxia or respiratory distress contributing to the client's agitation. However, without assessing the client's oxygenation status first, administering oxygen as the initial action may not address the underlying cause of agitation.

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The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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