When learning of a new cancer diagnosis, the client states, "If it is God's will, I will survive this." The nurse who is providing spiritually competent care would respond by:

conveying respect for the client's belief.

further assessing the client's knowledge of cancer.

notifying the physician immediately.

calling the chaplain for a consultation.

Answer and Explanation

The Correct Answer is A

A. Conveying respect for the client's belief: This response acknowledges and respects the client's faith and belief system. It demonstrates empathy and supports the client's coping mechanisms during a challenging time. It fosters a therapeutic relationship by validating the client's feelings and beliefs, which can be essential for providing holistic care.

B. Further assessing the client's knowledge of cancer: While assessing the client's understanding of cancer is important, in this context, the client's statement reflects their coping mechanism and reliance on faith. Addressing the client's belief system and providing support in alignment with their spiritual beliefs should be the initial focus.

C. Notifying the physician immediately: There is no indication in the scenario that immediate medical intervention is necessary. The client's statement reflects their coping strategy and does not suggest an urgent medical concern.

D. Calling the chaplain for a consultation: While spiritual support is valuable, the client's statement does not indicate an immediate need for chaplaincy services. The nurse should first acknowledge and respect the client's belief before considering further spiritual support options, based on the client's preferences and needs.

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Correct Answer is A

Explanation

A. Urinary leakage around the catheter: Securing the indwelling urinary catheter to the thigh helps prevent urinary leakage around the catheter site. Catheter movement or dislodgement can lead to leakage of urine around the catheter, which can cause skin irritation, increase the risk of urinary tract infections (UTIs), and compromise hygiene. Securing the catheter to the thigh helps maintain its position and prevents movement that could contribute to leakage.

B. Fecal matter from entering your bladder: While securing the catheter can help maintain proper positioning and prevent movement, its primary purpose is not to prevent fecal matter from entering the bladder. Indwelling urinary catheters are inserted into the bladder through the urethra, and proper catheter placement and hygiene practices are essential for preventing contamination of the urinary tract with fecal matter.

C. Injury to your urethra: Securing the catheter to the thigh does not directly prevent injury to the urethra. Proper insertion technique and appropriate catheter size selection are more critical for preventing urethral injury during catheterization. Securing the catheter primarily aims to maintain its position and prevent movement that could potentially cause discomfort or complications.

D. The catheter from slipping out of your bladder: While securing the catheter can help prevent inadvertent dislodgement, its primary purpose is not to prevent the catheter from slipping out of the bladder. Proper catheter securement techniques, including securing it to the thigh or using catheter stabilization devices, help maintain the catheter's position and minimize movement, reducing the risk of accidental removal.

A. ask about medications the client currently takes. B. check the client's vital signs. C. notify the healthcare provider about the bleeding. D. send the urine to the lab for culture and sensitivity.

Correct Answer is A

Explanation

A. Ask about medications the client currently takes: The first nursing action should be to gather information about potential causes of the pink coloration of the urine. Certain medications, foods, and medical conditions can cause urine discoloration. Asking about the medications the client currently takes can help identify if the pink coloration is due to a medication side effect, such as certain antibiotics, laxatives, or antipsychotics, which can cause urine to appear pink or reddish.

B. Check the client's vital signs: While assessing the client's vital signs is important for obtaining baseline data and assessing the client's overall health status, it may not provide immediate insights into the cause of the pink urine. Vital signs are unlikely to reveal the underlying cause of urine discoloration.

C. Notify the healthcare provider about the bleeding: Notifying the healthcare provider about the presence of pink urine is important, but it should not be the first action taken without gathering more information. Before contacting the healthcare provider, the nurse should assess the client's medications, recent dietary intake, and medical history to identify potential causes of the urine discoloration.

D. Send the urine to the lab for culture and sensitivity: Sending the urine to the lab for culture and sensitivity is not the first action indicated in this scenario. While urine analysis may be warranted to further evaluate the pink urine, it should be done after assessing the client's medications and obtaining additional information to determine the likely cause of the urine discoloration.

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When learning of a new cancer diagnosis, the client states, "If it is God's will, I will survive this." The nurse who is providing spiritually competent care would respond by:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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