Gait A patient with a normal gait will have a smooth and even walk-cycle. To assess posture, the nurse should ask the patient to stand still and observe the normal "plumb line" through the anterior ear, shoulder, hip, patella, and ankle. If the body parts of the patient look equal bilaterally, and are in relative proportion to each other, then the body parts are symmetrical. For this assessment, the patient is not required to walk across the room. In order to assess the correct body position of the patient, the nurse will ask the person to sit comfortably with the arms relaxed at sides and head turned toward the nurse. What is the yin/yang theory of health? Health exists in the absence of illness. Health exists when all aspects of the person are in perfect balance. Health exists when physical, psychological, spiritual, and social needs are met. Health exists when there is optimal functioning. Ethnicity pertains to a social group within the social system that claims shared values and traditions. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body. A nurse should be aware that adolescent clients who are discussing spirituality often: A. Have a good concept of a supreme being B. Question religious practices and/or values Adolescents often reconsider their childlike concept of a spiritual power, and in the search for an identity, they may either question practices and values or find the spiritual power as the motivation to seek a clearer meaning to life. A nurse's knowledge about spirituality begins with him or her: A. Researching all popular religions B. Looking at his or her own beliefs Knowledge about spirituality begins with nurses' insight about their own spirituality. This self-exploration may occur through reading, religious involvement, or activities such as medication to understand their own beliefs and values. It is essential for the nurse to be aware of his or her own beliefs so as to not impose them on others, and to be able to recognize and understand a client's spiritual needs. The client experienced a near-death experience and was successfully resuscitated. The nurse wants to provide the opportunity for the client to discuss the near-death experience. The most appropriate response by the nurse is: A. "This is a common experience that is easily explained." D. "What was your experience like, and how did it make you feel?" After a client has experienced a near-death experience, it is important for the nurse to remain open, such as asking about the experience and how it made the client feel, and give the client a chance to explore what happened. A 76 year old client has just been admitted to the nursing unit with terminal cancer of the liver. The nurse is assessing the client's spiritual needs and responds best by saying: A. "I notice you have a Bible; is that a source of spiritual strength to you?" A. "I notice you have a Bible; is that a source of spiritual strength to you?" Stating the observation of a client having a Bible opens communication regarding the client's source of strength. Assess and client's source of strength and faith can direct interaction with the client, including medical treatment plans. A client with diabetes is being cared for in the home, with the assistance of a home health nurse and a family member. The client asks you if eating a vegetarian diet will conflict with the disease. The nurse anticipates that the client will follow a vegetarian diet because he is a member of which of the following religions? A. Hinduism A. Hinduism Some sects of Hindus are vegetarians. The belief is not to kill any living creature. Followers of Judaism may observe the kosher dietary restriction of avoiding pork and shellfish and not preparing and eating milk and meat at the same time. People of Islamic faith do not consume pork and alcohol. Fasting is done during the month of Ramadan. Members of the Sikhism religion do not necessarily follow a vegetarian diet. A tool that may be used effectively with clients who have terminal diseases is hope. Hope provides a: A. Relationship with a divinity D. Meaning and purpose Hope provides a sense of meaning and purpose. When a person has hope, he or she has an attitude of something to life for and look forward to. Faith is a relationship with a divinity. Religion is a system of organized beliefs. Spirituality provides a cultural connectedness. The nurse, while working with a client to support and assess spirituality should first: A. Refer the client to the agency chaplain D. Determine the client's personal belief system While working with a client to assess and support spirituality, the nurse should first determine the client's perceptions and belief system. Exploring the client's spirituality may reveal responses to health problems that require nursing interventions, or it may reveal the existence of a strong set of resources that enable the client to cope effectively. If a client is identified as following the traditional health care beliefs of Judaism, the nurse should prepare to incorporate the following into care: A. Faith healing D. Observance of the Sabbath Observance of the Sabbath is important to a client who follows the traditional health care beliefs of Judaism. This client may refuse treatments scheduled on the Sabbath. The nurse is conferring with the nutritionist about the needs of a Native American. The nurse anticipates that the client will: A. Follow a strict vegetarian diet D. Follow a diet according to individual tribal beliefs Food practices of Native Americans are influenced by individual tribal beliefs. Some Hindus and Buddhists are vegetarians. Buddhists, Mormons, and some Baptists, Evangelicals, and Pentecostals avoid the use of alcohol and tobacco. Members of Hinduism, Islam, and Judaism may avoid pork products. The nurse had identified the following nursing diagnoses for his assigned clients. Of the following diagnoses, which one indicates the greatest potential need to plan for the client's spiritual needs? A. Altered health maintenance B. Ineffective individual coping Ineffective individual coping is a nursing diagnosis that may apply to clients in need of spiritual care. The nurse is working in the labor and delivery area with parents who are members of the Shinto and Buddhist religions. The nurse expects that after the birth of the child: A. Baptism will be performed immediately D. No particular rituals will usually be performed in the postpartum period No special rituals are usually performed in the immediate postpartum period with members of the Shinto, Buddhist, or Hindu religions. The nurse may incorporate similarities of nutritional needs into the plan of a care for clients who are Mormon and Buddhist. Members of these religions both: A. Fast on Fridays C. Avoid alcohol and tobacco Both Mormons and Buddhists avoid alcohol and tobacco. The nurse anticipates the gender-related needs of the clients and tries to accommodate those needs whenever possible. A female nurse is arranged for the female client who practices: A. Sikhism A. Sikhism Females are to be examined by females according to the Sikhism religion. The nurse working in the labor and delivery area is aware that special care is provided for the umbilical cord after the child's birth for the clients who are: A. Catholic B. Navajo After a Navajo child's delivery, the umbilical cord is taken from the newborn, dried, and buried near a place that symbolizes what parents want for the child's future. A client diagnosed with an autoimmune disorder uses guided imagery to help control anxiety. Which of the following assessment data supports the effectiveness of the intervention on the actual management of the disease? A. A noticeable increase in the client's appetite C. A white blood cell count at the low-normal range Current evidence has shown that relaxation exercises and guided imagery improve immune function. So a normal white cell count in a client diagnosed with an autoimmune disorder would be considered evidence of the therapeutic nature of the guided imagery. Which of the following statements made by a client diagnosed with terminal renal failure best expresses and client's sense of hope? A. "My father lives for years with this disease." D. "My daughter is getting married in 4 months, and I'm going to walk her down the aisle." When a person has the attitude of something to live for and look forward to, hope is presents. The plan to attend and participate in the daughter's wedding provides the focus of living. The wife of a client diagnosed with Alzheimer's disease shares with the home health nurse that, "We always went to church on Wednesday evenings. I miss that a lot." Which of the following statements made by the nurse has the greatest therapeutic value at this time? A. "Was religion as
important to your husband as well?" C. "May I help arrange for a sitter so you can attend church services again?" Encourage caregivers to participate in spiritual behaviors or practices to enhance spiritual well-being when appropriate. Since the client has introduced the wish to attend services, it is appropriate of the nurse to make a suggestion to help that happen. A client who has recently required advanced cardiac life support after experiencing a myocardial infarction shares with the nurse that, "I could hear voices talking about me dying and then there was this brightly lighted tunnel." Which of the following statements made by the nurse shows the best understanding of therapeutic communication regarding a client's near-death experience. A. "Tell me more about what you saw and heard." A. "Tell me more about what you saw and heard." Clients who have a near-death experience are often reluctant to discuss it, thinking family or caregivers will not understand. However, individuals experiencing a near-death experience who discuss it with family or caregivers find acceptance and meaning from this powerful experience. By encouraging the client to discuss the experience, the nurse is providing therapeutic care in an accepting manner. Which of the following statements made by the nurse regarding spiritual support provided displays an appropriate intervention or attitude? A. "I offer to pray with my clients as I prepare them for transport to surgery." A. "I offer to pray with my clients as I prepare them for transport to surgery." It is essential to promote an environment that respects client's values, customs, and spiritual beliefs. Routinely implementing nursing interventions such as prayer or meditation is coercive and/or unethical. Therefore, determine which interventions are compatible with the client's beliefs and values before selecting nursing interventions. When asked about his or her religious affiliation, a client responds, "That's personal; why do you want to know?" The most appropriate nursing response is: A. "You need not answer my question if you prefer not to share that information" C. "By knowing your religious preferences, I can best meet your spiritual needs." The Joint Commission requires health care organizations to acknowledge client's rights to spiritual care and provide for client's spiritual needs through pastoral care or others who are certified, ordained, or lay individuals. The Joint Commission requires nurses to assess their client's denomination, beliefs, and spiritual practices. Informing the client of this requirement and the purpose for which the information will be used is the most appropriate response. Which of the following interview questions will best determine a client's readiness for enhanced spiritual well-being? A. "Are you a religious person?" C. "To whom do you turn when you have a problem to deal with?" Readiness for enhanced spiritual well-being is based on defining characteristics that show a person's ability to experience and integrate meaning and purpose in life through connectedness with self and others. A client with this nursing diagnosis has potential resources to draw on when faced with illness or a threat to well-being. The nurse is caring for a terminally ill client who frequently engages in prayer with her family. The most therapeutic nursing intervention for this client regarding this practice would be to: A. Move the family into the unit's sunroom for the ritual D. Schedule the client's physical therapy treatments to avoid being an interruption Spiritual priorities do not need to be sacrificed for physical care priorities. For example, when a client is in acute distress, focus care to provide the client a sense of control, but when a client is terminally ill, spiritual care is possibly the most important nursing intervention. By arranging for the PT treatment at a time that will not interrupt the client's prayers, the nurse is showing attention to the client's spiritual needs most therapeutically. A client who has been severely burned has been taught meditation techniques to help manage stress of his recovery period. The nurse recognizes which of the following assessment findings as most conclusive of the effectiveness of the intervention? A. The client states, "I like to meditate" A. The client states, "I like to meditate" The most conclusive evidence of the effectiveness of the intervention is the client's verbalization of its worth. The client stating his positive feelings regarding meditation is the best option. |
Which is the best way for the nurse to determine the religious affiliation of a patient quizlet
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