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The nurse and the patient have the same religious affiliation. Which action will the nurse take to support the patient spiritually?

A.

Assume that both have the same spiritual beliefs.

B.

Skip the spiritual belief assessment.

C.

Must use a formal assessment tool to determine patient's beliefs.

D.

Do not impose personal values on the patient.

Answer and Explanation

The Correct Answer is D

A. Assuming that both have the same spiritual beliefs can lead to misunderstandings; individual beliefs can vary significantly even within the same affiliation.  

 

B. Skipping the spiritual belief assessment is inappropriate as it is essential to understand the patient's unique beliefs and values to provide holistic care.  

 

C. While a formal assessment tool can be helpful, it is not mandatory; what’s most important is engaging in a dialogue about the patient’s beliefs rather than strictly following a formal method.  

 

D. It is crucial for the nurse to respect the patient's unique spiritual beliefs and not impose personal values, making this the most appropriate action to support the patient spiritually.


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Correct Answer is A

Explanation

A. The tuberculin test is administered intradermally, and the needle should be inserted at a 15-degree angle to ensure the medication is delivered just under the surface of the skin.

B. A 90-degree angle is used for intramuscular injections, not for intradermal tests like the tuberculin test.

C. A 30-degree angle is commonly used for subcutaneous injections and is too deep for an intradermal injection.

D. A 45-degree angle is also used for subcutaneous injections but is not suitable for intradermal injections.

Correct Answer is B

Explanation

A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.

B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.

C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.

D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.

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