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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 C

Explanation

A. Certification relates to additional qualifications and does not directly involve independent nursing actions in patient care.

B. Licensure is the legal permission to practice nursing but does not describe decision-making and action in patient care.

C. Autonomy is demonstrated when the nurse independently assesses the patient’s fluid status and takes action to promote health by encouraging fluid intake. This reflects the nurse’s ability to make decisions and act based on professional judgment.

D. Accountability refers to being responsible for one's actions but does not specifically cover the independent decision-making shown here.

Correct Answer is C

Explanation

A. Discontinuing pain medication may not be appropriate, as it can lead to inadequate pain management for the patient. Pain management is crucial for terminally ill patients.

B. While abdominal massage may help relieve mild constipation, it is not a reliable primary intervention for more severe constipation caused by medication.

C. Laxatives are commonly prescribed for constipation related to pain medication and are an effective method to promote bowel movements, making this the best choice.

D. Administering enemas twice daily can be excessive and may cause discomfort or lead to dependency, making this option less favorable than using laxatives.

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