The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best?
Explain the importance of maintaining morning hygiene practices.
Tell the patient that daily morning baths are the "normal" routine.
Cancel hygiene for the day and attempt again in the morning.
Defer the bath until evening and pass on the information to the next shift.
The Correct Answer is D
A. Explaining the importance of morning hygiene may overlook the patient's established routine and could create resistance.
B. Stating that morning baths are the "normal" routine does not acknowledge the patient's preferences, potentially causing the patient to feel invalidated.
C. Canceling hygiene for the day disregards the patient's needs and preferred routine.
D. Deferring the bath until evening respects the patient’s routine and preference, promoting patient-centered care and improving comfort and compliance with hygiene practices.
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Correct Answer is D
Explanation
A. The belief tool typically involves assessing specific beliefs but does not encompass the broader scope of spiritual well-being.
B. The FICA assessment tool focuses on Faith, Importance, Community, and Address, but it is not characterized by a lengthy questionnaire.
C. The Hope scale assesses a patient's sense of hope but does not specifically address spirituality in depth.
D. The spiritual well-being scale includes multiple questions that explore various aspects of spirituality, including the relationship with God and life purpose, making it the most appropriate choice for this assessment.
Correct Answer is D
Explanation
A. Assessment has already been completed as the initial step, involving data collection.
B. Diagnosis is also completed, involving analysis and identification of the patient’s health problems.
C. Implementation occurs after planning, when nursing interventions are executed.
D. Planning is the appropriate next step, involving the creation of specific, measurable goals and interventions based on the identified nursing diagnoses.