The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention?

Establish a trusting nurse-client relationship.

Identify the client's belief in a Supreme Being.

Tell the client everything will be fine when they get home.

Have the client describe the physical problem.

Answer and Explanation

The Correct Answer is A

A. Establishing a trusting relationship is crucial in nursing care, including when addressing spiritual distress. This intervention allows the nurse to create a safe space for the client to express their feelings, concerns, and spiritual beliefs. It fosters open communication and helps the nurse understand the depth of the client's distress, which is essential for providing effective support and care.

B. Understanding the client's belief system, including their beliefs in a Supreme Being or higher power, is important in addressing spiritual distress. This information helps the nurse provide culturally and spiritually sensitive care that aligns with the client's values and preferences. However, while important, this would typically follow establishing a trusting relationship as it involves a deeper understanding of the client's spiritual perspective.

C. This response may come from a well-intentioned desire to reassure the client, but it oversimplifies the client's concerns and does not address the root of spiritual distress. Spiritual distress is often complex and may involve existential questions, fears, or conflicts related to beliefs, meaning, and purpose.

Offering simplistic reassurances without addressing these deeper issues may not effectively alleviate the client's distress.

D. Spiritual distress is distinct from physical problems, although it can manifest with physical symptoms. Focusing solely on the physical aspects may overlook the spiritual and existential concerns that underlie the client's distress. While it's important to assess physical symptoms comprehensively, this approach does not directly address the spiritual distress identified by the nurse.

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Correct Answer is C

Explanation

C. This is the priority intervention because clients in protective isolation have compromised immune systems and are at high risk of infection. Upper respiratory infections can be transmitted easily through respiratory droplets, posing a significant risk to the client. Restricting visitors with such infections helps minimize the risk of introducing pathogens into the client's environment.

A. While maintaining cleanliness is important in any healthcare setting, changing bed linens daily may not be the highest priority in protective environment isolation unless there is a specific indication (e.g., soiled linens, contamination). It is essential to minimize unnecessary contact and potential sources of infection, but this is not the priority in the given context.

B. Hydration is important for all clients, but the frequency of providing fresh drinking water every four hours is generally a routine nursing care measure. Unless there are specific medical orders or client needs, this action is not directly related to the specialized care required in protective environment isolation.

D. Monitoring intake and output is important for assessing fluid balance and kidney function in hospitalized clients. However, in the context of protective isolation, where infection control is paramount, restricting visitors who pose a potential infectious risk takes precedence over routine monitoring tasks.

Correct Answer is ["24"]

Explanation

For a client prescribed 2 grams of amoxicillin/clavulanic acid every 12 hours, and given that the medication is supplied in 500 mg capsules,

The client would need to take four capsules to meet the 2-gram requirement per dose. Since the medication is to be taken every 12 hours, this equates to two doses per day.

For a 3-day business trip, the client would need to take a total of 6 doses. Therefore, the client should take 24 capsules (4 capsules per dose multiplied by 6 doses) with them to ensure they have enough medication for the duration of their trip.

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The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for a client in protective environment isolation. Which nursing action is the priority intervention?

Correct Answer is C

Explanation

A client is to receive 2 grams of amoxicillin/clavulanic acid every 12 hours. The medication is supplied in 500 mg capsules. The client confirms with the nurse that they should take how many capsules with them on a 3-day business trip out of town? (Use preceding zeros. Do not use trailing zeros)

Correct Answer is ["24"]

Explanation

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