Answer to Question 1
Correct Answer: 3
Rationale 1: The fact that there is a policy to remove all jewelry is simply a policy, and an exception might be made and documented in this case.
Rationale 2: The nurse should not tell the client that the medal will be allowed as this decision belongs to those directly involved in the procedure.
Rationale 3: The nurse should explain the significance of the medal to the colonoscopy staff and request that the client be allowed to wear it during the procedure.
Rationale 4: Removing the medal and placing it on the head of the bed is not a good choice. There may be no reason to remove the medal. Placing the medal on the head of the bed might allow it to be lost.
Answer to Question 2
Correct Answer: 3
Rationale 1: Offering to pray with the client is over the boundary of professional practice unless the client requests such intervention and the nurse is comfortable with the arrangement.
Rationale 2: Offering to pray for the client is over the boundary of professional practice unless the client requests such intervention and the nurse is comfortable with the arrangement.
Rationale 3: The client can be asked general questions to elicit information about what beliefs and practices are important to the present health care situation, and what, if anything, the client would like from the health care team to support spiritual health.
Rationale 4: At this point, there is no information that indicates the client is in need of referral for counseling. This would occur only if the client demonstrates spiritual distress at the level best handled by a specialist.