Chapter 16

For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? Increased urinary output Increased eating Increased wakefulness Increased restlessness

Correct response: Increased restlessness Explanation: As the oxygen supply to the brain decreases, the patient may become restless. As the body weakens, the client will sleep more and begin to detach from the environment. For many clients, refusal of food is an indication that they are ready to die. Based on decreased intake, urinary output generally decreases in amount and frequency.

A 36-year-old mother of three was recently diagnosed with a chronic illness. The nurse prepared information for the patient on how to manage her illness. To help her cope with the shock and resentment that she was experiencing, the nurse gave her facts about her illness with honesty and empathy. Which of the following are the best comments that the nurse can include when talking to the patient about chronic illness? Select all that apply. It can be associated with exacerbations and remissions. It can require short-term management (<3 months). It is characterized by a progressive decline in normal physiologic function It results in residual disability due to non-reversible pathology. It is defined as long-term with the possibility of a cure if intervention is rapid and timely.

Correct response: It is characterized by a progressive decline in normal physiologic function It can be associated with exacerbations and remissions. It results in residual disability due to non-reversible pathology. Explanation: Chronic illnesses are often defined as medical illnesses or health problems with associated symptoms or disabilities that require long-term management (3 months or longer). Chronic illness refers to diseases that are caused by non-reversible pathology; are characterized by a slow progressive decline in normal physiological function; are permanent with cure unlikely; and require long-term surveillance, leaving residual disability.

Which term best describes a living will? Health care power of attorney Proxy directive Medical directive Durable power of attorney for health care

Correct response: Medical directive Explanation: A living will is a type of advance medical directive in which the individual, who is of sound mind, documents treatment preferences. A proxy directive and health care power of attorney are other names for a durable power of attorney for health care, in which one individual is appointed and authorized to make medical decisions on behalf of another person when that person is no longer able to speak for him or herself.

Which of the following interventions should the nurse perform while providing spiritual care for a dying client? Encourage family members in their frank communication. Provide spiritual books. Ask the family members about spiritual care. Allow a period of privacy.

Ask the family members about spiritual care. Explanation: When clients are too ill to express their wishes, the nurse should ask the family members about spiritual care. Encouraging family members in their frank communication and providing spiritual books may not be helpful in providing spiritual care for a dying client. Allowing a period of privacy may not be helpful. The nurse allows a period of privacy to the client's family members after the death of the client

Which intervention should a nurse perform during the grieving period when caring for a dying client? Spending time with client Avoiding criticizing or giving advice Providing palliative care Allowing a period of privacy

Avoiding criticizing or giving advice Explanation: The nurse should listen in a nonjudgmental manner and should avoid criticizing or giving advice during the grieving period when caring for dying clients. Allowing a period of privacy is necessary to help family members cope with the death of a client and is not necessary during the grieving period. Spending time with the client and providing palliative care are not required nursing interventions during the grieving period. Palliative care is provided to a dying client when the client is unable to live independently.

Which cardiovascular findings indicate to the nurse that the condition of the dying client is worsening? Pulse 60 beats/minute, blood pressure 90/42mm Hg, difficult to arouse Pulse 72 beats/minute, irregular; client confused and agitated Pulse 100 beats/minute, blood pressure 100/60 mm Hg, pale with poor skin turgor Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles

Correct response: Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles Explanation: Earlier, a client with failing cardiac function exhibits a higher pulse as the body attempts to circulate oxygen. Next, cardiac output is decreased due to ineffective filling of the chambers, impairing circulation, and diminishing the heart's own oxygen supply. The heart rate and blood pressure then decrease. Peripheral circulation is impaired with the feet and ankles becoming pale and mottled.

As a client approaches death, respirations become noisy. This is the result of which type physical event? musculoskeletal change cardiac dysfunction central nervous system alterations gastrointestinal impairment

musculoskeletal change Explanation: As death approaches, a client's reflexes become hypoactive. The jaw and facial muscles also relax. As the tongue falls to the back of the throat, respirations become noisy.

Which intervention should a nurse perform during the grieving period when caring for a dying client? Avoiding criticizing or giving advice Allowing a period of privacy Spending time with the client Providing palliative care

Avoiding criticizing or giving advice Explanation: The nurse should listen in a nonjudgmental manner and should avoid criticizing or giving advice during the grieving period when caring for dying clients. Allowing a period of privacy is necessary to help family members cope with the death of a client and is not necessary during the grieving period. Spending time with the client and providing palliative care are not the required nursing interventions during the grieving period. Palliative care is provided to a dying client when the client is unable to live independently

Which of the following nursing interventions is appropriate with regard to pain control in the dying client? Explain that morphine will be avoided because of its sedative effects. Give pain medications on a routine schedule. Explain that narcotics can cause addiction. Explain that oxygen will eventually be used.

Correct response: Give pain medications on a routine schedule. Explanation: The nurse usually gives pain medication on a routine schedule around the clock to avoid causing intense discomfort followed by a period of heavy sedation. Morphine may be used. Oxygen eventually may be used.

A nursing instructor is preparing a class discussion about hope and end-of-life care. Which of the following would the instructor include as an example of a hope-fostering activity? Pain Humor Abandonment Isolation

Correct response: Humor Explanation: Hope-fostering categories include love of family and friends, spirituality and faith, goal setting, maintenance of independence, positive relationships with clinicians, humor, personal characteristics, and uplifting memories. Hope-hindering categories include abandonment, isolation, uncontrollable pain or discomfort, and devaluation of personhood.

Which of the following is the nurse's primary concern when providing end-of-life care for a client and the family? Select all that apply. Encouraging fluids Supporting family members Arranging plans for after death Maintaining client comfort Completing a head-to-toe assessment Providing personal care

Correct response: Maintaining client comfort Supporting family members Providing personal care Explanation: Nursing care of dying clients focuses on providing palliative care to the client and supporting family members. Arranging the plans after death is not a priority at this time. Completing a head-to-toe assessment may be completed for information but is not a priority at the end of life. There is no need to encourage fluids

Nursing students are reviewing information about the signs and symptoms of impending death. The students demonstrate the need for additional review when they identify which of the following as a sign? Muscle wasting Restlessness Reduced urinary output Mental confusion

Correct response: Muscle wasting Explanation: Muscle wasting occurs as the client's condition deteriorates. It is not a sign of impending death. Mental confusion, reduced urinary output, and restlessness occur as a client approaches death

While talking with a client who has been diagnosed with a terminal illness, the client asks, " Am I dying?" Which response from the nurse would be appropriate? Select all that apply. "Let's focus on what your doctor has planned." "I know just how you must feel." "Tell me more about what's on your mind." "This must be very difficult for you." "You still have time for a good life."

Correct response: "This must be very difficult for you." "Tell me more about what's on your mind." Explanation: The nurse needs to listen effectively and empathetically, acknowledging the client's fears and concerns. Statements such as "This must be very difficult for you" and "Tell me more about what's on your mind" address the client's concerns and help to focus the discussion on the client. Telling the client that the nurse knows how the client feels ignores the client's concerns. Saying that there is still time for a good life or telling the client to focus on what the doctor has planned ignores the client's feelings and blocks communication.

The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following? A workshop on caring for the dying client Use evidence-based practice in daily care regimen. Participate in a support group to learn clients' feeling on care. Explore own feelings on mortality and death and dying.

Correct response: Explore own feelings on mortality and death and dying. Explanation: To care for others in the dying process, the nurse must explore his or her own feelings about mortality and death and dying. Understanding self provides a perspective to cope with and then support clients and families experiencing pain and grief. The other options are helpful in determining appropriate nursing care but not the first step

Which of the following would not be consistent with promoting nutrition in terminally ill patients? Avoiding arguments at mealtime Maintaining a balanced diet Offering cool foods rather than hot foods Offering small portion of favorite foods

Correct response: Maintaining a balanced diet Explanation: One should not be overly concerned about a "balanced" diet for terminally ill patients. Offering small portions of favorite foods, avoiding arguments at mealtime, and offering cool foods rather that hot foods are all tips that promote nutrition in terminally ill patients

A nurse is working with the family of a terminally ill client, providing them with suggestions about how to manage the client's anorexia. Which statement by the family indicates that they have understood the instructions? "We'll try to give him regularly scheduled meals throughout the day." "We'll make sure that any foods that we give him are mashed up or in liquid form instead so he doesn't have to chew." "We'll make sure that he is nearby the kitchen so he can smell the foods cooking." "We'll try adding powdered milk to milk and other foods to make them more nutritious."

"We'll try adding powdered milk to milk and other foods to make them more nutritious." Explanation: Increasing the nutritional value of foods, such as by adding powdered milk to milk and other foods, is appropriate. The client should be allowed and encouraged to eat when he is hungry regardless of the regular meal times. Cooking odors should be eliminated or reduced because they can precipitate nausea, vomiting, or anorexia. Unless there is a definite problem with chewing or swallowing, foods do not need to be pureed (mashed) or in liquid form

Which is also known as a proxy directive? Medical directive Durable power of attorney for health care Treatment directive Living will

Correct response: Durable power of attorney for health care Explanation: A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. The other options are incorrect

Despite having been administered prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea? Use imagery, humor, and progressive relaxation Encourage the patient to sleep Gently massage the arms and legs Offer small amounts of nourishment frequently

Correct response: Use imagery, humor, and progressive relaxation Explanation: Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication and to reduce dyspnea. Offering small amounts of nourishment frequently will not help potentiate the effects of pain medication. Gentle massaging of the arms and legs helps to regulate body temperature. Encouraging the client to fall asleep will not help in potentiate the effects of pain medication

In spite of administering the prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea? Encourage the patient to sleep Offer small amounts of nourishment frequently Use imagery, humor, and progressive relaxation Gently massage the arms and legs

Use imagery, humor, and progressive relaxation Explanation: Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication. Offering small amounts of nourishment frequently will not help potentiate the effects of pain medication. Gentle massaging of the arms and legs helps to regulate body temperature. Encouraging the client to fall asleep will not help potentiate the effects of pain medication

Evidence-based medical and nursing research (2009) has identified cardiovascular disease as the most prevalent chronic disease in the United States. Under this classification, one condition is the most common. Using this information, a nurse practitioner, treating a 50-year-old man, would do which of the following? Make certain that the patient was aware of the signs of coronary artery disease. Write a prescription for a serum cholesterol level. Suggest activity modifications and treatments to help minimize the physical limitations of dyspnea. Teach the patient how to assess his blood pressure weekly.

Correct response: Write a prescription for a serum cholesterol level. Explanation: Hypercholesterolemia is the most prevalent chronic disease in the United States, with 37.5% of all adults affected. Refer to Table 3-1 in the text.

A nurse is assessing a client with a terminal illness and finds that the client has cachexia. The nurse interprets this as indicating which of the following? Severe asthenia Profound protein loss Extreme anorexia Starvation

Correct response: Profound protein loss Explanation: Cachexia is associated with anabolic and catabolic changes in metabolism that relate to activity of neurohormones and proinflammatory cytokines, resulting in profound protein loss. Although anorexia may exacerbate cachexia, it is not a primary cause. Starvation refers to simple food deprivation and is not cachexia. Anorexia-cachexia syndrome, characterized by disturbances in carbohydrate, protein, and fat metabolism, endocrine dysfunction, and anemia results in severe asthenia (loss of energy).

A nurse is caring for a terminally ill client inquiring about physician-assisted suicide. Which statement if made by the nurse would correctly inform the client of this practice? The health care provider provides the means for the clients to take their life. The health care provider provides the means and waits to pronounce them dead. The health care provider provides counseling and has a third party physician assist in the suicide. The health care provider administers a lethal dose of medication via IV.

Correct response: The health care provider provides the means for the clients to take their life. Explanation: Physician-assisted suicide is the practice of providing a means by which a client can end his or her life. Much controversy exists concerning the practice. California, Vermont, Oregon, Washington, and Montana are the only states that permit physician-assisted suicide. The physician does not personally administer the dose, wait until the client is dead, or have a third party physician involved.

How does a nurse who has been providing home care to a terminally ill client know that the client's condition is beginning to deteriorate? urine output increases apical pulse reaches 100 beats/minute facial muscles contract skin appears red and flushed

Correct response: apical pulse reaches 100 beats/minute Explanation: Failing cardiac function is one of the first signs that a client's condition is worsening. At first, heart rate increases in a futile attempt to deliver oxygen to cells. The apical pulse rate may reach 100 or more beats/minute. In clients who are dying, the skin becomes pale or mottled, nail beds and lips may appear blue, and the client may feel cold. In clients who are dying, urine volume decreases, and the jaw and facial muscles relax.

According to federal guidelines, hospices may provide no more than what percentage of the aggregate annual patient-days at the inpatient level? 20 40 10 30

Correct response: 20 Explanation: According to federal guidelines, hospices may provide no more than 20% of the aggregate annual patient-days at the inpatient level. The other numerical values are incorrect.

Which of the following is an appropriate intervention for the client with pulmonary edema? Use chest percussion. Administer the prescribed sedative to decrease anxiety. Position the client supine. Suction as needed to clear the lungs.

Correct response: Administer the prescribed sedative to decrease anxiety. Explanation: Suctioning will not clear the lungs or ease breathing if the client has pulmonary edema. In this situation, the physician may prescribe a sedative to relieve the anxiety created by the feeling of suffocation.

A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using? End-of-life treatment directive Durable power of attorney for health care Living will declaration Medical directive by proxy

Correct response: Durable power of attorney for health care Explanation: A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.

A nurse is assessing a terminally ill female client. Which client statement indicates that the client is in the bargaining stage of dying? "I don't know how my husband is going to manage things when I'm gone." "I can't believe this. I'm going to get a second opinion." "Why is this happening to me. I've led a good life. Why is God punishing me?" "I just want to see my daughter graduate from college. That's all."

Correct response: "I just want to see my daughter graduate from college. That's all." Explanation: Bargaining is manifested by pleading for more time to reach an important goal. This is reflected in the client's statement about wanting to see her daughter's college graduation. The statement about going to get a second opinion reflects denial. The statement about why reflects anger. The statement about not knowing how the husband will manage reflects the depression stage.

The nurse is caring for a client who has diminished lung function due to emphysema. The terminally ill client is short of breath on exertion and reports difficulty sleeping in bed. The client states, "I am so afraid of getting any worse." Which statement, by the nurse, assists the client in sustaining hope? "I will talk with the health care provider to determine the next step in your care." "I hear you say that you are not sleeping well." "Your grandchild is almost here, and you will enjoy seeing him." "Do not worry, I will be here for you to help you with your needs."

Correct response: "I will talk with the health care provider to determine the next step in your care." Explanation: The client is assisted in hopefulness by believing that the healthcare team will make his remaining days meaningful. By conveying a sense that the nurse will discuss the client's condition with the health care provider, the client recognizes that the healthcare team will use whatever treatment and comfort measures are available. Telling a client not to worry is not therapeutic and is condescending. Waiting for a grandchild does not address the client's thought. Reflecting what the client said for clarification opens communication but does not instill hopefulness.

During a home care visit to a client in hospice, the client's spouse reveals to the nurse an understanding that the client's death is inevitable. Recognizing the spouse is exemplifying the Kübler-Ross stage of acceptance, which statement by the nurse is most appropriate? "Have you thought about what you will do when you find your spouse after he has died?" "Make sure you have made previous arrangements with the funeral home for burial arrangements." "Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." "I would make arrangements to have all your children present for the death vigil."

Correct response: "Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." Explanation: Anticipating and planning interventions is a cornerstone of end-of-life care. The nurse encourages communication and anticipatory grieving by using open-ended statements such as "Tell me. . . ." Effective communication techniques include the avoidance of closed-ended statements and giving advice

A dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be? "You know you're dying?" "I'm so sorry. I know how you must feel." "Tell me more about what's on your mind." "This must be very difficult for you."

Correct response: "This must be very difficult for you." Explanation: Using open-ended questions allows the nurse to elicit the patient's and family's concerns, explore misconceptions and needs for information, and form the basis for collaboration with physicians and other team members. For example, a seriously ill patient may ask the nurse, "Am I dying?" The nurse should avoid making unhelpful responses that dismiss the patient's real concerns or defer the issue to another care provider. In response to the question "Am I dying?" the nurse could establish eye contact and follow with a statement acknowledging the patient's fears ("This must be very difficult for you") and an open-ended statement or question ("Tell me more about what is on your mind")

A client and family are dealing with the client's recent terminal diagnosis. A nurse identifies a nursing diagnosis of hopelessness. Which of the following would be most helpful in supporting hope for this family? Select all that apply. Encouraging the client to participate in care to foster control Assisting in establishing long-term goals Arranging for appropriate psychosocial counseling Helping to obtain support from the community Avoiding the sharing of information and feelings

Correct response: Arranging for appropriate psychosocial counseling Encouraging the client to participate in care to foster control Helping to obtain support from the community Explanation: To enable, support, and foster hope in terminally ill clients and their families, nurses should encourage and support the client's control over circumstances, choices, and environment whenever possible, make referrals for psychosocial and spiritual counseling, and assist with developing supports in the home and community when none exist. Goals set should be realistic, rather than long-term. Information and feelings should be shared. The information provided also should be accurate.

A nurse is providing care to a terminally ill client who is experiencing dyspnea. Which of the following would be most appropriate to do to assess the severity of the client's complaint? Question the client about when the dyspnea eases or worsens. Have the client state if the dyspnea is mild, moderate, or severe. Auscultate the client's lung sounds for changes. Ask the client to rate the dyspnea on a scale of 0 to 10.

Correct response: Ask the client to rate the dyspnea on a scale of 0 to 10. Explanation: The most appropriate method for assessing the severity of the client's dyspnea is to have the client rate the severity using a scale from 0 to 10, with 0 indicating no dyspnea and 10 indicating the worst imaginable dyspnea. This provides an objective indicator of the severity. Asking the client to identify the complaint as mild, moderate, or severe, although somewhat helpful, is not the best means for assessing the severity because these terms are difficult to quantify. Questioning the client about easing or worsening of the complaint would be helpful to determine the possible underlying cause and obtain a more complete picture of the complaint, but it would not help determine severity. Dyspnea can occur for many reasons, including anxiety and fear. Therefore, auscultating the lungs would provide information only about respiratory involvement as a potential cause. It would not help determine the severity of the dyspnea.

A client is experiencing anorexia and the physician is to order a medication to stimulate the client's appetite. Which of the following would the nurse least likely expect the physician to prescribe? Megestrol Dronabinol Dexamethasone Atropine

Correct response: Atropine Explanation: Atropine is used to manage excessive oral and respiratory secretions when death is imminent. Dexamethasone, megestrol, and dronabinol may be used to stimulate appetite in clients who are at the end of life

A nurse has been working in hospice care for 10 years. Based on her experience, she drafts her plan of care with the understanding that the most significant barrier to improving care at the end of life is the: Lack of social support systems for the dying patient. Fear of over-medicating the patient when pain is severe. Patient's resistance to accepting care. Attitude of health care professionals toward terminal illness.

Correct response: Attitude of health care professionals toward terminal illness. Explanation: Clinicians' attitudes toward the terminally ill and dying remain the greatest barrier to improving care at the end of life. Clinicians' reluctance to discuss disease and death openly with patients stems from their own anxieties about death, as well as misconceptions about what and how much patients want to know about their illnesses

A client and their loved ones are in the grieving period of the client's dying, and the nurse wants to offer the best possible support to them in the process. Which is the best intervention the nurse could perform during the grieving period? Allow a period of privacy. Provide palliative care. Spend time with client. Avoid criticism or giving advice.

Correct response: Avoid criticism or giving advice. Explanation: The nurse should listen in a nonjudgmental manner and should avoid criticism or giving advice during the grieving period when caring for dying clients. Spending time with the client does not facilitate the grieving process for the client and his or her loved ones. The nurse is responsible for facilitating the grieving process and helping the client and family deal with their emotions. To do this, nurses may empathetically share perceptions of what the client and family are experiencing.

Which term refers to the period of time during which mourning of a loss takes place? Bereavement Grief Mourning Hospice

Correct response: Bereavement Explanation: Bereavement is the period of time during which mourning of a loss takes place. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Mourning is defined as the individual, family, group, and cultural expressions of grief and associated behaviors. Hospice is a coordinated program of interdisciplinary care and services provided primarily in the home to terminally ill clients and their families

The nurse is caring for a client who is interested in learning about hospice care. Which of the eligibility criteria would the nurse stress? Limited life expectancy Choice of palliative care over cure focused Serious, progressive illness Physician-certified illness

Correct response: Choice of palliative care over cure focused Explanation: An important focus of hospice care is that care is palliative in nature. No further aggressive treatment to find a cure for the illness is administered. The client must accept this philosophy of care. The other options are factual and agreed on.

A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply. Comfort the client by saying it will all be over soon. Recommend that the client consider physician-assisted suicide. Advise the client's health care provider of the client's condition. Encourage the client to explain his or her wishes. Control the client's pain with prescribed medication.

Correct response: Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Encourage the client to explain his or her wishes. Explanation: This client lives in Oregon, one of five states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation. Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however

A client with long-term breast cancer who was recently enrolled in a hospice program demonstrates signs and symptoms of clinical depression. Which action by the hospice nurse is appropriate? Perform a thorough pain assessment. Explain that antidepressants are not indicated for the client. Ask the client whether she is planning to hurt herself. Educate the client that depression is expected.

Correct response: Perform a thorough pain assessment. Explanation: An effective combined approach to clinical depression includes relief of physical symptoms such as pain. Clinical depression should not be accepted as an inevitable consequence of dying. Researchers have linked the psychological effects of cancer pain to suicidal thought and, less frequently, to carrying out a planned suicide. An effective combined approach to clinical depression includes relief of physical symptoms and pharmacologic intervention with tricyclic antidepressants.

A client with a brain tumor recently stopped radiation and chemotherapy for treatment of the cancer. The client recently reported dry mouth. Which intervention by the hospice nurse demonstrates that the nurse understands treatment measures for dry mouth? Begin 9% normal saline IV at 125 mL/hr. Place two drops of atropine ophthalmic 1% solution sublingually. Gently suction the client's mouth and buccal cavity. Provide gentle oral care after each meal.

Correct response: Provide gentle oral care after each meal. Explanation: Dry mouth can generally be managed through nursing measures such as mouth care. The use of artificial hydration (IV fluids) carries considerable risks and does not contribute to comfort at the end of life. Atropine ophthalmic 1% drops administered sublingually help to reduce oral secretions. Gentle oral suctioning reduces the production of secretions.