Chapter 7 End of Life Care

1. Which are direct causes of death? (Select all that apply.) a. GI bleeding b. Heart failure c. Respiratory failure d. Shock e. Kidney failure

b, c, d

Question 7 of 26 A nurse who is skilled in complementary and alternative medicine (CAM) therapies works on a cancer unit with clients who are terminally ill. For which client symptom does the nurse use these therapies? a. Constipation b. Cool extremities c. Increased pain d. Memory loss

c Increased pain CAM can help relieve pain and agitation, minimizing the need for increased opioids. CAM is not typically used for constipation or to deal with cool extremities. Memory loss is not a symptom that should receive priority in the dying client.

p. 95, Patient-Centered Care A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me." 4. What symptoms of distress do you anticipate?

Given that she has CHF, she will likely experience severe dyspnea and fatigue that will worsen over time.

3. Which statement regarding the approach to hospice/end-of-life care is correct? a. Hospice programs only include provision of care in the home. b. Admission to hospice is involuntary and directed by a health care provider's order. c. The focus is on facilitating quality of life just for the dying patient. d. An interdisciplinary team approach is used for the care of the patient and family.

d

Question 19 of 26 A client with terminal lung cancer is receiving hospice care at home. Which nursing action does the RN manager ask the LPN/LVN to do? a. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. b. Clarify family members' feelings about the meaning of client behaviors and symptoms. c. Develop a plan for care after assessing the needs and feelings of both the client and the family. d. Teach the family to recognize signs of client discomfort such as restlessness or grimacing.

a Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client is appropriate to delegate to the LPN/LVN. Clarifying family members' feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level.

Question 3 of 26 A client diagnosed with lung cancer 6 months ago is now ventilator-dependent and unresponsive. The family wants to remove the ventilator and stop antibiotics and IV fluids. What does the nurse do next? a. Facilitates a meeting with the family and health care team b. Removes the interventions, per the family's wishes c. Tells the family that removing the interventions is illegal d. Waits to obtain information on the client's wishes

a Facilitates a meeting with the family and health care team Withdrawing or withholding life-sustaining therapy involves discontinuing one or more therapies that might prolong the life of a person who cannot be cured by the therapy. To do this, a meeting is required between the family and the health care team. Withdrawing life support requires more than simply following the family's wishes. Removal of life-sustaining therapy is not illegal except in cases of active euthanasia or physician-assisted euthanasia. The client most likely will not regain consciousness; the client's wishes should have been determined and documented earlier in the course of his or her disease (advance directives, living will, etc.).

Question 25 of 26 In which newly admitted client situations does the nurse initiate a conversation about advance directives? Select all that apply. a. A client with a non-life-threatening illness b. A person who currently has advance directives c. The client with end-stage kidney disease d. The comatose client who was injured in an automobile crash e. The laboring mother expecting her first child

a, b, c, e A client with a non-life-threatening illness, A person who currently has advance directives, The client with end-stage kidney disease, The laboring mother expecting her All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with "healthy" clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with pre-existing advance directives still needs to be questioned; it is possible that the client's wishes have changed since the documents were established. Clients who have potentially life-threatening diseases or conditions should establish advance directives while they are able to do so. The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives.

Question 21 of 26 A client admitted with a non-life-threatening illness says, "I was asked to fill out an advance directive when I was admitted, but I was too stressed. What was it all about?" How does the nurse respond? a. "Advance directives are only for those individuals who are severely ill." b. "Advance directives allow a client to convey his or her wishes about health care ahead of time." c. "Most Americans have an advance directive in place; you will need to see a lawyer." d. "You should have completed the paperwork before you were admitted."

b "Advance directives allow a client to convey his or her wishes about health care ahead of time." Stating that advanced directives allow a client to convey his or her wishes about health care ahead of time is true and best addresses the client's comments. Advance directives should be in place before the client becomes severely ill. Most Americans do not have advance directives in place. Legal assistance is not necessary to complete them. Although completing paperwork pertaining to advance directives before admission would be ideal, any time is a good time to do this.

Question 26 of 26 The daughter of a dying client says, "I don't want my father to be uncomfortable." How does the nurse respond? a. "Do you want to talk to the bereavement nurse?" b. "Your father will be closely monitored and cared for." c. "Your father will be kept sedated." d. "We will send him to hospice when the time comes."

b "Your father will be closely monitored and cared for." Telling the daughter that her father will be closely monitored and cared for provides support and comfort. The daughter's comment does not require the expertise of a bereavement nurse. Also, asking if the daughter wants to talk to a bereavement nurse is a "yes-or-no" question and a nontherapeutic response; it shuts off the dialog. The dying client is not typically kept sedated; clients are kept comfortable with as little or as much pain medication as needed. A goal is to keep him or her alert and able to communicate. Telling the daughter that her father will be sent to hospice when the time comes does not address the daughter's concern about her father's comfort; it closes the dialog.

Question 12 of 26 A dying client is having difficulty swallowing oral medications. Which intervention does the nurse implement for this client? a. Asks the pharmacy to substitute intramuscular (IM) equivalents for the medications b. Asks the provider if the medications can be discontinued or substituted c. Crushes the pills, opens the sustained-release capsules, and mixes them with a spoonful of applesauce d. Does not give the medications and documents: "Unable to swallow"

b Asks the provider if the medications can be discontinued or substituted Since the client is in the dying process, he or she may no longer require some of the medications prescribed, and other routes may be available for medications that will promote comfort. The IM route is almost never used for clients at the end of life because this method is invasive and painful, and can cause infection. Although some pills may be crushed, sustained-release capsules should not be taken apart and their contents administered directly. The client may still need the medications prescribed for comfort; withholding them could cause discomfort throughout the dying process.

Question 15 of 26 The nurse recognizes signs and symptoms of depression in an 80-year-old client who is dying from metastatic breast cancer. What does the nurse do initially for this client? a. Assesses these behaviors as normal steps or stages in the grief process for the client b. Collaborates with the end-of-life (EOL) care team to manage these feelings in the client c. Documents these findings and continues to monitor the client d. Reduces the quantity of depression-causing opioids that are being administered to the client

b Collaborates with the end-of-life (EOL) care team to manage these feelings in the client Behaviors should be assessed and treated with the collaboration of the EOL care team. The nurse may be instrumental in performing a "depression" screening. Feelings of depression—hopelessness, helplessness, unhappiness—are not part of the aging process or the process of dying; they should be aggressively treated. These feelings should not only be documented and monitored, but also should be acknowledged as not a normal part of the dying process and should be treated with psychotherapy or medications or both. Inadequate analgesic pain control is one of the most noted and critical problems, especially in older adults. This scenario would not be a reason for opioid administration to be reduced; such an action is harmful to the client.

Question 18 of 26 A dying client says to the nurse, "I am afraid to die. I did a lot of wrong things in my life." How does the nurse respond? a. "Don't worry, God will forgive you." b. "I'm sure it is nothing to worry about." c. "Tell me more about that." d. "Why? What did you do wrong?"

c "Tell me more about that." A response such as, "Tell me more about that," acknowledges the client's spiritual pain and encourages verbalization. "Don't worry, God will forgive you" assumes that the client is religious and minimizes the client's concerns; it gives false reassurance and is a nontherapeutic response. Saying that it's nothing to worry about minimizes the client's concerns and is a nontherapeutic response; it shuts the client off from expressing his or her concerns. Asking why the client is afraid and what he or she did wrong assumes that the client did something wrong, which may not be the case. "Why" questions are never considered to be therapeutic because they place clients on defense; they often stop communication.

15. The most common treatment of pain in a terminally ill patient is administration of which kind of therapy? a. Opioids b. Steroids c. Nonsteroidal antiinflammatory agents d. Radiation treatments

a

21. Which end-of-life interventions must the nurse be prepared to perform for a dying patient and his or her family? (Select all that apply.) a. Allow the family to verbalize fears and concerns about the impending loss of their loved one. b. Listen and acknowledge the legitimacy of the family's pain. c. Minimize the family's loss by using statements such as "Don't be upset." d. Assist the patient and family with reminiscence or storytelling. e. Work to determine the patient's and family's spiritual needs.

a, b, d, e

14. A hospice patient is deteriorating and the family is concerned about his restlessness and agitation. Which intervention is the nurse prepared to perform? a. Notify the primary health care provider and request orders for transfer to the hospital. b. Determine if the patient is in pain, provide analgesics, and make the patient as comfortable as possible. c. Initiate IV hydration to provide the patient with necessary fluids. d. Encourage the family to assist the patient to eat in order to gain energy.

b

Question 16 of 26 A dying client exhibits signs of agitation. The Foley catheter has drained 100 mL in the last 3 hours, and the client's last bowel movement was yesterday evening. What does the nurse do first? a. Administers an analgesic b. Arranges for a consultation with a bereavement counselor c. Assesses the client for impaction d. Changes the Foley catheter to ensure adequate drainage

a Administers an analgesic Agitation may be indicative of pain, which must be addressed in the dying client. Arranging for a consultation with a counselor is not the priority in this situation. The dying client's metabolism has slowed, so assessing for impaction may not be necessary. The Foley catheter should not be changed, but the tubing should be assessed to ensure that there are no kinks.

A nurse plans care for a client who is nearing end of life. Which question should the nurse ask when developing this client's plan of care? a. "Is your advance directive up to date and notarized?" b. "Do you want to be at home at the end of your life?" c. "Would you like a physical therapist to assist you with range-of-motion activities?" d. "Have your children discussed resuscitation with your health care provider?"

B Rationale: When developing a plan of care for a dying client, consideration should be given for where the client wants to die. Advance directives do not need to be notarized. A physical therapist would not be involved in end-of-life care. The client should discuss resuscitation with the health care provider and children; do-not-resuscitate status should be the client's decision, not the family's decision.

p. 95, Patient-Centered Care A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me." 1. How would you respond to the patient at this time?

You need to teach her about what advance directives are and why everyone needs one. Explain to her what might happen to her without an advance directive if she becomes seriously ill and health decisions are needed.

Question 24 of 26 A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem action does the nurse implement? a. Asks the family if they wish to help wash the client b. Asks the family to leave c. Raises the head of the bed and opens the client's eyes d. Removes dentures and any prosthetics

a Asks the family if they wish to help wash the client The nurse may ask the family if they wish to be involved in washing the client after the client's death. The family should be allowed to grieve at the bedside of the client. The head of the bed should be flat and the client's eyes closed. The client's dentures and prosthetics should be replaced, not removed.

Question 10 of 26 A dying client cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do? a. Assist the family in leaving the room so that they can compose themselves. b. Place the client in a side-lying position so secretions can drain. c. Position the client in a high-Fowler's position to minimize secretions. d. Use a Yankauer suction tip to remove secretions from the client's upper airway.

b Place the client in a side-lying position so secretions can drain. Placing the client in a side-lying position to facilitate draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease. Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler's position is ineffective in helping the client who has lost the ability to swallow; the danger of choking and aspiration would increase. Not only is oropharyngeal suctioning outside the scope of practice of the nursing assistant, it is also not recommended for removal of secretions, because it is not effective and may even agitate the dying client.

13. Which interventions after a patient's death are appropriate to perform? (Select all that apply.) a. Remove the body to the morgue or funeral home immediately after death. b. Follow agency policies to remove all tubes and lines from the body. c. Make sure that the physician has completed and signed the death certificate. d. Provide privacy for the family and significant others with the deceased. e. Allow family and/or significant other to perform religious and cultural customs.

b, c, d, e

Question 6 of 26 Which condition, when assessed in a dying client, requires that the nurse take action? a. Alternating apnea and rapid breathing b. Anorexia c. Cool extremities d. Moaning

d Moaning Moaning indicates pain and requires pain medication. Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the dying client.

10. The terminally ill patient is nearing death. His wife expresses concern that he has no appetite and eats very little. What is the nurse's best response to this concern? a. Teach the patient's wife about the risk of aspiration and explain that loss of appetite is normal when a patient nears death. b. Encourage the patient's wife to feed the patient as much as he will take to maintain adequate nutrition. c. Request that the health care provider order a dietary nutrition consult to include foods that the patient prefers. d. Keep fluids and finger foods at the bedside for easy access whenever the patient is hungry or thirsty.

a

p. 99, Physiological Integrity The nurse is caring for a client who has severe dyspnea because of end-stage chronic obstructive pulmonary disease. Which interventions are the most appropriate to help improve his breathing? Select all that apply. A. Administer morphine sulfate on an around-the-clock schedule. B. Teach the client and family to keep him in a sitting position. C. Use a large electric fan to circulate the air. D. Keep the room temperature warm to prevent respiratory infection. E. Teach the client and family that he should use bronchodilators as prescribed.

Answer: A, B, C, E Rationale: Morphine helps to alleviate the work of breathing and is the first-line treatment for dyspnea near death. Bronchodilators open the airways to help with oxygen flow into and out of the lungs. Sitting the client in an upright position helps increase chest expansion; a fan to circular room air also helps with breathing.

Question 11 of 26 A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? a. Administers nutrition and fluids through a nasogastric tube b. Explains to the family that aspiration may be a concern c. Obtains a physician order to initiate an IV line d. Teaches the family how to provide oral care

d Teaches the family how to provide oral care Because the oral mucosa will become dry, family members should be taught how to moisten the lips and mouth. Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client's suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing.

A nurse is caring for a client who is terminally ill. The client's spouse states, "I am concerned because he does not want to eat." How should the nurse respond? a. "Let him know that food is available if he wants it, but do not insist that he eat." b. "A feeding tube can be placed in the nose to provide important nutrients." c. "Force him to eat even if he does not feel hungry, or he will die sooner." d. "He is getting all the nutrients he needs through his intravenous catheter."

A Rationale: When family members understand that the client is not suffering from hunger and is not "starving to death," they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family.

A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this client's pain management plan? (Select all that apply.) a. Play music that the client enjoys. b. Massage tissue that is tender from radiation therapy. c. Rub lavender lotion on the client's feet. d. Ambulate the client in the hall twice a day. e. Administer intravenous morphine.

A,C Rationale: Complementary therapies for pain management include massage therapy, music therapy, Therapeutic Touch, and aromatherapy. Nurses should not massage over sites of tissue damage from radiation therapy. Ambulation and intravenous morphine are not complementary therapies for pain management.

A nurse cares for a dying client. Which manifestation of dying should the nurse treat first? a. Anorexia b. Pain c. Nausea d. Hair loss

B Rationale: Only symptoms that cause distress for a dying client should be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the client's comfort. Even when symptoms, such as anorexia or hair loss, disturb the family, they should be treated only if the client is distressed by their presence. The nurse should treat the client's pain first.

18. Which statements about pain management in a patient who is dying are true? (Select all that apply.) a. The patient's pain may come from many areas. b. Patients who are dying should discontinue long-acting opioids. c. Alternative therapies have been shown to be useful when integrated into a pain management plan of care. d. When using massage for patients with cancer, deep pressure is the preferred method. e. Aromatherapy, massage, music therapy, and therapeutic touch are a few alternative therapies that have been shown to be useful.

a, c, e

4. A patient receiving nursing care in a home hospice program can expect which kind of care? a. The use of high-technology equipment such as ventilators until time of death. b. Around-the-clock skilled direct nursing patient care until time of death. c. Pain and symptom management that will achieve the best quality of life. d. Complete relief of only distressing physical symptoms.

c

Question 13 of 26 A Christian client is struggling with a diagnosis of cancer and says, "Why is life so unfair?" What health care team member does the nurse ask to provide support? a. Client's family b. Physician c. Hospital chaplain d. Psychiatrist

c Hospital chaplain Chaplains have the time and expertise to manage spiritual distress, no matter what the client's religious preference. The family is not a member of the health care team. Asking the physician to provide support is inappropriate. Asking the psychiatrist for support might make sense, but is not the best answer.

A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question? a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5 b. Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezes c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions d. Sodium biphosphate (Fleet) enema once a day PRN for impacted stool

A Rationale: Pain medications should be scheduled around the clock to maintain comfort and prevent reoccurrence of pain. The other medications are appropriate for this client.

A nurse teaches a client who is considering being admitted to hospice. Which statement should the nurse include in this client's teaching? a. "Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge." b. "Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms." c. "Hospice care will not help with your symptoms of depression. I will refer you to the facility's counseling services instead." d. "You seem to be experiencing some difficulty with this stage of the grieving process. Let's talk about your feelings."

B Rationale: As both a philosophy and a system of care, hospice care uses an interdisciplinary approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client.

The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client's anxiety and restlessness. Which statement made by the family member indicates understanding of the nurse's teaching? a. "Maybe we should just hire an around-the-clock sitter to stay with Grandmother." b. "I have some of her favorite hymns on a CD that I could bring for music therapy." c. "I don't think that she'll need pain medication along with her herbal treatments." d. "I will burn therapeutic incense in the room so we can stop the anxiety pills."

B Rationale: Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a client's inner restlessness. Hiring an around-the-clock sitter does not demonstrate that the client's family understands complementary therapies. Complementary therapies are used in conjunction with traditional therapy. Complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications.

8. Which statements about the assessment of a terminally ill patient are true? (Select all that apply.) a. Assess only the patient; do not include the family's perception of the patient's symptoms. b. When the patient is unable to communicate, there is no need to assess symptoms of distress any longer. c. Assess patients who are unable to communicate distress by observing for objective signs of discomfort. d. Assess the patient for dyspnea, agitation, nausea, and vomiting only. e. Identify alternative methods to assess for symptoms of distress. f. The family can help identify patient habits and preferences, which may aid in the overall assessment.

c, e, f

A client tells the nurse that, even though it has been 4 months since her sister's death, she frequently finds herself crying uncontrollably. How should the nurse respond? a. "Most people move on within a few months. You should see a grief counselor." b. "Whenever you start to cry, distract yourself from thoughts of your sister." c. "You should try not to cry. I'm sure your sister is in a better place now." d. "Your feelings are completely normal and may continue for a long time."

D Rationale: Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the client's response.

A nurse teaches a client's family members about signs and symptoms of approaching death. Which manifestations should the nurse include in this teaching? (Select all that apply.) a. Warm and flushed extremities b. Long periods of insomnia c. Increased respiratory rate d. Decreased appetite e. Congestion and gurgling

D,E Rationale: Common physical signs and symptoms of approaching death including coolness of extremities, increased sleeping, irregular and slowed breathing rate, a decrease in fluid and food intake, congestion and gurgling, incontinence, disorientation, and restlessness.

Question 14 of 26 In a comatose dying client's hospital room, the nurse overhears family discussing the memorial service. What action does the nurse take? a. Asks the family to speak in low tones or whispers so as not to disturb the client b. Offers to call and have a hospital chaplain come and discuss plans with them c. Shares some personal insights and experiences on planning a meaningful memorial service d. Suggests that the family leave the room to carry on their discussion

d Suggests that the family leave the room to carry on their discussion Discussions about the client should not be carried on while the family is in the client's room. Hearing is the last of the senses to leave dying clients, and it is believed that the client can hear even whispers until the end of his or her life. The family needs to have their discussion elsewhere. The chaplain may be helpful to the family, but the discussion still needs to happen outside of the hospital room. It is not at all appropriate for the nurse to interact with the family about planning for a service, especially within hearing range of the client.

A nurse assesses a client who is dying. Which manifestation of a dying client should the nurse assess to determine whether the client is near death? a. Level of consciousness b. Respiratory rate c. Bowel sounds d. Pain level on a 0-to-10 scale

B Rationale: Although all of these assessments should be performed during the dying process, periods of apnea and Cheyne-Strokes respirations indicate death is near. As peripheral circulation decreases, the client's level of consciousness and bowel sounds decrease, and the client would be unable to provide a numeric number on a pain scale. Even with these other symptoms, the nurse should continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near.

A nurse is caring for a dying client. The client's spouse states, "I think he is choking to death." How should the nurse respond? a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your husband comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your husband on his side."

D Rationale: The choking sound or "death rattle" is common in dying clients. The nurse should acknowledge the spouse's concerns and provide interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. The nurse should not minimize the spouse's concerns. Morphine will assist with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not appropriate in a dying client.

Question 20 of 26 The nurse is coordinating interdisciplinary palliative care interventions for the dying client. Which goal is the nurse seeking to meet? a. Avoiding symptoms of client distress b. Ensuring an expedited death c. Meeting all of the client's needs d. Facilitating a peaceful death for the client

d Facilitating a peaceful death for the client Facilitating a peaceful death for the client is one of the goals of palliative care. Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client's needs (e.g., to prevent death or lengthen life).

Question 23 of 26 A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention does the nurse implement? a. Brings in the client's favorite Chinese takeout food b. Calls the family to come in right away c. Gives intravenous hydration d. Offers ice chips

d Offers ice chips The dying client should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth." The dying client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not necessary at this point.

p. 97, Physiological Integrity A client with metastasis to the bone is receiving IV antibiotics for pneumonia but has declined further treatment for his disease. He is experiencing severe back pain rated as a 9 on a 0-to-10 scale. What interventions are the most appropriate for the nurse to implement for this client? Select all that apply. A. Provide both non-opioid and opioid analgesics. B. Offer music therapy to help the client relax and decrease anxiety. C. Obtain an order for physical therapy to encourage ambulation. D. Help the client assume the best position of comfort. E. Offer Reiki therapy, if available.

Answer: A, B, D, E Rationale: The client has a terminal illness that is very painful. Therefore, comfort and relaxation measures only are required at this time. He is likely too weak to walk with severe bone pain.

A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action should the nurse take first? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask family members if they would like to spend time alone with the client. c. Ensure that a death certificate has been completed by the physician. d. Request family members to prepare the client's body for the funeral home.

B Rationale: Before moving the client's body to the funeral home, the nurse should ask family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a death certificate has been completed before the client is moved to the mortuary, the nurse first should ask family members if they would like to be alone with the client. The client's family should not be expected to prepare the body for the funeral home.

p. 95, Patient-Centered Care A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me." 3. Is the patient a candidate for hospice at this time? Why or why not?

The patient likely has Medicare, which will pay for the hospice benefit if needed. However, the patient must be expected to live less than 6 months for this benefit to apply. Her primary care provider would need to make that determination.

p. 95, Patient-Centered Care A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me." 2. What types of referral might you make for her? How would you do this?

You might refer her to a social worker if she is willing to talk with someone about advance directives. Check with your agency to determine how consults or referrals are made.

5. To qualify for hospice benefits, a criterion for admission is that the patient's prognosis must be limited to what amount of time? a. 2 weeks or less b. 3 months or less c. 6 months or less d. 1 year or less

c

6. Which items are relevant to the concept of hospice? (Select all that apply.) a. Unit of care is the patient and family. b. Preferred location is the hospital setting. c. Interdisciplinary team approach is used. d. Focus is on alleviating pain and suffering. e. Hospice care does not hasten death.

a, c, d, e

7. Which characteristics apply to the concept of palliative care? (Select all that apply.) a. Patient must have less than a year to live. b. Care time is not limited to specific periods of time. c. Care focus is curative or may prolong life. d. Care is provided when curative treatments have been stopped. e. Patient can be in any stage of serious illness.

b, c, e

9. Which symptom is most distressing and feared by terminally ill patients? a. Difficulty breathing b. Confusion c. Pain d. Loss of consciousness

c

A hospice nurse is caring for a dying client and her family members. Which interventions should the nurse implement? (Select all that apply.) a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. c. Assist family members by offering an explanation for their loss. d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the client's and the nurse's beliefs may not be congruent.

A,B,D Rationale: The nurse should teach family members about the physical signs of death, because family members often become upset when they see physiologic changes in their loved one. Palliative care includes management of symptoms so that the peaceful death of the client is facilitated. Reminiscence will help both the client and family members cope with the dying process. The nurse is not expected to explain why this is happening to the family's loved one. The nurse can encourage spirituality if the client is agreeable, regardless of whether the client's religion is the same.

A nurse admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply.) a. Can communicate his treatment preferences b. Is able to read and write at an eighth-grade level c. Is oriented enough to understand information provided d. Can evaluate and deliberate information e. Has completed an advance directive

A,C,D Rationale: To have decision-making ability, a person must be able to perform three tasks: receive information (but not necessarily oriented ´ 4); evaluate, deliberate, and mentally manipulate information; and communicate a treatment preference. The client does not have to read or write at a specific level. Education can be provided at the client's level so that he can make the necessary decisions. The client does not need to complete an advance directive to make his own medical decisions. An advance directive will be necessary if he wants to designate someone to make medical decisions when he is unable to.

A nurse discusses inpatient hospice with a client and the client's family. A family member expresses concern that her loved one will receive only custodial care. How should the nurse respond? a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." b. "Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop." c. "A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given." d. "Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility."

A Rationale: Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity.

A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion? a. Roman Catholic - Autopsies are not allowed except under special circumstances. b. Christian - Upon death, a religious leader should perform rituals of bathing and wrapping the body in cloth. c. Judaism - A person who is extremely ill and dying should not be left alone. d. Islam - An ill or dying person should receive the Sacrament of the Sick.

C Rationale: According to Jewish law, a person who is extremely ill or dying should not be left alone. Orthodox Jews do not allow autopsies except under special circumstances. The Islamic faith requires a religious leader to perform rituals of bathing and wrapping the body in cloth upon death. A Catholic priest performs the Sacrament of the Sick for ill or dying people.

After teaching a client about advance directives, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching? a. "An advance directive will keep my children from selling my home when I'm old." b. "An advance directive will be completed as soon as I'm incapacitated and can't think for myself." c. "An advance directive will specify what I want done when I can no longer make decisions about health care." d. "An advance directive will allow me to keep my money out of the reach of my family."

C Rationale: An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client's residence or financial matters.

Question 17 of 26 A client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client? a. Classical music b. Deep muscle massage c. More pain medication d. Short, light massage

d Short, light massage Massage has been shown to decrease pain in individuals with cancer. Light pressure is best, and deep or intense pressure should be avoided. Although music therapy may be effective, the type of music played should be the client's choice; it should not be assumed that the client wants to hear classical music. The dying client who is frail may not tolerate an extensive deep massage. The client is already receiving high doses of opioids; complementary or alternative therapy can replace the need for increased pain medication.

16. Which phrase correctly describes palliative care? a. Care for patients with a prognosis of 6 months or less b. Diagnoses and treatment for patients with a life-threatening illness c. Patient care with a focus on treatment of symptoms d. Patient education about relevant treatment alternatives

c

12. Which intervention should be done when performing postmortem care? a. Place the head of the bed at 30 degrees. b. Remove pillows from under the head. c. Leave a Foley (indwelling) catheter in place in the bladder. d. Place pads under the hips and around the perineum.

d

Question 9 of 26 A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first? a. Albuterol (Proventil) 0.5% solution per nebulizer b. Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed c. Oxygen 2 to 6 L/min per nasal cannula d. Prednisone (Deltasone) elixir 10 mg orally

b Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed Morphine sulfate is the standard treatment for the dyspneic client who is near death. Albuterol (Proventil), oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine.

Question 8 of 26 The family of an unconscious dying client realizes that their mother will die soon. The client's children are having a difficult time letting go. How does the nurse respond to the needs of this family? a. "Don't be upset; she wouldn't want it that way." b. "She will soon be in a better place." c. "Things will be fine, try not to worry so much." d. "This must be difficult for you."

d "This must be difficult for you." Accept whatever the grieving person says about the situation. Remain present, be ready to listen attentively, and guide gently. In this way, the nurse can help the bereaved prepare for the necessary reminiscence and integration of the loss. The client's or family member's pain of loss should never be minimized. Trite assurances such as saying, "Don't be upset; she wouldn't want it that way" or "Things will be fine," should be avoided. Such comments can actually be barriers to demonstrating care and concern. Never try to explain a client's death or impending death in philosophic or religious terms; such statements are not helpful when the bereaved person has yet to express feelings of anguish or anger.

Question 4 of 26 A hospice client has just died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant? a. Assessing the client for cessation of respiratory effort and lack of pulse b. Documenting the time of death and required assessment data on the chart c. Notifying the spouse and other family members about the client's death d. Removing or cutting all IV lines or tubes according to the hospice policy

d Removing or cutting all IV lines or tubes according to the hospice policy Preparing the body for viewing by the family (such as removing tubing and lines) and/or transfer to the morgue is an appropriate task for unlicensed assistive personnel. Assessing for signs of life, documenting about the death, and spousal and family notification all require broader education and should be done by licensed nursing staff.

An intensive care nurse discusses withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. How should the nurse respond? a. "I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia." b. "You will need to talk to the provider because I am not legally allowed to participate in the withdrawal of life support." c. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death." d. "There is no need to worry. Most religious organizations support the client's decision to stop medical treatment."

C Rationale: The nurse should validate the family's concerns and provide accurate information about the discontinuation of therapy. The other statements address specific issues related to the withdrawal of care but do not provide appropriate information about their purpose. If the client's family asks for specific information about euthanasia, legal, or religious issues, the nurse should provide unbiased information about these topics.

p. 95, Patient-Centered Care A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me." 5. How do you feel about the patient wanting rehospitalization for heart failure?

Her desire for rehospitalization should not be judged; however, some health professionals would criticize her for wanting to use acute care for a terminal illness. As nurses, we must respect the patient's decisions, preferences, and values.

Question 2 of 26 A hospitalized client of the Islamic (Muslim) religion is dying. What concept does the nurse share with the health care team about this client's beliefs about death? a. Death is seen as the transition to the other side, with Islam as the vehicle. b. Life experiences do not affect the individual's preparation for "everlasting life." c. The timing of death is under the power of the person who is facing death. d. Plans for burial will take days, maybe even weeks, after the death.

a Death is seen as the transition to the other side, with Islam as the vehicle. In the Muslim faith, Islam is the vehicle that transports the person to the "other side." This is a fundamental belief of the religion. Life is meant to be a test of preparation for everlasting life in the hereafter; life experiences do affect the person's afterlife existence. Muslims believe that God (Allah), rather than the person, has prescribed a time of death for everyone. Preparation for burial takes place as soon as possible after death has occurred.

11. The terminally ill patient who is near death has loud, wet respirations that are disturbing to the family. Which interventions by the nurse are appropriate at this time? (Select all that apply.) a. Position the patient on her side. b. Place a small towel under her mouth. c. Use oropharyngeal suctioning to remove the secretions. d. Administer an ordered anticholinergic drug to dry up the secretions. e. Teach family members how to use the suctioning device whenever needed.

a, b, d

17. While caring for a patient of the orthodox Jewish faith who is dying, what cultural concept should the nurse keep in mind? a. Traditionally, Jewish cultures are male-dominant. b. Expression of grief is open, especially among women. c. An autopsy after death will not be permitted. d. Family members are likely to avoid visiting the terminally ill family member.

c

20. Which action is an example of active euthanasia for a dying patient? a. Removal of a patient from a mechanical ventilator b. Discontinuing intravenous fluids c. Withdrawal of telemetry heart monitoring d. Administering a large dose of intravenous morphine

d

Question 5 of 26 The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? a. A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety b. A 30-year-old with AIDS-associated dementia and agitation who is asking for assistance with calling family members c. A 62-year-old with lung cancer who has cool, clammy, dusky skin and blood pressure of 64/20 mm Hg d. A 70-year-old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations

a A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety Management of discomfort is the priority goal for hospice care, so decreasing this client's pain and anxiety should be the first action. The client with AIDS needs rapid assistance, but is the second priority for the nurse in this scenario. The client with lung cancer and the client with colon cancer are exhibiting normal signs and symptoms associated with dying.

19. Which statement about caring for a patient with dyspnea are true? (Select all that apply.) a. Pharamcologic interventions should begin early in the course of dyspnea. b. Nonpharmacologic, alternative treatments may be used successfully in place of pharmacologic interventions. c. Dyspnea may be caused by the primary diagnosis or its treatments. d. Diagnostic testing must be used to determine the cause of dyspnea before beginning treatment. e. Oropharyngeal suctioning is appropriate for patients with loud, wet respirations nearing death.

a, c

Question 1 of 26 The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life? a. "Do you believe in God?" b. "Tell me about the history of religion in your life." c. "What gives you purpose and meaning in your life?" d. "Where have you been attending church for the past several years?"

c "What gives you purpose and meaning in your life?" Spirituality is whatever or whoever gives ultimate meaning in one's life. It is not necessarily God, but it could be. It could be the client's definition of a higher power. The client may not believe in God and may find an inquiry about believing in God offensive and judgmental. Religion is affiliation or membership in a faith community; its members may be supportive of the client if the client is a member of a religious community, but this is not the best way to determine what the client's spirituality is. Church attendance is one way that some individuals express their religion, but it does not necessarily define a person's spirituality; asking about church could place the client on defense.

Question 22 of 26 The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the nursing assistant to visit? a. Advanced cirrhosis of the liver; called the hospice agency reporting nausea b. Aggressive brain tumor; needs daily assistance with ambulation and bathing c. Inoperable lung cancer; considering whether to have radiation and chemotherapy d. Prostate cancer and bone metastases; has new-onset leg weakness and tingling

b Aggressive brain tumor; needs daily assistance with ambulation and bathing Assisting clients with activities of daily living is a common role for nursing assistants working in home health or hospice agencies. Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions, which are within the RN scope of practice.

2. The terminally ill patient has an advance directive living will, which states that she does not want heroic measures such as cardiopulmonary resuscitation (CPR) and intubation. She also has a do not resuscitate order in her chart written by the provider. As the patient nears death, her daughter tells the hospice nurse that she wants everything possible done to save her mother's life. What is the nurse's best action? a. Call a code and bring the crash cart to the patient's bedside. b. Inform the health care provider of this change in the plan of care. c. Respect the patient's wishes and ask the chaplain to stay with the daughter. d. Inform the daughter that further interventions are futile.

c