Ch. 13 Med-Surg: Palliative and End-of-Life Care

17. The nurse is assessing a 73-year-old client who was diagnosed with metastatic prostate cancer. The nurse notes that the client is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the client is most likely in what stage of death and dying? A. Depression B. Denial C. Anger D. Resignation

A. Depression Rationale: Loss, grief, and intense sadness indicate depression. Denial is indicated by the refusal to admit the truth or reality. Anger is indicated by rage and resentment. Acceptance is indicated by a gradual, peaceful withdrawal from life. P 381

The nurse is caring for a client who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the client's death is imminent? A. Mottling of the lower limbs B. Slow, steady pulse C. Bowel incontinence D. Increased swallowing

A. Mottling of the lower limbs Rationale: The time of death is generally preceded by a period of gradual diminishment of bodily functions in which increasing intervals between respirations, weakened and irregular pulse, and skin color changes or mottling may be observed. The client will not be able to swallow secretions, so suctioning, frequent and gentle mouth care, and possibly the administration of a transdermal anticholinergic drug are appropriate actions. Bowel incontinence may or may not occur. P 377

24. A nurse who provides care on an acute medical unit has observed that health care providers are frequently reluctant to refer clients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply. A. Financial pressures on health care providers B. Client reluctance to accept this type of care C. Strong association of hospice care with prolonging death D. Advances in "curative" treatment in late-stage illness E. Ease of making a terminal diagnosis

A B D A. Financial pressures on health care providers B. Client reluctance to accept this type of care D. Advances in "curative" treatment in late-stage illness Rationale: Health care providers are reluctant to refer clients to hospice, and clients are reluctant to accept this form of care. Reasons include the difficulties in making a terminal prognosis (especially for those clients with noncancer diagnoses), the strong association of hospice with death, advances in "curative" treatment options in late-stage illness, and financial pressures on health care providers that may cause them to retain rather than refer hospice-eligible clients. P 373

18. A nurse on a medical unit in the hospital often provides palliative care to clients with a variety of diagnoses. Which activities describe the primary palliative care functions of this nurse? Select all that apply. A. Provides assessment of symptoms B. Manages basic nursing problems C. Handles difficult conversations with clients D. Uses therapeutic communication skills with clients E. Identifies multifactorial symptoms

A B D A. Provides assessment of symptoms B. Manages basic nursing problems D. Uses therapeutic communication skills with clients Rationale: A primary palliative care nurse uses fundamental nursing skills to care for clients in palliative care, such as basic assessment of symptoms, management of basic care, and use of therapeutic communication skills. A nurse who is a specialist in palliative care assesses and manages complex and multifactorial symptoms and engages in difficult end-of-life conversations with clients and families. P 369

The nurse is describing palliative care and hospice services to a client with end-stage congestive heart failure. The client and family have many questions about the differences between palliative care and hospice. Which statement should the nurse provide the family? A. "Hospice is the application of palliative care at the end of life." B. "Palliative care requires hospitalization." C. "Hospice occurs in a facility with specially trained staff." D. "Curative care can continue in hospice."

A. "Hospice is the application of palliative care at the end of life." Rationale: Palliative care focuses on symptom management and quality of life in clients with serious symptoms and life-limiting diseases. Hospice is a type of palliative care that focuses on comfort at the end of life. Palliative care can take place in a number of settings; it does not need to take place in the inpatient hospital setting. Hospice care may also occur in a variety of settings, or it can take place in a client's home without the need for a special facility. The client in hospice care is no longer receiving curative treatment. P 372

A nurse who sits on the hospital's ethics committee is reviewing a complex case that has many of the characteristics of assisted suicide. Which of the following would be an example of assisted suicide? A. Administering a lethal dose of medication to a client whose death is imminent B. Administering a morphine infusion without assessing for respiratory depression C. Granting a client's request not to initiate enteral feeding when the client is unable to eat D. Neglecting to resuscitate a client with a "do not resuscitate" order

A. Administering a lethal dose of medication to a client whose death is imminent Rationale: Assisted suicide refers to providing another person the means to end his or her own life. This is not to be confused with the ethically and legally supported practices of withholding or withdrawing medical treatment in accordance with the wishes of the terminally ill individual. The other listed options do not fit this accepted definition of assisted suicide. P 387

25. A client with end-stage kidney disease who immigrated to the United States several years ago is receiving care from family at home. When discussing the option of hospice care with a health care provider, the client and family explain through an interpreter that they do not want hospice care. Which factors are potential barriers to care for this client and family? Select all that apply. A. Lack of an understanding of hospice care B. A language barrier C. Mistrust of the health care system D. Wanting to care for the client at home E. Uncertainty about how long the client will live

A. Lack of an understanding of hospice care B. A language barrier C. Mistrust of the health care system Rationale: Historical mistrust of the health care system and unequal access to even basic medical care may underlie the beliefs and attitudes among ethnically diverse populations. In addition, lack of education or knowledge about end-of-life care treatment options and language barriers influence decisions among many socioeconomically disadvantaged groups. Because the goal of hospice is to enable the client to be at home, the family wanting to care for the client at home is not a barrier. Uncertainty about the time until death in a client in the end stages of a terminal disease is not a barrier to a client entering hospice. P 382

A client on the medical unit is dying and the nurse has determined that the family's psychosocial needs during the dying process need to be addressed. What is a cause of many client care dilemmas at the end of life? A. Poor communication between the family and the care team B. Denial of imminent death on the part of the family or the client C. Limited visitation opportunities for friends and family D. Conflict between family members

A. Poor communication between the family and the care team Rationale: Many dilemmas in client care at the end of life are related to poor communication between team members and the client and family, as well as to failure of team members to communicate with each other effectively. Regardless of the care setting, the nurse can ensure a proactive approach to the psychosocial care of the client and family. Denial of death may be a response to the situation, but it is not classified as a need. Visitation should accommodate wishes of the family member as long as client care is not compromised. P 369

3. The nurse is assessing a client whose spouse died 16 months ago. The client tells the nurse about joining a hiking group, volunteering as a college mentor, and thinking about dating again. The nurse determines that the client is in which stage of Rando's processes of mourning? A. Reinvestment B. Recognition of the loss C. Recollection and reexperiencing the deceased D. Relinquishing old attachments to the deceased

A. Reinvestment Rationale: Rando identified six processes of mourning that involve the detachment from ties that bind the mourner to the deceased and learning to live in a world without the deceased. By engaging in new activities and forming emotional attachments to new people, the client is reinvesting in a life without the spouse. Recognizing the loss refers to acknowledging the death of the spouse. Recollection and reexperiencing involve reviewing and reminiscing about the deceased spouse and the relationship. Relinquishing old attachments to the spouse involves letting go of the attachment to an old way of life. P 385

The family of a client receiving palliative care for end-stage congestive heart failure is upset that the client is not eating. Which intervention should the nurse recommend to the family? A. Remove unpleasant odors and sights during meals. B. Withhold antiemetics prior to a meal. C. Coax and cajole the client to eat more. D. Weigh the client daily to assess for weight gain.

A. Remove unpleasant odors and sights during meals. Rationale: To make food more palatable, the nurse should teach the family to remove any unpleasant odors (such as trash cans) and unpleasant sights (such as a bedpan) from the eating area. If the client is nauseated, administering antiemetics may help the client feel better and improve appetite. The nurse should also teach the family not to pressure the client to eat, because a lack of appetite is normal at the end of life. There is no need to weigh the client daily because weight gain is not a goal of palliative care. P 380

13.A medical nurse is providing end-of-life care for a client with metastatic bone cancer. The nurse notes that the client has been receiving oral analgesics for pain with adequate effect, but is now having difficulty swallowing the medication. What should the nurse do? A. Request the health care provider to prescribe analgesics by an alternative route. B. Crush the medication in order to aid swallowing and absorption. C. Administer the client's medication with the meal tray. D. Administer the medication rectally.

A. Request the health care provider to prescribe analgesics by an alternative route. Rationale: A change in medication route is indicated and must be made by a health care provider's prescription. Many pain medications cannot be crushed and given to a client. Giving the medication with a meal is not going to make it any easier to swallow. Rectal administration may or may not be an option. P 378

7.An adult oncology client has a diagnosis of bladder cancer with metastasis and the client has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? A. The client and family should be viewed as a single unit of care. B. Persistent symptoms of terminal illness should not be treated. C. Each member of the interdisciplinary team should develop an individual plan of care. D. Terminally ill clients should die in the hospital whenever possible.

A. The client and family should be viewed as a single unit of care. Rationale: Hospice care requires that the client and family be viewed as a single unit of care. The other listed principles are wholly inconsistent with the principles of hospice care. P 372

6. After caring for several clients who died in the hospital, the nurse has identified some lapses in the care that many of these clients received toward the end of their lives. What have research studies identified as a potential deficiency in the care of the dying in hospital settings? A. The perception that palliative care constitutes "giving up." B. Clients are too sedated to achieve adequate pain control. C. Clients are not given opportunities to communicate with caregivers. D. Clients are ignored by the care team toward the end of life.

A. The perception that palliative care constitutes "giving up." Rationale: One of the principal objections to palliative care is that palliative care is equated with "giving up." Oversedation, lack of communication, and lack of care are not noted to be deficiencies to the same degree. P 389

5. A medical nurse is providing palliative care to a client with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care? A. To improve the client's and family's quality of life B. To support aggressive and innovative treatments for cure C. To provide physical support for the client D. To help the client develop a separate plan with each discipline of the health care team

A. To improve the client's and family's quality of life Rationale: The goal of palliative care is to improve the client's and the family's quality of life. The support should include the client's physical, emotional, and spiritual well-being. Each discipline should contribute to a single care plan that addresses the needs of the client and family. The goal of palliative care is not aggressive support for curing the client. Providing physical support for the client is also not the goal of palliative care. Palliative care does not strive to achieve separate plans of care developed by the client with each discipline of the health care team. P 368

The nurse is assessing a client with end-stage liver failure for the presence of hope. What should the nurse identify as a hope-fostering category? A. Uplifting memories B. Ignoring negative outcomes C. Envisioning one specific outcome D. Avoiding an actual or potential threat

A. Uplifting memories Rationale: Hope is a multidimensional construct that provides comfort as a person endures life threats and personal challenges. Uplifting memories are noted as a hope-fostering category, whereas the other listed options are not identified as such. P 382

The nursing director of a hospice program has observed increasing levels of emotional exhaustion and poor work performance in the nursing staff and believes the staff are suffering from burnout. Which actions can the nursing director take to reduce burnout in the nursing staff? Select all that apply. A. Encourage a work-life balance. B. Support autonomy for nurses in decision-making. C. Assist nurses in identifying personal strengths. D. Mandate personal leave days after a client dies. E. Develop programs to increase nurse resilience.

ANS: A, B, C, E A. Encourage a work-life balance. B. Support autonomy for nurses in decision-making. C. Assist nurses in identifying personal strengths. E. Develop programs to increase nurse resilience. Rationale: Burnout in nursing staff may occur in the hospice setting, where death, grief, and loss are expected outcomes of client care. Burnout leads to emotional exhaustion, cynicism, and ineffectiveness in care. Interventions to reduce burnout include developing a balance between work and personal life, promoting nurse autonomy, identifying personal strengths, and encouraging participation in programs that increase resiliency. Mandating personal leave days does not promote nurse autonomy in decision-making or use of personal judgement. P 389

The nurse is admitting a client to palliative care and notices that the client has health care provider orders for life-sustaining treatment (POLST). Which concepts regarding POLST will the nurse use to develop a plan of care for this client? Select all that apply. A. It can be used in any health care setting. B. It names the durable power of health care attorney. C. It specifies preferences for artificial nutrition and hydration. D. It expresses the client's wishes toward cardiopulmonary resuscitation (CPR). E. It specifies the client's preferences for funeral arrangements.

ANS: A, C, D A. It can be used in any health care setting. C. It specifies preferences for artificial nutrition and hydration. D. It expresses the client's wishes toward. Rationale: POLST is a form that translates client's preferences expressed in advance directives into medical orders that are transferable across settings. The POLST form specifies client preferences related to CPR, intubation, artificial nutrition and hydration, antibiotics, and other medical interventions. The durable power of attorney for health care is a legal document authorizing another individual to make medical decisions on behalf of the client when the client is no longer able to make these decisions and is not specified on the POLST form. POLST does not specify a client's wishes for funeral arrangements. P 376

30. A client experienced the death of a spouse from a sudden myocardial infarction 5 weeks ago. The nurse recognizes that the client will be going through the process of mourning for an extended period of time. What process(es) of mourning will allow the client to accommodate the loss in a healthy way? Select all that apply. A. Reiterating the client's anger at the spouse's care team B. Reinvesting in new relationships at the appropriate time C. Reminiscing about the relationship the client had with her spouse D. Relinquishing old attachments to the spouse at the appropriate time E. Renewing lifelong commitments to the spouse

B C D B. Reinvesting in new relationships at the appropriate time C. Reminiscing about the relationship the client had with her spouse D. Relinquishing old attachments to the spouse at the appropriate time Rationale: Six key processes of mourning allow people to accommodate to the loss in a healthy way: (1) Recognition of the loss; (2) Reaction to the separation, and experiencing and expressing the pain of the loss; (3) Recollection and re-experiencing the deceased, the relationship, and the associated feelings; (4) Relinquishing old attachments to the deceased; (5) Readjustment to adapt to the new world without forgetting the old; (6) Reinvestment, as reiterating anger and renewing a lifelong commitment may be counterproductive to the mourning process. P 385

20. The nurse is admitting a client with a diagnosis of ovarian cancer. The client has just been told that her ovarian cancer is terminal. What question should the nurse include in a spiritual assessment of the client? A. "Can you tell your family about negative test results?" B. "Do you have a sense of peace of mind and a purpose to your life?" C. "Can you let go of her spouse so the spouse can start a new life?" D. "Do you need time and space to bargain with God for a cure?"

B. "Do you have a sense of peace of mind and a purpose to your life?" Rationale: In addition to assessment of the role of religious faith and practices, important religious rituals, and connection to a religious community, the nurse should further explore with the client the presence or absence of a sense of peace of mind and purpose in life; other sources of meaning, hope, and comfort; and spiritual or religious beliefs about illness, medical treatment, and care of the sick. Telling the client's family and letting her spouse move on are not parts of a spiritual assessment. Bargaining is a stage of death and dying, not part of a spiritual assessment. P 383

The nurse is caring for a client who is having difficulty adjusting to a terminal diagnosis. The nurse notes the client's tears and sits down by the bedside. The client tells the nurse, "There are so many things I still want to accomplish." Which response would be most therapeutic and appropriate for the nurse to make? A. "Can I give you some advice?" B. "Tell me what's most important to you now." C. "Do you want me to call the chaplain?" D. "I have cared for lots of clients in your position. It will get easier."

B. "Tell me what's most important to you now." Rationale: Asking the client what is most important at this point in life allows the nurse to learn about the client's values and goals. Giving advice is not a therapeutic response and does not allow the client to talk about what is most important to the client. Asking if the client wants to speak with a chaplain might be appropriate, but it is not a therapeutic response that encourages the client to verbalize concerns and preferences. Giving false reassurances and platitudes also is not therapeutic. P 375

9. The nurse learns that a computed tomography scan a client underwent to investigate new seizure activity revealed a brain tumor. When the client later asks about the results of the scan, which therapeutic response should the nurse give the client? A. "No, I have not seen the report." B. "What is your understanding of your condition?" C. "Yes, but I can't discuss the results with you." D. "Try not to worry; the doctor will be in later to talk with you."

B. "What is your understanding of your condition?" Rationale: By asking what the client knows, the nurse conveys acknowledgement of the client's question and establishes a baseline of knowledge for further discussion. Telling the client that the nurse has not seen the report is not therapeutic or supportive of the client and violates the tenet of veracity. Telling the client that the nurse knows the results but cannot discuss it, while true, is not therapeutic. Telling the client not to worry is dismissive of the client's feelings and is not therapeutic. P 375

31. A client with a terminal diagnosis has asked the nurse about "helping me end my suffering." What is the nurse's responsibility in the domain of assisted suicide? A. Educating the client about the moral implications of assisted suicide B. Discussing concerns and fears with the client C. Identifying resources that meet the client's desire to die D. Telling the client the request is not acceptable

B. Discussing concerns and fears with the client Rationale: Although the 2013 position statement by the American Nurses Association titled Euthanasia, Assisted Suicide, and Aid in Dying prohibits nurses from participating in assisted suicide, it encourages nurses to support symptom management, contribute to environments for care that honor client and family wishes, and identify client and family concerns and fears. Discussion of moral implications would normally be beyond the purview of the individual nurse and should be addressed by the interdisciplinary team. Telling the client that the request is not acceptable does not encourage discussions that can help the client have a more peaceful death. It is not the nurse's responsibility to identify resources that meet the client's desire to die. P 387

As the American population ages, nurses expect to see more clients admitted to long-term care facilities in need of palliative care. Regulations now in place that govern how the care in these facilities is both organized and reimbursed emphasize what aspect of care? A. Ongoing acute care B. Restorative measures C. Mobility and socialization D. Incentives to palliative care

B. Restorative measures Rationale: Regulations that govern how care in these facilities is organized and reimbursed tend to emphasize restorative measures and serve as a disincentive to palliative care. Long-term care facilities do not normally provide acute care for their clients. Regulations for long-term care facilities do not primarily emphasize mobility and socialization. P 371

26. Clients who are enrolled in hospice care are often believed to suffer unnecessarily because they do not receive adequate attention for their symptoms of the underlying illness. What factor most contributes to this phenomenon? A. Unwillingness to overmedicate the dying client B. Rules concerning completion of all cure-focused medical treatment C. Unwillingness of clients and families to acknowledge the client is terminal D. Lack of knowledge by clients and families regarding availability of care

B. Rules concerning completion of all cure-focused medical treatment Rationale: Because of rules concerning completion of all cure-focused medical treatment before the Medicare hospice benefit may be accessed, many clients delay enrollment in hospice programs until very close to the end of life. Hospice care does not include an unwillingness to medicate the client to keep him or her from suffering. Clients must accept that they are terminal before being admitted to hospice care. Lack of knowledge is common; however, this is not why some clients do not receive adequate attention for the symptoms of their underlying illness. P 373

A client's rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this client's care, the nurse should identify what primary aim? A. To prioritize emotional needs B. To prevent and relieve suffering C. To bridge between curative care and hospice care D. To provide care while there is still hope

B. To prevent and relieve suffering. Rationale: Palliative care, which is conceptually broader than hospice care, is both an approach to care and a structured system for care delivery that aims to prevent and relieve suffering and to support the best possible quality of life for clients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care goes beyond simple prioritization of emotional needs; these are always considered and addressed. Palliative care is considered a "bridge," but it is not limited to just hospice care. Hope is something clients and families have even while the client is actively dying. P 368

A client has just died following urosepsis that progressed to septic shock. The client's spouse says, "I knew this was coming, but I feel so numb and hollow inside." The nurse should know that these statements are characteristic of what phase? A. Complicated grief and mourning B. Uncomplicated grief and mourning C. Depression stage of dying D. Acceptance stage of dying

B. Uncomplicated grief and mourning Rationale: Uncomplicated grief and mourning are characterized by emotional feelings of sadness, anger, guilt, and numbness; physical sensations, such as hollowness in the stomach and tightness in the chest, weakness, and lack of energy; cognitions that include preoccupation with the loss and a sense of the deceased as still present; and behaviors such as crying, visiting places that are reminders of the deceased, social withdrawal, and restless overactivity. Complicated grief and mourning occur at a prolonged time after the death. The spouse's statement does not clearly suggest depression or acceptance. P 384

One of the functions of nursing care of the terminally ill is to support the client and his or her family as they come to terms with the diagnosis and progression of the disease process. How should nurses support clients and their families during this process? Select all that apply. A. Describe their personal experiences in dealing with end-of-life issues. B. Encourage the client and family to "keep fighting" as a cure may come. C. Try to appreciate and understand the illness from the client's perspective. D. Assist clients with performing a life review. E. Provide interventions that facilitate end-of-life closure.

C D E C. Try to appreciate and understand the illness from the client's perspective. D. Assist clients with performing a life review. E. Provide interventions that facilitate end-of-life closure. Rationale: Nurses are responsible for educating clients about their illness and for supporting them as they adapt to life with the illness. Nurses can assist clients and families with life review, values clarification, treatment decision making, and end-of-life closure. The only way to do this effectively is to try to appreciate and understand the illness from the client's perspective. The nurse's personal experiences should not normally be included and a cure is often not a realistic hope. P 377

10. A client with cancer has just been told that the disease is now terminal. The client tearfully states, "I can't believe I am going to die. Why me?" What is the nurse's best response to elicit more information from the client? A. "I know how you are feeling." B. "You have lived a long life; that should bring you peace." C. "Tell me more about how you feel about this news." D. "Life can be so unfair."

C. "Tell me more about how you feel about this news." Rationale: The most important intervention the nurse can provide is listening empathetically. To elicit more information about the client's feelings, the nurse should ask exploratory questions that encourage the client to relate a personal narrative. The other statements deflect, ignore, or offer false sympathy and should be avoided. P 382

36.A hospice nurse is well aware of how difficult it is to deal with others' pain on a daily basis. This nurse should put healthy practices into place to guard against what outcome? A. Inefficiency in the provision of care B. Illness C. Emotional exhaustion D. Social withdrawal

C. Emotional exhaustion Rationale: Well before the nurse exhibits symptoms of stress or burnout, he or she should acknowledge the difficulty of coping with others' pain on a daily basis and put healthy practices in place that guard against emotional exhaustion. Emotional exhaustion is more likely to have deleterious effects than inefficiency, social withdrawal, or illness, though these may signal emotional exhaustion. P 389

The organization of a client's care on the palliative care unit is based on interdisciplinary collaboration. How does interdisciplinary collaboration differ from multidisciplinary practice? A. It is based on the participation of clinicians without a team leader. B. It is based on clinicians of varied backgrounds integrating their separate plans of care. C. It is based on communication and cooperation between disciplines. D. It is based on medical expertise and client preference with the support of nursing.

C. It is based on communication and cooperation between disciplines. Rationale: Interdisciplinary collaboration, which is different from multidisciplinary practice, is based on communication and cooperation among the various disciplines, each member of the team contributing to a single integrated care plan that addresses the needs of the client and family. Multidisciplinary care refers to participation of clinicians with varied backgrounds and skill sets, but without coordination and integration. Interdisciplinary collaboration is not based on client preference and should not prioritize medical expertise over other disciplines. P 368

33. A hospice nurse is caring for a young adult client with a terminal diagnosis of leukemia. When updating this client's plan of nursing care, what should the nurse prioritize? A. Interventions aimed at maximizing quantity of life B. Providing financial advice to pay for care C. Providing realistic emotional preparation for death D. Making suggestions to maximize family social interactions after the client's death

C. Providing realistic emotional preparation for death Rationale: Hospice care focuses on quality of life but, by necessity, it usually includes realistic emotional, social, spiritual, and financial preparation for death. Financial advice and actions aimed at post-death interaction would not be appropriate priorities. P 372

11.The nurse has observed that an older adult client with a diagnosis of end-stage kidney disease seems to prefer to have the client's eldest child make all of the health care decisions. While the family is visiting, the client explains that this is a cultural practice and very important that it occurs. How should the nurse best handle this situation? A. Privately ask the child to allow the client to make the health care decisions. B. Explain to the client that the client is responsible for all decisions. C. Work with the team to negotiate informed consent. D. Avoid divulging information to the eldest child.

C. Work with the team to negotiate informed consent. Rationale: In the case of a client who wishes to defer decisions to his oldest child, the nurse can work with the team to negotiate informed consent, respecting the client's right not to participate in decision making and honoring his family's cultural practices. P 382

Which issue has most often presented challenging ethical issues, especially in the context of palliative care? A. Increased cultural diversity B. Staffing shortages in health care and questions concerning quality of care C. Increased costs of health care coupled with inequalities in access D. Ability of technology to prolong life beyond meaningful quality of life

D. Ability of technology to prolong life beyond meaningful quality of life Rationale: The application of technology to prolong life has raised several ethical issues. The major question is, "Because we can prolong life through increasingly sophisticated technology, does it necessarily follow that we must do so?" The increase in cultural diversity has not raised ethical issues in health care. Similarly, costs and staffing issues are relevant, but not central to the most common ethical issues surrounding palliative care. P 389

A client is in a hospice receiving palliative care for lung cancer which has metastasized to the client's liver and bones. For the past several hours, the client has been experiencing dyspnea. What nursing action is most appropriate? A. Administer a bolus of normal saline, as prescribed. B. Initiate high-flow oxygen therapy. C. Administer high doses of opioids. D. Administer bronchodilators and corticosteroids, as prescribed.

D. Administer bronchodilators and corticosteroids, as prescribed. Rationale: Bronchodilators and corticosteroids help to improve lung function, as do low doses of opioids. Low-flow oxygen often provides psychological comfort to the client and family. A fluid bolus is unlikely to be of benefit. P 378

A pediatric nurse is emotionally distraught by the death of a 9-year-old client who received care on the unit over the course of many admissions spanning several years. What action is the most appropriate response to the nurse's own grief? A. Take time off from work to mourn the death. B. Post mementos of the client on the unit. C. Solicit emotional support from the client's family. D. Attend the client's memorial service.

D. Attend the client's memorial service. Rationale: In many settings, staff members organize or attend memorial services to support families and other caregivers who find comfort in joining each other to remember and celebrate the lives of clients. Taking time off should not be necessary, and posting mementos would be inappropriate. It would be highly inappropriate to solicit emotional support from the client's family during their time of loss. P 390

In recent decades, nursing has moved into the forefront in providing care for the dying. Which phenomenon has most contributed to this increased focus of care of the dying? A. Increased incidence of infections and acute illnesses B. Increased focus of health care providers on disease prevention C. Larger numbers of people dying in hospital settings D. Demographic changes in the population

D. Demographic changes in the population Rationale: The focus on care of the dying has been motivated by the aging of the population, the prevalence of, and publicity surrounding, life-threatening illnesses (e.g., cancer and AIDS), and the increasing likelihood of a prolonged period of chronic illness prior to death. The salience of acute infections, prevention measures, and death in hospital settings are not noted to have had a major influence on this phenomenon. P 368

A nurse has made a referral to a grief support group, knowing that many individuals find these both comforting and beneficial after the death of a loved one. What is the most important positive action that can come from a grief support group? A. Providing a framework for incorporating the old life into the new life B. Normalizing adaptation to a continuation of the old life C. Aiding in adjusting to using old, familiar social skills D. Normalization of feelings and experiences

D. Normalization of feelings and experiences. Rationale: Although many people complete the work of mourning with the informal support of families and friends, many find that talking with others who have had a similar experience, such as in formal support groups, normalizes the feelings and experiences and provides a framework for learning new skills to cope with the loss and create a new life. The other listed options are incorrect because they indicate the need to hold onto the old life and not move on. P 385

28.The nurse is admitting a 52-year-old father of four into hospice care. The client has a diagnosis of Parkinson disease, which is progressing rapidly. The client has made clear his preference to receive care at home. What intervention should the nurse prioritize in the plan of care? A. Aggressively continuing to fight the disease process B. Moving the client to a long-term care facility when it becomes necessary C. Including the children in planning their father's care D. Supporting the client's and family's values and choices

D. Supporting the client's and family's values and choices Rationale: Nurses need to develop skill and comfort in assessing clients' and families' responses to serious illness and planning interventions that support their values and choices throughout the continuum of care. To be admitted to hospice care, the client must have come to terms with the fact that he is dying. The scenario states that the client wants to be cared for at home, not in a long-term care setting. The children may be able to participate in their father's care, but they should not be assigned responsibility for planning it. P 374

The hospice nurse is caring for a 45-year-old parent of three young children in the client's home. During the most recent visit, the nurse has observed that the client has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. Which goal of nursing interventions should the nurse identify? A. Helping the family to understand why the client needs to be sedated B. Making arrangements to promptly move the client to an acute-care facility C. Explaining to the family that death is near and the client needs around-the-clock nursing care D. Teaching family members how to interact with, and ensure safety for, the client with impaired cognition

D. Teaching family members how to interact with, and ensure safety for, the client with impaired cognition Rationale: Nursing interventions should be aimed at accommodating the change in the client's status and maintaining client safety. The scenario does not indicate the need either to sedate the client or to move the client to an acute-care facility. If the family has the resources, there is no need to bring in nurses to be with the client around-the-clock, and the scenario does not indicate that death is imminent. P 373

A client with cancer, who has just learned that the cancer has spread to distant organs, tells the nurse, "I am not sure how many more treatments I can put up with." The nurse responds by saying, "You have been through so many treatments for your cancer." Using the NURSE framework for responding to emotions, which empathic response did the nurse use? A. NAME the emotion B. SUPPORT the client C. EXPLORE the emotion. D. UNDERSTAND the emotion.

D. UNDERSTAND the emotion. Rationale: The NURSE framework provides a structure for nurses to use when responding to client's emotions. The response of "You have been through so many treatments for your cancer" represents the empathic response of UNDERSTAND the emotion. An example of NAME the emotion would be the nurse saying, "It sounds like you are worried." An example of SUPPORT the client includes, "I will be by your side through more treatments." An example of EXPLORE the emotion might be, "Tell me what's bothering you." P 375