Chapter 3
As a staff member in a local hospice, a nurse deals with death and dying on a frequent basis. Where would be the safe venue for the nurse to express her feelings of frustration and grief about a patient who has recently died? A) In the cafeteria B) At a staff meeting C) At a social gathering D) At a memorial service
B) At a staff meeting In hospice settings, where death, grief, and loss are expected outcomes of patient care, interdisciplinary colleagues rely on each other for support, using meeting time to express frustration, sadness, anger, and other emotions; to learn coping skills from each other; and to speak about how they were affected by the lives of those patients who have died since the last meeting. Public settings are inappropriate places to express frustration about the death of a patient.
The nurse is assessing a 73-year-old patient who was diagnosed with metastatic prostate cancer. The nurse notes that the patient is exhibiting signs of loss, grief, and intense sadness. Based on this assessment data, the nurse will document that the patient is most likely in what stage of death and dying? A) Depression B) Denial C) Anger D) Resignation
A) Depression 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.
TEST 1) Patients who are enrolled in hospice care through Medicare are often felt 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 patient B) Rules concerning completion of all cure-focused medical treatment C) Unwillingness of patients and families to acknowledge the patient is terminal D) Lack of knowledge of patients and families regarding availability of care
B) Rules concerning completion of all cure-focused medical treatment Because of Medicare rules concerning completion of all cure-focused medical treatment before the Medicare hospice benefit may be accessed, many patients delay enrollment in hospice programs until very close to the end of life. Hospice care does not include an unwillingness to medicate the patient to keep him or her from suffering. Patients must accept that they are terminal before being admitted to hospice care. Lack of knowledge is common; however, this is not why some Medicare patients do not receive adequate attention for the symptoms of their underlying illness.
A 66-year-old patient is in a hospice receiving palliative care for lung cancer which has metastasized to the patient's liver and bones. For the past several hours, the patient has been experiencing dyspnea. What nursing action is most appropriate to help to relive the dyspnea the patient is experiencing? A) Administer a bolus of normal saline, as ordered. B) Initiate high-flow oxygen therapy. C) Administer high doses of opioids. D) Administer bronchodilators and corticosteroids, as ordered.
D) Administer bronchodilators and corticosteroids, as ordered. Bronchodilators and corticosteroids help to improve lung function as well as low doses of opioids. Low-flow oxygen often provides psychological comfort to the patient and family. A fluid bolus is unlikely to be of benefit.
A patient tells the nurse that her doctor just told her that her new diagnosis of rheumatoid arthritis is considered to be a "chronic condition." She asks the nurse what "chronic condition" means. What would be the nurse's best response? Select one: A. "Chronic conditions are defined as health problems that require management of several months or longer." B. "Chronic conditions are medical conditions that culminate in disabilities that require hospitalization." C. "Chronic conditions are those that require short-term management in extended-care facilities." D. "Chronic conditions are diseases that come and go in a relatively predictable cycle."
A. "Chronic conditions are defined as health problems that require management of several months or longer." Feedback: Chronic conditions are often defined as medical conditions or health problems with associated symptoms or disabilities that require long-term management (3 months or longer). This makes option C incorrect. Option B is a correct answer, but it is not the best answer to the patient. Option D is incorrect because They are not always cyclical or predictable.
A patient has just been told that her illness is terminal. The patient tearfully states, "I can't believe I am going to die. Why me?" What is your best response? A) "I know how you are feeling." B) "You have lived a long life." C) "This must be very difficult for you." D) "Life can be so unfair."
C) "This must be very difficult for you." Feedback: The most important intervention the nurse can provide is listening empathetically. To communicate effectively, the nurse should ask open-ended questions and acknowledge the patient's fears. Deflecting the statement or providing false sympathy must be avoided.
A hospice nurse is caring for a 22-year-old with a terminal diagnosis of leukemia. When updating this patient'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 patient's death
C) Providing realistic emotional preparation for death 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.
A patient with end-stage lung cancer has been admitted to hospice care. The hospice team is meeting with the patient and her family to establish goals for care. What is likely to be a first priority in goal setting for the patient? Select one: A. Promotion of spirituality B. Maintenance of activities of daily living C. Social interaction D. Pain control
D. Pain control Once the phase of illness has been identified for a specific patient, along with the specific medical problems and related social and psychological problems, the nurse helps prioritize problems and establish the goals of care. Identification of goals must be a collaborative effort, with the patient, family, and nurse working together, and the goals must be consistent with the abilities, desires, motivations, and resources of those involved. Pain control is essential for patients who have a terminal illness. If pain control is not achieved, all activities of daily living are unattainable. This is thus a priority in planning care over the other listed goals.
You are caring for a 50-year-old man diagnosed with multiple myeloma; he has just been told by the care team that his prognosis is poor. He is tearful and trying to express his feelings, but he is having difficulty. What should you do first? A) Ask if he would like you to sit with him while he collects his thoughts. B) Tell him that you will leave for now but will be back shortly. C) Offer to call pastoral care or a member of his chosen clergy. D) Reassure him that you can understand how he is feeling.
A) Ask if he would like you to sit with him while he collects his thoughts. The most important intervention the nurse can provide is listening empathetically. Seriously ill patients and their families need time and support to cope with the changes brought about by serious illness and the prospect of impending death. The nurse who is able to listen without judging and without trying to solve the patient's and family's problems provides an invaluable intervention. The patient needs to feel that people are concerned with his situation. Leaving him does not show acceptance of his feelings. Offering to call pastoral care may be helpful for some patients, but should be done after you have spent time with the patient. Telling the patient that you understand how he is feeling is inappropriate because it does not help him express his feelings.
test 1) The nurse is caring for a patient who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the patient'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 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 patient will not be able to swallow secretions, so suctioning, frequent and gentle mouth care, and, possibly, the administration of a transdermal anticholinergic drug. Bowel incontinence may or may not occur.
A medical nurse is providing end-of-life care for a patient with metastatic bone cancer. The nurse notes that the patient has been receiving oral analgesics for her pain with adequate effect, but is now having difficulty swallowing the medication. What should the nurse do? A) Request the physician to order analgesics by an alternative route. B) Crush the medication in order to aid swallowing and absorption. C) Administer the patient's medication with the meal tray. D) Administer the medication rectally.
A) Request the physician to order analgesics by an alternative route. A change in medication route is indicated and must be made by a physician's order. Many pain medications cannot be crushed and given to a patient. 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.
An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? A) The patient 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 patients should die in the hospital whenever possible.
A) The patient and family should be viewed as a single unit of care. Feedback: Hospice care requires that the patient and family be viewed as a single unit of care. The other listed principles are wholly inconsistent with the principles of hospice care.
The nurse is caring for a patient who has been recently diagnosed with late stage pancreatic cancer. The patient refuses to accept the diagnosis and refuses to adhere to treatment. What is the most likely psychosocial purpose of this patient's strategy? A) The patient may be trying to protect loved ones from the emotional effects of the illness. B) The patient is being noncompliant in order to assert power over caregivers. C) The patient may be skeptical of the benefits of the Western biomedical model of health. D) The patient thinks that treatment does not provide him comfort.
A) The patient may be trying to protect loved ones from the emotional effects of the illness. Feedback: Patients who are characterized as being in denial may be using this strategy to preserve important interpersonal relationships, to protect others from the emotional effects of their illness, and to protect themselves because of fears of abandonment. Each of the other listed options is plausible, but less likely.
A patient who is receiving care for osteosarcoma has been experiencing severe pain since being diagnosed. As a result, the patient has been receiving analgesics on both a scheduled and PRN basis. For the past several hours, however, the patient's level of consciousness has declined and she is now unresponsive. How should the patient's pain control regimen be affected? A) The patient's pain control regimen should be continued. B) The pain control regimen should be placed on hold until the patient's level of consciousness improves. C) IV analgesics should be withheld and replaced with transdermal analgesics. D) The patient's analgesic dosages should be reduced by approximately one half.
A) The patient's pain control regimen should be continued. Pain should be aggressively treated, even if dying patients become unable to verbally report their pain. There is no need to forego the IV route. There is no specific need to discontinue the pain control regiment or to reduce it.
TEST 1) The nurse is part of the health care team at an oncology center. A patient has been diagnosed with leukemia and the prognosis is poor, but the patient is not yet aware of the prognosis. How can the bad news best be conveyed to the patient? A) Family should be given the prognosis first. B) The prognosis should be delivered with the patient at eye level. C) The physician should deliver the news to the patient alone. D) The appointment should be scheduled at the end of the day.
B) The prognosis should be delivered with the patient at eye level. Feedback: Communicating about a life-threatening diagnosis should be done in a team setting at eye level with the patient. The family cannot be notified first because that would breech patient confidentiality. The family may be present at the patient's request. The appointment should be scheduled when principles can all be in attendance and unrushed.
A patient's rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this patient'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 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 patients 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 patients and families have even while the patient is actively dying.
A nurse is caring for an 87-year-old Mexican-American female patient who is in end-stage renal disease. The physician has just been in to see the patient and her family to tell them that nothing more can be done for the patient and that death is not far. The physician offers to discharge the patient home to hospice care, but the patient and family refuse. After the physician leaves, the patient's daughter approaches you and asks what hospice care is. What would this lack of knowledge about hospice care be perceived as? A) Lack of an American education of the patient and her family B) A language barrier to hospice care for this patient C) A barrier to hospice care for this patient D) Inability to grasp American concepts of health care
C) A barrier to hospice care for this patient 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. The scenario does not indicate whether the patient's family has an American education, whether they are unable to grasp American concepts of health care, or whether they can speak or understand English.
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) Excessive weight gain C) Emotional exhaustion D) Social withdrawal
C) Emotional exhaustion 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 weight gain, though these may signal emotional exhaustion.
A patient with end-stage heart failure has participated in a family meeting with the interdisciplinary team and opted for hospice care. On what belief should the patient's care in this setting be based? A) Meaningful living during terminal illness requires technologic interventions. B) Meaningful living during terminal illness is best supported in designated facilities. C) Meaningful living during terminal illness is best supported in the home. D) Meaningful living during terminal illness is best achieved by prolonging physiologic dying.
C) Meaningful living during terminal illness is best supported in the home. The hospice movement in the United States is based on the belief that meaningful living is achievable during terminal illness and that it is best supported in the home, free from technologic interventions to prolong physiologic dying.
One of the functions of nursing care of the terminally ill is to support the patient and his or her family as they come to terms with the diagnosis and progression of the disease process. How should nurses support patients 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 patient and family to "keep fighting" as a cure may come. C) Try to appreciate and understand the illness from the patient's perspective. D) Assist patients with performing a life review. E) Provide interventions that facilitate end-of-life closure.
C) Try to appreciate and understand the illness from the patient's perspective. D) Assist patients with performing a life review. E) Provide interventions that facilitate end-of-life closure. Nurses are responsible for educating patients about their illness and for supporting them as they adapt to life with the illness. Nurses can assist patients 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 patient's perspective. The nurse's personal experiences should not normally be included and a cure is often not a realistic hope.
TEST 1) The nurse has observed that an older adult patient with a diagnosis of end-stage renal failure seems to prefer to have his eldest son make all of his health care decisions. While the family is visiting, the patient explains to you that this is a cultural practice and very important to him. How should you respond? A) Privately ask the son to allow the patient to make his own health care decisions. B) Explain to the patient that he is responsible for his own decisions. C) Work with the team to negotiate informed consent. D) Avoid divulging information to the eldest son.
C) Work with the team to negotiate informed consent. FEEDBACK: In this case of a patient who wishes to defer decisions to his son, the nurse can work with the team to negotiate informed consent, respecting the patient's right not to participate in decision making and honoring his family's cultural practices.
A 37-year-old woman with multiple sclerosis is married and has three children. The nurse has worked extensively with the woman and her family to plan appropriate care. What is the nurse's most important role with this patient? A) Ensure the patient adheres to all treatments B) Provide the patient with advice on alternative treatment options C) Provide a detailed plan of activities of daily living (ADLs) for the patient D) Help the patient develop strategies to implement treatment regimens
D) Help the patient develop strategies to implement treatment regimens Feedback: The most important role of the nurse working with patients with chronic illness is to help patients develop the strategies needed to implement their treatment regimens and carry out activities of daily living. The nurse cannot ensure the patient adheres to all treatments. Providing information of treatment options is not the nurse's most important role. The nurse does not provide the patient with a detailed plan of ADLs, though promotion of ADLs is a priority.
The nurse is admitting a 52-year-old father of four into hospice care. The patient has a diagnosis of Parkinson's disease, which is progressing rapidly. The patient has made clear his preference to receive care at home. What interventions should the nurse prioritize in the plan of care? A) Aggressively continuing to fight the disease process B) Moving the patient to a long-term care facility when it becomes necessary C) Including the children in planning their father's care D) Supporting the patient's and family's values and choices
D) Supporting the patient's and family's values and choices Nurses need to develop skill and comfort in assessing patients' 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 patient must have come to terms with the fact that he is dying. The scenario states that the patient wants to be cared for at home, not in a long-term setting. The children may be able to participate in their father's care, but they should not be assigned responsibility for planning it.
The hospice nurse is caring for a 45-year-old mother of three young children in the patient's home. During the most recent visit, the nurse has observed that the patient has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. What goal of nursing interventions should the nurse identify? A) Helping the family to understand why the patient needs to be sedated B) Making arrangements to promptly move the patient to an acute-care facility C) Explaining to the family that death is near and the patient needs around-the-clock nursing care D) Teaching family members how to interact with, and ensure safety for, the patient with impaired cognition
D) Teaching family members how to interact with, and ensure safety for, the patient with impaired cognition Nursing interventions should be aimed at accommodating the change in the patient's status and maintaining her safety. The scenario does not indicate the need either to sedate the patient or to move her to an acute-care facility. If the family has the resources, there is no need to bring in nurses to be with the patient around-the-clock, and the scenario does not indicate that death is imminent.
