ELNEC Palliative Care: Modules 1, 2, 3, 4, 5, and 6

Yolanda has osteoarthritis of the left knee for which she is receiving acetaminophen 1000mg every six hours. She rates her pain at a 4 every time you ask. What do you think an appropriate next step would be at this time?

Ask Yolanda what an acceptable pain score is for her.

Your patient, Mr. W, has been unresponsive for the past day and is actively dying. His family is with him. He had appeared comfortable but has been showing some signs of restlessness and agitation over the past hour. What should you do FIRST?

Assess for evidence of pain, constipation, urinary retention, or other possible physical cause.

Which of the following is an important way nurses can improve palliative care access for those who should receive it?

Being knowledgeable of the benefits of palliative and hospice care

Mr. T's wife tells the nurse she does not want him to take the morphine the doctor ordered for his cancer pain because she heard from a friend that he could stop breathing because of it. What is your BEST response?

Breathing problems are rare when these medications are used as ordered.

Mr. G has been told by the physician that his wife has weeks to live and that they should consider hospice. You have known Mr. and Mrs. G for about 6 months, as she has been in and out of the hospital frequently. Mr. G asks to talk with you because he is upset about this news. What is your BEST initial response?

Can you tell me what is the most upsetting to you right now?

Which of the following demonstrates good self-care when taking care of many patients with serious illness and their families?

Establish healthy eating, sleeping, and exercise habits especially when rotating shifts.

You are caring for a patient who has just died. What should you do to assist the family in understanding what will occur next?

Explain how the body will be cared for immediately following the death.

Which of the following demonstrates the impact serious illness has on the social domain of quality of life?

Financial burdens resulting from the high costs of medical care

Mr. T is nearing end of life and tells you that he has seen his deceased father coming to visit him in his room. What is your BEST action?

Find out from Mr. T how it feels to have his father visiting; is it frightening him?

You are caring for a patient who just had surgery that revealed stage IV ovarian cancer. She does not know her diagnosis. Which action should you take FIRST in preparation for the patient to be told her diagnosis?

Find out how much the patient and family want to know.

You are caring for a veteran who served in World War II and is now near the end of life. He has shared with you how important his service in the Navy was to him. Which of the following interventions would be MOST appropriate for you to do to honor his military service?

Find out if he would like you to see if the local veterans group could visit him.

Which of the following statements reflects the importance of learning about palliative care as a student or new nurse?

Future employers expect you to have education and training in palliative care services.

You have been the pediatric nurse caring for a young boy with a malignant brain tumor who just died on your unit. The parents are in the room with their son and they ask you if you would stay with them. What is your BEST response?

I am here and I will not leave you until you are ready for me to.

You are asking a nursing student to describe the assessment of a patient for dyspnea as part of end-of-life care. Which statement by the student indicates an understanding of the BEST method to assess for dyspnea?

I will ask my patient about their breathing.

You are caring for an older adult who is dying from Parkinson's disease. Her husband died years ago and all of her friends are also now deceased. She has no children or living family members. You are sitting with her and she tells you how lonely she feels. What is your BEST response?

It must feel so lonely with your family and friends no longer with you.

You are providing bereavement support to an 8-year-old child whose father just died on your unit. Which of the following statements would be appropriate for you to use?

Let the child know you wish that his father had not died.

What is the most common adverse effect related to the use of acetaminophen?

Liver dysfunction

Which of the following patients should never be given an opioid medication?

Mrs. Smith who reports developing a rash, hives, and shortness of breath after taking an opioid for dental work

You are caring for Ms. F who is dying from lung cancer. She is no longer taking in food or fluids and the family asks you why the team does not feed her with a tube. They state that the team is trying to starve her to death. What is your BEST response?

Ms. F's body can no longer handle food or fluids; it would cause her more harm than good to feed her with a tube.

What type of pain are antidepressants and anticonvulsants most beneficial for?

Neuropathic pain

You are caring for a 76-year-old patient who is unresponsive and close to end of life from a massive stroke. The patient has a history of breast cancer and had been experiencing severe bone pain in her left hip prior to her stroke. How do you assess her pain now that she is unresponsive?

Pain is a subjective experience and is what the patient reports it is.

You are caring for Ms. P, a 55-year-old woman with cancer. She received pain medication less than two hours ago. A nursing assistant reports that Mrs. P is complaining of pain again. The nursing assistant tells you that Ms. P. cannot be hurting as much as she says she is. What is your most appropriate response?

Pain is whatever the patient says it is. Let's assess her further.

You are developing a plan of care for a patient with cancer-related pain who is taking sustained-release morphine sulfate 30 mg twice a day, along with 15 mg of immediate release morphine sulfate every three hours as needed for breakthrough pain. Which goal is important to include in the patient's plan of care?

Patient will have a bowel movement at least once every three days.

A patient's daughter asks you what she can do to help make her mother, who is dying, more comfortable. The daughter has been sitting at her mother's bedside for the past two days and is feeling helpless. What is your BEST response?

Some patients relax when we give them a gentle foot massage. Would you like me to show you how?

Where is the majority of hospice care delivered?

The Home

You are speaking with the sister of a male patient who died after suffering fatal injuries in a car accident. What is MOST important for you to assess when planning for bereavement follow-up with the family?

The family support system

Which of the following statements is true about serious, chronic illnesses?

The majority of annual U.S. healthcare spending goes toward chronic illnesses.

What should be MOST important in driving decision-making in palliative care?

The patient's goals of care

You are teaching the son of a 65-year-old male patient with cancer about his father's anorexia. Which statement by the son reassures you that the son understands your teaching and ways to help his father?

We can offer Dad small, frequent feedings rather than large, overwhelming meals.

You are doing a spiritual assessment on Mrs. H. Which of the following questions is the MOST important for understanding her spirituality?

What gives your life meaning?

Ms. P is offered hospice care for her end-stage cardiac disease. Which statement by Ms. P. reflects a need for the nurse to provide further education?

Why would I get hospice? I thought hospice is really for patients with cancer.

The parents of a 2-year-old child who is dying from leukemia tell you they are so afraid that they will forget who their child was years after he dies. How can you BEST respond?

Would you like me to call our child life team who can help you with some memory making activities?

Mr. Tate tells you that he is very worried about dying. He knows his disease is terminal and he only has a few months to live. He tells you he has done "some bad things" in his younger days and thinks God is going to make him suffer with pain now because of his past. After listening to his story, what is your BEST response?

Would you like me to contact our chaplain? He's very good at helping people who have concerns like yours.

Mr. S. has stage IV lung cancer and was admitted to your unit yesterday because of shortness of breath. His breathing has improved with treatment and you tell him you are hoping to get to know him better so you can provide the best care possible. Which of the following statements or questions reflects your interest in getting to know him?

Would you tell me about things you like to do?

Mr. Lopez's partner just died and he has been unable to leave her side. He is grieving and tells you he will never be able to get over losing the love of his life. What is your BEST response?

You must have loved her very much; this has to be so hard for you.

Which of the following statements BEST describes hospice care?

Hospice supports the patient and family through the dying process.

Mr. Lopez is the partner of the 50-year-old woman you have been caring for who has just died following a long struggle with breast cancer. He is crying at the bedside and lying across the patient. What is your BEST initial response?

Support his privacy but offer to stay in the room if he would like you to

Mrs. F., a 78-year-old Italian woman, is caring for her husband who has end-stage COPD and is experiencing anorexia and cachexia. She tells you that she is so upset that he will not eat her pasta anymore, which was always his favorite. She cannot understand why he does not like it anymore. Which of the following is your BEST response?

Food is such an important way that we show we care; it must be so hard for you that he doesn't feel like eating.

Ms. H is very ill and her family has been told she will probably die during this hospital admission. You are walking by the waiting room and you see her family members seated together, crying. What is your BEST response?

Go into the waiting room, sit next to them, and allow them the opportunity to talk if they want to.

You are talking with the parents of a 2-year-old boy diagnosed with leukemia about pain management. Which statement indicates an understanding about pain management in children?

He needs to be assessed carefully so that he gets enough pain medication.

You are upset with the healthcare provider who wants the patient you are caring for to continue chemotherapy when that is not what the patient wants to do. Which of the following actions would help you BEST handle this conflict?

Help the healthcare professional understand that the most important outcome is honoring the patient's wishes.

Jack is a 6-year-old who just died at home with hospice from an aggressive type of brain cancer. His parents and his 12-year-old sister are having a very difficult time dealing with this terrible loss. Which of the following would be a help to them after Jack's death?

Hospice bereavement care

Mr. X has end-stage liver cancer, multiple organ failure, and probably has about 6 weeks to live. He wants to be home and comfortable. Which intervention would be most appropriate to offer him?

Hospice services

You are caring for a 55-year-old female patient with metastatic breast cancer. During a home visit, you find the patient's 22-year-old daughter weeping at the kitchen table. The daughter explains that she just realized that her mother will not be alive when she gets married or has children of her own. Recognizing anticipatory grief in the young woman, what is the BEST intervention to complete FIRST?

Provide active listening and therapeutic presence.

An 85-year-old patient with end-stage heart disease arrives unconscious at the emergency department after sustaining her third myocardial infarction. The physician has told the daughter that without resuscitation, her mother could die today. You find the daughter crying at the bedside. Which intervention is most appropriate in communicating with this family member?

Remain present with the daughter, using silence to impart comfort.

You have been assigned to care for a woman who was recently admitted for advanced cancer, and who reports ongoing fatigue. Her husband offers observations about his wife's fatigue. Which statement by the husband indicates the most correct understanding of his wife's fatigue?

She's been in pain. If we control that maybe she'll have more energy.

You are speaking with the family of a patient recently diagnosed with end-stage heart failure. How can you best demonstrate attentive listening?

Stay silent and when it is your turn to talk, repeat back a 2-3 word phrase.

You are caring for a 77-year-old patient at the end of life who has not had a bowel movement in five days. Which sign should you assess the patient to determine if a fecal impaction is present?

Sudden onset of liquid stool

The hospice interdisciplinary team is creating a bereavement plan for the family of Mr. A, a 50-year-old patient with advanced HIV/AIDS. The patient defines his family as consisting of his husband, his parents, and his four siblings, as well as his two closest friends. In creating the plan, what bereavement interventions MUST the interdisciplinary team include?

Take into account each survivor's cultural practices in mourning and grief reactions.

Which of the following is the MAIN reason symptom management in older adults with serious illness is complicated?

They have multiple comorbidities.

Mr. C, whose wife of 14 years died five months ago, returns to your unit to thank you all for your great care. He tells you he still cannot get through a week without crying and states that he knows he should be moving on from the death. Which of the following is your BEST response?

This is very hard; can you tell me a bit about what moving on means to you?

You are teaching a patient how to take her new prescription for morphine, an opioid pain medication. Which of the following teaching statements reflects an understanding of potential adverse effects?

This medication causes constipation, so you need to take a laxative to prevent that.

You are working in the emergency room and a patient came in with a massive heart attack and cannot be resuscitated. The physician has just informed the family that the patient is dead. While sitting with the family, they ask you if the body can stay in the emergency room until the other family members arrive. The remaining family live 2 hours away. The ER is full and the secretary told you they need the room. What should you tell the family?

We will do everything we can to give the other family members time to get to the ER.

You are caring for the following four patients. Which patient is at the highest risk for developing constipation?

A 48-year-old with metastatic cancer of the breast on high doses of opioids for pain.

You are making a bereavement visit to the 35-year-old daughter and primary caregiver of a female patient who died one month ago. The daughter reports she is experiencing mild breathlessness, loss of appetite, and difficulty concentrating. What is the daughter likely experiencing?

A normal grief reaction

Jane, a 72-year-old woman with end-stage renal disease, tells you she does not want to continue dialysis anymore. Which of the following would be your best response to this statement?

That is a very important statement, can you tell me more about that?

You are caring for a man who is near the end of life. During morning care, he asks you if he is dying. What is your BEST response?

That is a very serious question. What is it that makes you ask that today?

Mr. J is in the final hours of life. He is dying from his end-stage chronic lung disease. His breathing pattern has changed and is very irregular and he is even going 10-15 seconds without a breath. The family asks you to please call respiratory therapy to see what they can do to help his breathing. What is your BEST response?

His breathing pattern is difficult to watch, but the irregularity is a normal part of the dying process.

You are taking care of a 68-year-old woman who has advanced metastatic breast cancer. She tells you that she is afraid she is dying and will not be alive to see her first grandchild born in four weeks. You pull up a chair to talk with her. Which of the following statements would be your BEST response?

Tell me more about what you are most afraid of.