End-of-Life Care
7. 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.
Ans:A
23. As the American population ages, nurses expect see more patients 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
Ans:B
19. The nurse in a pediatric ICU is caring for a child who is dying of sickle cell anemia. The child's mother has been unable to eat or sleep and can talk only about her impending loss and the guilt she feels about the child's pain and suffering. What intervention has the highest priority? A) Allowing the patient to express her feelings without judging her B) Helping the patient to understand the phases of the grieving process C) Reassuring the patient that the child's death is not her fault D) Arranging for genetic counseling to inform the patient of her chances of having another child with the disease
Ans:A
Of the following terms, which is used to refer to the period of time during which mourning a loss takes place? a) Mourning b) Grief c) Hospice d) Bereavement
d) Bereavement Bereavement is the period of time during which mourning a loss takes place. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Mourning is defined as the individual, family, group and cultural expressions of grief and associated behaviors. Hospice is a coordinated program of interdisciplinary care and services provided primarily in the home to terminally ill patients and their families.
15. 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
Ans:A
35. A pediatric nurse is emotionally distraught by the death of a 9-year-old girl 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 patient on the unit. C) Solicit emotional support from the patient's family. D) Attend the patient's memorial service.
Ans:D
The nurse is caring for a dying client in a hospice setting. The family is unsure whether to go home for rest or spend the night with the client. Which body system would the nurse assess to provide the first data on decline? a) Respiratory system b) Gastrointestinal system c) Cardiovascular system d) Central nervous system
c) Cardiovascular system The key word is first. Failing of cardiac functioning is one of the first signs that a condition is worsening. Symptoms within the other systems can also denote deterioration over time.
8. A clinic nurse is providing patient education prior to a patient's scheduled palliative radiotherapy to her spine. At the completion of the patient teaching, the patient continues to ask the same questions that the nurse has already addressed. What is the plausible conclusion that the nurse should draw from this? A) The patient is not listening effectively. B) The patient is noncompliant with the plan of care C) The patient may have a low intelligence quotient or a cognitive deficit. D) The patient has not achieved the desired learning outcomes.
Ans:D
14. 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.
Ans:D
12. One aspect of the nurse's comprehensive assessment when caring for the terminally ill is the assessment of hope. The nurse is assessing a patient with liver failure for the presence of hope. What would 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
Ans:A
26. 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
Ans:C
18. 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 for 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
Ans:A
While providing care to a terminally ill client, the client asks, "Am I dying?" Which response by the nurse would be most appropriate? a) "Tell me some more about what is on your mind." b) "What makes you think that you might be dying?" c) "You're just having a bit of a set-back. You'll be fine." d) "What has your physician told you about your condition?"
a) "Tell me some more about what is on your mind."
A patient diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which of the following proxy directives is the patient using? a) Medical directive by proxy b) Living will declaration c) Durable power of attorney for health care d) End-of-life treatment directive
c) Durable power of attorney for health care A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. The other options are incorrect.
The physician is attending to a 72-year-old patient with a malignant brain tumor. Family members report that the patient rarely sleeps and frequently reports seeing things that are not real. Which of the following interventions is an appropriate request for the hospice nurse to suggest to the physician? a) Perform surgery to remove the tumor from the brain. b) Add haloperidol (Haldol) to the patient's treatment plan. c) Obtain a biopsy to analyze the lymph nodes. d) Begin radiation therapy to prevent cellular growth.
b) Add haloperidol (Haldol) to the patient's treatment plan. Haloperidol (Haldol) may reduce hallucinations. Radiation therapy helps in preventing cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present, and it can be used prophylactically to prevent spread. Biopsy is used for analyzing the lymph nodes or for destroying the surrounding tissues around the tumor.
Which of the following should the nurse report so that the team can consider alternative nutritional and fluid administration routes for a dying client? a) Weight loss and inadequate food intake b) Altered gastrointestinal function c) Drop in blood pressure and rapid heart rate d) Irregular eating habits
a) Weight loss and inadequate food intake The nurse should report weight loss and inadequate food intake so that the team can consider alternative nutritional and fluid administration routes for a dying client. The nurse need not report altered gastrointestinal function because it is a normal part of the dying process. A nurse should also not report a drop in blood pressure and rapid heart rate or irregular eating habits.
The family of a dying client being cared for at home is requesting information on how best to prepare food. Which suggestion by the nurse may stimulate appetite? a) Eating alone so the client can eat at his own pace and not be hurried b) Preparing cool or cold foods that may be better tolerated c) Providing several choices on the plate so that the client has what may appeal to him d) Offering high caloric foods to build fat and muscle
b) Preparing cool or cold foods that may be better tolerated Preparing cool or cold foods may be tolerated better by the client and thus stimulate appetite. Hot foods may have an aroma that may cause nausea. Clients may enjoy a mealtime companion making the eating experience more pleasurable. Offering small portions is appropriate because large, multiple portions/choices may shut down the appetite. Although weight loss may be significant, clients should have the ability to pick and choose foods that interest them.
The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle? a) The principle of justice b) The principle of autonomy c) The principle of nonmaleficence d) The principle of fidelity
b) The principle of autonomy By promoting open discussion and informed decision making, the nurse is empowering the client to make his own decisions leading to autonomy. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients.
A patient in hospice has end-stage renal failure. He says that, of late, he has lost his appetite and feels like everyday situations have become more stressful. He reports feeling restless. In addition, his wife notices that he is more and more confused. What is the most important nursing intervention that needs to be carried out at this point? a) Immediately administer drug therapy to restore renal function. b) Make arrangements for the patient to have nutritional counseling. c) Provide the wife with an emergency kit with small doses of oral morphine liquid. d) Make arrangements with the physician to administer immunosuppressants.
c) Provide the wife with an emergency kit with small doses of oral morphine liquid. One of the most important aspects of the care of the patient at the end of life is anticipating and planning interventions for symptoms. Both patients and family members cope more effectively with new symptoms and exacerbations of existing symptoms when they know what to expect and how to manage them. Nutritional counseling, involving the family in the plan of care, and providing psychosocial support to the patient are all relevant nursing interventions that form a part of the nursing management process for a patient with chronic renal failure. Nutritional counseling, administration of drug therapy to restore renal functions, and administration of immunosuppressant drugs are medical management tasks.
31. A 67-year-old woman experienced the death of her husband from a sudden myocardial infarction 5 weeks ago. The nurse recognizes that the woman will be going through the process of mourning for an extended period of time. What processes of mourning will allow the woman to accommodate the loss in a healthy way? Select all that apply. A) Reiterating her anger at her husband's care team B) Reinvesting in new relationships at the appropriate time C) Reminiscing about the relationship she had with her husband D) Relinquishing old attachments to her husband at the appropriate time E) Renewing her lifelong commitment to her husband
Ans:B, C, D
A terminally ill client is receiving morphine around-the-clock for pain control. As part of the client's plan of care focusing on pain management, which nursing diagnosis would the nurse most likely identify? a) Risk for constipation related to the effects of an opioid b) Caregiver role strain related to the need for around-the-clock pain control c) Impaired physical mobility related to sedative effects of the drug d) Risk for ineffective cerebral tissue perfusion related to central nervous system effects of the drug
a) Risk for constipation related to the effects of an opioid When an opioid is used for around-the-clock pain management, the nursing diagnosis, risk for constipation, would be most likely because of the opioid's effect on the gastrointestinal system. Therefore, a regimen to combat constipation is key. Although opioids depress the central nervous system and cause sedation, a risk for ineffection and impaired physical mobility would be less likely. Other factors involved in the client's care, not just the around-the-clock pain control, would contribute to caregiver role strain.
A patient is declared to have a terminal illness. What is the nursing intervention a nurse will perform in the final decision of a dying patient? a) Abide by all wishes of the dying patient. b) Respect the patient and family members' choices. c) Ask the family members about spiritual care. d) Share emotional pain.
b) Respect the patient and family members' choices. In the final decisions of a dying patient, the nurse will present options for terminal care and respect the patient's and family member's choices. Sharing emotional pain is a role in providing care and comfort to dying patients and their families. When the patient has a living will, physicians must abide by the patient's wishes. The nurse should ask the family members about spiritual care only if the patient wants someone associated with his or her religion.
Which of the following does not coincide with Kübler-Ross's stages related to a dying client? a) The client may be in several stages at once. b) Some client regress, then move forward again. c) Clients don't always follow the stages in order. d) The dying client usually exhibits anger first.
d) The dying client usually exhibits anger first. The dying client does not usually exhibit anger first. The client may be in several stages at once, clients don't always follow the stages in order, and some regress and then move forward.
13. 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.
Ans:A
16. A patient 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 patient 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 patient C) Limited visitation opportunities for friends and family D) Conflict between family members
Ans:A
17. 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
Ans:A
3. 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.
Ans:A
4. A nurse who sits on the hospital's ethics committee is reviewing a complex case that has many of the hallmarks of assisted suicide. Which of the following would be an example of assisted suicide? A) Administering a lethal dose of medication to a patient whose death is imminent B) Administering a morphine infusion without assessing for respiratory depression C) Granting a patient's request not to initiate enteral feeding when the patient is unable to eat D) Neglecting to resuscitate a patient with a do not resuscitate order
Ans:A
40. 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
Ans:A
5. A medical nurse is providing palliative care to a patient 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 patient's and family's quality of life B) To support aggressive and innovative treatments for cure C) To provide physical support for the patient D) To help the patient develop a separate plan with each discipline of the health care team
Ans:A
6. After contributing to the care of several patients who died in the hospital, the nurse has identified some lapses in the care that many of these patients 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) Families' needs for information and support often go unmet. B) Patients are too sedated to achieve adequate pain control. C) Patients are not given opportunities to communicate with caregivers. D) Patients are ignored by the care team toward the end of life.
Ans:A
25. A nurse who provides care on an acute medical unit has observed that physicians are frequently reluctant to refer patients 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) Patient 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
Ans:A, B, D
21. 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
Ans:B
27. 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
Ans:B
30. A patient has just died following urosepsis that progressed to septic shock. The patient'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? A) Complicated grief and mourning B) Uncomplicated grief and mourning C) Depression stage of dying D) Acceptance stage of dying
Ans:B
33. A patient's daughter has asked the nurse about ìhelping him end his terrible suffering.î The nurse is aware of the ANA Position Statement on Assisted Suicide, which clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. What does the Position Statement further stress? A) Educating families about the moral implications of assisted suicide B) Identifying patient and family concerns and fears C) Identifying resources that meet the patient's desire to die D) Supporting effective means to honor the patient's desire to die
Ans:B
36. 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
Ans:B
39. You are caring for a patient who has just been told that his illness is progressing and nothing more can be done for him. After the physician leaves, the patient asks you to stay with him for a while. The patient becomes tearful and tries several times to say something, but cannot get the words out. What would be an appropriate response for you to make at this time? A) Can I give you some advice? B) Do you need more time to think about this? C) Is there anything you want to say? D) I have cared for lots of patients in your position. It will get easier.
Ans:B
9. 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.
Ans:B
10. 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.
Ans:C
11. 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.
Ans:C
24. 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.
Ans:C
34. 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
Ans:C
37. 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
Ans:C
28. 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 ìkeep fightingî 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.
Ans:C, D, E
1. In the past three to four 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
Ans:D
2. A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care? A) The increase in cultural diversity in the United States 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
Ans:D
29. 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
Ans:D
32. 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 accomplishment available by attending 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
Ans:D
38. 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
Ans:D
A dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be? a) "This must be very difficult for you." b) "You know you're dying?" c) "I'm so sorry. I know how you must feel." d) "Tell me more about what's on your mind."
a) "This must be very difficult for you." Using open-ended questions allows the nurse to elicit the patient's and family's concerns, explore misconceptions and needs for information, and form the basis for collaboration with physicians and other team members. For example, a seriously ill patient may ask the nurse, "Am I dying?" The nurse should avoid making unhelpful responses that dismiss the patient's real concerns or defer the issue to another care provider. In response to the question "Am I dying?" the nurse could establish eye contact and follow with a statement acknowledging the patient's fears ("This must be very difficult for you") and an open-ended statement or question ("Tell me more about what is on your mind").
A patient near the end of life is experiencing anorexia-cachexia syndrome. What characteristics of the syndrome does the nurse recognize? (Select all that apply.) a) Anemia b) Neurologic dysfunction c) Endocrine dysfunction d) Bladder incontinence e) Alterations in carbohydrate, fat, and protein metabolism
a) Anemia c) Endocrine dysfunction e) Alterations in carbohydrate, fat, and protein metabolism Anorexia and cachexia are common in the seriously ill. The profound changes in the patient's appearance and a lack of interest in the socially important rituals of mealtime are particularly disturbing to families. The approach to the problem varies depending on the patient's stage of illness, level of disability associated with the illness, and desires. The anorexia- cachexia syndrome is characterized by disturbances in carbohydrate, protein, and fat metabolism; endocrine dysfunction; and anemia. The syndrome results in severe asthenia (loss of energy).
The family of a dying client is noticing that their loved one is short of breath, restless in bed, and appears to be trying to tell them something. Which nursing intervention is appropriate at this time? a) Call the physician to obtain an anxiolytic. b) Offer the client sips to drink. c) Offer the bedpan to urinate. d) Get the client out of bed to the chair.
a) Call the physician to obtain an anxiolytic. Clients may become restless and agitated when experiencing difficulty breathing. Obtaining an anxiolytic can reduce the client's anxiety and agitation. It is difficult for families to see the client agitated and trying to express something. It leaves the family feeling frustrated and with a lingering memory after death. Before death, the client loses muscle control of the bowel and bladder, needing a disposable undergarment. Sitting in the chair and offering sips to drink is not something necessary at the end of life.
While providing care to a client near death, the nurse is helping the family to prepare by teaching them what to expect. Which of the following would the nurse include in the teaching plan as a sign of approaching death? Select all that apply. a) Decrease in amount of urine produced b) Breathing that is very rapid c) Refusal to ingest food or fluids d) Gurgling as the client breathes through the mouth e) Increase in visual and auditory abilities
a) Decrease in amount of urine produced c) Refusal to ingest food or fluids d) Gurgling as the client breathes through the mouth As death approaches, a client typically has secretions that collect in the back of the throat and rattle or gurgle as the client breathes through the mouth. Breathing may become irregular with periods of no breathing. Urine output may decrease in amount and frequency, and loss of bladder and bowel control may occur. The person approaching death shows less interest in eating and drinking; for many, refusal of food is an indicator that they are ready to die. Vision and hearing may be somewhat impaired and speech may be difficult to understand.
A nurse is providing hospice care in Portland, Oregon,to client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which of the following interventions is the best for the nurse to implement? Select all that apply. a) Encourage the client to explain his wishes. b) Comfort the client by saying it will all be over soon. c) Advise the client's physician of the client's condition. d) Recommend that the client consider physician-assisted suicide. e) Control the client's pain with prescribed medication.
a) Encourage the client to explain his wishes. c) Advise the client's physician of the client's condition. e) Control the client's pain with prescribed medication. This client lives in Oregon, one of three states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation (Quill & Greenlaw, 2008). Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however.
A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care. Which of the following would the nurse include in the explanation for this client? Select all that apply. a) Enhances quality of life b) Includes chemotherapy c) Integrates spirituality d) Offers a team approach to care e) Hastens death f) Provides pain relief
a) Enhances quality of life c) Integrates spirituality d) Offers a team approach to care f) Provides pain relief The principles of palliative care include providing relief from pain and distressing symptoms. In the early course of disease, chemotherapy and radiation may be used to define care needed, but in the later stages, chemotherapy is typically not used. Psychological support including spirituality and bereavement counseling for family members is available. The care does not hasten nor postpone death but is aimed at enhancing a quality of the life that is remaining. A team approach meets the needs of the client and family.
A 36-year-old mother of three was recently diagnosed with a chronic illness. The nurse prepared information for the patient on how to manage her illness. To help her cope with the shock and resentment that she was experiencing, the nurse gave her facts about her illness with honesty and empathy. Which of the following are the best comments that the nurse can include when talking to the patient about chronic illness? Select all that apply. a) It results in residual disability due to non-reversible pathology. b) It is characterized by a progressive decline in normal physiologic function c) It can be associated with exacerbations and remissions. d) It can require short-term management (<3 months). e) It is defined as long-term with the possibility of a cure if intervention is rapid and timely.
a) It results in residual disability due to non-reversible pathology. b) It is characterized by a progressive decline in normal physiologic function c) It can be associated with exacerbations and remissions. Chronic illnesses are often defined as medical illnesses or health problems with associated symptoms or disabilities that require long-term management (3 months or longer). Chronic illness refers to diseases that are caused by non-reversible pathology; are characterized by a slow progressive decline in normal physiological function; are permanent with cure unlikely; and require long-term surveillance, leaving residual disability.
The nurse is providing care to a terminally ill client and his family who practice the Islamic faith. Which of the following concepts would the nurse need to integrate into this client's plan of care? Select all that apply. a) Pain is viewed as a mechanism for cleansing. b) Death occurs through God's permission. c) The caste of the client and family will determine their view of death. d) The family will create a new ethereal body the first 10 days after death. e) The way a person dies is of great individual importance.
a) Pain is viewed as a mechanism for cleansing. b) Death occurs through God's permission. e) The way a person dies is of great individual importance. According to Islamic beliefs, everyone will face death and the way a person dies is of great individual importance. Death cannot happen except by God's permission. People adhering to Islamic beliefs also view pain as a cleansing instrument from God and as a compensation for sin. In Hinduism, each caste system has a different view of death, and relatives must create a new ethereal body during the first 10 days after death.
Medicare and Medicaid hospice benefits criteria allow patients with a life expectancy of 6 months or less to be admitted to the hospice. However, the median length of stay in a hospice program is just 21.3 days. Which of the following reasons explains underuse of hospice care services? a) Patients/families view palliative care as giving up b) Lack of fully credentialed and trained hospice nurses c) Difficulty obtaining Medicare certification for hospice services d) Lack of Medicare/Medicaid funding for hospice
a) Patients/families view palliative care as giving up Lack of fully credentialed and trained hospice patients is not a barrier to hospice care. Patients equate hospice with "giving up" and are reluctant to accept hospice. Lack of Medicare funding or certification for hospice service providers has not been documented as a barrier to access of hospice services.
A patient with brain tumor recently stopped radiation and chemotherapy for treatment of his cancer. Of late, he is complaining of dry mouth. Which of the following interventions by the hospice nurse demonstrates the nurse understands treatment measures for dry mouth? a) Provide gentle mouth care after each meal. b) Place two drops of Atropine ophthalmic 1% solution sublingually. c) Begin IV fluids of 9% normal saline at 125 mL/hr. d) Gently suction the patient's mouth, and buccal cavity.
a) Provide gentle mouth care after each meal. The use of artificial hydration (IV fluids) carry considerable risks and do not contribute to comfort at end of life Atropine ophthalmic 1% drops when administered sublingually helps reduce oral secretions. Dry mouth can generally be managed through nursing measures such as mouth care. Gentle oral suctioning reduces the production of secretions.
How does a nurse who has been providing home care to a terminally ill client know that her client's condition is beginning to deteriorate? a) The client's apical pulse reaches 100 beats/minute. b) The client's facial muscles contract. c) The client's skin appears red and flushed. d) The client's urine output increases.
a) The client's apical pulse reaches 100 beats/minute. Failing cardiac function is one of the first signs that a client's condition is worsening. At first, heart rate increases in a futile attempt to deliver oxygen to cells. The apical pulse rate may reach 100 or more beats/minute. In clients who are dying, the skin becomes pale or mottled, nail beds and lips may appear blue, and the client may feel cold. In clients who are dying, urine volume decreases. In clients who are dying, the jaw and facial muscles relax.
A 25-year-old patient with cancer experiencing unrelieved pain rated at a 9 on the pain scale requests that the hospice nurse induce a state of unconsciousness until he dies. Which of the following statements by the nurse demonstrates understanding a key difference between conscious sedation and euthanasia? a) "I need to perform a complete pain assessment to confirm the amount of pain you are experiencing prior to recommending sedation." b) "Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death." c) "Total sedation is a commonly practiced method used in this situation; I will contact your physician and begin treatment as soon as possible." d) "I cannot legally administer pain medications that will induce unconsciousness to relieve your pain."
b) "Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death." When the terminally ill patient or the patient's legal proxy requests palliative sedation, the use of pharmacologic agents to induce sedation or near sedation when symptoms have not responded to other management measures), the purpose is not to hasten the patient's death but to relieve intractable symptoms. Palliative sedation may be controversial, but it is not illegal. Total sedation is rarely indicated in hospice care to provide comfort. Continuous pain assessments are not indicated at this stage; the patient requires intervention/treatment.
Which of the following interventions should the nurse perform while providing spiritual care for a dying client? a) Encourage family members in their frank communication. b) Ask the family members about spiritual care. c) Allow a period of privacy. d) Provide spiritual books.
b) Ask the family members about spiritual care. When clients are too ill to express their wishes, the nurse should ask the family members about spiritual care. Encouraging family members in their frank communication and providing spiritual books may not be helpful in providing spiritual care for a dying client. Allowing a period of privacy may not be helpful. The nurse allows a period of privacy to the client's family members after the death of the client.
Which of the following is the nurse's primary concern when providing end-of-life care for a client and the family?Select all that apply. a) Encouraging fluids b) Maintaining client comfort c) Arranging plans for after death d) Completing a head-to-toe assessment e) Supporting family members f) Providing personal care
b) Maintaining client comfort e) Supporting family members f) Providing personal care Nursing care of dying clients focuses on providing palliative care to the client and supporting family members. Arranging the plans after death is not a priority at this time. Completing a head-to-toe assessment may be completed for information but is not a priority at the end of life. There is no need to encourage fluids.
As a client approaches death, her respirations become noisy. This is the result of which type physical event? a) Cardiac dysfunction b) Musculoskeletal change c) Gastrointestinal impairment d) Central nervous system alterations
b) Musculoskeletal change As death approaches, a client's reflexes become hypoactive. The jaw and facial muscles also relax. As the tongue falls to the back of the throat, respirations become noisy.
As the moment of death approaches, which of the following does the nurse encourage the family to do? a) Lie next to the client and hold the client. b) Speak to the client in a calm and soothing voice. c) Have the family sit in front of the client so they can be seen. d) Rub the client’s hand and arm to comfort the client.
b) Speak to the client in a calm and soothing voice. Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.
A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? a) "It will hasten the death of the patient." b) "It will prolong life in a dignified manner." c) "It will enable the patient to remain home if that is what is desired." d) "It will use artificial means of life support if the patient requests it."
c) "It will enable the patient to remain home if that is what is desired." The goal of hospice is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. The patient and family make up the unit of care. Hospice care does not seek to hasten death or encourage the prolongation of life through artificial means.
While talking with a client who has been diagnosed with a terminal illness, the client asks, " Am I dying?" Which response from the nurse would be appropriate? Select all that apply. a) "You still have time for a good life." b) "Let's focus on what your doctor has planned." c) "Tell me more about what's on your mind." d) "This must be very difficult for you." e) "I know just how you must feel."
c) "Tell me more about what's on your mind." d) "This must be very difficult for you." The nurse needs to listen effectively and empathetically, acknowledging the client's fears and concerns. Statements such as "This must be very difficult for you" and "Tell me more about what's on your mind" address the client's concerns and help to focus the discussion on the client. Telling the client that the nurse knows how the client feels ignores the client's concerns. Saying that there is still time for a good life or telling the client to focus on what the doctor has planned ignores the client's feelings and blocks communication.
The family of a terminally ill client tells the nurse that the client has been breathing irregularly and, at times, it appears that he is not breathing at all. The client's daughter states, "He moans when he breathes. Is he in pain?" Which response by the nurse would be most appropriate? a) "He is getting less oxygen to the brain, so the moaning means he is dreaming." b) "He has secretions that are collecting at the back of the throat." c) "The moaning you hear is from air moving over very relaxed vocal cords." d) "His moaning does indicate pain, so we'll increase his pain medication."
c) "The moaning you hear is from air moving over very relaxed vocal cords." As a client approaches death, certain signs appear. The family is reporting irregular breathing with periods of apnea. The moaning that they hear reflects the sound of air passing over very relaxed vocal cords. It does not signify pain or distress. Therefore, no additional pain medication would be needed. Secretions collecting at the back of the throat are noted by a rattling or gurgling sound. Decreased oxygen to the brain would lead to confusion, which may be reported by the client as strange dreams or visions.
A nurse is working with the family of a terminally ill client, providing them with suggestions about how to manage the client's anorexia. Which statement by the family indicates that they have understood the instructions? a) "We'll make sure that any foods that we give him are mashed up or in liquid form instead so he doesn't have to chew." b) "We'll try to give him regularly scheduled meals throughout the day." c) "We'll try adding powdered milk to milk and other foods to make them more nutritious." d) "We'll make sure that he is nearby the kitchen so he can smell the foods cooking."
c) "We'll try adding powdered milk to milk and other foods to make them more nutritious." Increasing the nutritional value of foods, such as by adding powdered milk to milk and other foods, is appropriate. The client should be allowed and encouraged to eat when he is hungry regardless of the regular meal times. Cooking odors should be eliminated or reduced because they can precipitate nausea, vomiting, or anorexia. Unless there is a definite problem with chewing or swallowing, foods do not need to be pureed (mashed) or in liquid form.
A patient with end-stage chronic obstructive pulmonary disease is admitted to a hospice facility and asks the admitting nurse, "How long will I be allowed to stay here?" What is the best response by the nurse? a) "There is no time limit for your stay. You can stay until you die." b) "You will be able to stay only for approximately 1 month and then you will be discharged." c) "When your stay reaches 6 months, you will be recertified for a continued stay." d) "You will be able to stay for 2 months before being discharged."
c) "When your stay reaches 6 months, you will be recertified for a continued stay." Federal rules for hospices require that eligibility be reviewed periodically. Patients who live longer than 6 months under hospice care are not discharged, provided that their physician and the hospice medical director continue to certify that they are terminally ill with a life expectancy of 6 months or less (assuming that the disease continues its expected course)
All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? a) Allows for the nurse to take the client through in the appropriate order b) Allows the nurse to express his or her feelings c) Allows for the nurse to facilitate the grieving process d) Allows for the nurse to understand when the grieving process should be concluded
c) Allows for the nurse to facilitate the grieving process Grieving is a painful yet normal reaction that helps clients cope with loss and leads to emotional healing. The nurse is responsible for facilitating the grieving process and helping the client and family deal with their emotions. Evidence-based medical and nursing research (2009) has identified cardiovascular disease as the most prevalent chronic disease in the United States. Under this classification, one condition is the most common. Using this information, a nurse practitioner, treating a 50-year-old man, would do which of the following? a) Write a prescription for a serum cholesterol level. b) Teach the patient how to assess his blood pressure weekly. c) Make certain that the patient was aware of the signs of coronary artery disease. d) Suggest activity modifications and treatments to help minimize the physical limitations of dyspnea.
A nurse is providing in-home hospice care to a terminally ill client. The client experiences a medical crisis requiring monitoring and medication administration. Which level of hospice care would the nurse implement? a) Routine home care b) General inpatient care c) Continuous care d) Inpatient respite care
c) Continuous care Continuous care is provided in the home for management of medical crisis. Routine home care would be used to provide the usual services to a client, such as nursing care, medical social services, counseling, home health aide/homemaker servies, and various therapies. Inpatient respite care would be used for a 5-day stay to provide relief for family caregivers. General inpatient care is used for symptom management that cannot be provided in the home.
For individuals known to be dying by virtue of age and/or diagnoses which of the following signs indicate approaching death? a) Increased urinary output b) Increased wakefulness c) Increased restlessness d) Increased eating
c) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless. As the body weakens, the patient will sleep more and begin to detach from the environment. For many patients, refusal of food is an indication that they are ready to die. Based upon decreased intake, urinary output generally decreases in amount and frequency.
Nursing students are reviewing information about the signs and symptoms of impending death. The students demonstrate the need for additional review when they identify which of the following as a sign? a) Restlessness b) Mental confusion c) Muscle wasting d) Reduced urinary output
c) Muscle wasting Muscle wasting occurs as the client's condition deteriorates. It is not a sign of impending death. Mental confusion, reduced urinary output, and restlessness occur as a client approaches death.
A hospice nurse is visiting the home of a client who was recently diagnosed with a terminal illness. The nurse is developing the client's plan of care and is assessing beliefs and preferences about end-of-life care. The nurse would expect to complete this assessment at which time? a) When the client exhibits signs of imminent death b) As the client's condition begins to deteriorate c) Over the course of several visits d) During the initial visit
c) Over the course of several visits Information about end-of-life care beliefs, preferences, and practices should be gathered in short segments over a period of time, such as over several visits. Trying to elicit the information in one visit would be overwhelming. Waiting until the client's condition begins to deteriorate or when signs of imminent death appear would be too late. The nurse needs to integrate the client's beliefs, preferences, and practices into the plan of care.
The family of a patient in hospice decides to place their loved one in a long-term care setting to establish an effective pain control regimen. Which of the following aspects of hospice care is the family utilizing? a) Continuous care b) General inpatient care c) Palliative care d) Inpatient respite care
c) Palliative care Long-term care is increasing as a setting to provide palliative care addressing symptom management, such as pain. Inpatient respite care is a 5-day inpatient stay, provided on an occasional basis to relieve the family caregivers. Continuous care is provided in the home for management of a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home.
A patient with long-time breast cancer recently enrolled in a hospice program demonstrates signs and symptoms of clinical depression. Which of the following actions by the hospice nurse is appropriate? a) Ask the patient if she is planning to hurt herself. b) Explain that antidepressants are not indicated for the patient. c) Perform a thorough pain assessment with the patient. d) Educate the patient that depression is expected.
c) Perform a thorough pain assessment with the patient. An effective combined approach to clinical depression includes relief of physical symptoms such as pain. Clinical depression should not be accepted as an inevitable consequence of dying. Researchers have linked the psychological effects of cancer pain to suicidal thought and, less frequently, to carrying out a planned suicide. An effective combined approach to clinical depression includes relief of physical symptoms and pharmacologic intervention with tricyclic antidepressants.
The nurse is caring for a client at the end of life. The client is ordered a regular dosage of narcotics and short-acting narcotics for breakthrough pain. When administering the narcotics, the nurse is correct to realize which of the following? a) Dosages are restricted. b) Death is imminent. c) Side effects must be treated. d) Patient may become sedated.
c) Side effects must be treated. The nurse who is administering narcotics at the end of life still must realize that there are side effects from the narcotics which must be addressed. Depending on the status of the client, death may be days or weeks away, not imminent. Pain medications are liberally given at the end of life to ensure that the client is comfortable. Typically, pain medications relax the client as the pain level is eased. The client is not sedated.
The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care? a) Suggestions that the family offer the client foods that are hot. b) Arrangements for the client to eat meals while others are out of the home. c) Encouragement of the family to serve the client meat, especially beef. d) Advice for the family to have fruit juices readily available at the client's bedside.
d) Advice for the family to have fruit juices readily available at the client's bedside. To promote nutrition in the terminally ill, the nurse would encourage the family to have fruit juices and milkshakes readily available at the bedside so that the client can access them frequently. Cool foods may be better tolerated than hot foods. Cheese, eggs, peanut butter, mild fish, chicken, and turkey are often better choices than meat such as beef that may taste bitter and unpleasant. Meals should be scheduled when family members are present to provide company and stimulation.
A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? a) Bargaining b) Acceptance c) Denial d) Anger
d) Anger Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close.
Which of the following interventions should a nurse perform during the grieving period when caring for dying patients? a) Providing palliative care b) Spending time with the patient c) Allowing a period of privacy d) Avoiding criticism or giving advice
d) Avoiding criticism or giving advice The nurse should listen in a nonjudgmental manner and should avoid criticism or giving advice during the grieving period when caring for dying patients. Allowing a period of privacy is necessary to help the family members cope with the death of a patient and is not necessary during the grieving period. Spending time with the patient and providing palliative care are not the required nursing interventions during the grieving period. Palliative care is provided to a dying patient when the patient is unable to live independently.
The wife of your terminally ill client is confused by the new terminology being used during discussions regarding her husband's treatment. How would you explain palliative care to her? a) It is an alternative therapy that uses massage and progressive relaxation for pain relief. b) It is offered to terminally ill clients who wish to remain in their homes in lieu of hospice care. c) It is care that is provided at the very end of an illness to ease the dying process. d) It is care that will reduce her husband's physical discomfort and manage clinical symptoms.
d) It is care that will reduce her husband's physical discomfort and manage clinical symptoms. Palliative care is used in conjunction with other end-of-life treatments and has many principles. Its aim is to reduce physical discomfort and other distressing symptoms but does not alter a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life. Palliative care of a terminally ill client not only provides relief from pain and other distressing symptoms but it integrates other facets of patient care as well, including psychological and spiritual aspects. Palliative care reduces physical discomfort without altering a disease's progression and is part of hospice care, which emphasizes helping clients live however they wish until they die.
Which cardiovascular findings indicate to the nurse that the condition of the dying client is worsening? a) Pulse 100 beats/minute, blood pressure 100/60 mm Hg, pale with poor skin turgor b) Pulse 60 beats/minute, blood pressure 90/42mm Hg, difficult to arouse c) Pulse 72 beats/minute, irregular; patient confused and agitated d) Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles
d) Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles Earlier, a client with failing cardiac function exhibits a higher pulse as the body attempts to circulate oxygen. Next, cardiac output is decreased due to ineffective filling of the chambers, impairing circulation, and diminishing the heart's own oxygen supply. The heart rate and blood pressure then decrease. Peripheral circulation is impaired with the feet and ankles becoming pale and mottled.
