Ch 13: Palliative and End-of-Life Care

a) Dusky appearance Pg. 381 The body becomes dusky or bluish, waxen-appearing, and cool; blood darkens and pools in dependent areas of the body, and urine and stool may be evacuated.

20. Immediately on cessation of vital functions, the body begins to change. The nurse would expect which physical change to occur following death? a) Dusky appearance b) Increased body temperature c) Flushed appearance d) Absence of incontinence

b) Client's goals Pg. 376-377 When managing the symptoms of a client with a terminal illness, the client's goals take precedence over the clinician's goals to relieve all symptoms at all costs. Although the length and invasiveness of the treatment may influence decision making, ultimately it is the client's goals that determine what will be done.

32. A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms? a) Length of required treatment b) Client's goals c) Physician's orders d) Invasiveness of the treatment

d) Durable power of attorney for health care Pg. 376 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.

33. Which is also known as a proxy directive? a) Medical directive b) Treatment directive c) Living will d) Durable power of attorney for health care

a) Codeine Pg. 376-377 Morphine is a potent narcotic that relieves pain and diminishes anxiety, thus managing respirations. Concentrated morphine solution can be very effectively delivered by the sublingual route, because the small liquid volume is well tolerated even if swallowing is not possible.

19. A hospice nurse should be aware that the most effective pain medication used at the end of life that also relieves dyspnea and anxiety is which of the following? a) Codeine b) Demerol c) Percodan d) Morphine

c) "I just want to see my daughter graduate from college. That's all" Pg. 384 Bargaining is manifested by pleading for more time to reach an important goal. This is reflected in the client's statement about wanting to see her daughter's college graduation. The statement about going to get a second opinion reflects denial. The statement about why reflects anger. The statement about not knowing how the husband will manage reflects the depression stage.

2. A nurse is assessing a terminally ill female client. Which client statement indicates that the client is in the bargaining stage of dying? a) "I can't believe this. I'm going to get a second opinion" b) "I don't know how my husband is going to manage things when I'm gone" c) "I just want to see my daughter graduate from college. That's all" d) "Why is this happening to me. I've led a good life. Why is God punishing me?"

c) "When your stay reaches 6 months, you will be recertified for a continued stay" Pg. 372 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).

17. 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) "You will be able to stay for 2 months before being discharged" 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) "There is no time limit for your stay. You can stay until you die"

d) The response experienced by anyone who has suffered a loss Pg. 384-385 Grief refers to the universal response to any loss. It is experienced by anyone suffering any type of loss. Loss is part of the life cycle and occurs in the form of change, growth, and transition. Spirituality refers to the feeling of connectedness with self, others, a life force, or God that allows people to find meaning in life. Anxiety refers to feelings of apprehension or worry in response to or about a situation.

7. When describing the term "grief" to a group of students, which of the following would the instructor include? a) A part of the life cycle in the form of change, growth, and transition b) Feelings of apprehension or worry in response to a situation c) A feeling of connectedness with one's self and others d) The response experienced by anyone who has suffered a loss

a) Continuous care Pg. 373 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 services, 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.

1. 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) Continuous care b) General inpatient care c) Inpatient respite care d) Routine home care

a) Respect the client's and family members' choices Pg. 369 In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members' choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.

10. A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? a) Respect the client's and family members' choices b) Abide by the dying client's wishes c) Ask the family members about spiritual care d) Share emotional pain

b) Avoiding criticizing or giving advice Pg. 382-383 The nurse should listen in a nonjudgmental manner and should avoid criticizing or giving advice during the grieving period when caring for dying clients. Allowing a period of privacy is necessary to help family members cope with the death of a client and is not necessary during the grieving period. Spending time with the client and providing palliative care are not required nursing interventions during the grieving period. Palliative care is provided to a dying client when the client is unable to live independently.

11. Which intervention should a nurse perform during the grieving period when caring for a dying client? a) Providing palliative care b) Avoiding criticizing or giving advice c) Allowing a period of privacy d) Spending time with client

c) Care that will reduce the client's physical discomfort and manage clinical symptoms Pg. 368-369 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 is part of hospice care.

12. The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: a) Offered to terminally ill clients who wish to remain in their homes in lieu of hospice care b) An alternative therapy that uses massage and progressive relaxation for pain relief c) Care that will reduce the client's physical discomfort and manage clinical symptoms d) Care that is provided at the very end of an illness to ease the dying process

c) Focus on the client's basic needs Pg. 386 Initially, nurses focus assessment on the client's basic physical needs, such as pain, breathing, nutrition, hydration, and elimination. The other options are inappropriate in the assessment of the dying client.

13. Which of the following is an appropriate method of assessing the dying client? a) Repeat assessments as necessary b) Stimulate the client every 30 minutes c) Focus on the client's basic needs d) Sedate the client before completing range-of-motion exercises

a) There remains a conspiracy of silence about dying despite progress in the area Pg. 388 Despite the progress on many fronts associated with attitudes toward death and dying, there still is a belief in a conspiracy of silence about dying. Although a growing number of clinicians are becoming more comfortable with assessing clients' and families' information needs, many still avoid the topic in the hope that the client will ask or find out on his or her own. In addition, there are misconceptions that clients would subsequently lose all hope, give up, or be psychologically harmed by disclosure of a serious or terminal illness and that clients would ask for information if they really wanted to know.

21. Nursing students are reviewing information about attitudes related to death and dying. The students demonstrate understanding of the information when they identify which of the following as most accurate? a) There remains a conspiracy of silence about dying despite progress in the area b) Clients would ask for information if they really had a desire to know c) Clients, for the most part, would gain hope if they were told about a poor prognosis d) Most clinicians are very open to talking about disease and dying with clients

c) Participating in assisted suicide violates the Code of Ethics for Nurses Pg. 387 The American Nurses Association Position Statement on Assisted Suicide acknowledges the complexity of the assisted suicide debate but clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. Legally, nurses are not allowed to administer medications even if prescribed by a physician if that medication will hasten the client's end of life. Proponents of physician-assisted suicide argue that terminally ill people should have a legally sanctioned right to make independent decisions about the value of their lives and the timing and circumstances of their deaths. However, this is not the case at the present time. Two states have enacted legislation for physician-assisted suicide. These laws provide access to physician-assisted suicide by terminally ill clients under very controlled circumstances.

14. A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following? a) Most states have enacted laws that allow for physician-assisted suicide b) A client has the right to make independent decisions about the timing of his or her death c) Participating in assisted suicide violates the Code of Ethics for Nurses d) Nurses may administer medications prescribed by physicians to hasten end of life

d) Denial Pg. 384 The stages of grief include denial, anger, bargaining, depression, and acceptance. Anger is the second stage of the process. Bargaining is the third stage of the process. Depression is the fourth stage of the process.

15. Which is the initial stage of grief, according to Kübler-Ross? a) Bargaining b) Anger c) Depression d) Denial

c) "This must be very difficult for you" Pg. 382 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").

16. 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) "Let me explain to you what is happening" b) "I'm so sorry. I know how you must feel" c) "This must be very difficult for you" d) "You know you're dying?"

d) Palliative sedation Pg. 386 Effective control of symptoms can be achieved under most conditions; however, some clients may experience distressing, intractable symptoms and other clients may be incapacitated. Although palliative sedation remains controversial, it is offered in some settings to clients who are close to death or who have symptoms that do not respond to conventional pharmacologic and nonpharmacologic approaches, resulting in unrelieved suffering. Palliative sedation is distinguished from euthanasia and physician-assisted suicide in that the intent of palliative sedation is to relieve symptoms, not to hasten death. Proportionate palliative sedation uses the minimum drug necessary to relieve the symptom while preserving consciousness, whereas palliative sedation induces unconsciousness, which is more controversial. Barbiturate coma is a technique used to induce a coma in clients with specific conditions. Conscious sedation is used for some diagnostic tests and procedures. Clients who are incapacitated are not likely candidates for patient-controlled analgesia.

18. A client with a terminal illness who is incapacitated is experiencing intractable pain that is no longer effectively addressed by conventional pharmacology. Which type of pain management will the nurse anticipate for this client? a) Conscious sedation b) Patient-controlled analgesia c) Barbiturate coma d) Palliative sedation

a) Encourage the family members to express their feelings and listen to them in their frank communication Pg. 386-388 Family members usually find it difficult to communicate frankly with a dying person. By encouraging family members to express their feelings and listening to them as they frankly communicate, you may help family members feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members to express their feelings.

22. The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation? a) Encourage the family members to express their feelings and listen to them in their frank communication b) Encourage conversations about the impending death of the client c) Be a silent observer and allow the client to communicate with the family members d) Encourage the client's family members to spend time with the client

b) End-stage renal disease Pg. 155 Certain illnesses require advanced technology for survival, or intensive care for periods of weeks or months, as in end-stage renal disease (ESRD). People with this condition are chronically critical and progressively ill. Some chronic illnesses have little effect on quality of life, but others, like ESRD, have a considerable effect because it can result in a chronic progressive deterioration.

23. The nurse practitioner has four patients with chronic illness that require consistent medical and nursing management. Select the condition that is the best example of a "chronically critical and progressively ill" condition. a) Type 2 diabetes mellitus b) End-stage renal disease c) Coronary artery disease d) Carcinoma-in-situ

a) Durable power of attorney for health care Pg. 376 A durable power of attorney (DPOA) for health care or healthcare proxy is the person the client designates to make medical decisions on the client's behalf when the client no longer can do so. It allows competent clients to identify exactly what life-sustaining measures they want to be implemented, avoided, or withdrawn and offers reassurance that others will carry out their wishes. Power of attorney is a legal term used in a different context. A living will is a written or printed statement describing a person's wishes concerning medical care and life-sustaining treatments that are wanted or unwanted in the event that a person is unable to personally make those decisions. Although a living will describes a person's wishes, it does not designate decision-making power to another person in the same was as a DPOA. Designated signer is not a term used in healthcare.

24. A 90-year-old home care client's son has been designated to make decisions regarding the client's medical care when the client is no longer able to do so. As the client nears the end of life, the son is consulted on an ever-increasing basis. What legal instrument activates the son's decision-making designation? a) Durable power of attorney for health care b) Power of attorney c) Designated signer d) Living will

d) Ask the client to rate the dyspnea on a scale of 0 to 10 Pg. 378 The most appropriate method for assessing the severity of the client's dyspnea is to have the client rate the severity using a scale from 0 to 10, with 0 indicating no dyspnea and 10 indicating the worst imaginable dyspnea. This provides an objective indicator of the severity. Asking the client to identify the complaint as mild, moderate, or severe, although somewhat helpful, is not the best means for assessing the severity because these terms are difficult to quantify. Questioning the client about easing or worsening of the complaint would be helpful to determine the possible underlying cause and obtain a more complete picture of the complaint, but it would not help determine severity. Dyspnea can occur for many reasons, including anxiety and fear. Therefore, auscultating the lungs would provide information only about respiratory involvement as a potential cause. It would not help determine the severity of the dyspnea.

25. A nurse is providing care to a terminally ill client who is experiencing dyspnea. Which of the following would be most appropriate to do to assess the severity of the client's complaint? a) Auscultate the client's lung sounds for changes b) Question the client about when the dyspnea eases or worsens c) Have the client state if the dyspnea is mild, moderate, or severe d) Ask the client to rate the dyspnea on a scale of 0 to 10

a) Advice for the family to have fruit juices readily available at the client's bedside Pg. 386 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.

26. 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) Advice for the family to have fruit juices readily available at the client's bedside b) Suggestions that the family offer the client foods that are hot c) Arrangements for the client to eat meals while others are out of the home d) Encouragement of the family to serve the client meat, especially beef

c) Administer pain medication on a schedule that prevents pain from intensifying Pg. 377-378 Pain management is the most common concern for the dying patient. Medication should be given on a PRN schedule that keeps the patient comfortable.

27. Based on the most common concern of a dying patient, the hospice nurse should: a) Position the patient to prevent difficulties with breathing b) Offer supplemental fluids to prevent dehydration c) Administer pain medication on a schedule that prevents pain from intensifying d) Turn the patient every 2 hours to prevent decubitus ulcers

d) Weight loss and inadequate food intake Pg. 386 The nurse should report weight loss and inadequate food intake so that the team can consider adding appetite stimulants and the nutritionist can alter the meal plan to give more satisfying meals as a comfort measure. The nurse knows that changes of gastrointestinal function such as irregular eating or bowel changes occur as part of the dying process and are not relevant to the desired intervention. Deteriorating vital signs are part of the dying process so that these signs are not relevant to the desired intervention.

28. A nurse is evaluating a client with a terminal illness. What should the nurse report so that the health care team can consider alternative nutritional approaches and fluid administration routes for the client at the end of life? a) Altered gastrointestinal function b) Drop in blood pressure and rapid heart rate c) Irregular eating habits d) Weight loss and inadequate food intake

b) Anger Pg. 384 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.

29. 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) Acceptance b) Anger c) Bargaining d) Denial

b) Clients and families view hospice care as giving up Pg. 372-373 Clients often equate hospice with giving up and are reluctant to accept hospice care. Lack of fully credentialed and trained hospice nurses is not a barrier to hospice care. Lack of Medicare funding and lack of certification for hospice service providers have not been documented as barriers to access of hospice services.

3. Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services? a) Lack of Medicare/Medicaid funding for hospice b) Clients and families view hospice care as giving up c) Difficulty obtaining Medicare certification for hospice services d) Lack of fully credentialed and trained hospice nurses

c) Durable power of attorney for health care Pg. 376 A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.

30. A client 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 proxy directive is the patient using? a) End-of-life treatment directive b) Medical directive by proxy c) Durable power of attorney for health care d) Living will declaration

a) Use imagery, humor, and progressive relaxation Pg. 378-379 Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication. Offering small amounts of nourishment frequently will not help potentiate the effects of pain medication. Gentle massaging of the arms and legs helps to regulate body temperature. Encouraging the client to fall asleep will not help potentiate the effects of pain medication.

31. In spite of administering the prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea? a) Use imagery, humor, and progressive relaxation b) Gently massage the arms and legs c) Offer small amounts of nourishment frequently d) Encourage the patient to sleep

a) "The moaning you hear is from air moving over very relaxed vocal cords" Pg. 379 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.

34. 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) "The moaning you hear is from air moving over very relaxed vocal cords" b) "His moaning does indicate pain, so we'll increase his pain medication" c) "He has secretions that are collecting at the back of the throat" d) "He is getting less oxygen to the brain, so the moaning means he is dreaming"

d) Speak to the client in a calm and soothing voice Pg. 382 Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.

35. 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) Rub the client's hand and arm to comfort the client c) Have the family sit in front of the client so they can be seen d) Speak to the client in a calm and soothing voice

b) "Let's take this one day at a time; remember you have your daughter's dance recital next week" Pg. 382 Helping a client to find reasons to live and look forward to events promotes positive attitudes and ability to live for the moment, which in turn communicates a spirit of hopefulness. The statement about a second opinion is inappropriate because it gives the client false hope that her current diagnosis is inaccurate. Although he client may choose another medical opinion, she needs to come to that decision without the nurse's advice. Reponses should not convey false hope to the client. Nurses and clients should not confuse hope with unrealistic optimism.

4. A mother of three young children has been diagnosed with stage III breast cancer and is distraught. Which statement best communicates a spirit of hopefulness to this client? a) "You should seek a second medical opinion about your diagnosis" b) "Let's take this one day at a time; remember you have your daughter's dance recital next week" c) "I believe that you will fight hard to beat this and see your babies grow up" d) "I know another client with the same diagnosis who has been in remission for 10 years"

d) Call the health care provider to obtain an oxygen order Pg. 377-378 Obtaining an oxygen order can reduce the client's shortness of breath and help the family feel more comfortable. It is difficult for families to see the client with shortness of breath. The dying client and family need support, and the bedpan, sitting in a chair, or offering sips to drink do not address the feelings of shortness of breath.

5. A family of a dying client reports that their loved one is experiencing more shortness of breath. Which nursing intervention is most appropriate at this time? a) Get the client out of bed to the chair b) Offer the bedpan to urinate or defecat c) Offer the client sips to drink d) Call the health care provider to obtain an oxygen order

d) Add haloperidol to the client's treatment plan Pg. 381 Haloperidol may reduce hallucinations. Radiation therapy helps prevent 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 to analyze the lymph nodes or to destroy the tissues surrounding the tumor.

6. The physician is attending to a 72-year-old client with a malignant brain tumor. Family members report that the client rarely sleeps and frequently reports seeing things that are not real. Which intervention is an appropriate request for the hospice nurse to suggest to the physician? a) Obtain a biopsy to analyze the lymph nodes b) Begin radiation therapy to prevent cellular growth c) Perform surgery to remove the tumor from the brain d) Add haloperidol to the client's treatment plan

a) Increased restlessness Pg. 376-380 As the oxygen supply to the brain decreases, the patient may become restless. As the body weakens, the client will sleep more and begin to detach from the environment. For many clients, refusal of food is an indication that they are ready to die. Based on decreased intake, urinary output generally decreases in amount and frequency.

8. For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? a) Increased restlessness b) Increased urinary output c) Increased eating d) Increased wakefulness

a) Allows for the nurse to facilitate the grieving process Pg. 384-386 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.

9. 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 facilitate the grieving process b) Allows for the nurse to understand when the grieving process should be concluded c) Allows for the nurse to take the client through in the appropriate order d) Allows the nurse to express his or her feelings