Ch. 16 End of Life Care

Which is also known as a proxy directive? Medical directive Living will Durable power of attorney for health care Treatment directive

Durable power of attorney for health care Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Chart 16-4, p. 397.

A client nearing the end of life is experiencing delirium. Which action will the nurse take to help this client? Encourage family to visit. Apply restraints as needed. Increase environmental stimulation. Add additional lighting to the room.

Encourage family to visit. Explanation: Delirium can develop in the client who is near the end of life and may be due to an underlying treatable condition or the effects of the disease process. Actions should be taken to identify the underlying cause and provide appropriate interventions. The presence of familiar faces helps reduce the anxiety caused by the delirium. Restraints are not identified as an appropriate intervention for the client with delirium. Environmental stimuli should be reduced and harsh lighting avoided as these can increase the anxiety associated with delirium.

As the moment of death approaches, which of the following does the nurse encourage the family to do? Have the family sit in front of the client so they can be seen. Rub the client's hand and arm to comfort the client. Speak to the client in a calm and soothing voice. Lie next to the client and hold the client.

Speak to the client in a calm and soothing voice. Explanation: Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, The Death Vigil, p. 409.

According to federal guidelines, hospices may provide no more than what percentage of the aggregate annual patient-days at the inpatient level?

20

Which cardiovascular findings indicate to the nurse that the condition of the dying client is worsening?

Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles

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.)

1. Alterations in carbohydrate, fat, and protein metabolism 2. Endocrine dysfunction 3. Anemia

Stages of Kubler-Ross

denial, anger, bargaining, depression, acceptance

As a client approaches death, respirations become noisy. This is the result of which type physical event?

musculoskeletal change

A patient authorizes a son to make medical decisions and brings the completed forms for the nurse to place on the chart. What form does the nurse understand this is? An advance directive A living will A standard addendum to a will A proxy directive

A proxy directive Explanation: Advance directives are written documents that allow competent people to document their preferences regarding the use or nonuse of medical treatment at the end of life, specify their preferred setting for care, and communicate other valuable insights into their values and beliefs. The addition of a proxy directive (the appointment and authorization of another person to make medical decisions on behalf of the person who created the advance directive when he or she can no longer speak for himself or herself) is an important addition to the living will or medical directive that specifies the signer's preferences. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 395.

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?

Ask the client to rate the dyspnea on a scale of 0 to 10.

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? Offer the bedpan to urinate or defecate Call the health care provider to obtain an oxygen order Get the client out of bed to the chair. Offer the client sips to drink.

Call the health care provider to obtain an oxygen order Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Chart 16-10: Palliative Nursing Interventions for Dyspnea, p. 404.

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? Central nervous system Cardiovascular system Respiratory system Gastrointestinal system

Cardiovascular system Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, The Death Vigil, p. 409.

The nurse is caring for a client who is interested in learning about hospice care. Which of the eligibility criteria would the nurse stress?

Choice of palliative care over cure focused

The nurse is caring for a client who is interested in learning about hospice care. Which of the eligibility criteria would the nurse stress? Serious, progressive illness Choice of palliative care over cure focused Limited life expectancy Physician-certified illness

Choice of palliative care over cure focused Explanation: An important focus of hospice care is that care is palliative in nature. No further aggressive treatment to find a cure for the illness is administered. The client must accept this philosophy of care. The other options are factual and agreed on. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Palliative Care, p. 391.

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? Medical directive by proxy Living will declaration Durable power of attorney for health care End-of-life treatment directive

Durable power of attorney for health care Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Chart 16-4, p. 397.

A nurse is assessing a client with a terminal illness and finds that the client has cachexia. The nurse interprets this as indicating which of the following?

Profound protein loss

Which of the following does not coincide with Kübler-Ross's stages related to a dying client? Clients don't always follow the stages in order. Some client regress, then move forward again. The dying client usually exhibits anger first. The client may be in several stages at once.

The dying client usually exhibits anger first. Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 410.

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? The principle of justice The principle of nonmaleficence The principle of fidelity The principle of autonomy

The principle of autonomy Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Clinicians' Attitudes Toward Death, p. 389.

Evidence-based medical and nursing research 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? Make certain that the patient was aware of the signs of coronary artery disease. Write a prescription for a serum cholesterol level. Teach the patient how to assess his blood pressure weekly. Suggest activity modifications and treatments to help minimize the physical limitations of dyspnea.

Write a prescription for a serum cholesterol level. Explanation: Hypercholesterolemia is the most prevalent chronic disease in the United States, with 33.6% of all adults affected.

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.

As a client approaches death, respirations become noisy. This is the result of which type physical event? musculoskeletal change gastrointestinal impairment cardiac dysfunction central nervous system alterations

musculoskeletal change Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 408.

A type of comprehensive care for clients whose disease is not responsive to cure is a terminal illness. palliative care. euthanasia. interdisciplinary collaboration.

palliative care. Explanation: Palliative care is a type of comprehensive care for clients whose disease is not responsive to cure. Terminal illness is a progressive, irreversible illness that despite cure-focused medical treatment will result in the client's death. Euthanasia means the intentional killing by act or omission of a dependent human being for his or her alleged benefit. Interdisciplinary collaboration is communication and cooperation among members of diverse health care disciplines jointly to plan, implement, and evaluate care. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 391.

When evaluating a patient's response to acute pain, the nurse assesses for the presence of physiologic responses associated with the pain experience. Select all that apply:

1. Decreased urinary output 2. Hyperglycemia 3. Increased cardiac output 4. Increased metabolic rate

The nurse is caring for a client who has diminished lung function due to emphysema. The terminally ill client is short of breath on exertion and reports difficulty sleeping in bed. The client states, "I am so afraid of getting any worse." Which statement, by the nurse, assists the client in sustaining hope?

"I will talk with the health care provider to determine the next step in your care."

A terminally ill patient in pain asks the nurse to administer enough pain medication to end the suffering forever. What is the best response by the nurse? "I can't do that, I will go to jail." "I am surprised that you would ask me to do something like that." "I will see if the physician will order enough for that to occur." "I will notify the physician that the current dose of medication is not relieving your pain."

"I will notify the physician that the current dose of medication is not relieving your pain." Explanation: 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. Palliative sedation is most commonly used when the patient exhibits intractable pain, dyspnea, seizures, or delirium, and it is generally considered appropriate in only the most difficult situations. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 407.

Which statement, made by the nurse, can be most helpful when caring for a client in the third stage of Kubler-Ross' emotional reactions to dying? "Let's review the laboratory results and compare them with the diagnostic tests." "I understand that it would be wonderful to see your daughter's graduation." "What makes you most angry about getting the disease?" "I like your idea of living for today and enjoying those around you."

"I understand that it would be wonderful to see your daughter's graduation." Explanation: The third stage of Elisabeth Kubler-Ross' series of reactions is bargaining. Confirming the intention to live to a certain time is common in this stage. Reviewing laboratory and diagnostic tests occurs in the first stage, denial. Talking about anger occurs in the second stage, anger. Living for the day is an idea which occurs in the final stage, acceptance. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Assisting With Emotional Reactions, pp. 109-110.

A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? "It will hasten the death of the patient." "It will prolong life in a dignified manner." "It will use artificial means of life support if the patient requests it." "It will enable the patient to remain home if that is what is desired."

"It will enable the patient to remain home if that is what is desired." Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 391.

While providing care to a terminally ill client, the client asks, "Am I dying?" Which response by the nurse would be most appropriate? "What makes you think that you might be dying?" "Tell me some more about what is on your mind." "You're just having a bit of a set-back. You'll be fine." "What has your physician told you about your condition?"

"Tell me some more about what is on your mind." Explanation: When responding to the client, the nurse needs to acknowledge the client's fears. Having the client tell the nurse what's on his or her mind acknowledges the client's feelings and opens the way for more discussion. Asking the client about what makes him or her think he or she is dying is probing and does not address the client's feelings or needs. Telling the client that he or she will be fine gives the client false reassurance and does not address his or her fears. Asking about what the physician has told the client redirects the conversation away from the client's feelings and is inappropriate. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 399.

Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care? "A key component of hospice care is following your family for up to a year after your death." "Denial, sadness, anger, fear, and anxiety are normal grief reactions." "Mourning may be demonstrated by emotional feelings of sadness, anger, guilt, and numbness." "Tell me who or what gives you strength."

"Tell me who or what gives you strength." Explanation: Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. Assessment of people or things that provide strength to a terminally ill client is one way the nurse provides spiritually sensitive patient care. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 402.

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? "You will be able to stay only for approximately 1 month and then you will be discharged." "You will be able to stay for 2 months before being discharged." "There is no time limit for your stay. You can stay until you die." "When your stay reaches 6 months, you will be recertified for a continued stay."

"When your stay reaches 6 months, you will be recertified for a continued stay." Explanation: 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). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 394.

A nurse who provides care on a palliative unit of a busy urban hospital performs numerous task and roles in the provision of holistic care to patients and their families. Which of the following tasks is essential for nurses to manage patients at the end of life? Select all that apply.

1. Educate patients and families about end-of-life decision making. 2. Contribute to a coordinated, interdisciplinary plan of care. 3. Manage pain and symptoms.

Anorexia and cachexia are common problems at the end of life. The nurse plays an important role in managing symptoms and preventing complications. Which of the following are appropriate nursing interventions for these problems? Select all that apply.

1. Encourage the patient to eat in an upright position. 2. Recommend that the patient eat when hungry, regardless of usual meal times. 3. Teach the patient how to increase the nutritional value of meals (i.e., add dry milk powder to milk).

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

Administer pain medication on a schedule that prevents pain from intensifying. Explanation: Pain management is the most common concern for the dying patient. Medication should be given on a PRN schedule that keeps the patient comfortable. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 408.

The nurse manager of an oncology unit is concerned that the staff are experiencing symptoms of chronic loss caused by the death of many long-term clients. Which action will the manager take to support the staff's resilience? Select all that apply. Allow flexibility in scheduling. Assign support groups between staff. Encourage picking up shifts. Promote collaborative relationships. Ensure fairness with assignments.

Allow flexibility in scheduling. Promote collaborative relationships. Ensure fairness with assignments. Explanation: Burnout is defined as the triad of emotional exhaustion, cynicism, and ineffectiveness at work. By the time one notices burnout it is usually too late. In order to prevent burnout, there is a body of work to promote resilience, thereby providing clinicians with the skills needed to have work-life balance and the opportunity to remain productive and satisfied with their career. Actions that the manager can take to promote resilience with the staff include allowing flexibility in scheduling, supporting staff autonomy, promoting collaborative relationships, and ensuring fairness with assignments. Limiting time away from work is not an action to support staff resilience. Assigning staff to form support groups is not supporting autonomy.

All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? Allows for the nurse to facilitate the grieving process Allows for the nurse to take the client through in the appropriate order Allows for the nurse to understand when the grieving process should be concluded Allows the nurse to express his or her feelings

Allows for the nurse to facilitate the grieving process Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Grief, Mourning, and Bereavement, p. 410.

The client is 45 years old and has a family history of breast cancer. The client was diagnosed with breast cancer 2 months ago. During a routine visit, the physician prescribes dexamethasone to be taken over a 3-week period. Which symptom would prompt the physician to add dexamethasone to the client's treatment plan?

An 8-lb (3.6-kg) weight loss

Which of the following interventions should the nurse perform while providing spiritual care for a dying client? Encourage family members in their frank communication. Provide spiritual books. Ask the family members about spiritual care. Allow a period of privacy.

Ask the family members about spiritual care. Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 400.

Which of the following may be contained in an "emergency kit" for a hospice patient exhibiting restlessness? Benzodiazepine Oral sucrose Laxative Atropine sulfate drops

Benzodiazepine Explanation: A kit might contain small doses of oral morphine liquid for pain or shortness of breath, a benzodiazepine for restlessness, and an acetaminophen suppository for fever. Atropine sulfate drops may be used for excess respiratory secretions. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 403.

Which term refers to the period of time during which mourning of a loss takes place? Grief Mourning Hospice Bereavement

Bereavement Explanation: Bereavement is the period of time during which mourning of 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 clients and their families. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 410.

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? Lack of fully credentialed and trained hospice nurses Clients and families view hospice care as giving up Lack of Medicare/Medicaid funding for hospice Difficulty obtaining Medicare certification for hospice services

Clients and families view hospice care as giving up Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 392.

Glaser and Strauss (1965) identified four "awareness contexts." Which awareness context occurs when the client is unaware of their terminal state, whereas others are aware? Suspected awareness Open awareness Closed awareness Mutual pretense awareness

Closed awareness Explanation: Closed awareness occurs when the client is unaware of their terminal state, whereas others are aware. Suspected awareness occurs when the client suspects what others know and attempts to find out details about the condition. Open awareness occurs when the client, the family, and the health care professionals are aware that the client is dying and openly acknowledge that reality. Mutual pretense awareness occurs then the client, the family, and the health care professionals are aware that the client is dying but all pretend otherwise. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 389.

The nurse is participating in a family meeting with a client who is identifying preferences for end-of-life care. Which action will the nurse take to follow end-of-life care choices? Tell the family to file the client's living will with an attorney. Encourage the family to petition the court for a durable power of attorney. Contant the primary health care provider for a prescription for life-sustaining treatment. Discontinue medications and treatments for a "do not resuscitate" (DNR) prescription.

Contant the primary health care provider for a prescription for life-sustaining treatment. Explanation: A physician prescription for life-sustaining treatment (POLST) is a form that translates the client's preferences in the advance directive to medical orders that are transferable across settings and available to all health care providers. The form is signed by the client and health care providers. A living will is not filed with the client's attorney. The court is not petitioned for a client to identify a durable power of attorney for health care. Medications and treatments are not discontinued for a "do not resuscitate" (DNR) prescription. This type of order only withholds cardiopulmonary resuscitation.

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

Dusky appearance Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 409.

A client is dying, and the client and loved ones are in the grieving period. The nurse wants to support them in the grieving process. Which is the best intervention the nurse could perform? Encourage loved ones to express their feelings. Spend time alone with the client. Provide palliative care to the client. Disengage to give the grieving individuals privacy.

Encourage loved ones to express their feelings. Explanation: The nurse can encourage the client and loved ones to express their feelings. The nurse should listen in a nonjudgmental manner and avoid delivering criticism or advice. To help with this, the nurse should assess the client's family or other companions in terms of characteristics such as roles, cohesion, flexibility, and communication. Spending time alone with the client does not facilitate the grieving process for the client and loved ones. Disengaging is also not an effective intervention, as the grieving individuals often value the nurse's teaching about what to expect during the process of dying. Providing palliative care is often done during this time, but it does not address the grieving process. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 410.

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? Encourage the family members to express their feelings and listen to them in their frank communication. Encourage conversations about the impending death of the client. Be a silent observer and allow the client to communicate with the family members. Encourage the client's family members to spend time with the client.

Encourage the family members to express their feelings and listen to them in their frank communication. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, pp. 410-411.

The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following? A workshop on caring for the dying client Use evidence-based practice in daily care regimen. Explore own feelings on mortality and death and dying. Participate in a support group to learn clients' feeling on care.

Explore own feelings on mortality and death and dying. Explanation: To care for others in the dying process, the nurse must explore his or her own feelings about mortality and death and dying. Understanding self provides a perspective to cope with and then support clients and families experiencing pain and grief. The other options are helpful in determining appropriate nursing care but not the first step. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Clinicians' Attitudes Toward Death, p. 389.

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

Focus on the client's basic needs. Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 388.

For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? Increased wakefulness Increased eating Increased restlessness Increased urinary output

Increased restlessness Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Chart 16-11, p. 408.

The nurse is visiting the home of a client who has refused all medical treatment for a terminal illness. Which assessment findings indicate to the nurse that the client will die within a few hours? Select all that apply. Irregular pulse Mottled extremities Apnea lasting 45 seconds Verbalizing incoherent phrases Systolic blood pressure of 80 mm Hg with no diastolic reading

Irregular pulse Mottled extremities Apnea lasting 45 seconds Explanation: Symptoms indicating that a client is hours before dying, or is in the actively dying phase, include an irregular pulse and mottled extremities. The client may also have periods of apnea that last longer than 40 seconds. A blood pressure of 60 mm Hg without a diastolic reading indicates slowing of the cardiovascular system. Verbalizing with coherency is unlikely in the hours before dying, whereas verbalizing incoherent phrases indicates delirium that would occur weeks before death.

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? Barbiturate coma Palliative sedation Conscious sedation Patient-controlled analgesia

Palliative sedation Explanation: 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.

A client in hospice has end-stage renal failure. The client states that, of late, he has lost his appetite and feels like everyday situations have become more stressful. The client reports feeling restless. In addition, the client's spouse notices that the client is becoming more confused. What is the most important nursing intervention that needs to be carried out at this point?

Provide the spouse with an emergency kit that contains small doses of oral morphine liquid.

A client in hospice has end-stage renal failure. The client states that, of late, he has lost his appetite and feels like everyday situations have become more stressful. The client reports feeling restless. In addition, the client's spouse notices that the client is becoming more confused. What is the most important nursing intervention that needs to be carried out at this point? Make arrangements for the client to receive nutritional counseling. Immediately administer drug therapy to restore renal function. Make arrangements with the physician to administer immunosuppressants. Provide the spouse with an emergency kit that contains small doses of oral morphine liquid.

Provide the spouse with an emergency kit that contains small doses of oral morphine liquid. Explanation: One of the most important aspects of the care of a client at the end of life is anticipating and planning interventions for symptoms. Both clients 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 client are all relevant nursing interventions that form a part of the nursing management process for a client with chronic renal failure. Nutritional counseling, administration of drug therapy to restore renal functions, and administration of immunosuppressant drugs are medical management tasks. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 403.

Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions? Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous clients in hospice Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Offering reassurance that the nurse has had 5 years of assisting clients in hospice and their families care for loved ones at the end of life

Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Explanation: A key to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "I know just how you feel." Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Chart 16-5, p. 398.

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

Respect the client's and family members' choices. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 398.

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?

Side effects must be treated.

The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation? Sit with the client's daughter privately and encourage her to express her feelings frankly. Remind the daughter of the client's impending death and the importance of expressing herself. Remain focused on the client's needs and care because these are your main responsibilities. Insist that the daughter try her best to make the client's final days happy ones.

Sit with the client's daughter privately and encourage her to express her feelings frankly. Explanation: Failure to verbalize feelings, express emotions, and show tenderness for the dying person is often a source of regret for grieving relatives. Therefore, families must feel that they can express their feelings with nurses who are compassionate listeners. If nurses encourage family members and listen to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. Families must feel that they can express their feelings with nurses who are compassionate listeners. Reminding a family member that their loved one will die soon shows a lack of compassion in this situation. Although the client is the nurse's main priority, it is the nurse's role to encourage family members to identify strengths and express feelings as a method of coping with the death of their loved one. The response regarding making the father's final days happy ones shows a lack of caring on the part of the nurse. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 410.

A nurse has been providing in-home hospice care to an older adult client with lung cancer for more than six months. The family asks the nurse how long the Medicare hospice services will continue. What is the nurse's best response? The hospice services need to end now that the client has had the services for six months. The Medicare hospice services can continue as long as the physician and hospice director agree about the client's terminal condition. Medicare hospice services end at the seventh month of care. The client must begin to pay for other home health services since six months of hospice care have been received.

The Medicare hospice services can continue as long as the physician and hospice director agree about the client's terminal condition. Explanation: Eligibility for the Medicare Hospice Benefit includes physician and hospice medical director confirmation that the client is terminally ill, with a life expectancy of 6 months or less if the disease follows its natural course. The condition must be considered or classified as terminal, not just serious and progressive. The hospice services do not end at the sixth or seventh month of care. The client does not have to find other home health services as long as the Medicare certification process from the physician and hospice medical director was obtained. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 394.

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

The response experienced by anyone who has suffered a loss Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 410.

A nurse is developing a teaching plan for a terminally ill client and his family about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan? Each client experiences each of the stages. Typically, the stages occur in succession. The stages are applicable to any loss. Most clients reach acceptance by the time of death.

The stages are applicable to any loss. Explanation: The five stages of dying describe the five emotional reactions applicable to the experience of any loss. Not every client or family member experiences every stage. Many clients never reach a stage of acceptance. Clients and family fluctuate on a sometimes daily basis in their emotional responses. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 410.

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? altered gastrointestinal function drop in blood pressure and rapid heart rate weight loss and inadequate food intake irregular eating habits

weight loss and inadequate food intake Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 406.

The nurse is caring for a client who has diminished lung function due to emphysema. The terminally ill client is short of breath on exertion and reports difficulty sleeping in bed. The client states, "I am so afraid of getting any worse." Which statement, by the nurse, assists the client in sustaining hope? "Do not worry, I will be here for you to help you with your needs." "I will talk with the health care provider to determine the next step in your care." "Your grandchild is almost here, and you will enjoy seeing him." "I hear you say that you are not sleeping well."

"I will talk with the health care provider to determine the next step in your care." Explanation: The client is assisted in hopefulness by believing that the healthcare team will make his remaining days meaningful. By conveying a sense that the nurse will discuss the client's condition with the health care provider, the client recognizes that the healthcare team will use whatever treatment and comfort measures are available. Telling a client not to worry is not therapeutic and is condescending. Waiting for a grandchild does not address the client's thought. Reflecting what the client said for clarification opens communication but does not instill hopefulness. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Hope, p. 402.

The nurse arrives to the home of a client with a terminal illness who has just passed away. Which response will the nurse make when the family member states that the last dose of pain medication provided caused the death? "Do you remember what the medication was that you think caused the death?" "It is likely that the medication caused the body systems to slow, which precipitated the death." "There is always a chance that pain medication will cause death in a client with a terminal illness." "It is possible that your family member died close to the time of the medication but the medication did not cause the death."

"It is possible that your family member died close to the time of the medication but the medication did not cause the death." Explanation: The nurse teaches the family caregivers about comfort measures and pain medications when caring for a dying client. At the end-of-life, clients may receive more frequent doses of pain medication; however, there is always a strong possibility that a client approaching end-of-life will die in close proximity to the time of the medication. It will not help to comfort family members if a nurse asks what medication was given last. Family members should be prepared for this possibility and be reassured that they did not cause the death of the client by giving a dose of the medication. The last dose of pain medication given to a dying client will not cause death. There is no evidence to support that the medication caused the body systems to slow which precipitated the death. There is also no evidence to support that pain medication will cause death in a client with a terminal illness.

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? "Let's take this one day at a time; remember you have your daughter's dance recital next week." "You should seek a second medical opinion about your diagnosis." "I believe that you will fight hard to beat this and see your babies grow up." "I know another client with the same diagnosis who has been in remission for 10 years."

"Let's take this one day at a time; remember you have your daughter's dance recital next week." Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 410.

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

"This must be very difficult for you." Explanation: 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"). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 399.

The nurse is preparing to conduct a spiritual assessment with a client diagnosed with a terminal illness. Which question(s) will the nurse ask to complete this assessment? Select all that apply. "Do you believe in God?" "What is your faith or belief?" "What gives your life meaning?" "Are you a member of a spiritual community?" "What importance does faith have in your life?"

"What is your faith or belief?" "What gives your life meaning?" "Are you a member of a spiritual community?" "What importance does faith have in your life?" Explanation: The spiritual assessment is a key component of a comprehensive assessment for clients who are terminally ill. While the assessment should include religious affiliation, spiritually is a broader concept than just religion. A four-step spiritual assessment using the acronym FICA involves asking specific questions such as "What is your faith or belief?" "What gives your life meaning?" "Are you a member of a spiritual community?" "What importance does faith have in your life?" The question "Do you believe in God?" is not a question that is specific to a spirituality assessment because clients have varying belief systems.

The client is 45 years old and has a family history of breast cancer. The client was diagnosed with breast cancer 2 months ago. During a routine visit, the physician prescribes dexamethasone to be taken over a 3-week period. Which symptom would prompt the physician to add dexamethasone to the client's treatment plan? Frequent bloody discharge from the breast Massive swelling in the arm Coarse skin around the breast An 8-lb (3.6-kg) weight loss

An 8-lb (3.6-kg) weight loss Explanation: Dexamethasone initially increases appetite and may provide short-term weight gain in some clients. Massive swelling in the arm is indicative of edema, which occurs due to advanced nodal involvement. Radiation therapy with ionizing radiation stops cellular growth. This therapy 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. Other symptoms of breast cancer may include scaly skin around the nipple, skin changes, erythema, and clear, milky, or bloody discharge. These symptoms, however, will not prompt the physician to prescribe dexamethasone therapy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, pp. 405-406.

A client is experiencing anorexia and the physician is to order a medication to stimulate the client's appetite. Which of the following would the nurse least likely expect the physician to prescribe? Megestrol Dexamethasone Dronabinol Atropine

Atropine Explanation: Atropine is used to manage excessive oral and respiratory secretions when death is imminent. Dexamethasone, megestrol, and dronabinol may be used to stimulate appetite in clients who are at the end of life. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 409.

A client approaching end-of-life reports dyspnea as being 7 on a scale from 0 to 10. Which action will the nurse take to assist this client? Lower the head of the bed. Restrict the intake of oral fluids. Coach to use pursed lip breathing. Increase the air temperature in the room.

Coach to use pursed lip breathing. Explanation: Dyspnea is one of the most prevalent symptoms at the end of life and is considered a highly subjective symptom. To determine the intensity of dyspnea, the client can be asked to report the severity on a scale from 0 to 10, similar to using a pain rating scale. Interventions to reduce the subjective feeling of dyspnea includes the use of purse-lipped breathing. The head of the bed should be elevated or help the client assume a forward-learning posture. Oral fluids should not be restricted as this will help keep pulmonary secretions thin. The air temperature in the room should be cool as this helps facilitate breathing.

The nurse is providing care to a family who is facing a life-threatening illness. The nurse is assessing how family members bond and how the family works as a team. The nurse is assessing which of the following?

Cohesion and boundaries

The family members of a dying patient are finding it difficult to verbalize feelings and show tenderness for the dying person. Which of the following nursing interventions should a nurse perform in such situations? Encourage the family members to express their feelings and listen to them in their frank communication. Encourage conversations on the impending death of the patient. Be a silent observer and allow the patient to communicate with the family members. Encourage the patient's family members to spend time with the patient.

Encourage the family members to express their feelings and listen to them in their frank communication. Explanation: 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 in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying patient. It is not advisable for the nurse to encourage conversations on the impending death of the patient. Being a silent observer or encouraging the family members to spend time with the dying patient may not help the family members to express their feelings. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 398.

A nurse is working with a family of a deceased client and assisting them in working through their grief and mourning. Which of the following would be the priority to promote healthy accommodation of the loss by the family? Helping the family recognize the loss has occurred Assisting the family in expressing their feelings of loss Encouraging the family to remember the relationship they had with the client Urging them to give up their old attachments to the client

Helping the family recognize the loss has occurred Explanation: The priority in assisting the family to accommodate the loss of the client in a healthy way is to help them recognize the loss. Once this occurs, then the family can react to, experience, and express the feeling the of the pain of the loss; recollect and re-experience the deceased, the relationship, and associated feelings; and relinquish old attachments to the deceased. Reference: Timby, B. K., Smith, N. E. Introductory Medical-Surgical Nursing, 12th ed., Philadelphia: Wolters Assessment Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 10: End-of-Life Care, p. 411.

Which of the following would not be consistent with promoting nutrition in terminally ill patients? Maintaining a balanced diet Offering small portion of favorite foods Avoiding arguments at mealtime Offering cool foods rather than hot foods

Maintaining a balanced diet Explanation: One should not be overly concerned about a "balanced" diet for terminally ill patients. Offering small portions of favorite foods, avoiding arguments at mealtime, and offering cool foods rather that hot foods are all tips that promote nutrition in terminally ill patients. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 405.

A group of nursing students is reviewing information about palliative care. The students demonstrate a need for additional review when they identify which of the following? Palliative care is the same as hospice care. Palliative care developed after hospice care developed. Palliative care is conceptually broader than hospice care. Palliative care is often provided along with disease-lessening treatments.

Palliative care is the same as hospice care. Explanation: Palliative care is not synonymous with hospice care. All hospice care is palliative but not all palliative care is hospice care. Palliative care is conceptually broader than hospice care and is an approach to care as well as a structured system for delivering care. Palliative care followed the development of hospice care. It does not begin when cure-focused treatment ends but is most helpful when provided along with disease-remitting treatment. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, pp. 390-391.

A client with long-term breast cancer who was recently enrolled in a hospice program demonstrates signs and symptoms of clinical depression. Which action by the hospice nurse is appropriate? Educate the client that depression is expected. Perform a thorough pain assessment. Ask the client whether she is planning to hurt herself. Explain that antidepressants are not indicated for the client.

Perform a thorough pain assessment. Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 407.

The nurse visits the home of a client with terminal illness. Which assessment findings indicate to the nurse that the client might die within a few months? Select all that apply. Refuses to eat Sleeps most of the day Reports feeling fatigued Onset of generalized weakness Does not want to visit with family members

Refuses to eat Reports feeling fatigued Onset of generalized weakness Does not want to visit with family members Explanation: There are specific stages to the dying process. The first stage begins months before the actual death and includes a decreased appetite or refusal to eat. Other symptoms of this stage are the development of fatigue and generalized weakness. The one final symptom of this stage is social isolation or not wanting to visit with family members. An increase in sleeping is a symptom associated with the stage of dying that occurs weeks before actual death.

A client nearing the end of life is unconscious and is experiencing gurgling from the respiratory tract. Which route will the nurse use to provide the client atropine? Oral Rectal Topical Intravenous

Topical Explanation: In the last stage of dying, clients typically experience impaired secretions. This may be manifested by noisy, gurgling breathing or moaning. In most cases, the sounds of breathing at the end of life are related to oropharyngeal relaxation with inability to clear secretions through cough or swallowing due to somnolence. Treatment of impaired secretions in the actively dying is usually achieved with the use of anticholinergic medications, such as atropine, to dry secretions. Because the client is unconscious, topical is the safest route to provide the medication. The client is unconscious and not be given an oral medication. Rectal is not a route identified for these medications, nor is an intravenous route used to treat impaired secretions in a client who is dying.

How does a nurse who has been providing home care to a terminally ill client know that the client's condition is beginning to deteriorate? apical pulse reaches 100 beats/minute skin appears red and flushed urine output increases facial muscles contract

apical pulse reaches 100 beats/minute Explanation: 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, and the jaw and facial muscles relax. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 409.

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: care that will reduce the client's physical discomfort and manage clinical symptoms. care that is provided at the very end of an illness to ease the dying process. an alternative therapy that uses massage and progressive relaxation for pain relief. offered to terminally ill clients who wish to remain in their homes in lieu of hospice care.

care that will reduce the client's physical discomfort and manage clinical symptoms. Explanation: 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. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 390.

During a home care visit to a client in hospice, the client's spouse reveals to the nurse an understanding that the client's death is inevitable. Recognizing the spouse is exemplifying the Kübler-Ross stage of acceptance, which statement by the nurse is most appropriate? "Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." "Have you thought about what you will do when you find your spouse after he has died?" "Make sure you have made previous arrangements with the funeral home for burial arrangements." "I would make arrangements to have all your children present for the death vigil."

"Tell me how you plan to react when you first realize that your spouse is breathless and has no pulse." Explanation: Anticipating and planning interventions is a cornerstone of end-of-life care. The nurse encourages communication and anticipatory grieving by using open-ended statements such as "Tell me. . . ." Effective communication techniques include the avoidance of closed-ended statements and giving advice. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 403.

A nurse is caring for a client who is terminally ill and is inquiring about physician-assisted suicide. Which statement if made by the nurse would correctly inform the client of this practice? "The health care provider administers an analgesic at a level that renders the client unconscious." "The health care provider provides the means for the clients to take their life." "The health care provider provides the means and the nurse assists the client in ending their life." "The health care provider provides the means for suicide to clients who require palliative care."

"The health care provider provides the means for the clients to take their life." Explanation: Physician-assisted suicide is the practice of providing a means by which a client can end their life. Much controversy exists concerning the practice. California, Vermont, Oregon, Washington, and Montana are the only states that permit physician-assisted suicide. Administering analgesics at a level that renders the client unconscious is referred to as passive euthanasia as it is believed to facilitate death by letting "nature take its course." It is different than a provider providing the means for the client to take their own life. The health care provider may provide the means for the client to end their life, but the nurse does not assist the client in the act. Nurse practice prohibit nurses from assisting clients to die. Health care provider-assisted suicide is not considered part of palliative care. Palliative care is an approach that improves the quality of life of those at the end of life. It neither hastens nor postpones death; it provides relief from pain and discomfort, addresses spiritual needs, and provides emotional support to the client and family. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Assisted Suicide, p. 390.

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. "I know just how you must feel." "This must be very difficult for you." "Tell me more about what's on your mind." "You still have time for a good life." "Let's focus on what your doctor has planned."

"This must be very difficult for you." "Tell me more about what's on your mind." Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 399.

A 25-year-old client with cancer who is experiencing unrelieved pain rated a 9 on the pain scale requests that the hospice nurse induce a state of unconsciousness until the client dies. Which statement by the nurse demonstrates an understanding of a key difference between conscious sedation and euthanasia? "I cannot legally administer pain medications that will induce unconsciousness to relieve your pain." "Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death." "Total sedation is a commonly practiced method used in this situation; I will contact your physician and begin treatment as soon as possible." "I need to perform a complete pain assessment to confirm the amount of pain you are experiencing before recommending sedation."

"Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death." Explanation: When a terminally ill client or the client'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 client'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 client requires intervention/treatment. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 407.

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.) Alterations in carbohydrate, fat, and protein metabolism Endocrine dysfunction Anemia Neurologic dysfunction Bladder incontinence

Alterations in carbohydrate, fat, and protein metabolism Endocrine dysfunction Anemia Explanation: 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). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 405.

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? Denial Anger Bargaining Acceptance

Anger Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 410.

The nurse is caring for a 90-year-old client who has never completed an advance directive. The client has a child but has not seen the child in several years. A neighbor has assisted the client with meals and housecleaning for many years. The neighbor states that the client expressed only wanting to have comfort measures. The estranged offspring wants the client to be treated aggressively. Which would be the nurse's initial step? Follow the child's directive. Follow the neighbor's directive. Assess the client's ability to state wishes. Notify the physician of the discrepancy.

Assess the client's ability to state wishes. Explanation: It cannot be assumed that the client is unable to make decisions independently because of advanced age. Before any other person is asked about the client's wishes, the client needs to be asked first. The physician, who has a healthcare relationship with the client, may also have documented information about wishes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Psychosocial and Reglulatory Issues, p. 395.

A nurse has been working in hospice care for 10 years. Based on her experience, she drafts her plan of care with the understanding that the most significant barrier to improving care at the end of life is the: Attitude of health care professionals toward terminal illness. Lack of social support systems for the dying patient. Fear of over-medicating the patient when pain is severe. Patient's resistance to accepting care.

Attitude of health care professionals toward terminal illness. Explanation: Clinicians' attitudes toward the terminally ill and dying remain the greatest barrier to improving care at the end of life. Clinicians' reluctance to discuss disease and death openly with patients stems from their own anxieties about death, as well as misconceptions about what and how much patients want to know about their illnesses. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 389.

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

Avoiding criticizing or giving advice Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 398.

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? Physician's orders Client's goals Length of required treatment Invasiveness of the treatment

Client's goals Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 400.

Which of the following remains the greatest barrier to improving end-of-life care? Advances in technology available to prolong life Clinician's attitudes toward the terminally ill Client and family denial about the seriousness of terminal illness Focus on managing acute illness to achieve a cure

Clinician's attitudes toward the terminally ill Explanation: The greatest barrier to improving care at the end of life is the clinicians' attitude toward the terminally ill and dying. Clinicians' reluctance to discuss disease and death openly with clients stems from their own anxieties about death and misconceptions about what and how much clients want to know about their illness. Technological advances for prolonging life have led to numerous ethical issues, but these issues have affected all aspects of end-of-life care--for example, how clinicians care for the dying, how family and friends participate in care, how families prepare for terminal illness and death, and how they feel after the death of a loved one. Client and family denial may be considered a barrier, but denial often is considered a useful coping mechanism. The management of acute illness to achieve a cure reflects the sociocultural context of death and dying in America setting up a cure/care dichotomy. However the focus is shifting to include a care-focused perspective for healing. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 389.

The nurse is providing care to a family who is facing a life-threatening illness. The nurse is assessing how family members bond and how the family works as a team. The nurse is assessing which of the following? Family constellation Cohesion and boundaries Flexibility and adaptability Communication

Cohesion and boundaries Explanation: Assessment of family cohesion and boundaries focuses on how autonomous and interdependent family members are, such as their bonding and their ability to work as a team. Family constellation is revealed by the members of the family, who is important to the client and the roles and relationships among family members. Flexibility and adaptability is revealed by the family's ability to integrate new information and how they manage change. Communication is revealed by how open, clear, and direct the family is with information and by any topics that are avoided. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 411.

A client whose parents died over 2 years ago begins to cry when asked questions about the family health history during an assessment. Which type of grief would the nurse identify that this client is experiencing? Unresolved Anticipatory Complicated Disenfranchised

Complicated Explanation: Complicated or prolonged grief is characterized by an intense response after a loss where profound emotions persist usually over a year. The client who cries when talking about parents' health problems 2 years after their death is demonstrating signs of complicated grief. Unresolved grief is associated with a traumatic or unexpected loss. Anticipatory grief is unconsciously preparing for what might happen if someone were to die. Disenfranchised grief is when the grieving person feels that society does not acknowledge or support the person's right to grieve.

A hospice nurse performs a follow-up telephone call to the spouse of a client who died about 1 year ago. The spouse tells the nurse, "I'm always feeling so sad. Life just doesn't feel worth living." Further conversation reveals that the spouse is having trouble sleeping and eating since her husband's death and that the spouse is "drinking more since he died." The nurse identifies which nursing diagnosis as the priority?

Complicated grieving (Complicated grieving is characterized by prolonged feelings of sadness and feelings of general worthlessness or hopelessness that persist long after the death, prolonged symptoms that interfere with activities, or self-destructive behaviors such as alcohol or substance abuse and suicidal ideation or attempts. Thus, the nursing diagnosis of complicated grieving would be the priority and most appropriate. Although the client may be having trouble coping or experiencing stress, complicated grieving is more applicable. Although there is no time table to denote grieving, the nursing diagnosis of grieving would be more appropriate in the period surrounding the husband's death, rather than 1 year later.)

A client who has been demonstrating signs of impending death is awake, alert, and wants to see grandchildren after they attend school. Which action will the nurse take to support this client's request? Suggest the family bring one grandchild per day to visit the client. Contact the family to ask for grandchildren to come to visit the client. Tell the family that the client will most likely not last until the end of the day. Remind the client that they need rest and the grandchildren can visit another time.

Contact the family to ask for grandchildren to come to visit the client. Explanation: Days before death the client will demonstrate neurologic changes that include somnolence, restlessness, dulled senses, and a possible "rally" in energy. The client demonstrating signs of impending death who is now awake, alert, and asking to see grandchildren is experiencing a rally which should be supported by asking the family to bring the grandchildren to see the client. Bringing one grandchild per day to visit would not be appropriate because the rally is not going to last for several days and the client might die before all grandchildren have an opportunity to visit. A rally does not indicate impending death but rather death will most likely occur in a few days. The client's rally should be supported and not discouraged by reminding them to rest and visit with grandchildren another day.

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? Routine home care Continuous care Inpatient respite care General inpatient care

Continuous care Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 394.

A nurse is providing hospice care in Portland, Oregon to a 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 interventions should the nurse implement? Select all that apply. Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Comfort the client by saying it will all be over soon. Encourage the client to explain his or her wishes. Recommend that the client consider physician-assisted suicide.

Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Encourage the client to explain his or her wishes. Explanation: This client lives in Oregon, one of five 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. 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 or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed. Philadelphia: Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 390.

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. Type 2 diabetes mellitus Carcinoma-in-situ Coronary artery disease End-stage renal disease

End-stage renal disease Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 9: Chronic Illness and Disability, p. 140.

Which term is used to describe the personal feelings that accompany an anticipated or actual loss? Bereavement Grief Mourning Spirituality

Grief Explanation: Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 410.

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. Gurgling as the client breathes through the mouth Breathing that is very rapid Decrease in amount of urine produced Refusal to ingest food or fluids Increase in visual and auditory abilities

Gurgling as the client breathes through the mouth Decrease in amount of urine produced Refusal to ingest food or fluids Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 409.

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. It is characterized by a progressive decline in normal physiologic function It can be associated with exacerbations and remissions. It is defined as long-term with the possibility of a cure if intervention is rapid and timely. It can require short-term management (<3 months). It results in residual disability due to non-reversible pathology.

It is characterized by a progressive decline in normal physiologic function It can be associated with exacerbations and remissions. It results in residual disability due to non-reversible pathology. Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 9: Chronic Illness and Disability, p. 141.

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. Maintaining client comfort Arranging plans for after death Supporting family members Providing personal care Completing a head-to-toe assessment Encouraging fluids

Maintaining client comfort Supporting family members Providing personal care Explanation: 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. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Nursing Care of Patients Who Are Close to Death, p. 407.

Which term best describes a living will? Proxy directive Medical directive Health care power of attorney Durable power of attorney for health care

Medical directive Explanation: A living will is a type of advance medical directive in which the individual, who is of sound mind, documents treatment preferences. A proxy directive and health care power of attorney are other names for a durable power of attorney for health care, in which one individual is appointed and authorized to make medical decisions on behalf of another person when that person is no longer able to speak for him or herself. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Chart 16-4, p. 397.

Which of the following is a term that refers to individual, family, group, and cultural expressions of grief and associated behaviors? Mourning Grief Bereavement Spirituality

Mourning Explanation: Mourning refers to individual, family, group, and cultural expressions of grief and associated behaviors. Grief refers to the personal feelings that accompany an anticipated or actual loss. Bereavement refers to the period of time during which mourning takes place. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 410.

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? Mental confusion Reduced urinary output Restlessness Muscle wasting

Muscle wasting Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 406.

Which "awareness context" is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise? Mutual pretense awareness Closed awareness Suspected awareness Open awareness

Mutual pretense awareness Explanation: In mutual pretense awareness, the client, the family, and the health care professionals are aware that the client is dying, but all pretend otherwise. In closed awareness, the client is unaware of his or her terminal state, whereas others are aware. In suspected awareness, the client suspects what others know and attempts to find it out. In open awareness, all are aware that the client is dying and are able to openly acknowledge that reality. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 389.

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? Over the course of several visits During the initial visit As the client's condition begins to deteriorate When the client exhibits signs of imminent death

Over the course of several visits Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 400.

A nurse is providing care to a terminally ill client who follows Islamic traditions and is experiencing pain. When developing a plan of care for this client, an understanding of which of the following would the nurse need to integrate into the plan? Pain is viewed as a means of cleansing by God. Pain must be controlled regardless of the client's wishes. Pain is considered a positive aspect that leads to rebirth. Pain provides the client with an opportunity for repentance.

Pain is viewed as a means of cleansing by God. Explanation: The Islamic religion views pain as a cleansing instrument of God. Pain relief is appropriate when there is no doubt that the person's disease is causing untreatable suffering. However, all parties involved must agree formally to the method(s) chosen. Good karma, a view of Hinduism, leads to rebirth. Repentance is a view associated with traditional Christianity. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 396.

A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival. Palliative care Radiation Angiogenesis Respite care

Palliative care Explanation: In a study of referral to palliative care for clients newly diagnosed with a disease with very poor prognosis, researchers found that those clients receiving palliative care plus standard oncology demonstrated improved quality of life and mood and had longer median survival. Radiation is primarily used when a cancer spreads to other organs, and it has not been proven to affect mood. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Respite care is provided on an occasional basis to relieve the family caregivers. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, p. 392.

The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using? Inpatient respite care Palliative care Continuous care General inpatient care

Palliative care Explanation: Long-term care is increasing as a setting to provide palliative care that addresses management of symptoms 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 to manage a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, pp. 392-393.

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? Participating in assisted suicide violates the Code of Ethics for Nurses. Nurses may administer medications prescribed by physicians to hasten end of life. A client has the right to make independent decisions about the timing of his or her death. Most states have enacted laws that allow for physician-assisted suicide.

Participating in assisted suicide violates the Code of Ethics for Nurses. Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 407.

A nurse is assessing a client with a terminal illness and finds that the client has cachexia. The nurse interprets this as indicating which of the following? Extreme anorexia Starvation Profound protein loss Severe asthenia

Profound protein loss Explanation: Cachexia is associated with anabolic and catabolic changes in metabolism that relate to activity of neurohormones and proinflammatory cytokines, resulting in profound protein loss. Although anorexia may exacerbate cachexia, it is not a primary cause. Starvation refers to simple food deprivation and is not cachexia. Anorexia-cachexia syndrome, characterized by disturbances in carbohydrate, protein, and fat metabolism, endocrine dysfunction, and anemia results in severe asthenia (loss of energy). Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 406.

When a person authorizes another to make medical decisions on his or her behalf, the person has written which of the following? Treatment directive Living will Standard addendum to a will Proxy directive

Proxy directive Explanation: Durable power of attorney for health care is a legal document through which the signer appoints and authorizes another individual to make medical decisions on his or her behalf when he or she is no longer able to speak for him- or herself. This is also known as a health care power of attorney or a proxy directive. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed., Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 3: Critical Thinking, Ethical Decision Making, and the Nursing Process, p. 34; Chapter 16: End-of-Life Care, p. 395.

A client with a terminal illness is diagnosed with sarcopenia. Which mechanism(s) of the anorexia/cachexia syndrome does the nurse identify that contributed to the development of this condition? Select all that apply. Loss of appetite Intolerance to treatments Decreased immune response Reduced voluntary motor activity Reduced rate of muscle protein synthesis

Reduced voluntary motor activity Reduced rate of muscle protein synthesis Explanation: 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). Anorexia and cachexia differ from starvation (simple food deprivation) in several important ways. Anorexia is defined as inadequate nutritional intake, while cachexia refers to severe lean muscle loss. Cachexia is associated with anabolic and catabolic changes in metabolism that relate to activity of neurohormones and proinflammatory cytokines, resulting in profound protein loss. The development of sarcopenia in a client with this syndrome is caused by reduced voluntary motor activity and the reduced rate of muscle protein synthesis. The loss of appetite causes generalized tissue wasting. Intolerance to treatments leads to an increase in morbidity and mortality. A decreased immune response increases the risk for infection.

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? Risk for constipation related to the effects of an opioid Risk for ineffective cerebral tissue perfusion related to central nervous system effects of the drug Caregiver role strain related to the need for around-the-clock pain control Impaired physical mobility related to sedative effects of the drug

Risk for constipation related to the effects of an opioid Explanation: 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 infection 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 403.

The nurse is caring for a client with Huntington chorea who has decided to refuse all food and beverages. For which type of suffering will the nurse assess the client before supporting the client's decision? Select all that apply. Social Physical Spiritual Grieving Psychological

Social Physical Spiritual Psychological Explanation: The voluntary stopping of eating and drinking is an option of last resort and may be considered when a client cannot imagine prolonged dying and suffering from a life-limiting illness. Aggressive palliative treatments for all types of suffering to include social, physical, spiritual, and psychological measures should be explored and offered before supporting voluntarily stopping of eating and drinking. Grieving is specific to family loss, not something that the nurse would assess in the client.

A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion indicates that the client requires more teaching about hospice care? The client doesn't want to discuss death around his girlfriend. The client entered a clinical trial through the National Cancer Institute. The physician orders weekly blood transfusions to be given at home. The client explains that he isn't ready to complete his will.

The client entered a clinical trial through the National Cancer Institute. Explanation: The client involved in a clinical trial needs additional teaching about hospice care. This treatment option suggests that the client isn't ready for palliative care, which is a criterion for hospice care. Preferring not to discuss death around the girlfriend and not feeling ready to complete a will are normal responses to the grieving process. Blood transfusions are considered palliative care. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 391.

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. The caste of the client and family will determine their view of death. The way a person dies is of great individual importance. Pain is viewed as a mechanism for cleansing. The family will create a new ethereal body the first 10 days after death. Death occurs through God's permission.

The way a person dies is of great individual importance. Pain is viewed as a mechanism for cleansing. Death occurs through God's permission. Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 396.

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? There remains a conspiracy of silence about dying despite progress in the area. Most clinicians are very open to talking about disease and dying with clients. Clients, for the most part, would gain hope if they were told about a poor prognosis. Clients would ask for information if they really had a desire to know.

There remains a conspiracy of silence about dying despite progress in the area. Explanation: 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. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 389.

Despite having been administered 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? Offer small amounts of nourishment frequently Gently massage the arms and legs Use imagery, humor, and progressive relaxation Encourage the patient to sleep

Use imagery, humor, and progressive relaxation Explanation: Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication and to reduce dyspnea. 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 in potentiate the effects of pain medication. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 14th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 16: End-of-Life Care, Chart 16-10, pp. 403-404.

When assessing a terminally ill client, the nurse notices that the client has copious secretions at the back of the throat and in the mouth. The nurse is preparing a teaching plan for the family about caring for these secretions. Which of the following would be least appropriate to include? Positioning the client on the side with the head supported with a pillow Using a soft toothbrush to vigorously clean the mouth Performing gentle suctioning of the mouth Administering a prescribed anticholinergic agent

Using a soft toothbrush to vigorously clean the mouth Explanation: Secretions are often more distressing to the family than their presence is to the client. Gentle mouth care with a moistened swab or very soft toothbrush helps maintain the integrity of the client's mucous membranes. Other helpful measures include positioning the client on the side with the head supported with pillows to allow secretions to drain freely from the mouth, gently suctioning the oral cavity, and administering prescribed anticholinergic agents sublingually or transdermally. Deeper suctioning may cause significant discomfort to the dying client and rarely is of benefit because secretions tend to reaccumulate quickly. Reference: Hinkle, J. L., Cheever, K. H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing , 14th ed Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2018, Chapter 16: End-of-Life Care, p. 409.

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.

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 nonmaleficenced) The principle of fidelity

b) The principle of autonomyBy 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.

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.