CH.43 PREP U

The condition of a client with a traumatic brain injury continues to deteriorate despite medical efforts. The decision is made to terminally wean the client from mechanical ventilation. Which statement by the nurse is most significant in educating the family regarding terminal weaning?

- "All efforts will be taken to make sure your loved one is comfortable and out of pain." Explanation: A common and valid concern of families during terminal weaning is to make sure the client is not suffering. As such, the nurse's role is to educate the family regarding comfort measures, such as pain medication and additional sedation. It is inaccurate to tell the family that the client will no longer be able to breathe once the tube is removed. The client may continue breathing for several hours to days. When a decision is made to terminate mechanical ventilation, it should be clear that reintubation is no longer an option and death is inevitable. The nurse must be honest with the family, as the client may be aware of loved ones in the room and talking to the client is encouraged.

A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse?

- "Can you tell me about why you've made this decision?" Explanation: Having the client explain his decision-making process is open-ended and allows exploration of the client's feelings. A competent client is not required to continue with treatment that has been initiated. The other options are closed-ended and stop any further conversation.

A nurse is caring for a client whose spouse died more than 4 years ago. What assessment question will the nurse ask to determine if the client is experiencing abnormal grief?

- "Have you gone through and donated your spouse's clothing?" Explanation: Abnormal grief responses present beyond 3 years after a loss. The nurse can identify if a client suffers from abnormal grief through questions aimed at learning if the client has: - left the deceased's room and belongings intact - has reported physical symptoms similar to those the deceased had before death - has talked about the deceased as if the individual were still alive Remembering good times and keeping photos of loved ones are part of reminiscing and a healthy form of grieving. Crying on the anniversary of a loved one's death is part of the normal grieving response.

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis?

- "I feel like I have absolutely no idea what to do next." Explanation: In the disorganization stage of grief the client may exhibit: - difficulty making decisions - aimlessness - decreased resistance to illness, and loss of interest in people, work, and usual activities In the protest stage of grief the client may exhibit: - preoccupation with thoughts of the deceased - searching for the deceased - dreams/nightmares, hallucinations, and concerns about others' health and safety In the shock stage the client may exhibit: - slowed and disorganized thinking - blocking of thoughts - neglect of appearance, and wish to join the deceased. In the reorganization stage of grief the client may exhibit: - a realistic memory of the deceased - be comfortable when remembering the deceased - and return to previous level of ability.

A client with end-stage chronic obstructive pulmonary disease (COPD) has reached the end of the 6-month period for hospice services and the family caregiver states, "I don't know what we will do if they cut off our hospice services." What is the best response by the hospice nurse?

- "I will contact the health care provider to extend services since your family member meets the criteria." Explanation: Hospice care is generally provided to clients that have 6 months or less to live, although they are not automatically discharged when they reach 6 months after having been admitted to hospice care. The client may still receive care as long as the healthcare provider certifies that the client continues to meet the criteria for hospice services. The client should not be admitted to the hospital since the acceptance of palliative comfort care is required to qualify for hospice services. Based on the provided information, there is no need to admit the client to the hospital, and hospital admission may result in termination from the program due to the provision of non-palliative care.

A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?

- "In hospice care, the nurses make most of the care decisions for the clients." Explanation: The philosophy of hospice is that clients and families are empowered to achieve as much control over their lives as possible. Hospice focuses on relieving symptoms and supporting clients with a life expectancy of 6 months or less, rather than years, and their families. However, palliative care may be given at any time during a client's illness, from diagnosis to end of life.

The nurse is caring for a client who recently lost an older adult parent. Which client statement alerts the nurse that the stage of depression may have started within the grief process?

- "Please go away; I just want to be left alone." Explanation: The clinical definition of depression is anxiety and hostility turned inward. The statement asking the nurse to go away and a desire to be "left alone" indicates withdrawal, which is a characteristic of depression. "This does not seem real to me" indicates the client is in denial. Blaming oneself for the loss is an expression of guilt that may occur in the anger phase of grieving. Feeling uncertain about the future may occur as the grieving person accepts that the loved one is deceased and life will be different

The nurse visits a client in the home who is at the end stage of life from stage IV colon cancer and observes that the client is in obvious pain. The nurse asks the spouse when the client last had medication for pain and the spouse reports withholding the pain medication, fearing the client will become addicted. How should the nurse respond to the spouse?

- "The fear of addiction should not prevent the client from obtaining adequate pain relief so let us discuss the schedule of medication." Explanation: The fear of addiction is a very real issue, not only for family members but also for health care providers. The fear of addiction should not interfere with the client's ability to obtain adequate pain relief, and the family member should be educated or re-educated regarding this philosophy. The nurse should work with the spouse to form a schedule for administration so that there is not a period of time when the client is suffering from pain. Admonishing the spouse is nontherapeutic and will cause feelings of guilt. The spouse does not have the intention of creating suffering for the client but is uninformed. Stating that it makes no difference because the client is dying is a callous and insensitive comment as well as nontherapeutic. When the nurse discusses a parent, the comment deflects from the actual issue with the client and does not create an educational climate.

"My father has been dead for over a year and my mother still can't talk about him without crying. Is that normal?" What is the best response by the nurse?

- "The inability to talk about your dad without crying, even after a year, is still considered normal." Explanation: Normal responses to bereavement after 1 year include the inability to speak of the deceased without intense emotion, clinical signs of depression, and feelings of meaninglessness. Increased crying does not necessarily signal increased coping, however.

When a client with end-stage renal failure states, "I am not ready to die," what is the appropriate nursing response?

- "This must be very difficult for you." Explanation: The nurse should use statements with broad openings, such as "This must be difficult for you," to allow the client to continue expressing concerns and to acknowledge the client's feelings. This facilitates communication and allows the client to choose the topic or manner of response during this stage of the grieving process. Assuming the client is angry and sad or indicating that this is "a terrible diagnosis" is not an appropriate way to promote coping. The nurse should automatically assume a spiritual leader is desired.

The nurse is providing care for a client that is terminally ill with cancer. The client states to the nurse, "Am I going to die?" What is the most therapeutic response by the nurse?

- "What have you been told?" Explanation: When a client asks a question that is surprising or unexpected, it is best to find out what the client has been told about the situation or how they feel about it. The nurse should not try to avoid responding to the question by leaving to go care for another client. Making a cliché statement such as "you will go when it is your time" or telling the client to not worry about it does not meet the client's need for an answer or for expressing their feelings.

The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the anger stage of grief is the one who states:

- "Why did this have to happen to me?" Explanation: The client is expressing anger when displaying a "why me" attitude. The other statements are reflective of other stages of grief.

Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning?

- Administer sedation and analgesia. Explanation: Terminal weaning is the gradual withdrawal of mechanical ventilation from a client with a terminal illness. Providing sedation and analgesia is the best way to reduce the client's discomfort during the process. The nurse participates in the process by educating the client and family about the burdens and benefits of continued ventilation and what to expect when terminal weaning is initiated. Supporting the family and having the family remain at the bedside are important roles of the nurse during terminal weaning, but do not directly affect discomfort as much as sedation and analgesia.

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?

- 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.

Which statement regarding perceptions of death by children is accurate?

- At about age 9, the child perceives death as irreversible. Explanation: At about 9 years of age, the child's concept of death matures, and the child perceives death realistically as irreversible, universal, inevitable, and natural.

The nurse has noted that a dying client is increasingly withdrawn and is often teary at various times during the day. The nurse recognizes that the client may be experiencing which of Kübler-Ross's stages of grief?

- Depression Explanation: Depression is a commonly accepted form of grief and it represents the emptiness when the client realizes the person or situation is gone or over. Signs and symptoms may be withdrawn, sadness, crying, and flat affect. Denial is the stage where client may disregard that the news of diagnosis or death is not true. Anger is the stage where the client may think "why me?" and "life's not fair!" Bargaining is the stage of false hope. The client might falsely make themselves believe that they can avoid the grief through a type of negotiation. The stages are denial, anger, bargaining, depression, and acceptance.

The nurse is providing care for a confused client who no longer is able to make health care decisions. Which document will the nurse review on the client's medical record to determine the designated person to make decisions on the client's behalf?

- Durable power of attorney form Explanation: The nurse would review the durable power of attorney (DPA) for health care form identifying the client's chosen proxy for health care decision-making. The DPA for health care is a person legally designated by the client to make health care decisions if the client becomes physically or mentally unable to do so. A living will is a legal document detailing the client's wishes for end-of-life care and usually includes specifics such as resuscitation in the event of cardiopulmonary arrest and wishes regarding feeding tubes. An advance directive is a legal form filled out by the client or client's DPA for health care that identifies wishes regarding lifesaving treatment. The health care provider's progress notes are drafted by the health care provider regarding the client's current status and medical treatment plan.

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care. Which information would the nurse most likely include in the response?

- Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness. Explanation: Hospice programs, which, in effect, are a type of insurance benefit, focus on relieving symptoms and supporting clients with a life expectancy of 6 months or less, and their families. Palliative care, on the other hand, may be given at any time during a client's illness, from diagnosis to end of life. Hospice and palliative care programs provide care that focuses on quality rather than length of life. Both hospice and palliative care share a similar foundation. Hospice and palliative care provide physical, social, psychological, and spiritual support through a team of health care professionals and lay volunteers.

The client is a young mother whose spouse died 3 months ago. The client is tearful and unkempt, eats a poor diet, and has lost 50 lb (22.6 kg) since the death of the spouse. The client states, "I can't do this anymore." The nursing diagnosis best supported by these data is:

- Ineffective coping related to failure of previously used coping mechanisms Explanation: The nursing diagnosis best supported by the data is Ineffective coping. Defining characteristics include poor coping skills with activities of daily living as evidenced by unkempt appearance, eating poorly and losing weight, and client statement. Death anxiety refers to an impending death or thoughts of death. Ineffective denial refers to denying the reality of the situation. Decisional conflict refers to inability to make decisions.

A home hospice client who has Medicare is experiencing extreme pain at home and is refusing to receive inpatient care due to concerns over the cost of inpatient care. What teaching will the nurse include in the plan of care?

- Inpatient pain management for hospice clients is covered by Medicare. Explanation: Inpatient pain management is covered by Medicare as are any other Medicare-covered services needed to manage pain and other symptoms as recommended by the hospice team. Medicare will cover pain control in the home as well, but for extreme pain, hospitalization may be required. Telling a client not to worry about payment does not educate about what services are available.

A nurse is conducting grief resolution for a client who lost his wife in a motor vehicle accident in which he was the driver. Which interventions best accomplish this goal? Select all that apply. - Encourage the client's desire to keep silent about the event. - Avoid making empathetic statements about the client's grief. - Avoid identification of fears regarding the loss. - Listen to expressions of grief. - Include significant others in discussions and decisions as appropriate. - Communicate acceptance of discussing the loss.

- Listen to expressions of grief. - Include significant others in discussions and decisions as appropriate. - Communicate acceptance of discussing the loss. Grief resolution involves dealing with the loss. Listening to the client's expressions of grief, including significant others in discussions, and communicating acceptance helps the client deal effectively with the loss. Encouraging the client to keep silent about the event, not being empathetic, and avoiding identification of fears does not help the client in dealing with the loss.

A client has been diagnosed with a terminal illness and has periods of depression and periods of anger. The client's spouse is concerned, feeling as though their loved one is not moving forward in the stages of grief. What teaching is most appropriate for the nurse to include? Select all that apply. - Anger follows depression in the stages of grief. - Movement between stages can be progressive. - Movement back and forth between stages is expected. - Depression is not a stage in the grief process. - Bargaining should occur between depression and anger.

- Movement between stages can be progressive. - Movement back and forth between stages is expected. The Five Stages of Grief (the Kübler-Ross Model) are denial, anger, bargaining, depression, and acceptance. These stages, which represent a pattern of adjustment, may occur in a progressive fashion, or a person can move back and forth through the stages. There is no specific time period for the rate of progression, duration, or completion of the stages.

When assessing a person who is grieving using the grief cycle model, which concept would be most important for the nurse to keep in mind? Select all that apply. - People vary widely in their responses to loss. - Stages occur at varying rates among people. - The stages of grief occur linearly and are static. - Some people actually skip some stages of grief altogether. - The stages are relatively discrete and identifiable.

- People vary widely in their responses to loss. - Stages occur at varying rates among people. - Some people actually skip some stages of grief altogether. In reality, the stages of the grief cycle model are not as discrete as the model indicates. However, it is helpful to use the model as a general guide, while keeping in mind that people may vary greatly in their responses to loss and still fall within the normal response range. Grieving persons may go through the stages at varying rates, go back and forth between stages, or skip stages.

A nurse at the health care facility cares for several clients. Some of the clients may require end-of-life care. Which case may require the service of a coroner?

- The client did not have any recent medical consultation. Explanation: The services of a coroner may be needed in a case where the client did not have any recent medical consultation. A coroner is a person legally designated to investigate deaths that may not be the result of natural causes. Death following a diagnosis of acute renal failure, administration of oxygen therapy, or a history of hypertension does not call for the services of a coroner.

The nurse is making sure that all factors are in place for a client's death certificate. What potential error that may occur does the nurse identify?

- The client had a condition that has the potential to temporarily suspend life process. Explanation: Errors in certification of death have the potential to occur in conditions that might not permanently suspend life processes, such as from hypothermia, drug or metabolic intoxication, or circulatory shock. There is also a risk of error in children under 5 years of age. Previous good health or multiple comorbidities do not present a greatly increased risk of error when determining death.

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death?

- The client's breathing becomes noisy. Explanation: Noisy breathing, or death rattle, is common during the final stages of dying because of the accumulation of secretions in the lungs. Reduced urination is not seen during the final stages of dying. Instead, the client develops loss of control over bladder and bowels due to loss of neurological control. The peripheral parts of the client's body such as the arms and the legs are cold to touch (not warm) because the circulation is directed away from the periphery and toward the core of the body. Clients in the last stages of dying are usually not calm and peaceful; they occasionally exhibit sudden restlessness due to hunger for oxygen.

Which are signs of a "good death"? Select all that apply. - The person experiences moderate pain. - The person dies according to the wishes of the family. - The person dies with dignity. - The person is prepared for death. - The person has a sense of completion of life.

- The person dies with dignity. - The person is prepared for death. - The person has a sense of completion of life. A good death is one that allows a person to die on their own terms, relatively free of pain, and with dignity. It is free from avoidable distress and suffering for clients, families, and caregivers; in general accord with clients' families wishes; and reasonably consistent with clinical, cultural, and ethical standards (Institute of Medicine, 1997). The definition of a good death varies for each client, but there are factors important for a good death, including control of symptoms, preparation for death, opportunity to have a sense of completion of one's life, and a good relationship with health care professionals.

The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing?

- Unresolved grief Explanation: In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. Inhibited grief occurs when a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Normal expressions of grief may be: - physical (crying, headaches, difficulty sleeping, fatigue) - emotional (feelings of sadness and yearning) - social (feeling detached from others and isolating oneself from social contact) - spiritual (questioning the reason for the loss, the purpose of pain and suffering, the purpose of life, and the meaning of death)

The hospice nurse is caring for a client with lung cancer. The client's daughter states, "My mom isn't happy with anything I do for her. She is constantly yelling at me." The nurse understands that the client is in which stage of grief according to Kübler-Ross?

- anger Explanation: Kübler-Ross proposed five stages of grief: (a) denial, (b) anger, (c) bargaining, (d) depression, and (e) acceptance. Denial may range from complete denial of the illness and impending death to denial of the effect that dying will have on self and others. In the second stage, anger may be directed toward fate, God, family members, health care providers, or others. Bargaining occurs as the client seeks to delay the dreaded event; the client bargains with God for more time and, in return, promises to do something to repay God for this favor. Depression occurs when the client acknowledges the reality and inevitability of the impending death. In the final stage, acceptance, the client comes to terms with the loss, begins to detach from supportive people, and loses interest in worldly activities.

A client with a terminal illness is overheard by the nurse saying, "If I promise never to smoke another cigarette in my life, please let me recover from this lung cancer." How will the nurse document this stage of grief according to the Kübler-Ross model?

- bargaining Explanation: Bargaining is a psychological mechanism for delaying the inevitable, usually by negotiating with a higher power.

A widow develops cancer within 6 months of her husband's death. This may be a result of:

- bereavement. Explanation: Physical health and psychosocial adjustment are intricately intertwined. The bereaved are known to be at greater risk for mortality and morbidity than are comparable non-bereaved people.

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

- coping strategies Explanation: Dysfunctional grief can be unresolved or inhibited In unresolved grief, a person may have trouble expressing feelings of loss or may deny them. Unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms. Coping strategies are necessary in the grieving process and for resolution of grief. Many times individuals experiencing dysfunctional grief have difficulty with self-care activities; however, the individual should be encouraged to perform these activities independently. Pain management is usually not necessary in the management of dysfunctional grief. The spiritual needs of the client are important as well and should be considered after coping strategies have been addressed.

When preparing the care plan for a dying client, it is important for the nurse to include a goal that addresses which needs? Select all that apply. - expression of feelings - management of pain - use of coping strategies - nutritional therapy - urinary elimination

- expression of feelings - management of pain - use of coping strategies Nursing care for the dying client should be directed toward the achievement of several goals, including demonstration of the ability to express feelings, fears, and concerns. The client's pain should be managed effectively to allow the client to interact meaningfully with family. The client should also be able to identify and utilize effective coping strategies such as deep breathing, talking with family members, and rest periods. Nutritional therapy and urinary elimination are not specific to the dying client, and more assessment would be needed to determine if these are viable needs for the client.

Which manifestation of grief by the client who lost his wife 3 years earlier is considered abnormal?

- leaving the wife's room and belongings intact Explanation: Bereavement experts reported that they considered almost all bereavement manifestations to be normal during the early stages of grief, but considered most of the manifestations to be abnormal if they continue beyond 3 years.

The experience of parting with an object, person, belief, or relationship that one values is defined as:

- loss. Explanation: Loss is defined as the experience of parting with an object, person, belief, or relationship that one values; the loss requires a reorganization of one or more aspects of the person's life.

Which stage of grieving is exhibited by the husband of a victim of sudden death who refuses to accept that she is dead?

- shock Explanation: In the shock and disbelief stage, the survivor either refuses to accept the loss or shows intellectual acceptance of the loss but denies the emotional impact.

Palliative care is a structured system for care delivery. What is its aim?

- to prevent and relieve suffering Explanation: Palliative care, which is conceptually broader than hospice care, is both an approach to care and a structured system for care delivery that aims to "...prevent and relieve suffering and to support the best possible quality of life for clients and their families, regardless of the stage of the disease or the need for other therapies." Palliative care goes beyond giving traditional medical care. Palliative care is considered a "bridge" not exclusively limited to hospice care. "Hope" is something clients and families have even while the client is actively dying.

A client comes to the hospital because of complications related to newly diagnosed terminal cancer. The client is concerned about how his wife is coping with the diagnosis. Which information is important for the nurse to obtain to assess factors that may affect the family member's grief? Select all that apply. Financial concerns Cultural practices Religious beliefs Social support Previous relationships

Financial concerns Cultural practices Religious beliefs Social support Many factors, including: - socioeconomic position - cultural and religious influences - social support affect a person's reaction to, and expression of, grief. The socioeconomic position is the financial elements and how it affects treatment. Cultural and religious influences may impact the client and client's wife ability to belong to a larger entity and have empathy with others. Social support also provides empathy for the client and client's wife. Like the stages of grief reaction, these factors vary from person to person. Previous relationships may be a part of healing and working through the stages of grief but it is not important for the assessment.

The nurse is preparing a presentation on preparing children for death. What information should the nurse include? Select all that apply.

In preparing children for death, encourage expression of feelings, provide for stability and safety, talk openly about death, and encourage expression of feelings. Do not praise stoicism, nor encourage forgetting of the deceased, nor force the child to participate in mourning rituals.

A nurse is providing care to a terminally ill client. Which finding would alert the nurse to the fact that the client is dying? Select all that apply. - Pale, cool skin - Regular deep respirations - Decreased urine output - Irregular heart rate - Strong, bounding pulse

Pale, cool skin Decreased urine output Irregular heart rate Signs of dying include: - extremely pale, cyanotic, jaundiced, mottled or cool skin - irregular heart rate; weak, rapid, irregular pulse; -shallow, labored, faster, slower, or irregular respirations - decreased urine output.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia. The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.