Chapter 09: Palliative Care at End of Life

6. As the nurse admits a patient in end-stage kidney disease to the hospital, the patient tells the nurse, If my heart or breathing stop, I do not want to be resuscitated. Which action is best for the nurse to take? a. Ask if these wishes have been discussed with the health care provider. b. Place a Do Not Resuscitate (DNR) notation in the patients care plan. c. Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed. d. Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently.

ANS: A A health care providers order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patients request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patients wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patients current concern with possible resuscitation. DIF: Cognitive Level: Apply (application) REF: 135 TOP: Nursing Process: Implementation

15. Which action is best for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient? a. Ask the patient and family about their preferences for care during this time. b. Let the family decide whether to tell the patient about the terminal diagnosis. c. Obtain information from Filipino staff members about possible cultural needs. d. Remind family members that dying patients prefer to have someone at the bedside.

ANS: A Because cultural beliefs may vary among people of the same ethnicity, the nurses best action is to assess the expectations of both the patient and family. The other actions may be appropriate, but the nurse can only plan for individualized culturally competent care after assessment of this patient and family. DIF: Cognitive Level: Apply (application) REF: 134 TOP: Nursing Process: Assessment

14. The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning this patients care? a. Determine the patients wishes regarding end-of-life care. b. Emphasize the importance of addressing any family issues. c. Discuss the normal grief process with the patient and family. d. Encourage the patient to talk about any fears or unresolved issues.

ANS: A The nurses initial action should be to assess the patients wishes at this time. The other actions may be implemented if the patient or the family express a desire to discuss fears, understand the grief process, or address family issues, but they should not be implemented until the assessment indicates that they are appropriate. DIF: Cognitive Level: Apply (application) REF: 129 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

8. The nurse cares for a terminally ill patient who is experiencing pain that is continuous and severe. How should the nurse schedule the administration of opioid pain medications? a. Give around-the-clock routine administration of analgesics. b. Provide PRN doses of medication whenever the patient requests. c. Offer enough pain medication to keep the patient sedated and unaware of stimuli. d. Suggest analgesic doses that provide pain control without decreasing respiratory rate.

ANS: A The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs. Patients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate. DIF: Cognitive Level: Apply (application) REF: 139 TOP: Nursing Process: Planning

1. Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Provide postmortem care to the patient. b. Encourage the family members to talk with and reassure the patient. c. Determine how frequently physical assessments are needed for the patient. d. Teach family members about commonly occurring signs of approaching death. e. Administer the prescribed morphine sulfate sublingual as necessary for pain control.

ANS: A, B, E Medication administration, psychosocial care, and postmortem care are included in LPN/LVN education and scope of practice. Patient and family teaching and assessment and planning of frequency for assessments are skills that require registered nurse level education and scope of practice. DIF: Cognitive Level: Apply (application) REF: 138 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

3. A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patients family member, is most appropriate? a. These symptoms will continue to increase until death finally occurs. b. These symptoms are a normal response before these functions decrease. c. These symptoms indicate a reflex response to the slowing of other body systems. d. These symptoms may be associated with an improvement in the patients condition.

ANS: B An increase in heart and respiratory rate may occur before the slowing of these functions in the dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement, and it would be inappropriate for the nurse to indicate this to the family. The changes in pulse and respirations are not reflex responses. DIF: Cognitive Level: Apply (application) REF: 132 TOP: Nursing Process: Implementation

10. A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time? a. Contact a grief counselor as soon as possible. b. Cry along with the patients family members. c. Leave the home as soon as possible to allow the family to grieve privately. d. Consider whether working in hospice is desirable because patient losses are common.

ANS: B It is appropriate for the nurse to cry and express sadness in other ways when a patient dies, and the family is likely to feel that this is therapeutic. Contacting a grief counselor, leaving the family to grieve privately, and considering whether hospice continues to be a satisfying place to work are all appropriate actions as well, but the nurses initial action at this time should be to share the grieving process with the family. DIF: Cognitive Level: Apply (application) REF: 140 TOP: Nursing Process: Implementation

7. A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, I am not ready to die. Which action is best for the nurse to take? a. Remind the patient that no one feels ready for death. b. Sit at the bedside and ask if there is anything the patient needs. c. Insist that family members remain at the bedside with the patient. d. Tell the patient that everything possible is being done to delay death.

ANS: B Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual patients concerns. Telling the patient that everything is being done does not address the patients fears about dying, especially since the patient is likely to die soon. Family members may not feel comfortable staying at the bedside of a dying patient, and the nurse should not insist that they remain there. DIF: Cognitive Level: Apply (application) REF: 138 TOP: Nursing Process: Implementation

9. The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate? a. Discuss cancer risk factors and appropriate lifestyle modifications. b. Encourage the patient to discuss past life events and their meaning. c. Teach the patient about the purpose of chemotherapy and radiation. d. Accomplish a thorough head-to-toe assessment several times a week.

ANS: B The role of the hospice nurse includes assisting the patient with the important end-of-life task of finding meaning in the patients life. Frequent head-to-toe assessments are not needed for hospice patients and may tire the patient unnecessarily. Patients admitted to hospice forego curative treatments such as chemotherapy and radiation for lung cancer. Discussion of cancer risk factors and therapies is not appropriate. DIF: Cognitive Level: Apply (application) REF: 130 TOP: Nursing Process: Implementation

12. The son of a dying patient tells the nurse, Mother doesnt really respond any more when I visit. I dont think she knows that I am here. Which response by the nurse is appropriate? a. You may need to cut back your visits for now to avoid overtiring your mother. b. Withdrawal may sometimes be a normal response when preparing to leave life. c. It will be important for you to stimulate your mother as she gets closer to dying. d. Many patients dont really know what is going on around them at the end of life.

ANS: B Withdrawal is a normal psychosocial response to approaching death. Dying patients may maintain the ability to hear while not being able to respond. Stimulation will tire the patient and is not an appropriate response to withdrawal in this circumstance. Visitors are encouraged to be present with the patient, talking softly and making physical contact in a way that does not demand a response from the patient. DIF: Cognitive Level: Apply (application) REF: 137 TOP: Nursing Process: Implementation

13. Which patient should the nurse refer for hospice care? a. 60-year-old with lymphoma whose children are unable to discuss issues related to dying b. 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse c. 28-year-old with AIDS-related dementia who needs palliative care and pain management d. 56-year-old with advanced liver failure whose family members can no longer provide care in the home

ANS: C Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life. Patients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice patients. DIF: Cognitive Level: Apply (application) REF: 130 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

2. The nurse cares for an adolescent patient who is dying. The patients parents are interested in organ donation and ask the nurse how the decision about brain death is made. Which response by the nurse is most appropriate? a. Brain death occurs if a person is flaccid and unresponsive. b. If CPR is ineffective in restoring a heartbeat, the brain cannot function. c. Brain death has occurred if there is no breathing and certain reflexes are absent. d. If respiratory efforts cease and no apical pulse is audible, brain death is present.

ANS: C The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead. DIF: Cognitive Level: Apply (application) REF: 131 TOP: Nursing Process: Assessment

11. A middle-aged patient tells the nurse, My mother died 4 months ago, and I just cant seem to get over it. Im not sure it is normal to still think about her every day. Which nursing diagnosis is most appropriate? a. Hopelessness related to inability to resolve grief b. Complicated grieving related to unresolved issues c. Anxiety related to lack of knowledge about normal grieving d. Chronic sorrow related to ongoing distress about loss of mother

ANS: C The patient should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal for months or years after a death. The other nursing diagnoses imply that the patients grief is unusual or pathologic, which is not the case. DIF: Cognitive Level: Apply (application) REF: 133 TOP: Nursing Process: Diagnosis

1. The nurse cares for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be most appropriate? a. Suction the patient. b. Administer oxygen via face mask. c. Place the patient in high Fowlers position. d. Document the respirations as Cheyne-Stokes.

ANS: D Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life. There is also no need for supplemental oxygen by face mask or suctioning the patient. Raising the head of the bed slightly and/or turning the patient on the side may promote comfort. There is no need to place the patient in high Fowlers position. DIF: Cognitive Level: Apply (application) REF: 131 TOP: Nursing Process: Assessment

5. The spouse of a patient with terminal cancer visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, Im busy at work, but otherwise things are fine. Which nursing diagnosis is most appropriate? a. Ineffective coping related to lack of grieving b. Anxiety related to complicated grieving process c. Caregiver role strain related to feeling overwhelmed d. Hopelessness related to knowledge deficit about cancer

ANS: A The spouses behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious. DIF: Cognitive Level: Apply (application) REF: 132 TOP: Nursing Process: Diagnosis

4. A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans a trip across the country to settle some issues with sisters and brothers. The nurse recognizes that the patient is manifesting which psychosocial response to death? a. Restlessness b. Yearning and protest c. Anxiety about unfinished business d. Fear of the meaninglessness of ones life

ANS: C The patients statement indicates that there is some unfinished family business that the patient would like to address before dying. Restlessness is frequently a behavior associated with an inability to express emotional or physical distress, but this patient does not express distress and is able to communicate clearly. There is no indication that the patient is protesting the prognosis, or that there is any fear that the patients life has been meaningless. DIF: Cognitive Level: Apply (application) REF: 132 TOP: Nursing Process: Assessment