IGGY Ch.7 Elsevier - End-of-Life Care

A nurse assesses a client who is dying. Which manifestation of a dying client should the nurse assess to determine whether the client is near death? a. Level of consciousness b. Respiratory rate c. Bowel sounds d. Pain level on a 0-to-10 scale

B Rationale: Although all of these assessments should be performed during the dying process, periods of apnea and Cheyne-Strokes respirations indicate death is near. As peripheral circulation decreases, the client's level of consciousness and bowel sounds decrease, and the client would be unable to provide a numeric number on a pain scale. Even with these other symptoms, the nurse should continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near.

Question 8 of 26 The family of an unconscious dying client realizes that their mother will die soon. The client's children are having a difficult time letting go. How does the nurse respond to the needs of this family? a. "Don't be upset; she wouldn't want it that way." b. "She will soon be in a better place." c. "Things will be fine, try not to worry so much." d. "This must be difficult for you."

d "This must be difficult for you." Accept whatever the grieving person says about the situation. Remain present, be ready to listen attentively, and guide gently. In this way, the nurse can help the bereaved prepare for the necessary reminiscence and integration of the loss. The client's or family member's pain of loss should never be minimized. Trite assurances such as saying, "Don't be upset; she wouldn't want it that way" or "Things will be fine," should be avoided. Such comments can actually be barriers to demonstrating care and concern. Never try to explain a client's death or impending death in philosophic or religious terms; such statements are not helpful when the bereaved person has yet to express feelings of anguish or anger.

The nurse is caring for a Jewish patient in the hospice center. What is this patient's likely attitude and belief regarding terminal illness? A. The patient should not be left alone. B. Foregoing treatment is morally permissible. C. Lie facing Mecca during the last days of life. D. The sacrament of the sick must be administered by a priest.

A. As per Jewish law, a person who is extremely ill and dying should not be left alone. A Christian patient may forego treatment if it is morally permissible, and may also receive the sacrament of the sick administered by a priest. A patient of Islamic faith may want to lie facing Mecca during the last days of life.

What religious belief of the patient who is Jewish does the nurse consider when providing postmortem care? A. The body must not be embalmed. B. The body is displayed before cremation. C. The family observes a 14-day mourning period. D. The soul leaves this world as soon as death occurs.

A. As per the Jewish religion, the body of a deceased patient is not embalmed. The body is also not displayed or cremated. The Jewish faith believes that the soul does not leave this world until after burial. The body is not left unattended until the funeral, which takes place preferably within 24 hours. The family of the deceased patient observes a 7-day mourning period called Shiva.

The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client's anxiety and restlessness. Which statement made by the family member indicates understanding of the nurse's teaching? a. "Maybe we should just hire an around-the-clock sitter to stay with Grandmother." b. "I have some of her favorite hymns on a CD that I could bring for music therapy." c. "I don't think that she'll need pain medication along with her herbal treatments." d. "I will burn therapeutic incense in the room so we can stop the anxiety pills."

B Rationale: Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a client's inner restlessness. Hiring an around-the-clock sitter does not demonstrate that the client's family understands complementary therapies. Complementary therapies are used in conjunction with traditional therapy. Complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications.

A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action should the nurse take first? a. Call for emergency assistance so that resuscitation procedures can begin. b. Ask family members if they would like to spend time alone with the client. c. Ensure that a death certificate has been completed by the physician. d. Request family members to prepare the client's body for the funeral home.

B Rationale: Before moving the client's body to the funeral home, the nurse should ask family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a death certificate has been completed before the client is moved to the mortuary, the nurse first should ask family members if they would like to be alone with the client. The client's family should not be expected to prepare the body for the funeral home.

A patient with stage IV breast cancer is discharged from the hospital to hospice care. The patient's family is aware of impending death. Which response by the nurse best communicates with the family? A. "Don't cry. Accept it." B. "You will soon get over it." C. "This must be very difficult for you." D. "Don't be upset. Things will be fine."

C. The nurse should empathize with the family to provide psychological and emotional support by acknowledging that the family is going through a difficult time. The nurse must not offer false promises by saying that things will be fine. The family's pain of loss must be acknowledged and not minimized. Telling the family that they will soon "get over it" or asking them to accept their loved one's demise are not therapeutic forms of communication.

A nurse teaches a client's family members about signs and symptoms of approaching death. Which manifestations should the nurse include in this teaching? (Select all that apply.) a. Warm and flushed extremities b. Long periods of insomnia c. Increased respiratory rate d. Decreased appetite e. Congestion and gurgling

D,E Rationale: Common physical signs and symptoms of approaching death including coolness of extremities, increased sleeping, irregular and slowed breathing rate, a decrease in fluid and food intake, congestion and gurgling, incontinence, disorientation, and restlessness.

The nurse is caring for a patient who has a POLST (physician orders for life-sustaining treatment). What is a POLST? A. A special bracelet worn by the patient B. A special necklace worn by the patient C. A portable "do-not-resuscitate" (DNR) order D. A document where additional treatments in case of cardiac or pulmonary arrest are ordered

D. A POLST is an advanced directive in which documentation for additional treatments in case of cardiac or pulmonary arrest are ordered by the patient's physician. A POLST follows the patient across all health care settings. A portable DNR order is a state-designated, signed wallet card that is completed before the patient is admitted to the hospital. Like the POLST, a portable DNR follows the patient across health care settings. The patient may also wear a special DNR bracelet or necklace.

Question 18 of 26 A dying client says to the nurse, "I am afraid to die. I did a lot of wrong things in my life." How does the nurse respond? a. "Don't worry, God will forgive you." b. "I'm sure it is nothing to worry about." c. "Tell me more about that." d. "Why? What did you do wrong?"

c "Tell me more about that." A response such as, "Tell me more about that," acknowledges the client's spiritual pain and encourages verbalization. "Don't worry, God will forgive you" assumes that the client is religious and minimizes the client's concerns; it gives false reassurance and is a nontherapeutic response. Saying that it's nothing to worry about minimizes the client's concerns and is a nontherapeutic response; it shuts the client off from expressing his or her concerns. Asking why the client is afraid and what he or she did wrong assumes that the client did something wrong, which may not be the case. "Why" questions are never considered to be therapeutic because they place clients on defense; they often stop communication.

Question 13 of 26 A Christian client is struggling with a diagnosis of cancer and says, "Why is life so unfair?" What health care team member does the nurse ask to provide support? a. Client's family b. Physician c. Hospital chaplain d. Psychiatrist

c Hospital chaplain Chaplains have the time and expertise to manage spiritual distress, no matter what the client's religious preference. The family is not a member of the health care team. Asking the physician to provide support is inappropriate. Asking the psychiatrist for support might make sense, but is not the best answer.

Question 6 of 26 Which condition, when assessed in a dying client, requires that the nurse take action? a. Alternating apnea and rapid breathing b. Anorexia c. Cool extremities d. Moaning

d Moaning Moaning indicates pain and requires pain medication. Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the dying client.

A nurse admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply.) a. Can communicate his treatment preferences b. Is able to read and write at an eighth-grade level c. Is oriented enough to understand information provided d. Can evaluate and deliberate information e. Has completed an advance directive

A,C,D Rationale: To have decision-making ability, a person must be able to perform three tasks: receive information (but not necessarily oriented ´ 4); evaluate, deliberate, and mentally manipulate information; and communicate a treatment preference. The client does not have to read or write at a specific level. Education can be provided at the client's level so that he can make the necessary decisions. The client does not need to complete an advance directive to make his own medical decisions. An advance directive will be necessary if he wants to designate someone to make medical decisions when he is unable to.

Which of a patient's statements regarding passive euthanasia indicates a need for further teaching? A. "The U.S. court system does not support it." B. "It does not directly lead to the death of the patient." C. "Professional organizations and religious communities support it." D. "It involves discontinuing one or more therapies that might prolong the life of a person who cannot be cured."

A. The U.S. court system supports passive euthanasia and withdrawal of aggressive treatment and the rights of surrogate decision makers to refuse or stop treatment. Professional organizations such as the American Nurses Association and the American Medical Association and religious communities (e.g., the Catholic Church) support the right of patients and their surrogate decision makers to refuse or stop treatment when patients are close to death and such interventions are considered medically futile and/or capable of causing harm. In passive euthanasia, the withdrawal of the intervention does not directly cause the patient's death; rather, the progression of the patient's disease or poor health status is the cause of death. Passive euthanasia involves discontinuing one or more therapies that might prolong the life of a person who cannot be cured by the therapy.

Which part of an advance directive contains information about a patient's desires regarding care near death? A. Living will B. Do-not-resuscitate (DNR) order C. Durable power of attorney for health care (DPOAHC) D. Physician orders for life-sustaining treatment (POLST)

A. The living will is the second part of the advance directive; it contains information about what a patient wants or does not want when he or she is nearing death. A DNR form is an actual order containing the information that cardiopulmonary resuscitation (CPR) should not be provided in the event of cardiac or respiratory arrest. The DPOAHC is held by the surrogate decision maker; this is the person who is responsible for making decisions related to health care in the event that the patient loses decision-making capacity. POLST is another name for the advance directive; it documents supplementary treatments in the case of cardiac or pulmonary arrest.

What activity may the patient's family perform when participating in postmortem care? A. Wash the patient. B. Clean the patient's room. C. Insert the patient's dentures. D. Remove or cut all tubes lines.

A. The nurse may permit the family or significant other of a patient to assist with postmortem care by washing the patient and helping to comb and arrange the hair. This provides the family an opportunity to say their goodbyes. Family members often find it therapeutic, and it assists in coping with the situation. The nurse removes or cuts all the tubes and lines per agency policy and inserts the patient's dentures. Unlicensed assistive personnel (UAP) may help with cleaning the patient's room.

Which should the nurse include when assessing the spiritual needs of a patient during end-of-life care? A. The patient's cultural practices B. The caregiver's feelings about death C. The nurse's belief about end-of-life care D. The health care provider's prescribed medications

A. The nurse should include the patient's cultural beliefs and practices when assessing spiritual needs during end-of-life. The nurse's own beliefs, the caregiver's feelings about death, and the health care provider's prescribed medications are not included in the assessment of the patient's spiritual needs at the end-of-life.

A nurse is caring for a client who is terminally ill. The client's spouse states, "I am concerned because he does not want to eat." How should the nurse respond? a. "Let him know that food is available if he wants it, but do not insist that he eat." b. "A feeding tube can be placed in the nose to provide important nutrients." c. "Force him to eat even if he does not feel hungry, or he will die sooner." d. "He is getting all the nutrients he needs through his intravenous catheter."

A Rationale: When family members understand that the client is not suffering from hunger and is not "starving to death," they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family.

A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this client's pain management plan? (Select all that apply.) a. Play music that the client enjoys. b. Massage tissue that is tender from radiation therapy. c. Rub lavender lotion on the client's feet. d. Ambulate the client in the hall twice a day. e. Administer intravenous morphine.

A,C Rationale: Complementary therapies for pain management include massage therapy, music therapy, Therapeutic Touch, and aromatherapy. Nurses should not massage over sites of tissue damage from radiation therapy. Ambulation and intravenous morphine are not complementary therapies for pain management.

A nurse cares for a dying client. Which manifestation of dying should the nurse treat first? a. Anorexia b. Pain c. Nausea d. Hair loss

B Rationale: Only symptoms that cause distress for a dying client should be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the client's comfort. Even when symptoms, such as anorexia or hair loss, disturb the family, they should be treated only if the client is distressed by their presence. The nurse should treat the client's pain first.

A nurse is caring for a dying client. The client's spouse states, "I think he is choking to death." How should the nurse respond? a. "Do not worry. The choking sound is normal during the dying process." b. "I will administer more morphine to keep your husband comfortable." c. "I can ask the respiratory therapist to suction secretions out through his nose." d. "I will have another nurse assist me to turn your husband on his side."

D Rationale: The choking sound or "death rattle" is common in dying clients. The nurse should acknowledge the spouse's concerns and provide interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. The nurse should not minimize the spouse's concerns. Morphine will assist with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not appropriate in a dying client.

A dying patient with dyspnea is prescribed atropine ophthalmic solution 1% every 4 hours. What is the purpose of this drug? A. To treat bronchospasms B. To decrease fluid overload C. To treat respiratory infection D. To dry up secretions in the respiratory tract

D. Secretions in the respiratory tract and oral cavity may contribute to dyspnea near death. Atropine ophthalmic solution 1% may be administered orally every 4 hours to dry up these secretions. Antibiotics are administered to treat respiratory infections. Diuretics such as furosemide are administered to decrease fluid overload. Bronchodilators such as albuterol are administered for bronchospasms via a metered dose inhaler or nebulizer.

Question 5 of 26 The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? a. A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety b. A 30-year-old with AIDS-associated dementia and agitation who is asking for assistance with calling family members c. A 62-year-old with lung cancer who has cool, clammy, dusky skin and blood pressure of 64/20 mm Hg d. A 70-year-old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations

a A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety Management of discomfort is the priority goal for hospice care, so decreasing this client's pain and anxiety should be the first action. The client with AIDS needs rapid assistance, but is the second priority for the nurse in this scenario. The client with lung cancer and the client with colon cancer are exhibiting normal signs and symptoms associated with dying.

A hospice nurse is caring for a dying client and her family members. Which interventions should the nurse implement? (Select all that apply.) a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. c. Assist family members by offering an explanation for their loss. d. Encourage reminiscence by both client and family members. e. Avoid spirituality because the client's and the nurse's beliefs may not be congruent.

A,B,D Rationale: The nurse should teach family members about the physical signs of death, because family members often become upset when they see physiologic changes in their loved one. Palliative care includes management of symptoms so that the peaceful death of the client is facilitated. Reminiscence will help both the client and family members cope with the dying process. The nurse is not expected to explain why this is happening to the family's loved one. The nurse can encourage spirituality if the client is agreeable, regardless of whether the client's religion is the same.

A nurse teaches a client who is considering being admitted to hospice. Which statement should the nurse include in this client's teaching? a. "Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge." b. "Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms." c. "Hospice care will not help with your symptoms of depression. I will refer you to the facility's counseling services instead." d. "You seem to be experiencing some difficulty with this stage of the grieving process. Let's talk about your feelings."

B Rationale: As both a philosophy and a system of care, hospice care uses an interdisciplinary approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client.

A nurse plans care for a client who is nearing end of life. Which question should the nurse ask when developing this client's plan of care? a. "Is your advance directive up to date and notarized?" b. "Do you want to be at home at the end of your life?" c. "Would you like a physical therapist to assist you with range-of-motion activities?" d. "Have your children discussed resuscitation with your health care provider?"

B Rationale: When developing a plan of care for a dying client, consideration should be given for where the client wants to die. Advance directives do not need to be notarized. A physical therapist would not be involved in end-of-life care. The client should discuss resuscitation with the health care provider and children; do-not-resuscitate status should be the client's decision, not the family's decision.

Which activity must the nurse attending to a terminally ill patient avoid? A. Providing support at end of life B. Participating in active euthanasia C. Advocating for the patient's wishes D. Ensuring quality symptom management

B. The nurse caring for the terminally ill patient must not participate in active euthanasia or primary health care provider-assisted euthanasia. Active euthanasia is not supported by the American Nurses Association. Nurses, however, play a major role in advocating for the patient's wishes such as advance directives. Nurses are also expected to ensure quality symptom management by administering prescribed medications. Nurses provide moral support to the family and patient at the end of life.

A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion? a. Roman Catholic - Autopsies are not allowed except under special circumstances. b. Christian - Upon death, a religious leader should perform rituals of bathing and wrapping the body in cloth. c. Judaism - A person who is extremely ill and dying should not be left alone. d. Islam - An ill or dying person should receive the Sacrament of the Sick.

C Rationale: According to Jewish law, a person who is extremely ill or dying should not be left alone. Orthodox Jews do not allow autopsies except under special circumstances. The Islamic faith requires a religious leader to perform rituals of bathing and wrapping the body in cloth upon death. A Catholic priest performs the Sacrament of the Sick for ill or dying people.

After teaching a client about advance directives, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching? a. "An advance directive will keep my children from selling my home when I'm old." b. "An advance directive will be completed as soon as I'm incapacitated and can't think for myself." c. "An advance directive will specify what I want done when I can no longer make decisions about health care." d. "An advance directive will allow me to keep my money out of the reach of my family."

C Rationale: An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client's residence or financial matters.

Arrange in order the pathophysiological events that take place during the dying process. Correct1.Inadequate blood supply to body tissues Correct2.Occurrence of anaerobic metabolism Correct3.Release of toxic metabolites in vital organs Correct4.Multiple organ failure Correct5.Cardiac arrest

Inadequate blood supply to body tissues leads to unmet oxygen demand. It stimulates anaerobic metabolism leading to acidosis, hyperkalemia, and tissue ischemia. This results in release of toxic metabolites in the vital organs such as the kidneys and the liver, which may result in organ failure causing cardiac arrest.

Question 19 of 26 A client with terminal lung cancer is receiving hospice care at home. Which nursing action does the RN manager ask the LPN/LVN to do? a. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. b. Clarify family members' feelings about the meaning of client behaviors and symptoms. c. Develop a plan for care after assessing the needs and feelings of both the client and the family. d. Teach the family to recognize signs of client discomfort such as restlessness or grimacing.

a Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client is appropriate to delegate to the LPN/LVN. Clarifying family members' feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level.

Question 16 of 26 A dying client exhibits signs of agitation. The Foley catheter has drained 100 mL in the last 3 hours, and the client's last bowel movement was yesterday evening. What does the nurse do first? a. Administers an analgesic b. Arranges for a consultation with a bereavement counselor c. Assesses the client for impaction d. Changes the Foley catheter to ensure adequate drainage

a Administers an analgesic Agitation may be indicative of pain, which must be addressed in the dying client. Arranging for a consultation with a counselor is not the priority in this situation. The dying client's metabolism has slowed, so assessing for impaction may not be necessary. The Foley catheter should not be changed, but the tubing should be assessed to ensure that there are no kinks.

Question 3 of 26 A client diagnosed with lung cancer 6 months ago is now ventilator-dependent and unresponsive. The family wants to remove the ventilator and stop antibiotics and IV fluids. What does the nurse do next? a. Facilitates a meeting with the family and health care team b. Removes the interventions, per the family's wishes c. Tells the family that removing the interventions is illegal d. Waits to obtain information on the client's wishes

a Facilitates a meeting with the family and health care team Withdrawing or withholding life-sustaining therapy involves discontinuing one or more therapies that might prolong the life of a person who cannot be cured by the therapy. To do this, a meeting is required between the family and the health care team. Withdrawing life support requires more than simply following the family's wishes. Removal of life-sustaining therapy is not illegal except in cases of active euthanasia or physician-assisted euthanasia. The client most likely will not regain consciousness; the client's wishes should have been determined and documented earlier in the course of his or her disease (advance directives, living will, etc.).

Question 25 of 26 In which newly admitted client situations does the nurse initiate a conversation about advance directives? Select all that apply. a. A client with a non-life-threatening illness b. A person who currently has advance directives c. The client with end-stage kidney disease d. The comatose client who was injured in an automobile crash e. The laboring mother expecting her first child

a, b, c, e A client with a non-life-threatening illness, A person who currently has advance directives, The client with end-stage kidney disease, The laboring mother expecting her All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with "healthy" clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with pre-existing advance directives still needs to be questioned; it is possible that the client's wishes have changed since the documents were established. Clients who have potentially life-threatening diseases or conditions should establish advance directives while they are able to do so. The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives.

Question 21 of 26 A client admitted with a non-life-threatening illness says, "I was asked to fill out an advance directive when I was admitted, but I was too stressed. What was it all about?" How does the nurse respond? a. "Advance directives are only for those individuals who are severely ill." b. "Advance directives allow a client to convey his or her wishes about health care ahead of time." c. "Most Americans have an advance directive in place; you will need to see a lawyer." d. "You should have completed the paperwork before you were admitted."

b "Advance directives allow a client to convey his or her wishes about health care ahead of time." Stating that advanced directives allow a client to convey his or her wishes about health care ahead of time is true and best addresses the client's comments. Advance directives should be in place before the client becomes severely ill. Most Americans do not have advance directives in place. Legal assistance is not necessary to complete them. Although completing paperwork pertaining to advance directives before admission would be ideal, any time is a good time to do this.

Question 26 of 26 The daughter of a dying client says, "I don't want my father to be uncomfortable." How does the nurse respond? a. "Do you want to talk to the bereavement nurse?" b. "Your father will be closely monitored and cared for." c. "Your father will be kept sedated." d. "We will send him to hospice when the time comes."

b "Your father will be closely monitored and cared for." Telling the daughter that her father will be closely monitored and cared for provides support and comfort. The daughter's comment does not require the expertise of a bereavement nurse. Also, asking if the daughter wants to talk to a bereavement nurse is a "yes-or-no" question and a nontherapeutic response; it shuts off the dialog. The dying client is not typically kept sedated; clients are kept comfortable with as little or as much pain medication as needed. A goal is to keep him or her alert and able to communicate. Telling the daughter that her father will be sent to hospice when the time comes does not address the daughter's concern about her father's comfort; it closes the dialog.

Question 22 of 26 The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the nursing assistant to visit? a. Advanced cirrhosis of the liver; called the hospice agency reporting nausea b. Aggressive brain tumor; needs daily assistance with ambulation and bathing c. Inoperable lung cancer; considering whether to have radiation and chemotherapy d. Prostate cancer and bone metastases; has new-onset leg weakness and tingling

b Aggressive brain tumor; needs daily assistance with ambulation and bathing Assisting clients with activities of daily living is a common role for nursing assistants working in home health or hospice agencies. Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions, which are within the RN scope of practice.

Question 15 of 26 The nurse recognizes signs and symptoms of depression in an 80-year-old client who is dying from metastatic breast cancer. What does the nurse do initially for this client? a. Assesses these behaviors as normal steps or stages in the grief process for the client b. Collaborates with the end-of-life (EOL) care team to manage these feelings in the client c. Documents these findings and continues to monitor the client d. Reduces the quantity of depression-causing opioids that are being administered to the client

b Collaborates with the end-of-life (EOL) care team to manage these feelings in the client Behaviors should be assessed and treated with the collaboration of the EOL care team. The nurse may be instrumental in performing a "depression" screening. Feelings of depression—hopelessness, helplessness, unhappiness—are not part of the aging process or the process of dying; they should be aggressively treated. These feelings should not only be documented and monitored, but also should be acknowledged as not a normal part of the dying process and should be treated with psychotherapy or medications or both. Inadequate analgesic pain control is one of the most noted and critical problems, especially in older adults. This scenario would not be a reason for opioid administration to be reduced; such an action is harmful to the client.

Question 9 of 26 A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first? a. Albuterol (Proventil) 0.5% solution per nebulizer b. Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed c. Oxygen 2 to 6 L/min per nasal cannula d. Prednisone (Deltasone) elixir 10 mg orally

b Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed Morphine sulfate is the standard treatment for the dyspneic client who is near death. Albuterol (Proventil), oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine.

Question 10 of 26 A dying client cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do? a. Assist the family in leaving the room so that they can compose themselves. b. Place the client in a side-lying position so secretions can drain. c. Position the client in a high-Fowler's position to minimize secretions. d. Use a Yankauer suction tip to remove secretions from the client's upper airway.

b Place the client in a side-lying position so secretions can drain. Placing the client in a side-lying position to facilitate draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease. Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler's position is ineffective in helping the client who has lost the ability to swallow; the danger of choking and aspiration would increase. Not only is oropharyngeal suctioning outside the scope of practice of the nursing assistant, it is also not recommended for removal of secretions, because it is not effective and may even agitate the dying client.

Question 1 of 26 The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life? a. "Do you believe in God?" b. "Tell me about the history of religion in your life." c. "What gives you purpose and meaning in your life?" d. "Where have you been attending church for the past several years?"

c "What gives you purpose and meaning in your life?" Spirituality is whatever or whoever gives ultimate meaning in one's life. It is not necessarily God, but it could be. It could be the client's definition of a higher power. The client may not believe in God and may find an inquiry about believing in God offensive and judgmental. Religion is affiliation or membership in a faith community; its members may be supportive of the client if the client is a member of a religious community, but this is not the best way to determine what the client's spirituality is. Church attendance is one way that some individuals express their religion, but it does not necessarily define a person's spirituality; asking about church could place the client on defense.

Question 7 of 26 A nurse who is skilled in complementary and alternative medicine (CAM) therapies works on a cancer unit with clients who are terminally ill. For which client symptom does the nurse use these therapies? a. Constipation b. Cool extremities c. Increased pain d. Memory loss

c Increased pain CAM can help relieve pain and agitation, minimizing the need for increased opioids. CAM is not typically used for constipation or to deal with cool extremities. Memory loss is not a symptom that should receive priority in the dying client.

Question 20 of 26 The nurse is coordinating interdisciplinary palliative care interventions for the dying client. Which goal is the nurse seeking to meet? a. Avoiding symptoms of client distress b. Ensuring an expedited death c. Meeting all of the client's needs d. Facilitating a peaceful death for the client

d Facilitating a peaceful death for the client Facilitating a peaceful death for the client is one of the goals of palliative care. Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client's needs (e.g., to prevent death or lengthen life).

Question 23 of 26 A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention does the nurse implement? a. Brings in the client's favorite Chinese takeout food b. Calls the family to come in right away c. Gives intravenous hydration d. Offers ice chips

d Offers ice chips The dying client should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth." The dying client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not necessary at this point.

Question 17 of 26 A client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client? a. Classical music b. Deep muscle massage c. More pain medication d. Short, light massage

d Short, light massage Massage has been shown to decrease pain in individuals with cancer. Light pressure is best, and deep or intense pressure should be avoided. Although music therapy may be effective, the type of music played should be the client's choice; it should not be assumed that the client wants to hear classical music. The dying client who is frail may not tolerate an extensive deep massage. The client is already receiving high doses of opioids; complementary or alternative therapy can replace the need for increased pain medication.

Question 11 of 26 A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? a. Administers nutrition and fluids through a nasogastric tube b. Explains to the family that aspiration may be a concern c. Obtains a physician order to initiate an IV line d. Teaches the family how to provide oral care

d Teaches the family how to provide oral care Because the oral mucosa will become dry, family members should be taught how to moisten the lips and mouth. Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client's suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing.

What are the typical causes of nausea and vomiting in a terminally ill patient in the last week of life? Select all that apply. A. Uremia B. Hypocalcemia C. Stool impaction D. Bowel obstruction E. Reduced cranial pressure

A, C, D Increased serum urea nitrogen (uremia) often causes nausea and vomiting in the terminally ill patient. Stool impaction and bowel obstruction also may cause nausea and vomiting. A biphosphate enema or mineral oil enema followed by gentle disimpaction may help to relieve the patient's distress. The patient generally has hypercalcemia and increased cranial pressure in the last days, which lead to nausea and vomiting.

A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question? a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5 b. Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezes c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions d. Sodium biphosphate (Fleet) enema once a day PRN for impacted stool

A Rationale: Pain medications should be scheduled around the clock to maintain comfort and prevent reoccurrence of pain. The other medications are appropriate for this client.

A nurse discusses inpatient hospice with a client and the client's family. A family member expresses concern that her loved one will receive only custodial care. How should the nurse respond? a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." b. "Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop." c. "A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given." d. "Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility."

A Rationale: Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity.

An intensive care nurse discusses withdrawal of care with a client's family. The family expresses concerns related to discontinuation of therapy. How should the nurse respond? a. "I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia." b. "You will need to talk to the provider because I am not legally allowed to participate in the withdrawal of life support." c. "I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death." d. "There is no need to worry. Most religious organizations support the client's decision to stop medical treatment."

C Rationale: The nurse should validate the family's concerns and provide accurate information about the discontinuation of therapy. The other statements address specific issues related to the withdrawal of care but do not provide appropriate information about their purpose. If the client's family asks for specific information about euthanasia, legal, or religious issues, the nurse should provide unbiased information about these topics.

A client tells the nurse that, even though it has been 4 months since her sister's death, she frequently finds herself crying uncontrollably. How should the nurse respond? a. "Most people move on within a few months. You should see a grief counselor." b. "Whenever you start to cry, distract yourself from thoughts of your sister." c. "You should try not to cry. I'm sure your sister is in a better place now." d. "Your feelings are completely normal and may continue for a long time."

D Rationale: Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the client's response.

Question 24 of 26 A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem action does the nurse implement? a. Asks the family if they wish to help wash the client b. Asks the family to leave c. Raises the head of the bed and opens the client's eyes d. Removes dentures and any prosthetics

a Asks the family if they wish to help wash the client The nurse may ask the family if they wish to be involved in washing the client after the client's death. The family should be allowed to grieve at the bedside of the client. The head of the bed should be flat and the client's eyes closed. The client's dentures and prosthetics should be replaced, not removed.

Question 2 of 26 A hospitalized client of the Islamic (Muslim) religion is dying. What concept does the nurse share with the health care team about this client's beliefs about death? a. Death is seen as the transition to the other side, with Islam as the vehicle. b. Life experiences do not affect the individual's preparation for "everlasting life." c. The timing of death is under the power of the person who is facing death. d. Plans for burial will take days, maybe even weeks, after the death.

a Death is seen as the transition to the other side, with Islam as the vehicle. In the Muslim faith, Islam is the vehicle that transports the person to the "other side." This is a fundamental belief of the religion. Life is meant to be a test of preparation for everlasting life in the hereafter; life experiences do affect the person's afterlife existence. Muslims believe that God (Allah), rather than the person, has prescribed a time of death for everyone. Preparation for burial takes place as soon as possible after death has occurred.

Question 12 of 26 A dying client is having difficulty swallowing oral medications. Which intervention does the nurse implement for this client? a. Asks the pharmacy to substitute intramuscular (IM) equivalents for the medications b. Asks the provider if the medications can be discontinued or substituted c. Crushes the pills, opens the sustained-release capsules, and mixes them with a spoonful of applesauce d. Does not give the medications and documents: "Unable to swallow"

b Asks the provider if the medications can be discontinued or substituted Since the client is in the dying process, he or she may no longer require some of the medications prescribed, and other routes may be available for medications that will promote comfort. The IM route is almost never used for clients at the end of life because this method is invasive and painful, and can cause infection. Although some pills may be crushed, sustained-release capsules should not be taken apart and their contents administered directly. The client may still need the medications prescribed for comfort; withholding them could cause discomfort throughout the dying process.

Question 4 of 26 A hospice client has just died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant? a. Assessing the client for cessation of respiratory effort and lack of pulse b. Documenting the time of death and required assessment data on the chart c. Notifying the spouse and other family members about the client's death d. Removing or cutting all IV lines or tubes according to the hospice policy

d Removing or cutting all IV lines or tubes according to the hospice policy Preparing the body for viewing by the family (such as removing tubing and lines) and/or transfer to the morgue is an appropriate task for unlicensed assistive personnel. Assessing for signs of life, documenting about the death, and spousal and family notification all require broader education and should be done by licensed nursing staff.

Question 14 of 26 In a comatose dying client's hospital room, the nurse overhears family discussing the memorial service. What action does the nurse take? a. Asks the family to speak in low tones or whispers so as not to disturb the client b. Offers to call and have a hospital chaplain come and discuss plans with them c. Shares some personal insights and experiences on planning a meaningful memorial service d. Suggests that the family leave the room to carry on their discussion

d Suggests that the family leave the room to carry on their discussion Discussions about the client should not be carried on while the family is in the client's room. Hearing is the last of the senses to leave dying clients, and it is believed that the client can hear even whispers until the end of his or her life. The family needs to have their discussion elsewhere. The chaplain may be helpful to the family, but the discussion still needs to happen outside of the hospital room. It is not at all appropriate for the nurse to interact with the family about planning for a service, especially within hearing range of the client.