MedSurg PrepU Chapter 17

Of the following terms, which is used to refer to the period of time during which mourning a loss takes place?

Bereavement Bereavement is the period of time during which mourning a loss takes place. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Mourning is defined as the individual, family, group and cultural expressions of grief and associated behaviors. Hospice is a coordindinated program of interdisciplinary care and services provided primarily in the home to terminally ill patients and their families.

Nursing students are reviewing information about the signs and symptoms of impending death. The students demonstrate the need for additional review when they identify which of the following as a sign?

Muscle wasting Muscle wasting occurs as the client's condition deteriorates. It is not a sign of impending death. Mental confusion, reduced urinary output, and restlessness occur as a client approaches death.

A nurse is assessing a terminally ill female client. Which client statement indicates that the client is in the bargaining stage of dying?

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

While providing care to a terminally ill client, the client asks, "Am I dying?" Which response by the nurse would be most appropriate?

"Tell me some more about what is on your mind." When responding to the client, the nurse needs to acknowledge the client's fears. Having the client tell the nurse what's on his or her mind acknowledges the client's feelings and opens the way for more discussion. Asking the client about what makes him or her think he or she is dying is probing and does not address the client's feelings or needs. Telling the client that he or she will be fine gives the client false reassurance and does not address his or her fears. Asking about what the physician has told the client redirects the conversation away from the client's feelings and is inappropriate.

Your nursing career has spanned 15 years in multiple hospital settings. Throughout your career, many clients have died and you've developed a method of coping which assures quality care. How do you cope?

All of the options are components of effective coping strategies Recognizing that nursing care always requires sensitivity and compassion for clients, families, and significant others is an essential component of quality end-of-life care. Healthcare providers must acknowledge death as the final stage of growth and development (Kübler-Ross, 1975). Nurses who care for dying clients share emotional pain with them and their families. Denying death creates a barrier to becoming involved with clients and families and interferes with personal growth.

While palliative care can be offered in a multitude of settings (home, inpatient hospice, etc.), there are instances where institutionally based palliative care is most appropriate. Which of the following are factors that contribute to the decision of whether to use institutional palliative care?

All of the options are correct Factors that influence the decision to use institutionally based palliative care include the following: The client's weakness or immobility causes him or her to require more assistance than can be provided at home; the client cannot manage elimination needs; the client has uncontrolled or inadequately controlled pain or nausea; the family cannot provide adequate care; the client requires too complex and demanding care; and, finally, the caregiver is too exhausted to provide care.

A nurse is part of a team involved with informing a client and his wife about the spread of his cancer. When communicating with the client and wife, which of the following would be most appropriate?

Allowing time for the client and wife to absorb and respond to the information When communicating with the client and his wife about the spread of cancer, the team members should allow the couple time to absorb and respond to the information presented. The setting should be quiet with minimal distractions. Information should be presented using the language of the client and wife in terms that they can understand. Technical language should be avoided. Information should be presented in small chunks, to allow the client and his wife to absorb it and cope with it.

A terminal patient has feelings of rage toward the nurse. According to Kubler-Ross, the patient is in which stage of dying?

Anger Anger includes feelings of rage or resentment. Denial includes feelings of isolation. Bargaining occurs when a patient and/or family plead for more time to reach an important goal. Depression includes sadness, grief, and mourning for an impending loss

A client and his loved ones are in the grieving period of his dying and you want to offer the best, possible support to them in the process. Which is the best intervention you could perform during the grieving period?

Avoiding criticism or giving advice The nurse should listen in a nonjudgmental manner and should avoid criticism or giving advice during the grieving period when caring for dying clients

Which of the following interventions should a nurse perform during the grieving period when caring for dying patients?

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

Which of the following may be contained in an "emergency kit" for a hospice patient exhibiting restlessness?

Benzodiazepine A kit might contain small doses of oral morphine liquid for pain or shortness of breath, a benzodiazepine for restlessness, and an acetaminophen suppository for fever. Atropine sulfate drops may be used for excess respiratory secretions.

A 35-year-old mother of four has been informed she has advanced lymphoma. As her world crashes about her, she begins to call other physicians to have additional blood test performed. Within which emotional reaction is she functioning?

Denial Dying clients usually first deny that the diagnosis is accurate. A common response is 'No, not me—there must be some mistake.' They may imagine that test results are erroneous or reports have been confused.

Which of the following is the initial stage of grieving according to Kubler-Ross?

Denial The stages include: denial, anger, bargaining, depression, and acceptance. Anger is the second stage of the process. Bargaining is the third stage of the process. Depression is the fourth stage of the process.

A 60-year-old grandmother of 12 has been fighting brain cancer for more than 20 years. She has just been diagnosed with cancer metastases to the brain and finds it very difficult to get out of bed in the morning, has no interest in eating, and no longer finds fulfillment in her favorite hobbies. Within which emotional reaction is she functioning?

Depression As clients realize the reality of their situation, they may mourn their potential losses, such as separation from their loved ones, the inability to fulfill their future goals, or loss of control.

An 80-year-old client is one of your favorite home care clients. As her dementia began to increase, she designated her son to make decisions regarding her medical care when she is no longer able to do so. As she nears the end of her life, her son is consulted on an ever-increasing basis. What is the name of the legal instrument that activates her son's decision-making designation?

Durable power of attorney A durable power of attorney or healthcare proxy is the person the client designates to make medical decisions on the client's behalf when the client no longer can do so. It allows competent clients to identify exactly what life-sustaining measures they want implemented, avoided, or withdrawn, and offers reassurance that others will carry out their wishes.

Which of the following is also known as a proxy directive?

Durable power of attorney for health care A Durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. The other options are incorrect.

Immediately on cessation of vital functions, the body begins to change. The nurse would expect which physical change to occur following death?

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

Which of the following would be inconsistent with a normal grief reaction?

Elation Denial, sadness, anger, fear, and anxiety are normal grief reactions in people with life-threatening illness and those close to them. Elation would not be a normal grief reaction.

The family members of a dying patient are finding it difficult to verbalize their feelings and show tenderness for the dying person. Which of the following nursing interventions should a nurse perform in such situations?

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

The family members of a dying patient are finding it difficult to verbalize feelings and show tenderness for the dying person. Which of the following nursing interventions should a nurse perform in such situations?

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

A patient has been declared to have a terminal illness. What is the nursing intervention a nurse will perform in the final decision of a dying patient?

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

Which of the following is one of the levels of hospice care covered under Medicare and Medicaid hospice benefits that includes a 5-day inpatient stay and is provided on an occasional basis to relive the family caregivers?

Respite care Inpatient respite care is a 5-day inpatient stay, provided on an occasional basis to relieve the family caregivers. Routine home care entails that all services provided are included in the daily rate to the hospice. Continuous care is provided in the home for management of a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home.

A terminally ill client is receiving morphine around-the-clock for pain control. As part of the client's plan of care focusing on pain management, which nursing diagnosis would the nurse most likely identify?

Risk for constipation related to the effects of an opioid When an opioid is used for around-the-clock pain management, the nursing diagnosis, risk for constipation, would be most likely because of the opioid's effect on the gastrointestinal system. Therefore, a regimen to combat constipation is key. Although opioids depress the central nervous system and cause sedation, a risk for ineffection and impaired physical mobility would be less likely. Other factors involved in the client's care, not just the around-the-clock pain control, would contribute to caregiver role strain.

While talking with a client who has been diagnosed with a terminal illness, the client asks, " Am I dying?" Which response from the nurse would be appropriate? Select all that apply.

• "This must be very difficult for you." • "Tell me more about what's on your mind." The nurse needs to listen effectively and empathetically, acknowledging the client's fears and concerns. Statements such as "This must be very difficult for you" and "Tell me more about what's on your mind" address the client's concerns and help to focus the discussion on the client. Telling the client that the nurse knows how the client feels ignores the client's concerns. Saying that there is still time for a good life or telling the client to focus on what the doctor has planned ignores the client's feelings and blocks communication.

Which of the following nursing interventions is appropriate with regard to pain control in the dying client?

Give pain medications on a routine schedule. The nurse usually gives pain medication on a routine schedule around the clock to avoid causing intense discomfort followed by a period of heavy sedation. Morphine and Demerol may be used. Oxygen eventually may be used.

Your 93-year-old client is in end-stage renal failure. She frequently relates memories of her early childhood, including the unforgettable event of her grandmother's death when the client was quite young. It is the client's wish that she die in the same manner as her "Grama." Which option would you expect the client to relate?

Grama died at home surrounded by family Earlier in the 20th century, many people died in their homes, surrounded by family and loved ones.

Which of the following terms is used to describe the personal feelings that accompany an anticipated or actual loss?

Grief Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life.

A nurse is providing care to a client who has just been diagnosed with a terminal illness. Which of the following would be most appropriate for the nurse to do?

Listen nonjudgmentally while allowing time for client reflection. A client needs time to adjust to and cope with the information that he or she has just learned. The nurse's most appropriate action is to listen effectively, without making any judgments or attempting to solve the client's problems. Engaging the client in conversation and telling the client the nurse understands do not address the client's needs at this time. The client needs time to make sense of the information before he or she makes and decisions.

Which of the following terms best describes a living will?

Medical directive A living will is a type of advance medical directive in which the individual, who is of sound mind, documents treatment preferences. A proxy directive is the appointment and authorization of another individual to make medical decisions on behalf of the person who created an advance directive when he or she is no longer able to speak for him or herself. Health care power of attorney is a legal document that enables the signer to designate another individual to make health care decisions on his or her behalf when he or she is unable to do so

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

Mourning Mourning refers to individual, family, group, and cultural expressions of grief and associated behaviors. Grief refers to the personal feelings that accompany an anticipated or actual loss. Bereavement refers to the period of time during which mourning takes place. Spirituality is a personal belief system that focuses on a search for meaning and purpose of life.

Which of the following "awareness contexts" is characterized by the patient, family, and health care professionals understanding that the patient is dying but pretending otherwise?

Mutual pretense awareness In mutual pretense awareness, the patient, the family and the health care professionals are aware that the patient is dying but all pretend otherwise. In closed awareness, the patient is unaware of his or her terminality in a context where others are aware. In suspected awareness, the patient suspects what others know and attempts to find it out. In open awareness, all are aware that the patient is dying and are able to openly acknowledge that reality.

A nurse is providing care to a terminally ill client who follows Islamic traditions and is experiencing pain. When developing a plan of care for this client, an understanding of which of the following would the nurse need to integrate into the plan?

Pain is viewed as a means of cleansing by God. The Islamic religion views pain as a cleansing instrument of God. Pain relief is appropriate when there is no doubt that the person's disease is causing untreatable sufferring. However, all parties involved must agree formally to the method(s) chosen. Good karma, a view of Hinduism, leads to rebirth. Repentance is a view associated with traditional Christianity.

A group of nursing students is reviewing information about palliative care. The students demonstrate a need for additional review when they identify which of the following?

Palliative care is the same as hospice care. Palliative care is not synonomous with hospice care. All hospice care is palliative but not all palliative care is hospice care. Palliative care is concepturally broader than hospice care and is an approach to care as well as a structured system for delivering care. Palliative care followed the development of hospice care. It does not begin when cure-focused treatment ends but is most helpful when provided along with disease-remitting treatment.

Your client has been informed that he has terminal COPD. As his nurse, your role is to advocate for the best quality of life for the client and his family, who have not agreed upon his final arrangements and continue to discuss his options. How can you best intervene as his nurse in his final decisions?

Respect the client's decision and facilitate discussions to reconcile points of view In the final decisions of a dying client, the nurse will present options for terminal care and respect the client and family member's choices.

Within a care team meeting in your long-term care facility, discussions continue with family members of a 59-year-old client regarding his deteriorating condition. The physician has indicated that the client's condition is terminal and his family doesn't want the client to know the gravity of his condition - they don't want him to worry. As his nurse, why do you advocate that the client needs to know the truth?

All of the options are correct. Outcomes of being truthful include the following: The nurse-client relationship is based on honesty rather than on the false pretense; clients' autonomy and right to determine how to spend the rest of their life is upheld; clients can complete unfinished business. Meaningful communication between clients and family members is promoted.

The family of a terminally ill client tells the nurse that the client has been breathing irregularly and, at times, it appears that he is not breathing at all. The client's daughter states, "He moans when he breathes. Is he in pain?" Which response by the nurse would be most appropriate?

"The moaning you hear is from air moving over very relaxed vocal cords." As a client approaches death, certain signs appear. The family is reporting irregular breathing with periods of apnea. The moaning that they hear reflects the sound of air passing over very relaxed vocal cords. It does not signify pain or distress. Therefore, no additional pain medication would be needed. Secretions collecting at the back of the throat are noted by a rattling or gurgling sound. Decreased oxygen to the brain would lead to confusion, which may be reported by the client as strange dreams or visions

A nurse is working with the family of a terminally ill client, providing them with suggestions about how to manage the client's anorexia. Which statement by the family indicates that they have understood the instructions?

"We'll try adding powdered milk to milk and other foods to make them more nutritious." Increasing the nutritional value of foods, such as by adding powdered milk to milk and other foods, is appropriate. The client should be allowed and encouraged to eat when he is hungry regardless of the regular meal times. Cooking odors should be eliminated or reduced because they can precipitate nausea, vomiting, or anorexia. Unless there is a definite problem with chewing or swallowing, foods do not need to be pureed (mashed) or in liquid form.

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

20 According to federal guidelines, hospices may provide no more than 20% of the aggregate annual patient days at the inpatient level. The other numerical values are incorrect.

The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care?

Advice for the family to have fruit juices readily available at the client's bedside. To promote nutrition in the terminally ill, the nurse would encourage the family to have fruit juices and milkshakes readily available at the bedside so that the client can access them frequently. Cool foods may be better tolerated than hot foods. Cheese, eggs, peanut butter, mild fish, chicken, and turkey are often better choices than meat such as beef that may taste bitter and unpleasant. Meals should be scheduled when family members are present to provide company and stimulation.

A nurse assesses a client with a terminal illness and determines that the client is in denial about the condition. Which of the following would be most important for the nurse to do when developing the client's plan of care?

Accept the client's denial of the situation. When working with terminally ill clients, nurses need to understand that denial is often a useful coping mechanism that enables the client to gain temporary emotional distance from a situation that is too painful to think about. Therefore, nurses must accept clients regardless of the degree to which they are in denial about their illness and work with other health care providers to present the same message. Consulting with other team members would be helpful to ensure that all members present the same information to the client. Denial is a coping mechanism and only becomes unhealthy if the client or family refuses to acknowledge a diagnosis or refuse to hear about treatment options. Correcting the client's misconceptions would disrupt the client's coping mechanism of denial and possibly lead to greater upset.

A 55-year-old client was diagnosed with Hodgkin's lymphoma 3 years ago and has been feeling the effects of his advanced condition as of late. He customarily goes dancing at least twice monthly and enjoys meeting new people. Within the past month, he no longer goes dancing - preferring to stay home with his wife. While he enjoys the visits of his children and grandchildren, he has increased the amount of time he spends alone with his wife. Within which emotional reaction is he functioning?

Acceptance Dying clients accept their fate and make peace spiritually and with those to whom they are close. Clients may begin to detach themselves from activities and acquaintances and seek to be with only a small circle of relatives or friends

A nurse is providing care to a terminally ill client who is experiencing dyspnea. Which of the following would be most appropriate to do to assess the severity of the client's complaint?

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

While providing care to a terminally ill client, the client's niece asks the nurse about the client's condition and prognosis. Which of the following would be most appropriate?

Ask the client's consent before sharing any information with the niece. Before disclosing any health information about a client to family members, nurses should follow the agency's policy for obtaining consent from the client in accordance with the Health Insurance Portability and Accountability Act (HIPAA) rules. Information is shared only with the client's consent.

Which of the following interventions should the nurse perform while providing spiritual care for a dying client?

Ask the family members about spiritual care. When clients are too ill to express their wishes, the nurse should ask the family members about spiritual care. Encouraging family members in their frank communication and providing spiritual books may not be helpful in providing spiritual care for a dying client. Allowing a period of privacy may not be helpful. The nurse allows a period of privacy to the client's family members after the death of the client.

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

Atropine Atropine is used to manage excessive oral and respiratory secretions when death is imminent. Dexamethasone, megestrol, and dronabinol may be used to stimulate appetite in clients who are at the end of life

A nurse is providing in-home hospice care to a terminally ill client. The client experiences a medical crisis requiring monitoring and medication administration. Which level of hospice care would the nurse implement?

Continuous care Continuous care is provided in the home for management of medical crisis. Routine home care would be used to provide the usual services to a client, such as nursing care, medical social services, counseling, home health aide/homemaker servies, and various therapies. Inpatient respite care would be used for a 5-day stay to provide relief for family caregivers. General inpatient care is used for symptom management that cannot be provided in the home.

A nurse is providing in-home hospice care to a 75-year-old client with lung cancer. The nurse determines that the client is eligible for Medicare hospice benefits based on which of the following?

Client has a life expectancy of 6 months or less. Eligibility for the Medicare Hospice Benefit includes physician certification of a client as terminally ill, with a life expectancy of 6 months or less if the disease follows its natural course. The condition must be considered or classified as terminal, not just serious and progressive. Although the presence of family members in the home is helpful, their presence is not a criterion for eligibility. Lack of other insurance also is not a criterion for eligibility.

A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms?

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

Which of the following remains the greatest barrier to improving end-of-life care?

Clinician's attitudes toward the terminally ill The greatest barrier to improving care at the end of life is the clinicians' attitude toward the terminally ill and dying. Clinicians' reluctance to discuss disease and death openly with clients stems from their own anxieties about death and misconceptions about what and how much clients want to know about their illness. Technological advances for prolonging life have led to numerous ethical issues, but these issues have affected all aspects of end-of-life care--for example, how clinicians care for the dying, how family and friends participate in care, how families prepare for terminal illness and death, and how they feel after the death of a loved one. Client and family denial may be considered a barrier, but denial often is considered a useful coping mechanism. The management of acute illness to achieve a cure reflects the sociocultural context of death and dying in America setting up a cure/care dichotomy. However the focus is shifting to include a care-focused perspective for healing.

Glaser and Strauss (1995) identified four "awareness contexts". Which awareness context occurs when the patient is unaware of his or her terminal state, but others are aware?

Closed awareness Closed awareness occurs when the patient is unaware of his or her terminal state, whereas others are aware. Suspected awareness occurs when the patient suspects what others know and attempts to find out details about his or her condition. Open awareness occurs when the patient, the family, and the health care professionals are aware that the patient is dying and openly acknowledge that reality. Mutual pretense awareness occurs then the patient, the family, and the health care professionals are aware that the patient is dying but all pretend otherwise.

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

Cohesion and boundaries Assessment of family cohesion and boundaries focuses on how autonomous and interdependent family members are, such as their bonding and their ability to work as a team. Family constellation is revealed by the members of the family, who is important to the client and the roles and relationships among family members. Flexibility and adaptability is revealed by the family's ability to integrate new information and how they manage change. Communication is revealed by how open, clear, and direct the family is with information and by any topics that are avoided.

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

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

As you orient to your new nursing position at your local inpatient hospice, you begin to question if you are "strong enough" to withstand the continual dying of clients. Your mentor relates the most effective method of dealing with client loss. What action is instrumental to being able to offer effective care and comfort to dying clients?

Explore personal mortality and feelings on death and dying. Healthcare providers must acknowledge death as the final stage of growth and development (Kübler-Ross, 1975). They also must explore their own mortality and feelings about dying and death. This is the only way that they can then provide care and comfort to dying clients and their families

A nurse is conducting a spiritual assessment of a terminally ill client using the four step FICA process and asks the question, "What gives your life meaning?" The nurse is assessing which of the following?

Faith and belief The question about what gives life meaning provides information about the client's faith and belief. Importance and influence are addressed by questions focusing on the role faith plays in the client's life and how his or her beliefs affect the way the client cares for self and illness. Community is addressed by questions focusing on the client's participation in a spiritual or religious community and the support obtained from it. Address in care focuses on how the nurse would integrate the issues involving spirituality in the client's care.

A nurse is working with a family of a deceased client and assisting them in working through their grief and mourning. Which of the following would be the priority to promote healthy accomodation of the loss by the family?

Helping the family recognize the loss has occurred The priority in assisting the family to accommodate the loss of the client in a healthy way is to help them recognize the loss. Once this occurs, then the family can react to, experience, and express the feeling the of the pain of the loss; recollect and re-experience the deceased, the relationship, and associated feelings; and relinquish old attachments to the deceased.

For individuals known to be dying by virtue of age and/or diagnoses which of the following signs indicate approaching death?

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

Which of the following is a sign of approaching death?

Irregular breathing patterns Irregular breathing patterns are a sign of impending death. Other signs of approaching death include decreased urinary output, mental confusion, and sleeping for longer periods of time.

A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following?

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

Which of the following is a true statement regarding hospice care?

Patients have a life expectancy of 6 months or less A criterion of hospice care is that the patient has a life expectancy of 6 months or less, due to a terminal illness. It is not cure-focused and it does not seek to encourage prolongation of life through artificial means.

During unplanned, spontaneous moments, dying patients usually discuss fears or concerns that nurses should not ignore or rush. What is the nurse's best response in such situations?

The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the patient's direction, and making direct eye contact. The nurse should communicate interest and a willingness to listen by sitting down, leaning forward in the patient's direction, and making direct eye contact with the patient. Calling out to the patient's family member and asking them to sit next to the patient may not be the best intervention. The nurse should not distract the dying patient's attention and should not administer a pain killer or sedative.

A nurse is developing a teaching plan for a terminally ill client and his family about about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan?

The stages are applicable to any loss. The five stages of dying describe the five emotional reactions applicable to the experience of any loss. Not every client or family member experiences every stage. Many clients never reach a stage of acceptance. Clients and family fluctutate on a sometimes daily basis in their emotional responses.

Nursing students are reviewing information about attitudes related to death and dying. The students demonstrate understanding of the information when they identify which of the following as most accurate?

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

When assessing a terminally ill client, the nurse notices that the client has copious secretions at the back of the throat and in the mouth. The nurse is preparing a teaching plan for the family about caring for these secretions. Which of the following would be least appropriate to include?

Using a soft toothbrush to vigorously clean the mouth Secretions are often more distressing to the family than their presence is to the client. Gentle mouth care with a moistened swab or very soft toothbrush helps maintain the integrity of the client's mucous membranes. Other helpful measures include positioning the client on the side with the head supported with pillows to allow secretions to drain freely from the mouth, gently suctioning the oral cavity, and admnistering prescribed anticholingergic agents sublingually or transdermally. Deeper suctioning may cause significant discomfort to the dying client and rarely is of benefit because secretions tend to reaccummulate quickly.

A 6-year-old client is in the last stage of leukemia. Despite your administration of prescribed pain medication, she is still in pain due to fear and anxiety. Which nursing intervention should you use to increase the efficacy of the pain medication and make the client more comfortable?

Utilize imagery, humor, and progressive relaxation Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication.

Which of the following should the nurse report so that the team can consider alternative nutritional and fluid administration routes for a dying client?

Weight loss and inadequate food intake The nurse should report weight loss and inadequate food intake so that the team can consider alternative nutritional and fluid administration routes for a dying client. The nurse need not report altered gastrointestinal function because it is a normal part of the dying process. A nurse should also not report a drop in blood pressure and rapid heart rate or irregular eating habits

According to Kubler-Ross, when the dying patient pleas for more time to reach an important goal, the patient is using

bargaining. Bargaining occurs when a patient and/or family plead for more time to reach an important goal. Anger includes feelings of rage or resentment. Denial includes feelings of isolation. Acceptance occurs when the patient and/or family are neither angry nor depressed.

A type of comprehensive care for patients whose disease is not responsive to cure is

palliative care. Palliative care is a type of comprehensive care for patients whose disease is not responsive to cure. Terminal illness is a progressive, irreversible illness that despite cure-focused medical treatment will result in the patient's death. Euthanasia means the intentional killing by act or omission of a dependent human being for his or her alleged benefit. Interdisciplinary collaboration is communication and cooperation among members of diverse health care disciplines jointly to plan, implement and evaluate care.

A client and family are dealing with the client's recent terminal diagnosis. A nurse identifies a nursing diagnosis of hopelessness. Which of the following would be most helpful in supporting hope for this family? Select all that apply.

• Arranging for appropriate psychosocial counseling • Encouraging the client to participate in care to foster control • Helping to obtain support from the community To enable, support, and foster hope in terminally ill clients and their families, nurses should encourage and support the client's control over circumstances, choices, and environment whenever possible, make referrals for psychosocial and spiritual counseling, and assist with developing suports in the home and community when none exist. Goals set should be realistic, rather than long-term. Information and feelings should be shared. The information provided also should be accurate.

While providing care to a client near death, the nurse is helping the family to prepare by teaching them what to expect. Which of the following would the nurse include in the teaching plan as a sign of approaching death? Select all that apply.

• Gurgling as the client breathes through the mouth • Refusal to ingest food or fluids • Decrease in amount of urine produced As death approaches, a client typically has secretions that collect in the back of the throat and rattle or gurgle as the client breathes through the mouth. Breathing may become irregular with periods of no breathing. Urine output may decrease in amount and frequency, and loss of bladder and bowel control may occur. The person approaching death shows less interest in eating and drinking; for many, refusal of food is an indicator that they are ready to die. Vision and hearing may be somewhat impaired and speech may be difficult to understand.

The nurse is providing care to a terminally ill client and his family who practice the Islamic faith. Which of the following concepts would the nurse need to integrate into this client's plan of care? Select all that apply.

• The way a person dies is of great individual importance. • Pain is viewed as a mechanism for cleansing. • Death occurs through God's permission. According to Islamic beliefs, everyone will face death and the way a person dies is of great individual importance. Death cannot happen except by God's permission. People adhering to Islamic beliefs also view pain as a cleansing instrument from God and as a compensation for sin. In Hinduism, each caste system has a different view of death, and relatives must creat a new ethereal body during the first 10 days after death.