Nursing Chapter 42
The nurse is caring for an emergency room patient who died because of a mishap with a loaded gun. The patient's body will be transported to the coroner's office for an autopsy. Which items will the nursing staff remove from the body before it leaves the hospital? a.Endotracheal tube b.Foley catheter and IV line c.Dentures d.Necklace and watch
d.Necklace and watch Rationale: Medical devices and tubes are not removed from the body if an autopsy is to be performed. The patient's necklace and watch may be removed and given to the patient's family members before the body is transported to the coroner's office for autopsy. Dentures should be left in the patient's mouth.
The nurse is caring for a patient who suffered a miscarriage at 24 weeks of pregnancy. The patient is devastated by the loss but her husband minimizes her grief by stating, "Quit crying. It's not like you lost a real baby." What term best describes the anguish felt by the patient? a.Disenfranchised grief b.Delayed grief c.Moral distress d.Masked grief
A patient has recently been given a terminal diagnosis. When family members offer to help, the patient snaps and yells at them, but then angrily accuses them of not helping. The patient's spouse is frustrated and asks the hospice nurse what to do about this situation. What response by the nurse is best? a."Don't worry. Your spouse will get over this phase soon." b."Anger is an expected part of the grieving process." c."Would your spouse be open to professional counseling?" d."This diagnosis is difficult to handle; just be patient."
The hospice nurse is caring for a terminally ill patient who will probably die within the next hour or two. The patient's daughter is keeping a vigil by the bedside and asks what she can do to help her father at this time. What is the appropriate response of the nurse? a."Just let him know you are here, talk to him, and let him know that you love him." b."You can try to feed him a few bites of ice cream to keep his mouth from getting dry." c."You can take this time to ensure that arrangements are set with the funeral home." d."You should let me know when your father's breathing pattern changes."
a."Just let him know you are here, talk to him, and let him know that you love him." Rationale: The patient's daughter should be encouraged to spend the last moments of her father's life with him, reassuring him with her presence. The daughter should be encouraged to continue talking with him because the patient may still hear her even if his eyes are closed and he does not speak. The nurse is responsible for monitoring the patient for breathing changes. Oral intake will lead to nausea and/or aspiration. This is not the time to make arrangements with the funeral home.
The nurse is caring for a terminally ill patient who is actively dying and refuses to eat anything other than a few bites of ice cream. The patient's family member approaches the nurse and requests that a feeding tube be inserted so that her loved one will not starve to death. What is the best response of the nurse? a."Loss of appetite is a natural part of the dying process. Tube feedings would be uncomfortable and cause nausea." b."I will contact the provider to obtain an order to insert the tube and start tube feedings." c."Intravenous fluids would be more comfortable for the patient than a tube feeding. I will call the doctor to get the order." d."I will listen to the patient's abdomen to make sure that bowel sounds are present and try encouraging oral fluids."
a."Loss of appetite is a natural part of the dying process. Tube feedings would be uncomfortable and cause nausea." Rationale: Common physical symptoms at the end of life include anorexia and cachexia. Tube feedings will cause discomfort as the tube is inserted and nausea as the GI tract is given food that it cannot handle. Encouraging oral intake will lead to increased secretions and congestion as well as possible aspiration of fluids. Intravenous fluids will increase congestion and edema. The nurse would educate the family on this part of the dying process.
The nurse is caring for a terminally ill patient whose children have come home to be with their mother during her last few days. They spend time looking through picture albums, watching old home movies, and remembering fun times spent together. The nurse identifies which term that best describes the activity of the patient's children? a.Anticipatory grieving b.Bereavement c.Caregiver role strain d.Death anxiety
a.Anticipatory grieving Rationale: The patient and her children are experiencing anticipatory grief as they prepare for the expected death of the patient. Reminiscence and life review are used to assist those experiencing anticipatory grief with the realization that death is approaching.
The nurse is caring for a patient who is having difficulty coping after being in a motor vehicle crash in which her brother was killed. The patient was driving the car and blames herself for the accident. What is the priority nursing intervention of the nurse? a.Check to make sure that the patient does not want to hurt or kill herself. b.Educate the patient about available support systems for grief resolution. c.Enhance the patient's coping skills to alleviate depression and anxiety. d.Encourage the patient to meet with a spiritual leader for guidance.
a.Check to make sure that the patient does not want to hurt or kill herself. Rationale: The highest priority for the nurse is to ensure the safety of the patient, so assessment of potential suicidal tendencies is paramount. The other interventions can take place once the nurse is confident that the patient will not try to hurt or kill herself.
The nurse is caring for a patient who is terminally ill with metastatic bone cancer. The patient tells the nurse that he is not afraid of death but does not want to be in pain and suffer before he dies. Which intervention by the nurse will be most appropriate to meet this patient's wishes? a.Establish around-the-clock dosing for pain medications with additional doses for breakthrough pain. b.Assist the patient to reminisce and review his life, spending as much time as possible with loved ones. c.Use therapeutic touch, guided imagery, and soft music to put the patient at ease and relieve anxiety. d.Encourage the patient to participate in prayer and meditation along with preferred religious practices.
a.Establish around-the-clock dosing for pain medications with additional doses for breakthrough pain. Rationale: The patient's primary wish is to die without pain, and the best intervention to meet this goal is administration of pain medication around the clock with extra doses for breakthrough pain. The other interventions may make the patient more comfortable but will not address his primary desire for adequate pain management.
The nurse is caring for a patient who has just died in a motor vehicle accident. What is the priority action of the nurse before the patient's family arrives to see the patient's body? a.Gently wash the body and provide perineal care. b.Remove the patient's dentures and jewelry. c.Ensure that the death certificate has been signed. d.Determine which funeral home will pick up the body.
a.Gently wash the body and provide perineal care. Rationale: Release of bowel and bladder contents often occur at the time of death, and the perineal care is a priority before the family arrives. The body should be gently cleaned to remove blood and debris from the accident. The patient's dentures and jewelry should not be removed from the body. The death certificate does not need to be signed before the family arrives. The family can decide which funeral home will be used and notify the nurse after their arrival.
The nurse is caring for a patient who just died after a lengthy illness. Which portions of postmortem care may be delegated by the nurse to the nursing assistant? (Select all that apply.) a.Gently washing the body and closing the patient's eyes b.Offering support and empathy to the patient's family members c.Documenting the patient's time of death in the medical record d.Notifying all of the patient's consulting providers of the patient's death e.Removing the patient's hospital ID band, IV lines, and urinary catheter f.Gathering the patient's belongings so they may be taken home by the family
a.Gently washing the body and closing the patient's eyes b.Offering support and empathy to the patient's family members f.Gathering the patient's belongings so they may be taken home by the family Rationale: The nurse assistant can gently wash the patient's body, close the patient's eyes, and gather the patient's belongings. Offering support and empathy to the patient's family members would be done by all of the involved members of the nursing staff. Documenting the time of death in the chart and notifying all of the patient's providers is performed by the nurse. The nurse assistant can remove the patient's IV lines and urinary catheter if allowed by policy, but the hospital ID band would be left in place.
The nurse is caring for a patient who has just died. Which assessment findings by the physician and nurse are used to confirm that death has occurred? (Select all that apply.) a.The patient was incontinent of bowel and bladder. b.The patient's pupils are fixed and dilated. c.The provider does not hear a heartbeat. d.The patient's extremities are cool and mottled. e.The patient has no palpable peripheral pulses. f.The patient's face is relaxed and the mouth is open.
a.The patient was incontinent of bowel and bladder. b.The patient's pupils are fixed and dilated. c.The provider does not hear a heartbeat. e.The patient has no palpable peripheral pulses. Rationale: Assessment findings that confirm death has occurred include lack of pulse/heartbeat and fixed dilated pupils. Cool, mottled extremities, relaxed muscles, and incontinence of bowel and/or stool are common assessment findings in patients who are dying.
The nurse is caring for a patient who lost her husband 1 year ago after 55 years of marriage. The patient no longer takes care of herself or cooks and rarely eats, stating she has no appetite. The nurse determines that the Nursing diagnosis of complicated grieving applies to the patient. Which is the priority goal for the patient? a.The patient will shower every other day and eat at least two meals a day. b.The patient will identify personal strengths that will increase coping ability. c.The patient will discuss the meaning of her loss with a family member or friend. d.The patient will be provided with phone numbers for local community resources.
a.The patient will shower every other day and eat at least two meals a day. Rationale: The highest priority goal of this patient is self-care including showering and eating in order to protect her health and safety. The other goals are lower priority after the patient's necessary activities of daily living are addressed. Goals should also reflect what the patient accomplishes; so the goal of being provided with phone numbers is actually something for the nurse to do.
A patient has recently been given a terminal diagnosis. When family members offer to help, the patient snaps and yells at them, but then angrily accuses them of not helping. The patient's spouse is frustrated and asks the hospice nurse what to do about this situation. What response by the nurse is best? a."Don't worry. Your spouse will get over this phase soon." b."Anger is an expected part of the grieving process." c."Would your spouse be open to professional counseling?" d."This diagnosis is difficult to handle; just be patient."
b."Anger is an expected part of the grieving process." Rationale: Anger is one of the stages of grief as identified by Elizabeth Kubler-Ross. The nurse would first explain this to the spouse. Telling the spouse the patient will get over the phase soon or that the diagnosis is difficult to handle is false reassurance and dismissive of the concerns. It is too early to consider counseling although the patient may need it later. This is also a yes/no question which is not therapeutic.
Which statement by the patient indicates to the nurse that it may be an appropriate time to consider hospice care rather than further aggressive measures to treat his terminal illness? a."I am praying every day that this last round of chemotherapy will work." b."I want to spend what time I have left at home with my grandchildren." c."I need to meet with my financial planner to make sure my life insurance is all set." d."I am concerned that my wife won't be able to live on her own after my death."
b."I want to spend what time I have left at home with my grandchildren." Rationale: Hospice care is provided to patients who are terminally ill and wish to have no further aggressive treatment in attempt to cure the disease. The patient's statement that she just wants to be home with her grandchildren indicates a readiness for hospice care.
The nurse is caring for a terminally ill patient whose family is insistent that additional chemotherapy be administered even though the patient will most likely die within the next few days. What is the best response of the nurse? a."The insurance company will not pay for chemotherapy at this stage." b."The focus right now needs to be on keeping your loved one comfortable." c."I will call the provider and relay your wishes." d."The patient needs to get stronger first before chemotherapy can be administered."
b."The focus right now needs to be on keeping your loved one comfortable." Rationale: Nurses advocate for patients to ensure that they are aware of their options for care that include interventions, treatments, anticipated outcomes, as well as risk and benefits of any decision made concerning medical care. The nurse must function as the patient's advocate and encourage what is in the best interest of the patient. Chemotherapy will not extend the patient's life when death is expected within the next few days and will only make the patient suffer needlessly when it is administered. The patient will not get stronger over the next few days, and this criterion for chemotherapy will never be met.
The nurse sees a young child in the clinic whose mother has only a few weeks to live. The child has been misbehaving at school recently and is suspended after picking fights with other students and defying teachers. The nurse identifies which stage of grieving that the patient is experiencing? a.Denial b.Anger c.Bargaining d.Depression
b.Anger Rationale: The patient is angry over the impending death of the mother and is acting out this anger at school by picking fights and defying his teachers. Denial is a temporary defense while processing the information. Bargaining is negotiation to change the predicted outcome. Depression includes crying and sadness.
The nurse is caring for a terminally ill patient who appears to be calmly having a conversation with someone even though there is nobody else in the room. The patient reaches out and appears to take something out of thin air and hold it close. Which is the appropriate action of the nurse? a.Reorient the patient and reassure that nobody else is in the room. b.Be present but quiet and let the patient continue the conversation. c.Carefully assess the patient's mental status and level of attention. d.Obtain a set of vital signs and check the patient's pulse oximetry.
b.Be present but quiet and let the patient continue the conversation. Rationale: Patients who are near death sometimes have a special communication with loved ones who have already died. It is important to recognize that these experiences can be comforting to the dying patient, and nurses would not contradict or argue with the person. It is imperative to simply be present with the person, listen, and be open to any attempts to communicate. It is acceptable to ask gentle questions such as "What are you seeing?" or "How does that make you feel?" Having an open discussion with the family while describing what is occurring may provide further insight to the nurse as the health care provider, as well as promoting a sense of understanding and acceptance for the family. As long as the patient is calm and content, the best action of the nurse is to be present but let the patient continue the conversation undisturbed.
The hospice nurse is caring for a terminally ill patient. The patient's son is distraught because the patient will probably die within the next few days and there is nothing he can do about it. What is the most appropriate nursing diagnosis for the patient's son currently? a.Chronic grief related to impending death of mother b.Death anxiety related to feeling powerless over situation c.Powerlessness related to progression of mother's terminal illness d.Complicated grieving related to desired avoidance of mourning
b.Death anxiety related to feeling powerless over situation Rationale: The patient's son is experiencing death anxiety because he is unable to change the outcome of his mother's imminent death. The son makes no mention of religious beliefs, so impaired religiosity is not appropriate. Complicated grieving is applicable to individuals who have recently experienced a loss. Chronic grief is grief that continues for a long period of time.
The nurse is caring for an Islamic patient who has just died. The family is traveling from overseas. Which action is the priority for the nurse to take right after the patient dies? a.Arranging for embalming to preserve the body until burial b.Rearrange the furniture so the bed can face Mecca c.Arranging for transportation of the body to the crematorium d.Bringing in fruit for the patient's journey to the other world
b.Rearrange the furniture so the bed can face Mecca Rationale: After death, a patient's body can be turned to face Mecca which is the holy site for Muslims. The nurse would need to find out which direction that is. The family will work with the funeral home to determine when and where burial will take place. Buddhists often bring fruit when someone dies.
The nurse is caring for a terminally ill patient who will probably die within the next 2 weeks. What is the priority nursing intervention? a.Encouraging the patient to limit fluid intake to minimize congestion b.Limiting the use of pain medications so that the patient can visit with family c.Helping the patient to identify and complete desired tasks and activities d.Completing funeral arrangements with the patient's next of kin
c.Helping the patient to identify and complete desired tasks and activities Rationale: The priority intervention for the nurse currently is to help the patient identify and complete desired tasks and activities while the patient is still able to do so. Pain management is a high priority at this time, so analgesics should never be limited unless requested by the patient. The patient can drink as much or as little fluid as desired.
The hospice nurse is caring for a patient who is terminally ill. The patient's spouse is the primary caregiver, providing constant care and spending all his or her time meeting the patient's needs. The spouse says to the nurse "After my spouse dies, I will finally get that colonoscopy my provider has been bugging me about." What does the nurse understand about this statement? a.The spouse is looking forward to being freed from the caretaker role. b.The spouse has neglected his or her own physical needs for too long. c.The spouse is making some realistic plans for life after the death. d.The spouse is in denial that the patient is dying and the important role of caregiver will end.
c.The spouse is making some realistic plans for life after the death. Rationale: Often caregivers neglect their own needs while in the caregiver role. The spouse understands the patient will die soon and is being realistic in understanding his or her own physical needs have been neglected. This shows healthy coping.
The hospice nurse is caring for a several adult children shortly after the death of a parent. They have various reactions as they deal with their loss. The nurse recognizes which reactions to be in the cognitive domain? a.They let the house get filthy because they can't be bothered to clean it. b.They are tossing and turning all night and are unable to get a good night's sleep. c.They are easily distracted and often lose train of thought during conversation. d.They have lost their appetites and have no desire to eat anything.
c.They are easily distracted and often lose train of thought during conversation. Rationale: Cognitive deficits include the inability to concentrate and follow a conversation. Letting the house get filthy is a sign of apathy, which is in the behavioral domain. Insomnia falls within the behavioral and physical domains. Loss of appetite is within the physical domain.
The home care nurse is caring for a terminally ill patient who states that he wants to set up a scholarship in his name at the local university before he dies. What is the best action by the nurse? a.Suggest that the patient think it over and wait a few days before contacting the school. b.Direct the patient to ask his family about the possibility of starting a scholarship. c.Assess the patient's mental status to ensure that he is competent to make the decision. d.Assist the patient to find the necessary information about endowed scholarships.
d.Assist the patient to find the necessary information about endowed scholarships. Rationale: As the patient's advocate, the nurse should help provide the necessary information for the patient to set up a scholarship if that is his decision. The patient does not need to discuss the subject with his family first, and assessment of the patient's mental status is not needed. The patient may not have the time to wait a few days before contacting the university.
The nurse is caring for a female patient who died a few minutes previously. The patient's family comes in to the room and immediately starts to wash the body in preparation for burial. What is the most appropriate action of the nurse currently? a.Inform the patient's family that the body must be transported to the morgue. b.Instruct the patient's family that hospital staff will provide postmortem care. c.Obtain needed signatures for organ donation and autopsy. d.Offer to provide any needed supplies and provide privacy for the family.
d.Offer to provide any needed supplies and provide privacy for the family. Rationale: The most appropriate action of the nurse currently is to allow the family to wash the patient's body in accordance with their wishes and cultural values. The family may wish to participate in this procedure or may complete this procedure in private. Health care personnel should abide by their wishes as much as possible. Signatures may be obtained from the next of kin when washing is complete. The patient's body may be transported to the morgue or funeral home after washing is completed.
The nurse is caring for a patient who died a few minutes ago. The patient's family is at the bedside and very demonstrative in their grief, weeping loudly and holding on to the patient's body. What is the most appropriate action of the nurse? a.Inform the family that the patient's body must be taken to the morgue shortly. b.Ask the family members to step outside while postmortem care is provided. c.Obtain required signatures for the body to be taken to the funeral home. d.Provide privacy and allow the patient's family to grieve over the body.
d.Provide privacy and allow the patient's family to grieve over the body. Rationale: The nurse should allow the patient's family to grieve in private over the loss of their loved one. Some cultures favor free expression of emotions after death, and the nurse should respect this. Signatures can be obtained, postmortem care can be provided, and the body brought to the morgue after an appropriate time of grieving has been provided to the family.
The nurse is caring for a patient whose mother recently passed away. The patient states that she has not been able to concentrate or sleep since the funeral and is consuming increasing amounts of alcohol to get through each day. The nurse knows which goal to be most appropriate for this patient? a.The patient will be referred to medical social services for evaluation and counseling. b.The patient will be encouraged to describe previous stressors and coping mechanisms. c.Nursing staff support patient's coping attempts and encourage verbalization of feelings. d.The patient will use effective coping strategies with no alcohol consumption.
d.The patient will use effective coping strategies with no alcohol consumption. Rationale: Goals are met by the patient rather than nursing or medical staff. The patient's use of effective coping strategies without drinking alcohol is an appropriate goal. Referring the patient for counseling and encouraging the patient to verbalize stressors are interventions rather than goals.
