Palliative Care - NCLEX
Which statement made by the graduate nurse working in the hospice unit with a patient near the end of life requires intervention by the preceptor nurse? A. "The patient has eaten only small amounts the past 48 hours; will the physician consider placing a feeding tube?" B. "The family seems comfortable with the long periods of silence." C. "The physician ordered an increase in the dosage of morphine; I will administer the new dose right away." D. "The blood pressure is lower this afternoon than it was this morning; I will communicate the changes to the family."
A. "The patient has eaten only small amounts the past 48 hours; will the physician consider placing a feeding tube?" Nursing management related to physical care at the end of life deals with symptom management and caring rather than treatment aimed at curing a disease or disorder. Meeting the patient's physiologic and safety needs is the priority. Physical care focuses on the needs for oxygen, nutrition, pain relief, mobility, elimination, and skin care. People who are dying deserve and require the same physical care as people who are expected to recover.
A patient with terminal cancer tells you, "I know I am going to die pretty soon, perhaps in the next month." Which of the following is your most appropriate response? A. "What are your feelings about being so sick and thinking you may die soon?" B. "None of us knows when we are going to die. Is this a particularly difficult day?" C. "Would you like for me to call your spiritual advisor so you can talk about your feelings?" D. "Perhaps you are depressed about your illness; I will speak to the doctor about getting some medications for you."
A. "What are your feelings about being so sick and thinking you may die soon?" The most appropriate response to psychosocial questions is to acknowledge the patient's feelings and explore his or her concerns. This option does both and is a helpful response that encourages further communication between the patient and nurse.
The caregiver children of an elderly patient whose death is imminent have not left the bedside for the past 36 hours. In your assessment of the family, which of the following findings indicates the potential for an abnormal grief reaction by family members (select all that apply)? A. Family members cannot express their feelings to one another. B. The dying patient is becoming more restless and agitated. C. A family member is going through a difficult divorce. D. The family talks with and reassures the patient at frequent intervals. E. Siblings who were estranged from each other have now reunited.
A. Family members cannot express their feelings to one another. C. A family member is going through a difficult divorce. You must be able to recognize signs and behaviors among family members who may be at risk for abnormal grief reactions. These may include dependency and negative feelings about the dying person, inability to express feelings, sleep disturbances, a history of depression, difficult reactions to previous losses, perceived lack of social or family support, low self-esteem, multiple previous bereavements, alcoholism, and substance abuse. Caregivers with concurrent life crises are especially at risk.
An 80-year-old patient is receiving palliative care for heart failure. What are the primary purposes of her receiving palliative care (select all that apply)? A. Improve her quality of life. B. Assess her coping ability with disease. C. Have time to teach patient and family about disease. D. Focus on reducing the severity of disease symptoms. E. Provide care that the family is unwilling or unable to give.
A. Improve her quality of life. D. Focus on reducing the severity of disease symptoms. The focus of palliative care is to reduce the severity of disease symptoms. The goals of palliative care are to prevent and relieve suffering and to improve quality of life for patients with serious, life-limiting illnesses.
A hospice nurse is visiting with a dying patient. During the interaction, the patient is silent for some time. What is the best response? A. Recognize the patient's need for silence, and sit quietly at the bedside. B. Try distraction with the patient. C. Change the subject, and try to stimulate conversation. D. Leave the patient alone for a period.
A. Recognize the patient's need for silence, and sit quietly at the bedside. Frequently, silence is related to the overwhelming feelings experienced at the end of life. Silence can also allow time to gather thoughts. Listening to the silence sends a message of acceptance and comfort.
The nurse is listening to a client who says, "I am so scared about how bad my heart failure symptoms have gotten lately." What would be the nurse's best action following this statement? A. Respond with non-verbal nodding, leaning forward towards the client. B. Tell the client not to worry, that the symptoms can be controlled. C. Teach the client about the usual progression of heart failure. D. Respond with a verbal statement that the client's symptoms do not seem that bad.
A. Respond with non-verbal nodding, leaning forward towards the client.
Which aspects of anticipatory grief are associated with positive outcomes for the caregiver of a palliative patient (select all that apply)? A. Strong spiritual beliefs B. Medical diagnosis of the patient C. Advanced age of the palliative patient D. Acceptance of the expected death of the patient E. Adequate time for the caregiver to prepare for the death
A. Strong spiritual beliefs D. Acceptance of the expected death of the patient E. Adequate time for the caregiver to prepare for the death Acceptance of an impending loss, spiritual beliefs, and adequate preparation time are all associated with positive outcomes regarding anticipatory grief. The age and diagnosis of the patient are not key factors in influencing the quality of caregivers' anticipatory grief.
The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning this patient's care? a. Determine the patient's wishes regarding end-of-life care. b. Emphasize the importance of addressing any family issues. c. Discuss the normal grief process with the patient and family. d. Encourage the patient to talk about any fears or unresolved issues
ANS: A The nurse's initial action should be to assess the patient's wishes at this time. The other actions may be implemented if the patient or the family express a desire to discuss fears, understand the grief process, or address family issues, but they should not be implemented until the assessment indicates that they are appropriate
The nurse is caring for a terminally ill patient who is experiencing continuous and severe pain. How should the nurse schedule the administration of opioid pain medications? a. Plan around-the-clock routine administration of analgesics. b. Provide PRN doses of medication whenever the patient requests them. c. Suggest small analgesic doses to avoid decreasing the respiratory rate. d. Offer enough pain medication to keep the patient sedated and unaware of stimuli
ANS: A The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs.
A patient with terminal cancer is being admitted to a family-centered inpatient hospice. The patient's spouse visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, "I'm busy at work, but otherwise things are fine." Which provisional nursing diagnosis is appropriate for the patient's spouse? a. Ineffective coping related to lack of grieving b. Anxiety related to complicated grieving process c. Hopelessness related to knowledge deficit about cancer d. Caregiver role strain related to spouse's complex care needs
ANS: A The spouse's behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious
A patient in hospice is manifesting a decrease in all body system functions except for a heart rate of 124 beats/min and a respiratory rate of 28 breaths/min. Which statement, if made by the nurse to the patient's family member, is most appropriate? a. "These vital signs will continue to increase until death finally occurs." b. "These vital signs are an expected response now but will slow down later." c. "These vital signs may indicate an improvement in the patient's condition." d. "These vital signs are a helpful response to the slowing of other body systems."
ANS: B An increase in heart and respiratory rate may occur before the slowing of these functions in a dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement or compensation, and it would be inappropriate for the nurse to indicate this to the family
Which action is most important for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient? a. Let the family decide how to tell the patient about the terminal diagnosis. b. Ask the patient and family about their preferences for care during this time. c. Obtain information from Filipino staff members about possible cultural needs. d. Remind family members that dying patients prefer to have someone at the bedside
ANS: B Because cultural beliefs may vary among people of the same ethnicity, the nurse's best action is to assess the expectations of both the patient and family. The other actions may be appropriate, but the nurse can only plan for individualized culturally competent care after assessment of this patient and family
A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time? a. Contact a grief counselor as soon as possible. b. Cry along with the patient's family members. c. Leave the home quickly to allow the family to grieve privately. d. Consider leaving hospice work because patient losses are common
ANS: B It is appropriate for the nurse to cry and express sadness in other ways when a patient dies, and the family is likely to feel that this is supportive. Contacting a grief counselor, leaving the family to grieve privately, and considering whether hospice continues to be a satisfying place to work are all appropriate actions as well, but the nurse's initial action at this time should be to share the grieving process with the family
A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, "I am not ready to die." Which action is best for the nurse to take? a. Remind the patient that no one feels ready for death. b. Sit at the bedside and ask if there is anything the patient needs. c. Insist that family members remain at the bedside with the patient. d. Tell the patient that everything possible is being done to delay death.
ANS: B Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual patient's concerns.
The nurse is caring for an adolescent patient who is dying. The patient's parents are interested in organ donation and ask the nurse how the health care providers determine brain death. Which response by the nurse accurately describes brain death determination? a. "If CPR does not restore a heartbeat, the brain cannot function." b. "Brain death has occurred if there is not any breathing or brainstem reflexes." c. "Brain death has occurred if a person has flaccid muscles and does not awaken." d. "If respiratory efforts cease and no apical pulse is audible, brain death is present."
ANS: B The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead
A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans a trip across the country "to settle some issues with family members." The nurse recognizes that the patient is manifesting which psychosocial response to death? a. Protesting the unfairness of death b. Anxiety about unfinished business c. Fear of having lived a meaningless life d. Restlessness about the uncertainty of prognosis
ANS: B The patient's statement indicates that there is some unfinished family business that the patient would like to address before dying. There is no indication that the patient is protesting the prognosis, feels uncertain about the prognosis, or fears that life has been meaningless
The son of a dying patient tells the nurse, "Mother doesn't really respond any more when I visit. I don't think she knows that I am here." Which response by the nurse is appropriate? a. "Cut back your visits for now to avoid overtiring your mother." b. "Withdrawal can be a normal response in the process of dying." c. "Most dying patients don't know what is going on around them." d. "It is important to stimulate your mother so she can't retreat from you."
ANS: B Withdrawal is a normal psychosocial response to approaching death. Dying patients may maintain the ability to hear while not being able to respond. Stimulation will tire the patient and is not an appropriate response to withdrawal in this circumstance.
The nurse is caring for an unresponsive terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be appropriate? a. Suction the patient's mouth. b. Administer oxygen via face mask. c. Document Cheyne-Stokes respirations. d. Place the patient in high Fowler's position
ANS: C Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. Cheyne-Stokes respirations are expected in the last days of life and are not position dependent. There is also no need for supplemental oxygen by face mask or suctioning the patient.
Which patient should the nurse refer for hospice care? a. A 70-yr-old patient with lymphoma whose children are unable to discuss issues related to dying b. A 60-yr-old patient with chronic severe pain as a result of spinal arthritis and vertebral collapse c. A 40-yr-old patient with AIDS-related dementia who needs palliative care and pain management d. A 50-yr-old patient with advanced liver failure whose family members can no longer provide care in the home
ANS: C Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life. Patients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice patients
A middle-aged patient tells the nurse, "My mother died 4 months ago, and I just can't get over it. I'm not sure it is normal to still think about her every day." Which nursing diagnosis is most appropriate? a. Hopelessness related to inability to resolve grief b. Complicated grieving related to unresolved issues c. Anxiety related to lack of knowledge about normal grieving d. Chronic sorrow related to ongoing distress about loss of mother
ANS: C The patient should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal for months or years after a death. The other nursing diagnoses imply that the patient's grief is unusual or pathologic, which is not the case
The nurse is caring for a patient with lung cancer in a home hospice program. Which action by the nurse is appropriate? a. Discuss cancer risk factors and appropriate lifestyle modifications. b. Teach the patient about the purpose of chemotherapy and radiation. c. Encourage the patient to discuss past life events and their meanings. d. Accomplish a thorough head-to-toe assessment several times a week
ANS: C The role of the hospice nurse includes assisting the patient with the important end-of-life task of finding meaning in the patient's life. Frequent head-to-toe assessments are not needed for hospice patients and may tire the patient unnecessarily.
As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first? a. Place a "Do Not Resuscitate" (DNR) notation in the patient's care plan. b. Invite the patient to add a notarized advance directive in the health record. c. Advise the patient to designate a person to make future health care decisions. d. Ask if the decision has been discussed with the patient's health care provider.
ANS: D A health care provider's order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient's request but does not have the authority to place the DNR order in the care plan.
The nurse is caring for a patient who has been admitted to the hospital while receiving home hospice care. The nurse interprets that the patient has a general prognosis of which of the following? A. 3 months or less to live B. 6 months or less to live C. 12 months or less to live D. 18 months or less to live
B. 6 months or less to live Two criteria must be met to be eligible for hospice care. First, the patient must wish to receive it, and second, the physician must certify that the patient has a prognosis of 6 months or less to live.
The home health nurse visits a 40-year-old breast cancer patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7 (on a 10-point scale). In prioritizing activities for the visit, you would do which of the following first? A. Auscultate for breath sounds. B. Administer prn pain medication. C. Check pressure points for skin breakdown. D. Ask family members about patient's dietary intake.
B. Administer PRN pain medication. Meeting the patient's physiologic and safety needs is the priority. Physical care focuses on the needs for oxygen, nutrition, pain relief, mobility, elimination, and skin care. The patient is not experiencing oxygenation problems; the priority is to treat the severe pain with pain medication.
A 67-year-old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis, she was very active in her neighborhood association. Her husband is concerned because his wife is staying at home and missing her usual community activities. Which common end-of-life (EOL) psychologic manifestation is she most likely demonstrating? A. Peacefulness B. Decreased socialization C. Decreased decision-making D. Anxiety about unfinished business
B. Decreased socialization Decreased socialization is a common psychosocial manifestation of approaching death.
A client has just heard from his oncologist that his chemotherapy is no longer working and that his cancer has gotten worse. The doctor shared this information with the nurse and said that he was worried the client is very distressed. Which of the following should the nurse use to begin a conversation with the client? A. "I heard your cancer is back and your chemo is not working." B. "Don't worry. I see you are upset, but everything will be okay." C. "Can you tell me what the doctor just shared with you about how you are doing?" D. "I know the doctor give you bad news, but there are always new treatments to try."
C. "Can you tell me what the doctor just shared with you about how you are doing?"
During admission of a patient diagnosed with metastatic lung cancer, you assess for which of the following as a key indicator of clinical depression related to terminal illness? A. Frustration with pain B. Anorexia and nausea C. Feelings of hopelessness D. Inability to carry out activities of daily living
C. Feelings of hopelessness Feelings of hopelessness are likely in a patient with a terminal illness who has clinical depression. This can be attributed to lack of control over the disease process or outcome. You should assess for depression routinely when working with patients with a terminal illness.
Mr. Johansen died at the age of 71 after a myocardial infarction that he experienced while performing yard work. What indicates that Mrs. Johansen is experiencing prolonged grief disorder? A. She initially denied that Mr. Johansen died. B. She talked about her husband extensively in the years after his death. C. She stated that she expects him home soon on the anniversary of his death. D. She cried uncontrollably and unpredictably in the weeks after her husband's death.
C. She stated that she expects him home soon on the anniversary of his death. Denial of an individual's death that persists beyond 6 months indicates prolonged grief disorder. Strong emotions and denial immediately after the death are expected responses, and talking about the deceased loved one is not considered to be evidence of the disorder.
The family attorney informed a patient's adult children and wife that he did not have an advance directive after he suffered a serious stroke. Who is responsible for identifying end-of-life (EOL) measures to be instituted when the patient cannot communicate his or her specific wishes? A. Notary and attorney B. Physician and family C. Wife and adult children D. Physician and nursing staff
C. Wife and adult children In the event that the person is not capable of communicating his or her wishes, the surrogate decision maker who is usually the next of kin (spouse or other family members) determines what measures will or will not be taken.
You have been working full time with terminally ill patients for 3 years. You are experiencing irritability and mixed emotions when expressing sadness since four of your patients died on the same day. To optimize the quality of your nursing care, you should examine your own A. full-time work schedule. B. past feelings toward death. C. patterns for dealing with grief. D. demands for involvement in patient care.
C. patterns for dealing with grief. Caring for dying patients is intense and emotionally charged, and you need to be aware of how grief affects you personally. You will have feelings of loss, helplessness, and powerlessness when dealing with death. Feelings of sorrow, guilt, and frustration need to be expressed. Recognizing personal feelings allows openness in exchanging feelings with the patient and family.
The hospice nurse identifies an abnormal grief reaction by the wife of a dying patient, who says A. "I don't think that I can live without my husband to take care of me." B. "I wonder if expressing my sadness makes my husband feel worse." C. "We have shared so much that it is hard to realize that I will be alone." D. "I don't feel guilty about leaving him to go to lunch with my friends."
D. "I don't feel guilty about leaving him to go to lunch with my friends." Being present during a family member's dying process can be highly stressful. It is important for the hospice nurse to recognize signs and behaviors among family members who may be at risk for abnormal grief reactions and be prepared to intervene if necessary.
A patient has been receiving palliative care for the past several weeks in light of her worsening condition after a series of strokes. The caregiver has rung the call bell, stating that the patient "stops breathing for a while, then breathes fast and hard, and then stops again." You recognize that the patient is experiencing A. Apnea B. Bradypnea C. Death rattle D. Cheyne-Stokes respirations
D. Cheyne-Stokes respirations Cheyne-Stokes respirations are a pattern of breathing characterized by alternating periods of apnea and deep, rapid breathing. This type of breathing is usually seen as a person nears death.
For the past 5 years, Tom has repeatedly asked his mother to donate his deceased father's belongings to charity, but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type of grief is Tom's mother experiencing? A. Adaptive grief B. Disruptive grief C. Anticipatory grief D. Prolonged grief disorder
D. Prolonged grief disorder Prolonged grief disorder is prolonged and intense mourning. It includes symptoms such as recurrent distressing emotions, intrusive thoughts related to the loss of a loved one, severe pangs of emotion, self-neglect, and denial of the loss for longer than 6 months.
What is the primary purpose of hospice? A. Allow patients to die at home. B. Provide better quality of care than the family can. C. Coordinate care for dying patients and their families. D. Provide comfort and support for dying patients and their families.
D. Provide comfort and support for dying patients and their families. Hospice provides support and care at the end of life to help patients live as fully and as comfortably as possible. The emphasis is on symptom management, advance care planning, spiritual care, and family support, including bereavement.
You are visiting with the wife of a patient who is having difficulty making the transition to palliative care for her dying husband. What is the most desirable outcome for the couple? A. They express hope for a cure. B. They comply with treatment options. C. They set additional goals for the future. D. They acknowledge the symptoms and prognosis.
D. They acknowledge the symptoms and prognosis. The grief experience for the caregiver of the patient with a chronic illness often begins long before the death. This is called anticipatory grief. Acceptance of the expected loss is associated with more positive outcomes.