Chapter 16: End-of-Life Care Oncology
Which term is used to describe the personal feelings that accompany an anticipated or actual loss? Spirituality Mourning Bereavement Grief
Grief Explanation: 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 client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using? Living will declaration Medical directive by proxy Durable power of attorney for health care End-of-life treatment directive
Durable power of attorney for health care Explanation: A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.
According to federal guidelines, hospices may provide no more than what percentage of the aggregate annual patient-days at the inpatient level? 40 30 20 10
20 Explanation: 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.
As a client approaches death, respirations become noisy. This is the result of which type physical event? central nervous system alterations gastrointestinal impairment cardiac dysfunction musculoskeletal change
musculoskeletal change Explanation: As death approaches, a client's reflexes become hypoactive. The jaw and facial muscles also relax. As the tongue falls to the back of the throat, respirations become noisy
Based on the most common concern of a dying patient, the hospice nurse should: Position the patient to prevent difficulties with breathing. Offer supplemental fluids to prevent dehydration. Turn the patient every 2 hours to prevent decubitus ulcers. Administer pain medication on a schedule that prevents pain from intensifying.
Administer pain medication on a schedule that prevents pain from intensifying. Explanation: Pain management is the most common concern for the dying patient. Medication should be given on a PRN schedule that keeps the patient comfortable.
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 provides the client with an opportunity for repentance. Pain is considered a positive aspect that leads to rebirth. Pain is viewed as a means of cleansing by God. Pain must be controlled regardless of the client's wishes.
Pain is viewed as a means of cleansing by God. Explanation: 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 suffering. 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 nurse is developing a teaching plan for a terminally ill client and his family about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan? Each client experiences each of the stages. Most clients reach acceptance by the time of death. Typically, the stages occur in succession. The stages are applicable to any loss.
The stages are applicable to any loss. Explanation: 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 fluctuate on a sometimes daily basis in their emotional responses.
Which of the following is a term that refers to individual, family, group, and cultural expressions of grief and associated behaviors? Mourning Spirituality Grief Bereavement
Mourning Explanation: 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 is an appropriate method of assessing the dying client? Focus on the client's basic needs. Stimulate the client every 30 minutes. Repeat assessments as necessary. Sedate the client before completing range-of-motion exercises.
Focus on the client's basic needs. Explanation: Initially, nurses focus assessment on the client's basic physical needs, such as pain, breathing, nutrition, hydration, and elimination. The other options are inappropriate in the assessment of the dying client.
When a person authorizes another to make medical decisions on his or her behalf, the person has written which of the following? Standard addendum to a will Living will Proxy directive Treatment directive
Proxy directive Explanation: Durable power of attorney for health care is a legal document through which the signer appoints and authorizes another individual to make medical decisions on his or her behalf when he or she is no longer able to speak for him- or herself. This is also known as a health care power of attorney or a proxy directive.
A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply. Encourage the client to explain his or her wishes. Comfort the client by saying it will all be over soon. Advise the client's health care provider of the client's condition. Recommend that the client consider physician-assisted suicide. Control the client's pain with prescribed medication.
Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Encourage the client to explain his or her wishes. Explanation: This client lives in Oregon, one of five states that have decriminalized physician-assisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation. Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however.
Anorexia and cachexia are common problems at the end of life. The nurse plays an important role in managing symptoms and preventing complications. Which of the following are appropriate nursing interventions for these problems? Select all that apply. Encourage the patient to eat in an upright position. Suggest a daily weighing time to monitor treatment plan. Teach the patient how to increase the nutritional value of meals (i.e., add dry milk powder to milk). Advise the patient and family about the importance of a balanced diet. Recommend that the patient eat when hungry, regardless of usual meal times.
Encourage the patient to eat in an upright position. Recommend that the patient eat when hungry, regardless of usual meal times. Teach the patient how to increase the nutritional value of meals (i.e., add dry milk powder to milk). Explanation: It is important not to emphasize eating a "balanced meal." Encourage the patient to eat whatever he wants, whenever he wants. Minimize emphasis on daily weighing to take the focus off of weight loss or gain.
A type of comprehensive care for clients whose disease is not responsive to cure is a terminal illness. palliative care. interdisciplinary collaboration. euthanasia.
palliative care. Explanation: Palliative care is a type of comprehensive care for clients whose disease is not responsive to cure. Terminal illness is a progressive, irreversible illness that despite cure-focused medical treatment will result in the client'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 dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be? "You know you're dying?" "This must be very difficult for you." "I'm so sorry. I know how you must feel." "Let me explain to you what is happening."
"This must be very difficult for you." Explanation: Using open-ended questions allows the nurse to elicit the patient's and family's concerns, explore misconceptions and needs for information, and form the basis for collaboration with physicians and other team members. For example, a seriously ill patient may ask the nurse, "Am I dying?" The nurse should avoid making unhelpful responses that dismiss the patient's real concerns or defer the issue to another care provider. In response to the question "Am I dying?" the nurse could establish eye contact and follow with a statement acknowledging the patient's fears ("This must be very difficult for you") and an open-ended statement or question ("Tell me more about what is on your mind").
A terminally ill patient is admitted to the hospital. The patient grabs the nurse's hand and asks, "Am I dying?" What response would be best for the nurse to give? "Tell me more about what's on your mind." "Did someone tell you that you are dying?" "I am not at liberty to disclose that information." "Why do you think that?"
"Tell me more about what's on your mind." Explanation: In response to the question "Am I dying?" the nurse could establish eye contact and follow with a statement acknowledging the patient's fears ("This must be very difficult for you") and an open-ended statement or question ("Tell me more about what is on your mind"). The nurse then needs to listen intently, ask additional questions for clarification, and provide reassurance only when it is realistic.
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. "Tell me more about what's on your mind." "This must be very difficult for you." "I know just how you must feel." "You still have time for a good life." "Let's focus on what your doctor has planned."
"This must be very difficult for you." "Tell me more about what's on your mind." Explanation: 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.
A patient with end-stage chronic obstructive pulmonary disease is admitted to a hospice facility and asks the admitting nurse, "How long will I be allowed to stay here?" What is the best response by the nurse? "When your stay reaches 6 months, you will be recertified for a continued stay." "There is no time limit for your stay. You can stay until you die." "You will be able to stay only for approximately 1 month and then you will be discharged." "You will be able to stay for 2 months before being discharged."
"When your stay reaches 6 months, you will be recertified for a continued stay." Explanation: Federal rules for hospices require that eligibility be reviewed periodically. Patients who live longer than 6 months under hospice care are not discharged, provided that their physician and the hospice medical director continue to certify that they are terminally ill with a life expectancy of 6 months or less (assuming that the disease continues its expected course).
A 25-year-old client with cancer who is experiencing unrelieved pain rated a 9 on the pain scale requests that the hospice nurse induce a state of unconsciousness until the client dies. Which statement by the nurse demonstrates an understanding of a key difference between conscious sedation and euthanasia? "Total sedation is a commonly practiced method used in this situation; I will contact your physician and begin treatment as soon as possible." "Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death." "I cannot legally administer pain medications that will induce unconsciousness to relieve your pain." "I need to perform a complete pain assessment to confirm the amount of pain you are experiencing before recommending sedation."
"Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death." Explanation: When a terminally ill client or the client's legal proxy requests palliative sedation, the use of pharmacologic agents to induce sedation or near sedation when symptoms have not responded to other management measures), the purpose is not to hasten the client's death but to relieve intractable symptoms. Palliative sedation may be controversial, but it is not illegal. Total sedation is rarely indicated in hospice care to provide comfort. Continuous pain assessments are not indicated at this stage; the client requires intervention/treatment.
For a client to use the Medicare Hospice Benefit, life expectancy needs to be what length of time? 6 months 4 months 8 months 2 months
6 months Explanation: The client who wishes to use his or her Medicare Hospice Benefit must be certified by a health care provider as terminally ill, with a life expectancy of 6 months or less if the disease follows its natural course.
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? Arrangements for the client to eat meals while others are out of the home. Encouragement of the family to serve the client meat, especially beef. Advice for the family to have fruit juices readily available at the client's bedside. Suggestions that the family offer the client foods that are hot.
Advice for the family to have fruit juices readily available at the client's bedside. Explanation: 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.
All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? Allows the nurse to express his or her feelings Allows for the nurse to take the client through in the appropriate order Allows for the nurse to facilitate the grieving process Allows for the nurse to understand when the grieving process should be concluded
Allows for the nurse to facilitate the grieving process Explanation: Grieving is a painful yet normal reaction that helps clients cope with loss and leads to emotional healing. The nurse is responsible for facilitating the grieving process and helping the client and family deal with their emotions.
A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? Anger Acceptance Denial Bargaining
Anger Explanation: Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close.
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 Dexamethasone Megestrol Dronabinol
Atropine Explanation: 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.
Which term refers to the period of time during which mourning of a loss takes place? Grief Mourning Bereavement Hospice
Bereavement Explanation: Bereavement is the period of time during which mourning of 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 coordinated program of interdisciplinary care and services provided primarily in the home to terminally ill clients and their families.
A client nearing the end of life is experiencing delirium. Which action will the nurse take to help this client? Encourage family to visit. Add additional lighting to the room. Apply restraints as needed. Increase environmental stimulation.
Encourage family to visit. Explanation: Delirium can develop in the client who is near the end of life and may be due to an underlying treatable condition or the effects of the disease process. Actions should be taken to identify the underlying cause and provide appropriate interventions. The presence of familiar faces helps reduce the anxiety caused by the delirium. Restraints are not identified as an appropriate intervention for the client with delirium. Environmental stimuli should be reduced and harsh lighting avoided as these can increase the anxiety associated with delirium.
The nurse practitioner has four patients with chronic illness that require consistent medical and nursing management. Select the condition that is the best example of a "chronically critical and progressively ill" condition. Coronary artery disease Carcinoma-in-situ Type 2 diabetes mellitus End-stage renal disease
End-stage renal disease Explanation: Certain illnesses require advanced technology for survival, or intensive care for periods of weeks or months, as in end-stage renal disease (ESRD). People with this condition are chronically critical and progressively ill. Some chronic illnesses have little effect on quality of life, but others, like ESRD, have a considerable effect because it can result in a chronic progressive deterioration.
The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to clients who are dying and their families is to first do which of the following? Participate in a support group to learn clients' feeling on care. A workshop on caring for the client who is dying Explore own feelings on mortality and death and dying. Use evidence-based practice in daily care regimen.
Explore own feelings on mortality and death and dying. Explanation: To care for others in the dying process, the nurse must explore their own feelings about mortality and death and dying. Understanding the self provides a perspective to cope with and then support clients and families experiencing pain and grief. The other options are helpful in determining appropriate nursing care but not the first step.
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. Refusal to ingest food or fluids Decrease in amount of urine produced Breathing that is very rapid Gurgling as the client breathes through the mouth Increase in visual and auditory abilities
Gurgling as the client breathes through the mouth Decrease in amount of urine produced Refusal to ingest food or fluids Explanation: 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.
For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death? Increased urinary output Increased wakefulness Increased eating Increased restlessness
Increased restlessness Explanation: As the oxygen supply to the brain decreases, the client may become restless. As the body weakens, the client will sleep more and begin to detach from the environment. For many clients, refusal of food is an indication that they are ready to die. Based on decreased intake, urinary output generally decreases in amount and frequency.
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 often provided along with disease-lessening treatments. Palliative care is conceptually broader than hospice care. Palliative care developed after hospice care developed.
Palliative care is the same as hospice care. Explanation: Palliative care is not synonymous with hospice care. All hospice care is palliative but not all palliative care is hospice care. Palliative care is conceptually 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.
A client with a brain tumor recently stopped radiation and chemotherapy for treatment of the cancer. The client recently reported dry mouth. Which intervention by the hospice nurse demonstrates that the nurse understands treatment measures for dry mouth? Place two drops of atropine ophthalmic 1% solution sublingually. Begin 9% normal saline IV at 125 mL/hr. Gently suction the client's mouth and buccal cavity. Provide gentle oral care after each meal.
Provide gentle oral care after each meal. Explanation: Dry mouth can generally be managed through nursing measures such as mouth care. The use of artificial hydration (IV fluids) carries considerable risks and does not contribute to comfort at the end of life. Atropine ophthalmic 1% drops administered sublingually help to reduce oral secretions. Gentle oral suctioning reduces the production of secretions.
A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? Abide by the dying client's wishes. Respect the client's and family members' choices. Ask the family members about spiritual care. Share emotional pain.
Respect the client's and family members' choices. Explanation: In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members' choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.
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? Impaired physical mobility related to sedative effects of the drug Risk for constipation related to the effects of an opioid Caregiver role strain related to the need for around-the-clock pain control Risk for ineffective cerebral tissue perfusion related to central nervous system effects of the drug
Risk for constipation related to the effects of an opioid Explanation: 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 infection 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.
The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation? Sit with the client's daughter privately and encourage her to express her feelings frankly. Insist that the daughter try her best to make the client's final days happy ones. Remind the daughter of the client's impending death and the importance of expressing herself. Remain focused on the client's needs and care because these are your main responsibilities.
Sit with the client's daughter privately and encourage her to express her feelings frankly. Explanation: Failure to verbalize feelings, express emotions, and show tenderness for the dying person is often a source of regret for grieving relatives. Therefore, families must feel that they can express their feelings with nurses who are compassionate listeners. If nurses encourage family members and listen to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. Families must feel that they can express their feelings with nurses who are compassionate listeners. Reminding a family member that their loved one will die soon shows a lack of compassion in this situation. Although the client is the nurse's main priority, it is the nurse's role to encourage family members to identify strengths and express feelings as a method of coping with the death of their loved one. The response regarding making the father's final days happy ones shows a lack of caring on the part of the nurse.
A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion indicates that the client requires more teaching about hospice care? The client explains that he isn't ready to complete his will. The client doesn't want to discuss death around his girlfriend. The client entered a clinical trial through the National Cancer Institute. The physician orders weekly blood transfusions to be given at home.
The client entered a clinical trial through the National Cancer Institute. Explanation: The client involved in a clinical trial needs additional teaching about hospice care. This treatment option suggests that the client isn't ready for palliative care, which is a criterion for hospice care. Preferring not to discuss death around the girlfriend and not feeling ready to complete a will are normal responses to the grieving process. Blood transfusions are considered palliative care.
During unplanned, spontaneous moments, dying clients 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 client's direction, and making direct eye contact. The nurse should administer a pain killer and sedative to the client and allow them to sleep. The nurse can call out to the client's family members and ask them to sit next to the client. The nurse should ask the client questions about their feelings about death and talk about other things to distract the client's attention.
The nurse can communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact. Explanation: The nurse should communicate interest and a willingness to listen by sitting down, leaning forward in the client's direction, and making direct eye contact with the client. Calling out to the client's family members and asking them to sit next to the client may not be the best intervention. The nurse should not distract the dying client's attention and should not administer a pain killer or sedative.
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? Clients, for the most part, would gain hope if they were told about a poor prognosis. Clients would ask for information if they really had a desire to know. Most clinicians are very open to talking about disease and dying with clients. There remains a conspiracy of silence about dying despite progress in the area.
There remains a conspiracy of silence about dying despite progress in the area. Explanation: 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 families' 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.
In spite of administering the prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea? Offer small amounts of nourishment frequently Encourage the patient to sleep Gently massage the arms and legs Use imagery, humor, and progressive relaxation
Use imagery, humor, and progressive relaxation Explanation: Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication. Offering small amounts of nourishment frequently will not help potentiate the effects of pain medication. Gentle massaging of the arms and legs helps to regulate body temperature. Encouraging the client to fall asleep will not help potentiate the effects of pain medication.
A nurse is evaluating a client with a terminal illness. What should the nurse report so that the health care team can consider alternative nutritional approaches and fluid administration routes for the client at the end of life? altered gastrointestinal function drop in blood pressure and rapid heart rate irregular eating habits weight loss and inadequate food intake
weight loss and inadequate food intake Explanation: The nurse should report weight loss and inadequate food intake so that the team can consider adding appetite stimulants and the nutritionist can alter the meal plan to give more satisfying meals as a comfort measure. The nurse knows that changes of gastrointestinal function such as irregular eating or bowel changes occur as part of the dying process and are not relevant to the desired intervention. Deteriorating vital signs are part of the dying process so that these signs are not relevant to the desired intervention.
Which statement, made by the nurse, can be most helpful when caring for a client in the third stage of Kubler-Ross' emotional reactions to dying? "Let's review the laboratory results and compare them with the diagnostic tests." "What makes you most angry about getting the disease?" "I like your idea of living for today and enjoying those around you." "I understand that it would be wonderful to see your daughter's graduation."
"I understand that it would be wonderful to see your daughter's graduation." Explanation: The third stage of Elisabeth Kubler-Ross' series of reactions is bargaining. Confirming the intention to live to a certain time is common in this stage. Reviewing laboratory and diagnostic tests occurs in the first stage, denial. Talking about anger occurs in the second stage, anger. Living for the day is an idea which occurs in the final stage, acceptance.
A mother of three young children has been diagnosed with stage III breast cancer and is distraught. Which statement best communicates a spirit of hopefulness to this client? "Let's take this one day at a time; remember you have your daughter's dance recital next week." "I know another client with the same diagnosis who has been in remission for 10 years." "You should seek a second medical opinion about your diagnosis." "I believe that you will fight hard to beat this and see your babies grow up."
"Let's take this one day at a time; remember you have your daughter's dance recital next week." Explanation: Helping a client to find reasons to live and look forward to events promotes positive attitudes and ability to live for the moment, which in turn communicates a spirit of hopefulness. The statement about a second opinion is inappropriate because it gives the client false hope that her current diagnosis is inaccurate. Although he client may choose another medical opinion, she needs to come to that decision without the nurse's advice. Reponses should not convey false hope to the client. Nurses and clients should not confuse hope with unrealistic optimism
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 Physician's orders Invasiveness of the treatment Length of required treatment
Client's goals Explanation: 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 is also known as a proxy directive? Medical directive Living will Durable power of attorney for health care Treatment directive
Durable power of attorney for health care Explanation: 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.
The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using? Continuous care Inpatient respite care Palliative care General inpatient care
Palliative care Explanation: Long-term care is increasing as a setting to provide palliative care that addresses management of symptoms such as pain. Inpatient respite care is a 5-day inpatient stay provided on an occasional basis to relieve the family caregivers. Continuous care is provided in the home to manage a medical crisis. General inpatient care provides inpatient stay for symptoms management that cannot be provided in the home.
As the moment of death approaches, which of the following does the nurse encourage the family to do? Lie next to the client and hold the client. Have the family sit in front of the client so they can be seen. Speak to the client in a calm and soothing voice. Rub the client's hand and arm to comfort the client.
Speak to the client in a calm and soothing voice. Explanation: Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.
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? Performing gentle suctioning of the mouth Administering a prescribed anticholinergic agent Positioning the client on the side with the head supported with a pillow Using a soft toothbrush to vigorously clean the mouth
Using a soft toothbrush to vigorously clean the mouth Explanation: 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 administering prescribed anticholinergic agents sublingually or transdermally. Deeper suctioning may cause significant discomfort to the dying client and rarely is of benefit because secretions tend to reaccumulate quickly.
A client approaching end-of-life reports dyspnea as being 7 on a scale from 0 to 10. Which action will the nurse take to assist this client? Restrict the intake of oral fluids. Lower the head of the bed. Increase the air temperature in the room. Coach to use pursed lip breathing.
Coach to use pursed lip breathing. Explanation: Dyspnea is one of the most prevalent symptoms at the end of life and is considered a highly subjective symptom. To determine the intensity of dyspnea, the client can be asked to report the severity on a scale from 0 to 10, similar to using a pain rating scale. Interventions to reduce the subjective feeling of dyspnea includes the use of purse-lipped breathing. The head of the bed should be elevated or help the client assume a forward-learning posture. Oral fluids should not be restricted as this will help keep pulmonary secretions thin. The air temperature in the room should be cool as this helps facilitate breathing.
The family of a dying client being cared for at home is requesting information on how best to prepare food. Which suggestion by the nurse may stimulate appetite? Offering high caloric foods to build fat and muscle Preparing cool or cold foods that may be better tolerated Providing several choices on the plate so that the client has what may appeal to him Eating alone so the client can eat at his own pace and not be hurried
Preparing cool or cold foods that may be better tolerated Explanation: Preparing cool or cold foods may be tolerated better by the client and thus stimulate appetite. Hot foods may have an aroma that may cause nausea. Clients may enjoy a mealtime companion making the eating experience more pleasurable. Offering small portions is appropriate because large, multiple portions/choices may shut down the appetite. Although weight loss may be significant, clients should have the ability to pick and choose foods that interest them.
A client in hospice has end-stage renal failure. The client states that, of late, he has lost his appetite and feels like everyday situations have become more stressful. The client reports feeling restless. In addition, the client's spouse notices that the client is becoming more confused. What is the most important nursing intervention that needs to be carried out at this point? Immediately administer drug therapy to restore renal function. Provide the spouse with an emergency kit that contains small doses of oral morphine liquid. Make arrangements with the physician to administer immunosuppressants. Make arrangements for the client to receive nutritional counseling.
Provide the spouse with an emergency kit that contains small doses of oral morphine liquid. Explanation: One of the most important aspects of the care of a client at the end of life is anticipating and planning interventions for symptoms. Both clients and family members cope more effectively with new symptoms and exacerbations of existing symptoms when they know what to expect and how to manage them. Nutritional counseling, involving the family in the plan of care, and providing psychosocial support to the client are all relevant nursing interventions that form a part of the nursing management process for a client with chronic renal failure. Nutritional counseling, administration of drug therapy to restore renal functions, and administration of immunosuppressant drugs are medical management tasks.
Which of the following does not coincide with Kübler-Ross's stages related to a dying client? The dying client usually exhibits anger first. Clients don't always follow the stages in order. The client may be in several stages at once. Some client regress, then move forward again.
The dying client usually exhibits anger first. Explanation: The dying client does not usually exhibit anger first. The client may be in several stages at once, clients don't always follow the stages in order, and some regress and then move forward.
The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: care that will reduce the client's physical discomfort and manage clinical symptoms. offered to terminally ill clients who wish to remain in their homes in lieu of hospice care. care that is provided at the very end of an illness to ease the dying process. an alternative therapy that uses massage and progressive relaxation for pain relief.
care that will reduce the client's physical discomfort and manage clinical symptoms. Explanation: Palliative care is used in conjunction with other end-of-life treatments and has many principles. Its aim is to reduce physical discomfort and other distressing symptoms but does not alter a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life. Palliative care of a terminally ill client not only provides relief from pain and other distressing symptoms but it integrates other facets of patient care as well, including psychological and spiritual aspects. Palliative care is part of hospice care.
The nurse arrives to the home of a client with a terminal illness who has just passed away. Which response will the nurse make when the family member states that the last dose of pain medication provided caused the death? "There is always a chance that pain medication will cause death in a client with a terminal illness." "Do you remember what the medication was that you think caused the death?" "It is possible that your family member died close to the time of the medication but the medication did not cause the death." "It is likely that the medication caused the body systems to slow, which precipitated the death."
"It is possible that your family member died close to the time of the medication but the medication did not cause the death." Explanation: The nurse teaches the family caregivers about comfort measures and pain medications when caring for a dying client. At the end-of-life, clients may receive more frequent doses of pain medication; however, there is always a strong possibility that a client approaching end-of-life will die in close proximity to the time of the medication. It will not help to comfort family members if a nurse asks what medication was given last. Family members should be prepared for this possibility and be reassured that they did not cause the death of the client by giving a dose of the medication. The last dose of pain medication given to a dying client will not cause death. There is no evidence to support that the medication caused the body systems to slow which precipitated the death. There is also no evidence to support that pain medication will cause death in a client with a terminal illness.
A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? "It will prolong life in a dignified manner." "It will enable the patient to remain home if that is what is desired." "It will hasten the death of the patient." "It will use artificial means of life support if the patient requests it."
"It will enable the patient to remain home if that is what is desired." Explanation: The goal of hospice is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. The patient and family make up the unit of care. Hospice care does not seek to hasten death or encourage the prolongation of life through artificial means.
Which of the following interventions should the nurse perform while providing spiritual care for a dying client? Allow a period of privacy. Provide spiritual books. Encourage family members in their frank communication. Ask the family members about spiritual care.
Ask the family members about spiritual care. Explanation: 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.
Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services? Lack of fully credentialed and trained hospice nurses Difficulty obtaining Medicare certification for hospice services Clients and families view hospice care as giving up Lack of Medicare/Medicaid funding for hospice
Clients and families view hospice care as giving up Explanation: Clients often equate hospice with giving up and are reluctant to accept hospice care. Lack of fully credentialed and trained hospice nurses is not a barrier to hospice care. Lack of Medicare funding and lack of certification for hospice service providers have not been documented as barriers to access of hospice services.
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? Importance and influence Faith and belief Address in care Community
Faith and belief Explanation: 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.
Which term best describes a living will? Durable power of attorney for health care Health care power of attorney Proxy directive Medical directive
Medical directive Explanation: 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 and health care power of attorney are other names for a durable power of attorney for health care, in which one individual is appointed and authorized to make medical decisions on behalf of another person when that person is no longer able to speak for him or herself.
Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions? Offering reassurance that the nurse has had 5 years of assisting clients in hospice and their families care for loved ones at the end of life Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous clients in hospice Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview
Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care Explanation: A key to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "I know just how you feel."
The nurse is caring for a client who has diminished lung function due to emphysema. The terminally ill client is short of breath on exertion and reports difficulty sleeping in bed. The client states, "I am so afraid of getting any worse." Which statement, by the nurse, assists the client in sustaining hope? "Do not worry, I will be here for you to help you with your needs." "I will talk with the health care provider to determine the next step in your care." "Your grandchild is almost here, and you will enjoy seeing him." "I hear you say that you are not sleeping well."
"I will talk with the health care provider to determine the next step in your care." Explanation: The client is assisted in hopefulness by believing that the healthcare team will make his remaining days meaningful. By conveying a sense that the nurse will discuss the client's condition with the health care provider, the client recognizes that the healthcare team will use whatever treatment and comfort measures are available. Telling a client not to worry is not therapeutic and is condescending. Waiting for a grandchild does not address the client's thought. Reflecting what the client said for clarification opens communication but does not instill hopefulness.
Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care? "A key component of hospice care is following your family for up to a year after your death." "Tell me who or what gives you strength." "Denial, sadness, anger, fear, and anxiety are normal grief reactions." "Mourning may be demonstrated by emotional feelings of sadness, anger, guilt, and numbness."
"Tell me who or what gives you strength." Explanation: Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. Assessment of people or things that provide strength to a terminally ill client is one way the nurse provides spiritually sensitive patient care. 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.
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. Encourage conversations on the impending death of the patient. Be a silent observer and allow the patient to communicate with the family members. Encourage the patient's family members to spend time with the patient.
Encourage the family members to express their feelings and listen to them in their frank communication. Explanation: 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 36-year-old mother of three was recently diagnosed with a chronic illness. The nurse prepared information for the patient on how to manage her illness. To help her cope with the shock and resentment that she was experiencing, the nurse gave her facts about her illness with honesty and empathy. Which of the following are the best comments that the nurse can include when talking to the patient about chronic illness? Select all that apply. It results in residual disability due to non-reversible pathology. It can be associated with exacerbations and remissions. It can require short-term management (<3 months). It is defined as long-term with the possibility of a cure if intervention is rapid and timely. It is characterized by a progressive decline in normal physiologic function
It is characterized by a progressive decline in normal physiologic function It can be associated with exacerbations and remissions. It results in residual disability due to non-reversible pathology. Explanation: Chronic illnesses are often defined as medical illnesses or health problems with associated symptoms or disabilities that require long-term management (3 months or longer). Chronic illness refers to diseases that are caused by non-reversible pathology; are characterized by a slow progressive decline in normal physiological function; are permanent with cure unlikely; and require long-term surveillance, leaving residual disability.
Which "awareness context" is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise? Open awareness Closed awareness Mutual pretense awareness Suspected awareness
Mutual pretense awareness Explanation: In mutual pretense awareness, the client, the family, and the health care professionals are aware that the client is dying, but all pretend otherwise. In closed awareness, the client is unaware of his or her terminal state, whereas others are aware. In suspected awareness, the client suspects what others know and attempts to find it out. In open awareness, all are aware that the client is dying and are able to openly acknowledge that reality.
A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival. Respite care Radiation Palliative care Angiogenesis
Palliative care Explanation: In a study of referral to palliative care for clients newly diagnosed with a disease with very poor prognosis, researchers found that those clients receiving palliative care plus standard oncology demonstrated improved quality of life and mood and had longer median survival. Radiation is primarily used when a cancer spreads to other organs, and it has not been proven to affect mood. Angiogenesis is the growth of new capillaries from the tissue of origin. This process helps malignant cells obtain needed nutrients and oxygen to promote growth. Respite care is provided on an occasional basis to relieve the family caregivers.
A client with a terminal illness who is incapacitated is experiencing intractable pain that is no longer effectively addressed by conventional pharmacology. Which type of pain management will the nurse anticipate for this client? Barbiturate coma Patient-controlled analgesia Conscious sedation Palliative sedation
Palliative sedation Explanation: Effective control of symptoms can be achieved under most conditions; however, some clients may experience distressing, intractable symptoms and other clients may be incapacitated. Although palliative sedation remains controversial, it is offered in some settings to clients who are close to death or who have symptoms that do not respond to conventional pharmacologic and nonpharmacologic approaches, resulting in unrelieved suffering. Palliative sedation is distinguished from euthanasia and physician-assisted suicide in that the intent of palliative sedation is to relieve symptoms, not to hasten death. Proportionate palliative sedation uses the minimum drug necessary to relieve the symptom while preserving consciousness, whereas palliative sedation induces unconsciousness, which is more controversial. Barbiturate coma is a technique used to induce a coma in clients with specific conditions. Conscious sedation is used for some diagnostic tests and procedures. Clients who are incapacitated are not likely candidates for patient-controlled analgesia.
A nurse on a medical unit in the hospital often provides palliative care to clients with a variety of diagnoses. Which activities describe the primary palliative care functions of this nurse? Select all that apply. Identifies multifactorial symptoms Provides assessment of symptoms Uses therapeutic communication skills with clients Manages basic nursing problems Handles difficult conversations with clients
Provides assessment of symptoms Manages basic nursing problems Uses therapeutic communication skills with clients Explanation: A primary palliative care nurse uses fundamental nursing skills to care for clients in palliative care, such as basic assessment of symptoms, management of basic care, and use of therapeutic communication skills. A nurse who is a specialist in palliative care assesses and manages complex and multifactorial symptoms and engages in difficult end-of-life conversations with clients and families.
A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care. Which of the following would the nurse include in the explanation for this client? Select all that apply. Hastens death Includes chemotherapy Integrates spirituality Offers a team approach to care Enhances quality of life Provides pain relief
Provides pain relief Integrates spirituality Offers a team approach to care Enhances quality of life Explanation: The principles of palliative care include providing relief from pain and distressing symptoms. In the early course of disease, chemotherapy and radiation may be used to define care needed, but in the later stages, chemotherapy is typically not used. Psychological support including spirituality and bereavement counseling for family members is available. The care does not hasten nor postpone death but is aimed at enhancing a quality of the life that is remaining. A team approach meets the needs of the client and family.
A client with a terminal illness is diagnosed with sarcopenia. Which mechanism(s) of the anorexia/cachexia syndrome does the nurse identify that contributed to the development of this condition? Select all that apply. Reduced rate of muscle protein synthesis Decreased immune response Loss of appetite Intolerance to treatments Reduced voluntary motor activity
Reduced voluntary motor activity Reduced rate of muscle protein synthesis Explanation: The anorexia-cachexia syndrome is characterized by disturbances in carbohydrate, protein, and fat metabolism; endocrine dysfunction; and anemia. The syndrome results in severe asthenia (loss of energy). Anorexia and cachexia differ from starvation (simple food deprivation) in several important ways. Anorexia is defined as inadequate nutritional intake, while cachexia refers to severe lean muscle loss. Cachexia is associated with anabolic and catabolic changes in metabolism that relate to activity of neurohormones and proinflammatory cytokines, resulting in profound protein loss. The development of sarcopenia in a client with this syndrome is caused by reduced voluntary motor activity and the reduced rate of muscle protein synthesis. The loss of appetite causes generalized tissue wasting. Intolerance to treatments leads to an increase in morbidity and mortality. A decreased immune response increases the risk for infection.
