IWCC Nursing Semester One- Unit 7

A client has a terminal illness, and her spouse is distraught about the unrelenting pain she experiences. Which should the nurse implement as the most effective measures to alleviate the spouse's distress? Select all that apply.

- Engage the spouse in providing comfort. - Encourage the spouse and client to hold hands.

The nurse is caring for a client who has just died. Which end-of-life information needs to be documented in the clients medical record?

- Time and date of death - Time of body transfer and destination - Medical tubes, devices, or lines left in the body - Name of primary health care provider certifying death

The nurse is caring for a client at the end of life. Which skin changes would the nurse expect to note?

- Wax-like texture - Mottling of arms, legs, hands, and feet - Cyanosis of the nose, nail beds, and knees

A clients spouse becomes distraught when thinking about his wife's terminal prognosis. Which action would the nurse implement to best assist the spouse?

Encourage development of realistic goals.

The nurse is caring for a client at the end of life. Which late cardiovascular and respiratory findings would the nurse expect to note while collecting data?

Irregular heart rate Decreased pulse rate Decreased blood pressure Irregular breathing patterns

The nurse enters a patient's room and notes that the patient is dressed in street clothes. The patient states, "I am leaving. They cannot do anything to help a dying man anyway." What traditional stage of death and dying does the nurse recognize?

Anger

A client who was struck by a car while jogging is brought to the emergency department by emergency medical services. The client is unconscious, and a ruptured spleen is suspected. Emergency measures are instituted but are unsuccessful. The client's fiancé is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which would the nurse implement?

Close the deceased client's eyes and places gauze and a small ice pack on the eyes.

The nurse notes that the family members of a patient who is terminally ill frequently encourage the patient to take sips of fluids. The family voices concern about the patient being dehydrated. Which facts about the benefits of of dehydration should the nurse share with the patient and family?

Decreased urine output decreased incontinence Decreased food intake decreases pulmonary secretions Dehydration ultimately decreased edema and advises Dehydration results in decreased pain and perception

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family?

Encourage expression of feelings, concern, and fears Touch and hold the client's or family member's hand if appropriate Be honest and let the client and family know that they will not be abandoned by the nurse

A 39 year old man learned today that his 36 year old wife had an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which responses by the husband as indicative of effective individual coping?

He expresses his anger at god and the primary health care providers for allowing this to happen. He tells the nurse he has prayed that god will allow his wife to live long enough to watch their children's high school graduation He has asked his wife and children to assist him in making funeral arrangements, such as casket selection and cemetery burial sites.

The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent?

Irregular, noisy breathing and cold, clammy skin

The nurse is caring for a client with terminal cancer who is close to death. In reviewing the plan of care, the nurse determines that which action is a priority?

Maintain the client's dignity and self-esteem, and make the client as comfortable as possible.

The nurse is caring for a client at the end of life. Which gastrointestinal findings indicate the death is approaching?

Nausea Incontinence Accumulation of gas Abdominal distention

The nurse is caring for an 8-year-old child in the late stage of a terminal illness. The child is semiconscious. The nurse notices the child has a dry mouth, and the family believes the child is thirsty. The family is attempting to give the child a large glass of apple juice. Which actions would the nurse take?

Perform frequent oral care with mouth swabs Encourage the family to participate in oral cares as much as desired Give the child small sips of water or ice chips if alert and requested by the child

A licensed practical nurse is providing instructions to an assistive personnel who is preparing to care for a deceased client whose eyes will be donated. The nurse intervenes if the AP performs which action?

Places a dry sterile dressing over the open eyes

The nurse is caring for a client at the end of life. The client is withdrawn and agitated and is experiencing visual hallucinations. Which actions would the nurse take to provide end-of-life psychological care?

Provide privacy to the client and family Encourage the family to talk with and reassure the client Encourage visits by appropriate spiritual services as desired

The nurse is participating in a care plan session for a client with a terminal illness. Which nursing actions would be included?

Respond to requests from the client and family promptly Support the clients decision-making in order to promote client control Provide information about what to expect during the dying process to the client and family

The nurse is working with a new nurse employee in a hospice agency. The nurse recognizes the new employee needs further assistance in facilitating effective communication between a client and the family if the new nurse employee performs which action?

The new nurse employee makes decisions for the client and family in order to relieve them of unnecessary demands.

A client and her husband are being discharged from the hospital after delivering a stillborn infant. They ask about the possibility of attending a bereavement support group in the community. The nurse realizes this action corresponds to which aspect of grieving?

Normal grieving

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?

Remain with the family member without discussing funeral arrangements.