N3 Quiz 6 End of Life Palliative Care

How soon does death comes with VSED What comes with this?

10 to 14 days Extreme thirst, delirium

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? Medical directive by proxy Living will declaration 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.

Which term best describes a living will? Proxy directive Medical directive Health care power of attorney Durable power of attorney for health care

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.

Stages of grief

denial, anger, bargaining, depression, and acceptance.

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." "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."

"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.

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." "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." "I know another client with the same diagnosis who has been in remission for 10 years."

"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 family of a dying client reports that their loved one is experiencing more shortness of breath. Which nursing intervention is most appropriate at this time? Offer the bedpan to urinate or defecate Call the health care provider to obtain an oxygen order Get the client out of bed to the chair. Offer the client sips to drink.

Call the health care provider to obtain an oxygen order Explanation: Obtaining an oxygen order can reduce the client's shortness of breath and help the family feel more comfortable. It is difficult for families to see the client with shortness of breath. The dying client and family need support, and the bedpan, sitting in a chair, or offering sips to drink do not address the feelings of shortness of breath.

A client nearing the end of life is experiencing delirium. Which action will the nurse take to help this client? Encourage family to visit. Apply restraints as needed. Increase environmental stimulation. Add additional lighting to the room.

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.

Which "awareness context" is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise? Mutual pretense awareness Closed awareness Suspected awareness Open 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 acknowledge that reality openly.

With responding to emotions, what does N.U.R.S.E. stand for?

N. Name the emotion. A.understand the emotion. R. Respect the patient. S. Support the patient. E. Explore the emotion.

Which of the following does not coincide with Kübler-Ross's stages related to a dying client? Clients don't always follow the stages in order. Some client regress, then move forward again. The dying client usually exhibits anger first. The client may be in several stages at once.

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.

What is a proxy directive and health care power of attorney?

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.

--------- , the appointment and authorization of another person to make medical decisions on behalf of the person who created the advance directive when he or she can no longer speak for himself or herself, is an important addition to the living will or medical directive that specifies the signer's preferences.

proxy directive

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 Clients and families view hospice care as giving up Lack of Medicare/Medicaid funding for hospice Difficulty obtaining Medicare certification for hospice services

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 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? Lower the head of the bed. Restrict the intake of oral fluids. Coach to use pursed lip breathing. Increase the air temperature in the room.

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.

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.

provides inpatient stay for symptoms management that cannot be provided in the home.

General inpatient care

What are the signs of dying months before death?

Generalized weakness, fatigue, social isolation, decreased appetite

--------- written documents that allow competent people to document their preferences regarding the use or nonuse of medical treatment at the end of life, specify their preferred setting for care, and communicate other valuable insights into their values and beliefs.

Advance directives

is provided in the home to manage a medical crisis.

Continuous care

What type of medication might be given for a patient with dyspnea who is at the end of their life?

Low-dose, opiates and oxygen

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? "This must be very difficult for you." "Let me explain to you what is happening." "I'm so sorry. I know how you must feel." "You know you're dying?"

"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 nurse is providing in-home hospice care to a terminally ill client. The client experiences a medical crisis requiring monitoring and medication administration. Which level of hospice care would the nurse implement? Routine home care Continuous care Inpatient respite care General inpatient care

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

How soon as death is, the patient is restless, has weakness, fatigue, social, isolation, increased appetite, lots of sleep, increased, heart rate, and respiratory rate, decrease in blood pressure and urinary output

Days before death

a 5-day inpatient stay provided on an occasional basis to relieve the family caregivers.

Inpatient respite care

Settings for Palliative Care and End-of-Life Care

Institution-based palliative care programs (e.g., programs within hospitals or long-term care facilities) Outpatient-based palliative care programs (e.g., outpatient clinics, ambulatory settings) Community-based palliative care program (consultative teams collaborate with hospice or home health agencies, to support patients not yet receiving hospice care in their place of residence) Hospice care (under Medicare Part A)

What is a living will? How is MOLST/Polst different?

a written statement detailing a person's desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive. MOLST/polst is more generic

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 weight loss and inadequate food intake irregular eating habits

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.

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? Positioning the client on the side with the head supported with a pillow Using a soft toothbrush to vigorously clean the mouth Performing gentle suctioning of the mouth Administering a prescribed anticholinergic agent

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.

The family of a terminally ill client tells the nurse that the client has been breathing irregularly and, at times, it appears that he is not breathing at all. The client's daughter states, "He moans when he breathes. Is he in pain?" Which response by the nurse would be most appropriate? "His moaning does indicate pain, so we'll increase his pain medication." "The moaning you hear is from air moving over very relaxed vocal cords." "He has secretions that are collecting at the back of the throat." "He is getting less oxygen to the brain, so the moaning means he is dreaming."

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

A patient authorizes a son to make medical decisions and brings the completed forms for the nurse to place on the chart. What form does the nurse understand this is? An advance directive A living will A standard addendum to a will A proxy directive

A proxy directive Explanation: Advance directives are written documents that allow competent people to document their preferences regarding the use or nonuse of medical treatment at the end of life, specify their preferred setting for care, and communicate other valuable insights into their values and beliefs. The addition of a proxy directive (the appointment and authorization of another person to make medical decisions on behalf of the person who created the advance directive when he or she can no longer speak for himself or herself) is an important addition to the living will or medical directive that specifies the signer's preferences.

The physician is attending to a 72-year-old client with a malignant brain tumor. Family members report that the client rarely sleeps and frequently reports seeing things that are not real. Which intervention is an appropriate request for the hospice nurse to suggest to the physician? Perform surgery to remove the tumor from the brain. Begin radiation therapy to prevent cellular growth. Obtain a biopsy to analyze the lymph nodes. Add haloperidol to the client's treatment plan.

Add haloperidol to the client's treatment plan. Explanation: Haloperidol may reduce hallucinations. Radiation therapy helps prevent cellular growth. It may be used to cure the cancer or to control malignancy when the tumor cannot be removed or when lymph node involvement is present, and it can be used prophylactically to prevent spread. Biopsy is used to analyze the lymph nodes or to destroy the tissues surrounding the tumor.

-------- stage of grief exhibited by statement similar to "Why me?"

Anger, second stage of grief

With cancer, at what point should palliative care become involved? What are some of the most common diagnosis for palliative care?

As soon as cancer, metastasizes, palliative care Common causes are cancer, dementia, cardiac, respiratory

For individuals known to be dying by virtue of age and/or diagnosis, which signs indicate approaching death?

As the oxygen supply to the brain decreases, the patient 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.

While providing care to a terminally ill client, the client's niece asks the nurse about the client's condition and prognosis. Which of the following would be most appropriate? Provide the niece with the information that she is requesting. Ask the client's consent before sharing any information with the niece. Check with the client's immediate family members about sharing information. Refer the niece to the client's physician for information.

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

Which med is used to manage excessive oral and respiratory secretions when death is imminent.

Atropine

Which of the following may be contained in an "emergency kit" for a hospice patient exhibiting restlessness? Benzodiazepine Oral sucrose Laxative Atropine sulfate drops

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

The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation? Encourage the family members to express their feelings and listen to them in their frank communication. Encourage conversations about the impending death of the client. Be a silent observer and allow the client to communicate with the family members. Encourage the client's family members to spend time with the client.

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 as they frankly communicate, you may help family members feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members to express their feelings.

Which term is used to describe the personal feelings that accompany an anticipated or actual loss? Bereavement Grief Mourning Spirituality

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.

How soon is death when the patient is nonresponsive, the heart rate is increased, but may become irregular, there's a decrease in blood pressure, apnea, or agonal, breathing, oliguria, or an area, and a modeling of extremities.

Hours

A nurse is providing care to a terminally ill client who follows Islamic traditions and is experiencing pain. When developing a plan of care for this client, an understanding of which of the following would the nurse need to integrate into the plan? Pain is viewed as a means of cleansing by God. Pain must be controlled regardless of the client's wishes. Pain is considered a positive aspect that leads to rebirth. Pain provides the client with an opportunity for repentance.

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 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. Palliative care Radiation Angiogenesis Respite care

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.

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?

Palliative care in the form of Long-term care

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 Palliative sedation Conscious sedation Patient-controlled analgesia

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.

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? Eating alone so the client can eat at his own pace and not be hurried Providing several choices on the plate so that the client has what may appeal to him Offering high caloric foods to build fat and muscle Preparing cool or cold foods that may be better tolerated

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.

The client has been diagnosed with terminal COPD. The client and the client's family have not yet agreed on the final arrangements and are discussing options. How can the nurse best intervene in these final decisions? Respect the client's autonomy and right to determine how to spend the rest of his or her life. Persuade the client to follow their family's preferences for end-of-life care. Remind the family that the client needs to focus energy on recovery. Ask the family members about coordinating spiritual care for the client.

Respect the client's autonomy and right to determine how to spend the rest of his or her life. Explanation: Nurses honor a dying client's right to know the seriousness of their condition. One outcome of being truthful includes respecting the client's autonomy and right to determine how to spend the rest of their life. The nurse-client relationship is based on honesty rather than on the false pretense that recovery will occur. Spiritual care is one component of end-of-life care for many clients but not a factor in this situation.

As the moment of death approaches, which of the following does the nurse encourage the family to do? Have the family sit in front of the client so they can be seen. Rub the client's hand and arm to comfort the client. Speak to the client in a calm and soothing voice. Lie next to the client and hold 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.

Nursing students are reviewing information about attitudes related to death and dying. The students demonstrate understanding of the information when they identify which of the following as most accurate? There remains a conspiracy of silence about dying despite progress in the area. Most clinicians are very open to talking about disease and dying with clients. 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.

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.

What is the role of the nurse at a family meeting?

They share updates, actors, interpreters, help with the emotions, help the family, develop questions for the provider

Despite having been administered 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 Gently massage the arms and legs Use imagery, humor, and progressive relaxation Encourage the patient to sleep

Use imagery, humor, and progressive relaxation Explanation: Imagery, humor, and progressive relaxation are the various techniques to potentiate the effects of pain medication and to reduce dyspnea. 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 in potentiate the effects of pain medication.

When does the death rattle typically happen?

Usually within 24 hours of death

How soon is death when there is an increased amount of sleep, increased, heart rate, and respiratory rate, and a decrease in blood pressure and urinary output.

Weeks before death