Ch 16 Brunner

Which of the following is a term that refers to individual, family, group, and cultural expressions of grief and associated behaviors?

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.

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?

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 of the following is an appropriate method of assessing the dying client?

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.

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?

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.

All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason?

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.

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

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.

As the moment of death approaches, which of the following does the nurse encourage the family to do?

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.

Which of the following would be inconsistent with a normal grief reaction?

Elation Explanation: Denial, sadness, anger, fear, and anxiety are normal grief reactions in people with life-threatening illness and those close to them. Elation would not be a normal grief reaction.

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?

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.

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?

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.

A woman experienced the death of her husband from a sudden myocardial infarction 5 weeks ago. The nurse recognizes that the woman will be going through the process of mourning for an extended period of time. What processes of mourning will allow the woman to accommodate the loss in a healthy way? Select all that apply.

Reinvesting in new relationships at the appropriate time Reminiscing about the relationship she had with her husband Relinquishing old attachments to her husband at the appropriate time Explanation: Six key processes of mourning allow people to accommodate to the loss in a healthy way:1.) Recognition of the loss2.) Reaction to the separation, and experiencing and expressing the pain of the loss3.) Recollection and re-experiencing the deceased, the relationship, and the associated feelings4.) Relinquishing old attachments to the deceased5.) Readjustment to adapt to the new world without forgetting the old6.) Reinvestment Reiterating her anger and renewing her lifelong commitment may be counterproductive to the mourning process.

A nurse who provides care on an acute medical unit has observed that physicians are frequently reluctant to refer clients to hospice care. What are contributing factors that are known to underlie this tendency? Select all that apply.

Financial pressures on health care providers Client reluctance to accept this type of care Advances in "curative" treatment in late-stage illness Explanation: Physicians are reluctant to refer clients to hospice, and clients are reluctant to accept this form of care. Reasons include the difficulties in making a terminal prognosis (especially for those clients with noncancer diagnoses), the strong association of hospice with death, advances in "curative" treatment options in late-stage illness, and financial pressures on health care providers that may cause them to retain rather than refer hospice-eligible clients.

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

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.

Which term best describes a living will?

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.

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." 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 patient with amyotrophic lateral sclerosis (ALS) wishes to use his Medicare Hospice Benefit in an effort to maximize his quality of life prior to death. What criterion will determine whether the patient qualifies for this benefit?

A life expectancy of less than 6 months Explanation: According to Medicare, the patient 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. Exhaustion of treatment options, copayment, and a lack of social support are not criteria used to determine qualification

A client with a terminal illness has feelings of rage toward the nurse. According to Kubler-Ross, the client is in which stage of dying?

Anger Explanation: Anger includes feelings of rage or resentment. Denial includes feelings of isolation. Bargaining occurs when a client and/or family pleads for more time to reach an important goal. Depression includes sadness, grief, and mourning for an impending loss.

A nursing instructor is preparing a class discussion about hope and end-of-life care. Which of the following would the instructor include as an example of a hope-fostering activity?

Humor Explanation: Hope-fostering categories include love of family and friends, spirituality and faith, goal setting, maintenance of independence, positive relationships with clinicians, humor, personal characteristics, and uplifting memories. Hope-hindering categories include abandonment, isolation, uncontrollable pain or discomfort, and devaluation of personhood.

Which of the following nursing interventions should a nurse perform to promote the dignity and self-esteem of a dying client?

Keep the client clean and well groomed. Explanation: A nurse should keep the client clean, well groomed, and free of unpleasant odors to promote his or her dignity and self-esteem. Although sharing emotional pain is an essential component of care for dying clients, it will not promote their dignity and self-esteem. Communicating hopefulness helps sustain hope in dying clients. Helping the client live according to his or her wishes is a feature of hospice care.

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. 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.

While providing care to a terminally ill client, the client asks, "Am I dying?" Which response by the nurse would be most appropriate?

"Tell me some more about what is on your mind." Explanation: When responding to the client, the nurse needs to acknowledge the client's fears. Having the client tell the nurse what's on his or her mind acknowledges the client's feelings and opens the way for more discussion. Asking the client about what makes him or her think he or she is dying is probing and does not address the client's feelings or needs. Telling the client that he or she will be fine gives the client false reassurance and does not address his or her fears. Asking about what the physician has told the client redirects the conversation away from the client's feelings and is inappropriate.

Which is also known as a proxy 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.

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?

"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.

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. 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.

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?

"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 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.

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.

Which of the following nursing interventions will a nurse perform to transfer heat and improve circulation in a dying client?

Gently massage the arms and legs. Explanation: A nurse should gently massage the client's arms and legs to transfer heat and improve circulation in a dying client. Changing the position frequently helps protect the client's skin from breakdown. Administering warm intravenous fluids and intramuscular injections will not help transfer heat and improve circulation in a dying client.

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?

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.

One of the functions of nursing care of the terminally ill is to support the client and his or her family as they come to terms with the diagnosis and progression of the disease process. How should nurses support clients and their families during this process? Select all that apply.

Try to appreciate and understand the illness from the client's perspective. Assist clients with performing a life review. Provide interventions that facilitate end-of-life closure. Explanation: Nurses are responsible for educating clients about their illness and for supporting them as they adapt to life with the illness. Nurses can assist clients and families with life review, values clarification, treatment decision making, and end-of-life closure. The only way to do this effectively is to try to appreciate and understand the illness from the client's perspective. The nurse's personal experiences should not normally be included and a cure is often not a realistic hope.

A nurse is caring for a terminally ill client who is receiving chemotherapy and radiation for an aggressive lung cancer. The treatment success is limited in shrinking the tumor, and the treatments are making the client very ill. The client states, "I feel that I would like to stop treatments. I would like to enjoy the time that I have remaining with my family." Which emotional reaction does the nurse recognize that the client is experiencing?

Acceptance Explanation: In the final stage, dying clients accept their fate and makes peace spiritually and with those to whom they are close. Clients begin to detach themselves socially and wish to be with only a small group of close friends and family. The other options are stages that occur earlier in the process.

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?

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."

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?

"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.

Based on the most common concern of a dying patient, the hospice nurse should:

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.

Which term refers to the period of time during which mourning of a loss takes place?

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 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?

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.

Immediately on cessation of vital functions, the body begins to change. The nurse would expect which physical change to occur following death?

Dusky appearance Explanation: The body becomes dusky or bluish, waxen-appearing, and cool; blood darkens and pools in dependent areas of the body, and urine and stool may be evacuated.

Which of the following is the nurse's primary concern when providing end-of-life care for a client and the family? Select all that apply.

Maintaining client comfort Supporting family members Providing personal care Explanation: Nursing care of dying clients focuses on providing palliative care to the client and supporting family members. Arranging the plans after death is not a priority at this time. Completing a head-to-toe assessment may be completed for information but is not a priority at the end of life. There is no need to encourage fluids.

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?

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.

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?

"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.

A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse?

"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 statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care?

"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.

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.

"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.

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?

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.

A client and family are dealing with the client's recent terminal diagnosis. A nurse identifies a nursing diagnosis of hopelessness. Which of the following would be most helpful in supporting hope for this family? Select all that apply.

Arranging for appropriate psychosocial counseling Encouraging the client to participate in care to foster control Helping to obtain support from the community Explanation: To enable, support, and foster hope in terminally ill clients and their families, nurses should encourage and support the client's control over circumstances, choices, and environment whenever possible, make referrals for psychosocial and spiritual counseling, and assist with developing supports in the home and community when none exist. Goals set should be realistic, rather than long-term. Information and feelings should be shared. The information provided also should be accurate.

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. 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.

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 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.

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 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 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.

The nurse has given an older adult an oral opioid for postoperative pain. What should the nurse do first to make the pain medication more effective?

Position the client for comfort. Explanation: The nurse should provide a comfort level with positioning first. Hydroxyzine may be given with opioid analgesics. However, elderly clients are more susceptible to adverse reactions of this medication, and alternative measures should be tried first. Providing a fresh gown will not make the medication more effective. Ingesting food with an opioid medication does not make the medication more effective.

Which of the following does not coincide with Kübler-Ross's stages related to a dying client?

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.

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. 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.

A 90-year-old home care client's son has been designated to make decisions regarding the client's medical care when the client is no longer able to do so. As the client nears the end of life, the son is consulted on an ever-increasing basis. What legal instrument activates the son's decision-making designation?

durable power of attorney for health care Explanation: A durable power of attorney (DPOA) for health care or healthcare proxy is the person the client designates to make medical decisions on the client's behalf when the client no longer can do so. It allows competent clients to identify exactly what life-sustaining measures they want to be implemented, avoided, or withdrawn and offers reassurance that others will carry out their wishes. Power of attorney is a legal term used in a different context. A living will is a written or printed statement describing a person's wishes concerning medical care and life-sustaining treatments that are wanted or unwanted in the event that a person is unable to personally make those decisions. Although a living will describes a person's wishes, it does not designate decision-making power to another person in the same was as a DPOA. Designated signer is not a term used in healthcare.

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.

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 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?

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 care to a terminally ill client and his family who practice the Islamic faith. Which of the following concepts would the nurse need to integrate into this client's plan of care? Select all that apply.

The way a person dies is of great individual importance. Pain is viewed as a mechanism for cleansing. Death occurs through God's permission. Explanation: According to Islamic beliefs, everyone will face death and the way a person dies is of great individual importance. Death cannot happen except by God's permission. People adhering to Islamic beliefs also view pain as a cleansing instrument from God and as a compensation for sin. In Hinduism, each caste system has a different view of death, and relatives must create a new ethereal body during the first 10 days after death.

Which intervention should a nurse perform during the grieving period when caring for a dying client?

Avoiding criticizing or giving advice Explanation: The nurse should listen in a nonjudgmental manner and should avoid criticizing or giving advice during the grieving period when caring for dying clients. Allowing a period of privacy is necessary to help family members cope with the death of a client and is not necessary during the grieving period. Spending time with the client and providing palliative care are not the required nursing interventions during the grieving period. Palliative care is provided to a dying client when the client is unable to live independently.

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?

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.

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 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.

The nurse is caring for a 90-year-old male who has never completed an advanced directive. The man has a son but has not seen him in several years. A neighbor has assisted him with meals and housecleaning for many years. The neighbor states that the client expressed only wanting to have comfort measures. The estranged son wants his father to be treated aggressively. Which would be the nurse's initial step?

Assess the client's ability to state wishes. Explanation: It cannot be assumed that the client is unable to make his own decisions just because of his advanced age. Before any other person is asked about the client's wishes, the client needs to be asked first. The physician, who has a healthcare relationship with the client, may also have documented information about wishes.

The nurse is caring for a dying client in a hospice setting. The family is unsure whether to go home for rest or spend the night with the client. Which body system would the nurse assess to provide the first data on decline?

Cardiovascular system Explanation: The key word is "first". Failing of cardiac functioning is one of the first signs that a condition is worsening. Symptoms within the other systems can also denote deterioration over time.

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 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.

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?

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.

The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following?

Explore own feelings on mortality and death and dying. Explanation: To care for others in the dying process, the nurse must explore his or her own feelings about mortality and death and dying. Understanding 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.

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.

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. 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 nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following?

Participating in assisted suicide violates the Code of Ethics for Nurses. Explanation: The American Nurses Association Position Statement on Assisted Suicide acknowledges the complexity of the assisted suicide debate but clearly states that nursing participation in assisted suicide is a violation of the Code for Nurses. Legally, nurses are not allowed to administer medications even if prescribed by a physician if that medication will hasten the client's end of life. Proponents of physician-assisted suicide argue that terminally ill people should have a legally sanctioned right to make independent decisions about the value of their lives and the timing and circumstances of their deaths. However, this is not the case at the present time. Two states have enacted legislation for physician-assisted suicide. These laws provide access to physician-assisted suicide by terminally ill clients under very controlled circumstances.

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?

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.

The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle?

The principle of autonomy Explanation: By promoting open discussion and informed decision making, the nurse is empowering the client to make his own decisions leading to autonomy. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients.

A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client?

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.

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. 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 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.

When describing the term "grief" to a group of students, which of the following would the instructor include?

The response experienced by anyone who has suffered a loss Explanation: Grief refers to the universal response to any loss. It is experienced by anyone suffering any type of loss. Loss is part of the life cycle and occurs in the form of change, growth, and transition. Spirituality refers to the feeling of connectedness with self, others, a life force, or God that allows people to find meaning in life. Anxiety refers to feelings of apprehension or worry in response to or about a situation.

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?

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.

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?

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 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

a) Enhances quality of life c) Integrates spirituality d) Offers a team approach to care f) Provides pain relief 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.

How does a nurse who has been providing home care to a terminally ill client know that the client's condition is beginning to deteriorate?

apical pulse reaches 100 beats/minute Explanation: Failing cardiac function is one of the first signs that a client's condition is worsening. At first, heart rate increases in a futile attempt to deliver oxygen to cells. The apical pulse rate may reach 100 or more beats/minute. In clients who are dying, the skin becomes pale or mottled, nail beds and lips may appear blue, and the client may feel cold. In clients who are dying, urine volume decreases, and the jaw and facial muscles relax.

A type of comprehensive care for clients whose disease is not responsive to cure is

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.