Chapter 13 - Palliative Care (Questions)
As the nurse admits a client with severe heart failure to the hospital, the client tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which of the following actions should the nurse take? a. Ask if these wishes have been discussed with the health care provider. b. Place a "Do-Not-Resuscitate" (DNR) notation in the client's care plan. c. Inform the client that a notarized advance directive must be included in the record or resuscitation must be performed. d. Advise the client to designate a person to make health care decisions when the client is not able to make them independently.
ANS: A A health care provider's order should be written describing the actions that the nurses should take if the client requires CPR, but the primary right to decide belongs to the client or family. The nurse should document the client's request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the client's wishes. The client may need a durable power of attorney for health care (or the equivalent), but this does not address the client's current concern with possible resuscitation.
A terminally ill client is admitted to the hospital. Which of the following actions should the nurse include in the initial plan of care? a. Determine the client's wishes regarding end-of-life care. b. Emphasize the importance of addressing any family issues. c. Discuss the normal grief process with the client and family. d. Encourage the client to talk about any fears or unresolved issues.
ANS: A The nurse's initial action should be to assess the client's wishes at this time. The other actions may be implemented if the client or the family express a desire to discuss fears, understand the grief process, or address family issues, but they should not be implemented until the assessment indicates that they are appropriate.
The nurse is caring for a client in a hospice palliative care program who is experiencing continuous, increasing amounts of pain. Which of the following time schedules should the nurse implement for the administration of opioid pain medications? a. Around-the-clock routine administration of analgesics. b. PRN doses of medication whenever the client requests. c. Enough pain medication to keep the client sedated and unaware of stimuli. d. Analgesic doses that provide pain control without decreasing respiratory rate.
ANS: A The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill client is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the client needs. Clients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate.
The spouse of a client with terminal lung cancer visits daily and cheerfully talks with the client about vacation plans for the next year. When the nurse asks about any concerns, the spouse says, "I'm busy at work, but otherwise things are fine." Which of the following nursing diagnoses is appropriate? a. Ineffective denial related to threat of unpleasant reality b. Anxiety related to threat to current status c. Caregiver role strain related to inexperience with caregiving d. Hopelessness related to chronic stress
ANS: A The spouse's behaviour and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the client progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious about the partner's impending death.
The nurse is providing hospice care to a client who is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which of the following is the basis for the nurses' response about these symptoms? a. They will continue to increase until death finally occurs. b. They are a normal response before these functions decrease. c. They indicate a reflex response to the slowing of other body systems. d. They may be associated with an improvement in the client's condition.
ANS: B An increase in heart and respiratory rate may occur before the slowing of these functions in the dying client. Heart and respiratory rate typically slow as the client progresses further toward death. In a dying client, high respiratory and pulse rates do not indicate improvement, and it would be inappropriate for the nurse to indicate this to the family. The changes in pulse and respirations are not reflex responses.
The nurse has been caring for a terminally ill client for the past 10 months. The nurse and the family are present when the client dies and feels saddened and tearful as the family members begin to cry. Which of the following actions should the nurse take at this time? a. Contact a grief counsellor as soon as possible. b. Cry along with the client's family members. c. Leave the home as quickly as possible to allow the family to grieve privately. d. Consider whether working in hospice is desirable since client losses are common.
ANS: B It is appropriate for the nurse to cry and express sadness in other ways when a client dies, and the family is likely to feel that this is therapeutic. Contacting a grief counsellor, leaving the family to grieve privately, and considering whether hospice continues to be a satisfying place to work are all appropriate actions as well, but the nurse's initial action at this time should be to share the grieving process with the family.
The nurse is planning for an end-of-life care discussion with a newly admitted client who is terminally ill and has decided to use the NURSE protocol during the difficult conversation to respond to client and/or family emotions. Which of the following terms describes the "E" in the NURSE protocol? a. Experimentation b. Exploration c. Empathy d. Emotion
ANS: B Nurses may use several approaches to difficult conversations that share common features. Suggested approaches are "ask-tell-ask," "tell me more," responding to emotions with the NURSE protocol (naming, understanding, respecting, supporting, and exploring).
A client who is very close to death is very restless and keeps repeating, "I am not ready to die." Which of the following actions should the nurse take? a. Remind the client that no one feels ready for death. b. Sit at the bedside and ask if there is anything the client needs. c. Insist that family members remain at the bedside with the client. d. Tell the client that everything possible is being done to delay death.
ANS: B Staying at the bedside and listening allows the client to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual client's concerns. Telling the client that everything is being done does not address the client's fears about dying, especially since the client is likely to die soon. Family members may not feel comfortable staying at the bedside of a dying client; the nurse should not insist they remain there.
The nurse is caring for a client with lung cancer as part of a home hospice palliative program. Which of the following interventions should the nurse implement? a. Discuss cancer risk factors and appropriate lifestyle modifications. b. Encourage the client to discuss past life events and their meaning. c. Accomplish a thorough head-to-toe assessment once a week. d. Educate the client about the purpose of chemotherapy and radiation.
ANS: B The role of the hospice palliative nurse includes assisting the client with the important end-of-life task of finding meaning in the client's life. Frequent head-to-toe assessments are not needed for hospice clients and may tire the client unnecessarily. Clients admitted to hospice forego curative treatments such as chemotherapy and radiation for lung cancer; discussion of cancer risk factors and therapies is not appropriate.
The family member of a client who is dying tells the nurse, "Mother doesn't really respond any more when I visit. I don't think she knows that I am here." Which of the following responses by the nurse is most appropriate? a. "You may need to cut back your visits for now to avoid overtiring your mother." b. "Withdrawal may sometimes be a normal response when preparing to leave life." c. "It will be important for you to stimulate your mother as she gets closer to dying." d. "Many clients don't really know what is going on around them at the end of life."
ANS: B Withdrawal is a normal psychosocial response to approaching death. Dying clients may maintain the ability to hear while not being able to respond. Stimulation will tire the client and is not an appropriate response to withdrawal in this circumstance. Visitors are encouraged to be "present" with the client, talking softly and making physical contact in a way that does not demand a response from the client.
The nurse is caring for a young adult who is dying after an automobile accident. The family members want to donate the client's organs and ask the nurse how the decision when death has occurred is made. Which of the following is the basis for the nurses' response to the family in this situation? a. The client is flaccid and unresponsive. b. The client is experiencing respiratory acidosis and is on a ventilator. c. The client is unconscious with no brain stem activity. d. Respiratory efforts cease and no apical pulse is audible.
ANS: C Death is the permanent loss of capacity for consciousness and all brain stem functions. This may result from permanent cessation of circulation or catastrophic brain injury. In the context of death determination, permanent refers to loss of function that cannot resume spontaneously and will not be restored through intervention. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a client brain dead.
Which of the following clients is most appropriate for the nurse to refer to hospice palliative care? a. A 60-year-old with lymphoma whose children are unable to discuss issues related to dying b. A 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse c. A 28-year-old with AIDS-related dementia who needs palliative care and pain management d. A 56-year-old with advanced liver failure whose family members can no longer care for him or her at home
ANS: C Hospice is designed to provide palliative care such as symptom management and pain control for clients at the end of life. Clients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice clients.
A client who is in the clinic for an immunization tells the nurse, "My mother died 4 months ago, and I just can't seem to get over it. I'm not sure it is normal to still think about her every day." Which of the following nursing diagnoses is most appropriate? a. Ineffective role performance related to depression b. Complicated grieving related to emotional disturbance (death of loved one) c. Anxiety related to unmet needs (lack of knowledge about normal grieving) d. Impaired mood regulation related to loneliness
ANS: C The client should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal for months or years after a death. The other nursing diagnoses imply that the client's grief is unusual or pathological, which is not the case.
The nurse is caring for a client who has been diagnosed with metastatic cancer and plans a trip across the country "to settle some issues with my sisters and brothers." Which of the responses should the nurse recognize that the client is manifesting? a. Restlessness b. Yearning and protest c. Anxiety about unfinished business d. Fear of the meaninglessness of one's life
ANS: C The client's statement indicates that there is some unfinished family business that the client would like to address before dying. Restlessness is frequently a behaviour associated with an inability to express emotional or physical distress, but this client does not express distress and is able to communicate clearly. There is no indication that the client is protesting the prognosis, or that there is any fear that the client's life has been meaningless.
The nurse is caring for a terminally ill client who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which of the following terms should the nurse use to document this finding? a. Agonal breathing b. Apneustic breathing c. Death rattle respirations d. Cheyne-Stokes respirations
ANS: D Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. The "death rattle" is caused by accumulation of mucus in the airways, causing wet-sounding respirations. Agonal breathing has a very slow and irregular rate and rhythm. Apneustic respirations are irregular and gasping.
