End of Life - Med Surg

A terminally ill patient in pain asks the nurse to administer enough pain medication to end the suffering forever. What is the best response by the nurse?

"I will notify the physician that the current dose of medication is not relieving your pain." Explanation: 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. Palliative sedation is most commonly used when the patient exhibits intractable pain, dyspnea, seizures, or delirium, and it is generally considered appropriate in only the most difficult situations.

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.

A patient with end-stage chronic obstructive pulmonary disease is admitted to a hospice facility and asks the admitting nurse, "How long will I be allowed to stay here?" What is the best response by the nurse?

"When your stay reaches 6 months, you will be recertified for a continued stay." Explanation: Federal rules for hospices require that eligibility be reviewed periodically. Patients who live longer than 6 months under hospice care are not discharged, provided that their physician and the hospice medical director continue to certify that they are terminally ill with a life expectancy of 6 months or less (assuming that the disease continues its expected course).

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.

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.

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.

A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD?

An LVAD only supports a failing left ventricle. Explanation: A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.

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.

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.

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?

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 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.

A patient diagnosed with terminal pancreatic cancer is unaware of the diagnosis and his daughter has requested that he not be told. What awareness context does the nurse determine this is?

Closed awareness Explanation: In closed awareness, the patient is unaware of his or her terminal state, whereas others are aware. In suspected awareness, the patient suspects what others know and attempts to find out details about his or her condition. In mutual pretense awareness, the patient, the family, and the health care professionals are aware that the patient is dying, but all pretend otherwise. In open awareness, the patient, the family, and the health care professionals are aware that the patient is dying and openly acknowledge that reality.

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?

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.

A terminally ill client asks the nurse, "Am I dying?" The family has asked the health care team not to disclose the client's terminal illness. What is the best action by the nurse with the client's question?

Communicate the client's wishes to the family. Consult with the health care provider Provide correct information to the client. Explanation: It is essential that nurses freely engage in dialogue concerning moral situations, even though such dialogue is difficult for everyone involved. Improved interdisciplinary communication is supported when all members of the health care team can voice concerns and come to an understanding of the moral situation. Consultation with an ethics committee could be helpful to assist the health care team, client, and family to identify the moral dilemma and possible approaches to the dilemma. Nurses should be familiar with agency policy supporting patient self-determination and resolution of ethical issues. The nurse should speak the truth (veracity) to the client, which entails providing correct information and not saying "you will be fine" when this is not the case. Because the client has asked the nurse the question, the nurse should be the one to speak to the client; the nurse should not have the health care provider answer the client.

The nurse is caring for a terminally ill client in the intensive care unit that is on life support measures. The family members are opposed in their decision to take the client off of life support. What option does the nurse discuss with the nurse manager?

Contact the ethics committee for their input. Explanation: The ethics committee may be called on to act as an advocate for clients who no longer are mentally capable of making their own decisions. Ethics committees are a valuable resource for reviewing difficult cases and helping ensure a careful and unbiased decision. The nurse is not practicing within the scope of practice by taking the client off of life support. The nurse does not mandate to the health care provider decisions that should be made. It is nontherapeutic for the nurse to ask the family to go out and make a decision.

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease Explanation: Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Parkinson disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia.

Which is the initial stage of grief, according to Kübler-Ross?

Denial Explanation: The stages of grief include denial, anger, bargaining, depression, and acceptance. Anger is the second stage of the process. Bargaining is the third stage of the process. Depression is the fourth stage of the process.

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.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to

Encourage the family to touch and talk to the client. Explanation: The client is in the irreversible stage of shock and unlikely to survive. The family should be encouraged to touch and talk to the client. A spiritual advisor may be of comfort to the family. However, this is not definite. The second option provides false hope of the client's survival to the family as does the third option.

The nurse practitioner has four patients with chronic illness that require consistent medical and nursing management. Select the condition that is the best example of a "chronically critical and progressively ill" condition.

End-stage renal disease Explanation: Certain illnesses require advanced technology for survival, or intensive care for periods of weeks or months, as in end-stage renal disease (ESRD). People with this condition are chronically critical and progressively ill. Some chronic illnesses have little effect on quality of life, but others, like ESRD, have a considerable effect because it can result in a chronic progressive deterioration.

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

Explore own feelings on mortality and death and dying. Explanation: To care for others in the dying process, the nurse must explore their own feelings about mortality and death and dying. Understanding the self provides a perspective to cope with and then support clients and families experiencing pain and grief. The other options are helpful in determining appropriate nursing care but not the first step.

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.

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.

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.

The nurse is describing hospice services to the family of a patient with end-stage heart failure. Which of the following would the nurse be least likely to include as a major focus of care?

Invasive therapy Explanation: The goal of hospice is to improve the patient's quality of life by focusing on symptom management, pain control, and emotional support.

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.

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

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.

Which type of surgery is used in an attempt to relieve complications of cancer?

Palliative Explanation: Palliative surgery is performed to relieve complications of cancer. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach.

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.

Which guideline is appropriate for a nurse to implement while helping family members cope with the sudden death of a loved one?

Show acceptance of the body by touching it, giving the family permission to touch. Explanation: The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as "passed on." The nurse should avoid giving sedation to family members, because this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (e.g., client was drinking at the time of the accident).

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.

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.

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.

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.

Evidence-based medical and nursing research has identified cardiovascular disease as the most prevalent chronic disease in the United States. Under this classification, one condition is the most common. Using this information, a nurse practitioner, treating a 50-year-old man, would do which of the following?

Write a prescription for a serum cholesterol level. Explanation: Hypercholesterolemia is the most prevalent chronic disease in the United States, with 33.6% of all adults affected.

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.

The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is:

care that will reduce the client's physical discomfort and manage clinical symptoms. Explanation: Palliative care is used in conjunction with other end-of-life treatments and has many principles. Its aim is to reduce physical discomfort and other distressing symptoms but it does not hasten or delay a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies. Palliative care of a terminally ill client not only provides relief from pain and other distressing symptoms but it integrates other facets of patient care as well, including psychological and spiritual aspects. Palliative care is part of hospice care.

A nurse is preparing a presentation for a local senior center about the health status of older adults. What trends in health promotion and disease prevention activities would the nurse explain as contributing to declining death rates in the older adult population?

decreased smoking improved nutrition screening for hypertension early detection of elevated cholesterol levels Explanation: Most deaths in the United States occur in people 65 years or older, with one-half of these caused by heart disease and cancer. Decreased smoking, improved nutrition, screening for hypertension, and early detection of elevated cholesterol levels are contributing factors to a decreased death rate in older adults. Older adults are encouraged to increase exercise and increase community-based services.

Which written medical instruction explicitly states that no action should be taken to revive a client if he or she experiences cardiac arrest?

do-not-resuscitate order Explanation: Do-not-resuscitate (DNR) orders involve a written medical order for end-of-life instructions. If a DNR order is written, the client wishes to have no resuscitative action taken if he or she experiences a cardiac arrest. An advance directive provides the means for clients to communicate their wishes regarding life-sustaining treatment and other medical care, so that their significant others will know what decisions the clients desire. It is not a medical order. A living will is a type of advance directive; it is not a medical order. A durable power of attorney is a legal document that appoints a person to act as an agent for another person. A DPOA for healthcare appoints a person to make medical decisions for a client who is incapacitated and unable to make decisions for himself or herself.

A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis?

poor Explanation: An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate. Decerebrate posturing indicates deeper and more severe dysfunction than does decorticate posturing; it implies brain pathology, which is a poor prognostic sign. Decorticate posture is the flexion and internal rotation of forearms and hands. Decerebrate posture is extension and external rotation. Flaccidity is the absence of motor response and the most severe neurologic impairment.

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.