Maternal Child Nursing Care Chapter 36 Chronic Illness, Disability, and End-of-Life-Care

The nurse is caring for a child dying from cancer. Physical signs that the child is approaching death include: 1 rapid pulse. 2 change in respiratory pattern. 3 sensation of cold, although body feels hot. 4 loss of hearing followed by loss of other senses.

2 In the final hours of life the respiratory pattern may become labored, with periods of apnea. The pulse becomes weak and slowed. There is a sensation of heat, although the body feels cold. Hearing is the last sense to fail.

A preschooler is diagnosed with terminal stage bronchial carcinoma. What would the child consider the most probable reason for the condition? 1 The child will blame the parents for acquiring the disease. 2 The child will blame the grandparents for acquiring this condition. 3 The child would consider it to be a punishment for his or her own actions. 4 The child would understand the pathophysiology of the disease.

3 Preschoolers tend to believe that their thoughts or actions are sufficient to cause death or disease. Therefore, the child is most likely to think that the disease is a punishment for the child's action. This may result in the child feeling guilty. The nurse should help parents to understand this kind of reaction of their child and encourage them to be with the child. The child will not blame the parents or grandparents for the condition. The child is too young to understand the pathophysiology of the disease.

A child who is terminally ill with bone cancer is in severe pain. Nursing interventions should be based on knowledge that: 1 children tend to be overmedicated for pain. 2 giving large doses of opioids causes euthanasia. 3 narcotic addiction is common in terminally ill children. 4 large doses of opioids are justified when there are no other treatment options.

4 Large doses may be needed because the child has become physiologically tolerant to the drug, requiring higher doses to achieve the same degree of pain control. Continuing studies report that children are consistently undermedicated for pain. The dose is titrated to relieve pain. Addiction refers to a psychological dependence on the medication, which does not happen in terminal care.

A child who was terminally ill died. What intervention should the nurse provide for the child and the family? 1 Allow the family be with and hold or rock the child. 2 Do not remove any of the tubes or catheters. 3 Follow the hospital policy to administer last rites. 4 Instruct the family that the nurse bathes the body.

1 The nurse should be very sensitive to the emotions of the family members who are grieving their loss and try to support them as much as possible. The nurse should allow privacy to the family with the child and allow them to hold or rock the child if they want. The nurse should remove the tubes and catheters from the child's body and let the family hold the child. The nurse should allow the family to provide last rites according to their culture rather than following hospital policy. It helps the family cope. The family should be allowed to bathe and dress the child, as per their cultural practice.

Which behaviors would characterize a child adequately coping with a chronic illness? Select all that apply. 1 Behavior problems at home and school 2 Negative attitudes about his or her condition 3 Acceptance of his or her limitations and coping accordingly 4 Taking responsibility for his or her own physical care 5 Identification with other similarly affected people

3, 4, 5 There are two ways of coping with the illness. Children with healthy coping mechanisms accept their limitations and assume responsibility for their care. These children may also identify with other similarly affected people. Maladaptive coping is evident in behavior problems at home and school. These children may also have a negative attitude toward the illness and begin acting out.

Which child behaviors indicate maladaptive coping toward chronic illness? Select all that apply. 1 Is irritable both at home and during school 2 Demonstrates feelings of pessimism and inadequacy 3 Expresses feelings of worthlessness to others 4 Expresses anxiety during remissions 5 Demonstrates confidence during an exacerbation

1, 2, 3 Children with negative and declining attitudes toward their chronic illness use maladaptive coping patterns. These maladaptive coping patterns are characterized by irritability at home and school. The child has a pessimistic outlook toward the disease and feels inadequate in managing it. The child may feel different, withdrawn, and less worthy than others. The child who has healthy coping skills may expresses appropriate emotions, such as anxiety, sadness, and anger, during periods of illness exacerbations. Demonstrating confidence during remissions indicates healthy coping skills

Several nurses tell their nursing supervisor that they want to be able to attend the funeral of a child for whom they had cared. They say they felt especially close to both the child and the family. The supervisor should recognize that attending the funeral is: 1 appropriate because families expect this expression of concern. 2 appropriate because it can assist in the resolution of personal grief. 3 inappropriate because it is unprofessional. 4 inappropriate because it increases burnout.

2 Nurses should attend the funeral of a child if they felt closeness with the family. This will help the nurses grieve and gain closure. Families may or may not expect this expression of concern. The behavior is appropriate if a relationship existed between the nurses and family. This may prevent burnout.

The nurse finds that the parent of a terminally ill child is unusually optimistic about the child's condition. What should the nurse interpret from this? The parent: 1 Is in the denial stage of grief. 2 Believes the diagnosis is wrong. 3 Normally has a cheerful nature. 4 Is optimistic about the treatment

1 Parents may be in a state of shock when first hearing about the terminal illness of their child. The parent's abnormal optimism about the child's condition indicates that the parent is in denial and has not accepted the child's illness. It is unlikely that the parent believes that the diagnosis is wrong. The diagnosis of a terminally ill condition in a child is depressing for any parent, even one with a cheerful nature. Being optimistic when there is no cure indicates the stage of shock and denial.

Which approaches should the nurse adopt to provide support and guidance to a grieving family? Select all that apply. 1 Follow up regularly with telephone calls. 2 Provide a referral to a support group. 3 Recommend bereavement counseling. 4 Refrain from sending them cards. 5 Ask the family come for an office visit.

1, 2, 3 Nurses play an important role in helping the grieving family cope with their loss. The nurse should plan regular follow-ups through phone calls or meetings to assess whether they are coping well. Support groups and bereavement counseling may help the family vent their feelings and learn coping skills. The nurse should initiate contact by sending cards. The nurse should not expect the family to come in for a visit. The nurse should ask permission to make a home visit to make it easier on the family. This helps the family feel cared for.

Parents ask the nurse for advice when telling their 4-year-old about a grandmother's death. The nurse's best response involves teaching the parents that the child's concept of death is: 1 temporary. 2 permanent. 3 personified in various forms. 4 inevitable at some age.

1 Death is seen as a temporary departure. Death is thought of as not permanent; life and death can change places with each other. Personification is typical of school-age children. Children 9 to 10 years old have this understanding of death.

The parents of a terminally ill child ask the nurse how hospice care is different from hospital care. What information should the nurse give them? Select all that apply. 1 No extraordinary efforts would be made to prolong the child's life. 2 Pain and control of symptoms are the primary concerns of treatment. 3 The child's needs are considered to be the priority over the family's needs. 4 Hospice professionals are solely responsible for providing care to the child. 5 Family members are the principal caregivers supported by the hospice team.

1, 2, 5 Nurses should offer information about hospice care to the parents of a terminally ill child. Hospice is a community health care organization which specializes in caring for a dying child. It combines principles of hospice care and palliative care. The client is taken care of at home in the final stages of life. The concepts that make it different from hospital care include: no extraordinary efforts are made to prolong the child's life, and pain and control of symptoms are the primary concerns of treatment. The family members are usually the principal caregivers supported by a team of professionals, and the family's needs are given the same importance as the child's needs.

A baby is diagnosed with Turner syndrome shortly after birth. The parent is showing signs of depression and is finding it difficult to bond with the baby. Which characteristics indicate that the parent is in the adjustment stage? Select all that apply. 1 Assumes that the disability is genetically inherited 2 Acts happy and optimistic despite the diagnosis 3 Focuses on caregiving as the condition progresses 4 Believes the disability happened during pregnancy 5 Believes the disability is a punishment from God

1, 4, 5 The adjustment stage is the next phase after shock and is most often characterized by an open admission that the condition exists. This stage is accompanied by responses such as guilt. Many parents may feel responsible for the disability because it was genetically inherited. The mother may also believe she caused the disability by doing something wrong during pregnancy or may believe God is punishing her for previous misdeeds. Acting happy and optimistic despite the revealed diagnosis indicates the parent is still in denial and has not accepted the child's disability. Focusing on new caregiving practices as the condition progresses indicates total acceptance of the condition.

A nursing professor is teaching a group of graduate nurses about anticipatory grief reactions. What information should be included in this presentation? 1 It may last for weeks or up to a few months. 2 It can happen when the death is expected. 3 It happens more than 1 year after the death. 4 It can result in feelings of excessive loneliness.

2 Nurses should be able to identify family members having anticipatory grief reactions. When death is expected, family members may experience anticipatory grief. Anticipatory grief may be manifested in varying behaviors and intensities and may include denial, anger, depression, and other psychological and physical symptoms. Anticipatory grief lasts while the loved one is preparing to die. There is no standard time frame for anticipatory grief. Complicated grief reactions are seen more than 1 year after the loss, whereas anticipatory grief happens before the death. The patient with complicated grief can display symptoms such as unusual sleep disturbances and feelings of excessive loneliness or emptiness.

The nurse is working with a family who has a child with a chronic illness. The nurse notices that the parents watch television and play on their electronic devices instead of spending time with the child. The parents are frequently reprimanding the child. What should the nurse interpret from these findings? The parents: 1 Are being overprotective. 2 Are displaying rejection. 3 Are in denial of the illness. 4 Have gradual acceptance.

2 The parents' reaction of detaching themselves from the child and constantly rebuking the child indicates rejection. However, even though the parents are rejecting the child, they may still meet the child's physical needs. When parents do not let their children learn new skills for fear of injury, this indicates overprotection. Pretending that the child does not have a problem indicates denial. Placing necessary restrictions on the child indicates gradual acceptance.

A 14-year-old patient with Ewing's sarcoma is scheduled for an amputation of the right leg. The patient has been grieving about the loss ever since the health care provider prescribed the surgery. What type of grief does the nurse identify in this patient? 1 Acute grief 2 Universal loss 3 Anticipatory grief 4 Complicated grief

3 Because the amputation has not occurred, the patient's reaction is caused by anticipation of a future loss. This is a healthy response to the anticipated loss of the leg. It will help foster healthy grieving. Acute grief is a definite syndrome characterized by psychological and somatic symptoms. It is characterized by emotional distancing in relationships with others, accompanied by erratic responses of irritability, hostility, and anger. Universal loss does not describe the emotions of grieving before an actual loss. Some people feel constantly upset and preoccupied with a person who has died, to the point where their relationships and work suffer for months on end. Such a reaction is known as complicated grief.

The nurse is caring for an 8-year-old child who has a chronic illness. The child has a tracheostomy, and a parent is rooming-in during this hospitalization. The parent insists on providing almost all of the child's care and tells the nurses how to care for the child. When planning the child's care, the primary nurse should recognize that the parent is: 1 controlling and demanding. 2 assuming the nurse's role. 3 the expert in care of the child. 4 not allowing nurses to function independently.

3 Because these parents care for this child with complex health needs at home, they are most familiar with the care requirements and routine. The nurse's role includes assessment and evaluation, not just the implementation phase. The nurse recognizes that the philosophy of family-centered care states that the parents are the experts in the care of their child. The nurse functions collaboratively with the family.

The parents of a child are grieving the loss of their child. The mother of the child has disturbed sleep. The father informs the nurse that the mother can hear their child talk. The mother wants to be left alone and does not speak to any of the family members. What should be the most appropriate response of the nurse? 1 Tell the father that his wife may have mental breakdown in near future. 2 Tell the father that his wife is coping very poorly and needs professional help. 3 Inform the father that his wife has hallucinations and needs psychiatric referral. 4 Inform the father that it is a normal part of grief and would subside over time.

4 Grief reactions vary from person to person and it is required for the healing to occur. It is important for the nurse to inform the husband that hearing the dead person talk and distancing from others is very common reaction. It does not indicate any impending mental breakdown, poor coping, or psychiatric problem. Therefore, the husband should be reassured that his wife is trying to cope with the grief and she is normal.

The parents of a child who is dying of leukemia are grieving their impending loss. What intervention should the nurse perform to provide effective care for the family? 1 Encourage the use of alcohol and drugs as a way to escape grief. 2 Refer the family to a self-help group to manage their grief. 3 Emphasize that acute grieving is a process that lasts for years. 4 Provide the child and family with time to share memories.

4 The nurse should be very sensitive to the feelings of a grieving family. The nurse should also provide the child and family with the opportunity to review special experiences or memories in their lives. This helps the family members share their emotions and bond with each other. Parents and family members should be advised to seek professional counseling or work with each other to handle grief. The nurse should never encourage people to use alcohol or drugs to escape grief. The nurse can refer the family to a self-help group, but this is not always an effective way to help grieving parents. They may need a professional counselor to help guide them through the grieving process. The nurse should emphasize to the family that acute grieving only lasts for a few weeks to months, but the entire grieving process is a painful process that often takes years to resolve.

What information should the nurse provide to a group of nursing students when teaching them about the analgesic stepladder for pain management in children with terminal illness? Select all that apply. 1 "It was implemented by the World Health Organization (WHO)." 2 It provides for the use of adjunctive drug therapy to ease pain." 3 It outlines the principles of analgesic selection and titration." 4 "It describes the use of combination therapy to decrease side effects." 5 It was created to prevent drug dependence and drug addiction."

1, 2, 3 Children with terminal illness experience some amount of pain in the last stage of their illness. Nurses should follow the analgesic stepladder framed by World Health Organization (WHO) for pain management in children. It outlines the use of adjunctive therapy depending on the severity of the pain as mild or severe/persistent. It outlines the principles of analgesic selection such as administration of nonnarcotic analgesics to ease mild pain and administration of narcotic analgesics (opioids) to ease severe or persistent pain. It outlines the use of combination therapy to counteract adverse effects, not side effects. A patient with a terminal illness will require increased levels of pain medication to manage pain. The patient will not become dependent or addicted.

The parents of a 12-year-old child are informed that the child is in the terminal stages of osteosarcoma. The nurse explains to the parents about the care that needs to be provided for the child. Which characteristics in the parents indicate that they are in denial? Select all that apply. 1 Want the child to be admitted for more treatment 2 Refuse to believe the results of the tests 3 Pleased to receive the medical diagnosis 4 Ask questions about treatment or prognosis 5 Insist that nobody is telling them the truth

1, 2, 3, 5 The initial diagnosis of a terminal illness in a child is met with shock or denial. Parents experience this reaction, and it can last for days, weeks, or months. If the parents ask questions about the child's treatment or prognosis, this indicates that they have accepted the diagnosis. Parents in denial may want the child to be admitted for more medical treatment. They may feel the terminal diagnosis is wrong and refuse to believe the test results. People are usually not pleased to receive a terminal diagnosis; they are upset and angry. Insisting that nobody is telling them the truth is also an indicator of denial.

Which behaviors of the family members indicate avoidance coping behavior? Select all that apply. 1 Refuses to agree to the treatment 2 Demonstrates anger and hostility 3 Expresses deep feelings of sorrow 4 Makes realistic plans for the future 5 Seeks cures from the faith healers

1, 2, 5 Coping reactions to stressors include those that indicate avoidance. Avoidance includes behaviors that help the person deny the truth or escape from it. Refusing to agree to treatment, being angry toward the staff, and seeking nontraditional medical treatments such as faith healing are examples of avoidance behavior. Expressing feelings of sorrow and planning realistically for the future are approach behaviors that indicate acceptance of the condition.

The parents of a terminally ill child are overwhelmed with the volume of telephone calls asking about the child's condition. What suggestion should the nurse give to the family to make communication easier? 1 "Allow open visiting hours for all family members and the child's friends." 2 "Designate one family member or friend to relay information to everyone else." 3 "Instruct the family to create a website for information and to post updates." 4 "Tell the parents that answering calls and e-mails will help keep them busy."

2 To minimize stress on parents, the family should designate one family member or friend to relay information to others. Open visiting hours would increase the workload of the staff and interfere with care. In addition, the parents would not get any rest because of the continual need to entertain friends and family. Suggesting that the family create a website to post updates or asking parents to answer calls to keep busy may not be helpful. The parents do not need more work to do while dealing with the child's condition.

The nurse is caring for a child who is in the terminal stage of acute lymphocytic leukemia. What should be the goals of palliative care in the child? Select all that apply. 1 To assess the severity of disease symptoms 2 To provide effective pain management 3 To strive for the best possible quality of life 4 To mandate that the family join in the care 5 To support the family and the child

2, 3, 5 Palliative care focuses on relieving pain and managing symptoms related to a terminal disease. It also addresses the psychological, social, and spiritual problems of children living with terminal conditions. The goal of palliative care is to achieve the best quality of life for patients and their families, consistent with their values. Palliative care seeks to improve the quality of life for a patient with a terminal condition. The nurse will assess the severity of the child's symptoms, but this is not the goal of palliative care. The nurse should encourage family members to participate in the child's care but should not mandate their help.

A child is brought to the clinic for a routine check-up. The parent informs the nurse that the child wants to go to school, but the parent does not want the child to go. What other characteristics in the parent would indicate that the parent is overprotective? Select all that apply. 1 Sets same rules for the child and the siblings 2 Continually helps child even if the child is capable 3 Helps the child to learn new skills to be independent 4 Sets high goals without understanding child's abilities 5 Puts restrictions on child's play due to fear of injury

2, 4, 5 A nurse should be able to identify parents who tend to be overprotective about their child with disabilities. The parent may continually help the child even when the child is capable of doing the task. Setting very high or low goals without understanding the child's capabilities makes the child feel incapable and inadequate. Putting restrictions on their child's play due to fear of injury indicates that the parent is too concerned about the child. Setting same rules for all children is not suggestive of an overprotective attitude in the parent. A parent who is not overprotective of the child helps the child to learn skills to be independent.

The parents of a 10-year-old child diagnosed with terminal cancer ask the nurse not to inform their child about the condition. What would be the most appropriate response of the nurse? 1 Report the situation to the appropriate child welfare organization. 2 Ignore the parents' request and tell the child about the condition. 3 Inform the parents that being honest with the child is important. 4 Tell the parents that treatment cannot be initiated until the child is informed.

3 Often, parents ask health care providers not to reveal the prognosis to the terminally ill child. This is a difficult situation for health care providers. Although children do not understand that they are going to die, they are in a position to understand that something is seriously wrong with them. Therefore the nurse should make the parents understand that being honest with the child is important. Being honest creates an open environment where feelings may be shared by the entire family. This often encourages the parents to communicate openly with the child. The nurse is not required to report to the child welfare organization at this stage. The parents' decision should not be ignored; rather, the parents should be encouraged to talk openly with the child. The nurse cannot withhold treatment.

The parents of a terminally ill child are speaking with the nurse to learn about palliative care and how it differs from hospice care. What should the nurse tell them? "Palliative care: 1 Requires that a patient be a Medicare recipient." 2 Does not provide care for hospitalized patients." 3 Is provided when no effective cure is available." 4 Does not provide spiritual support to the family."

3 The terms palliative care and hospice care are associated with end-of-life care. Palliative care may be provided when no cure is available. Palliative care seeks to prevent, relieve, reduce, or soothe the symptoms of disease or disorder without effecting cure. Hospice care supports the patient and the family during the dying process (medical prognosis of 6 months or less) and the surviving family members through the process of bereavement. It provides total care for the patient in the hospital, home, and nursing home when the patient's disease is unresponsive to the curative treatment. To qualify for hospice care, the patient does not need to be a Medicare recipient. Most insurance programs cover hospice care. However, for palliative care, the patient needs to be a Medicare recipient. Palliative care can be provided to patients in a variety of settings, including hospitals. Both palliative care and hospice care include spirituality in order to provide holistic care. Nurses need to familiarize themselves with the attitudes and needs of various religious groups so that they can address the spiritual needs of their patients, families, and other members.

The nurse is reviewing the plan of care with the parent of a child with Crohn's disease. Which statement made by the parent indicates a need for further education? 1 "This illness is why my child has delayed puberty." 2 "This illness is caused by the intake of fiber-rich food." 3 "This illness has impaired my child's growth and development." 4 "This illness is God's way of testing our religious faith."

4 A parent who states that the child's illness is a trial sent by God to test religious faith is expressing a self-accusatory feeling that indicates a lack of understanding of the condition. Crohn's disease is an autoimmune disorder that affects the gastrointestinal tract, causing inflammation that can result in excessive diarrhea, abdominal pain, and other symptoms. Crohn's disease can stunt growth and weaken bones in children who are going through puberty. Parents are advised to refrain from serving fiber-rich food to such children because these foods are difficult to digest and may block the intestine.

The nurse is caring for a child who is in the final stages of death. What can the nurse do to provide comfort for the parents? 1 Explain to the parents that births and deaths are normal. 2 Inform the family that their child will soon be at peace. 3 Ask the parents to stay away from the child at this time. 4 Have the parents focus on the quality of the child's remaining life.

4 Acknowledging grief is often the first step toward facing the reality of the child's illness. It is important to have the parents spend the time that is left with their child. Such acceptance may help parents focus on the quality of the child's remaining life. The nurse should not be so blunt as to say that births and deaths are normal. It is not showing compassion. Even though the child will be at peace when the child dies, this is not the best response because it does not provide comfort. The nurse should not ask the parents to stay away from their child in their final stages of life.

A 27-year-old patient reports having difficulty sleeping, having a poor appetite, and feeling sad since the death of her spouse. What should the nurse identify in this patient as a normal response to the death of the spouse? 1 Grief 2 Mourning 3 Acceptance 4 Bereavement

4 Bereavement is a process of grief experienced by most people. Examples include feelings of sadness, insomnia, poor appetite, deprivation, and desolation. The grieving person may seek professional help for the relief of symptoms if they interfere with daily activities and do not subside within a few months of the loss. Grief is a normal, appropriate emotional response to an external or consciously recognized loss. Mourning is a term used to describe a person's outward expression of grief. The person experiences emotional detachment from the loved object or person. Acceptance is the stage where the patient has achieved inner and outer peace through a personal victory over fear.

The student nurse is caring for a 10-year-old child in the terminal stages of acute lymphocytic leukemia. Which instructions should the nursing instructor provide to the student nurse when caring for the child? Select all that apply. "You should: 1 Challenge the child to learn ways to manage her own care." 2 Advise the child's parents to pray to God for recovery." 3 "Not involve yourself in the family's emotional distress." 4 "Urge the parents to accept the truth and spend time together." 5 "Encourage the child's parents to ask for help when they need it."

4, 5 The nurse should encourage child's parents to accept the truth and spend the remainder of the time left making memories with the sick child. The nurse should encourage the child's parents to ask for help when they need it and not try to handle everything alone. The child should not be asked to manage her own care. During terminal illness the child needs to depend on her parents and family more than ever. The nurse should not advise the child's parents to pray to God because it is unethical to force religion on a family. The nurse should not get involved in the family's emotional distress. Instead, the nurse should teach them about ways to manage the child's condition.