NUR 256 PrepU Ch 13 Palliative and End of life care
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.
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.
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 Arranging plans for after death Supporting family members Providing personal care Completing a head-to-toe assessment Encouraging fluids
Maintaining client comfort Supporting family members Providing personal care
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 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 dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be?
"This must be very difficult for you."
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).
According to federal guidelines, hospices may provide no more than what percentage of the aggregate annual patient-days at the inpatient level?
20
Which term best describes a living will?
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 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
A client is experiencing anorexia and the physician is to order a medication to stimulate the client's appetite. Which of the following would the nurse least likely expect the physician to prescribe?
Atropine Explanation: Atropine is used to manage excessive oral and respiratory secretions when death is imminent. Dexamethasone, megestrol, and dronabinol may be used to stimulate appetite in clients who are at the end of life
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
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 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 client who has been demonstrating signs of impending death is awake, alert, and wants to see grandchildren after they attend school. Which action will the nurse take to support this client's request?
Contact the family to ask for grandchildren to come to visit the client
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 family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which intervention should a nurse perform in such a situation?
Encourage the family members to express their feelings and listen to them in their frank communication
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
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 would not be consistent with promoting nutrition in terminally ill patients?
Maintaining a balanced diet Explanation: One should not be overly concerned about a "balanced" diet for terminally ill patients. Offering small portions of favorite foods, avoiding arguments at mealtime, and offering cool foods rather that hot foods are all tips that promote nutrition in terminally ill patients
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.
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
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
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
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
Which is one level of hospice care covered under Medicare and Medicaid hospice benefits that includes a 5-day inpatient stay and is provided occasionally to relive the family caregivers?
Respite care Explanation: Inpatient respite care is a 5-day inpatient stay, provided on an occasional basis to relieve the family caregivers. Routine home care entails that all services provided are included in the daily rate to the hospice. Continuous care is provided in the home for management of a medical crisis. General inpatient care provides an inpatient stay for symptoms management that cannot be provided in the home.
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
The nurse is caring for a client who just learned of a 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 decisions independently. 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
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
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
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 does not alter a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life. 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
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?
ct response: 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.
A nurse is assessing a terminally ill female client. Which client statement indicates that the client is in the bargaining stage of dying?
"I just want to see my daughter graduate from college. That's all."
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 nurse is part of a team involved with informing a client and his wife about the spread of his cancer. When communicating with the client and wife, which of the following would be most appropriate?
Allowing time for the client and wife to absorb and respond to the information Explanation: When communicating with the client and his wife about the spread of cancer, the team members should allow the couple time to absorb and respond to the information presented. The setting should be quiet with minimal distractions. Information should be presented using the language of the client and wife in terms that they can understand. Technical language should be avoided. Information should be presented in small chunks, to allow the client and his wife to absorb it and cope with it
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 client with a terminal illness who is incapacitated is experiencing intractable pain that is no longer effectively addressed by conventional pharmacology. Which type of pain management will the nurse anticipate for this client?
Palliative sedation Explanation: Effective control of symptoms can be achieved under most conditions; however, some clients may experience distressing, intractable symptoms and other clients may be incapacitated. Although palliative sedation remains controversial, it is offered in some settings to clients who are close to death or who have symptoms that do not respond to conventional pharmacologic and nonpharmacologic approaches, resulting in unrelieved suffering. Palliative sedation is distinguished from euthanasia and physician-assisted suicide in that the intent of palliative sedation is to relieve symptoms, not to hasten death. Proportionate palliative sedation uses the minimum drug necessary to relieve the symptom while preserving consciousness, whereas palliative sedation induces unconsciousness, which is more controversial. Barbiturate coma is a technique used to induce a coma in clients with specific conditions. Conscious sedation is used for some diagnostic tests and procedures. Clients who are incapacitated are not likely candidates for patient-controlled analgesia.
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.
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
