Saunders

The nurse is caring for a dying client who adheres to Judaism. The nurse demonstrates cultural sensitivity when caring for this client by taking which action? 1. Encouraging a rabbi to sit with the client 2. Encouraging the client to have time alone 3. Asking the family if they would like an autopsy done 4. Encouraging family to agree to removal of life support

1. Encouraging a rabbi to sit with the client Rationale: When caring for a client who adheres to Judaism, end-of-life care includes recognizing that prolongation of life is important (a client on life support must remain so until death). A dying client should not be left alone (a rabbi's presence is desired), and autopsy and cremation are forbidden.

The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which best describes Cheyne-Stokes respirations? 1. Continuous rapid regular breathing 2. Periods of apnea followed by bradypnea 3. Periods of apnea followed by deep rapid breathing 4. Periods of bradypnea followed by periods of tachypnea

3. Periods of apnea followed by deep rapid breathing Rationale: Cheyne-Stokes respirations are characterized by alternating periods of apnea and deep rapid breathing. Therefore options 1, 2, and 4 are incorrect.

The nurse is caring for a terminally ill child who is receiving palliative care. When explaining the purpose of palliative care to the child's caregiver, the nurse recognizes the need for additional instruction when the caregiver makes which statement? 1. "Palliative care interventions hasten death." 2. "Palliative care promotes optimal functioning." 3. "Palliative care will provide pain management." 4. "Palliative care will provide symptom management."

1. "Palliative care interventions hasten death." Rationale: Palliative care interventions do not serve to hasten death; rather, they provide pain and symptom management, attention to issues faced by the child and family with regard to death and dying, and promotion of optimal functioning and quality of life.

A nurse is supervising the postmortem care of a client. Which action by the unlicensed assistive personnel (UAP) performing the care is appropriate? 1. Keeps the client's body in a flat, supine position 2. Closes the client's eyes by taping the eyelids shut 3. Elevates the head of the bed 30 degrees as soon as possible after death 4. Removes the client's dentures and places them in a denture cup with the client's name on the lid

3. Elevates the head of the bed 30 degrees as soon as possible after death Rationale: The nurse may delegate postmortem care to unlicensed assistive personnel, but the nurse must supervise the postmortem care. The care given must protect the client's body from damage or disfigurement. Elevating the head of bed immediately after the client's death can help reduce facial discoloring from livor mortis. Using tape may damage the delicate eyelid tissues; dentures should be placed inside the client's mouth during postmortem care to maintain facial structure.

The nurse is caring for a terminally ill client who is experiencing dyspnea. When caring for this client, the nurse should place the client in which position? 1. Prone 2. Supine 3. Lateral 4. Trendelenburg's

3. Lateral Rationale: Dyspnea may occur during the last days of life. Nursing management of a terminally ill client experiencing dyspnea includes elevating the head and/or positioning the client on the side to improve chest expansion. The positions noted in options 1, 2, and 4 will increase the dyspnea.

The spouse of a terminally ill client steps out of his room in tears. The spouse tells the nurse, "I don't know what I'm going to do when he's gone!" What is the nurse's best response? 1. "This must be very hard for you." 2. "Don't worry, things will be fine." 3. "I know. It will get easier with time." 4. "You need to be strong for him! Don't cry."

1. "This must be very hard for you." Rationale: When a family member or caregiver is expressing the pain of loss, the nurse should not minimize their feelings. It is important to avoid general or trite assurances. Simply listening to the spouse and acknowledging how difficult this situation is, as in "This must be very hard for you" is the best example of therapeutic communication. Responses that belittle or minimize the family member's feelings, or those that place the client's feelings on hold are not therapeutic.

Which interventions should the nurse take for a deceased client whose eyes will be donated? Select all that apply. 1. Close the client's eyes. 2. Elevate the head of the bed. 3. Place a warm compress on the eyes. 4. Place a dry sterile dressing over the eyes. 5. Place wet saline gauze pads and a cool pack on the eyes.

1. Close the client's eyes. 2. Elevate the head of the bed. 5. Place wet saline gauze pads and a cool pack on the eyes. Rationale: When a corneal donor dies, the eyes are closed, the head of the bed is elevated to prevent edema formation, and gauze pads wet with saline are placed over them with a cool pack or small ice pack. A warm compress will promote edema. Placing dry sterile dressings over the eyes serves no useful purpose. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted with 24 to 48 hours.

The nurse is caring for a terminally ill toddler. When interacting with the toddler's parents, the nurse should implement which interventions? Select all that apply. 1. Retain ritualism. 2. Avoid significant changes in lifestyle. 3. Maintain sensitivity toward the parents. 4. Encourage the parents to be near the child. 5. Encourage as normal an environment as possible. 6. Discourage the parents from dealing with their feelings.

1. Retain ritualism. 2. Avoid significant changes in lifestyle. 3. Maintain sensitivity toward the parents. 4. Encourage the parents to be near the child. 5. Encourage as normal an environment as possible. Rationale: Once infants and toddlers have established trust with a parent, separation, even if temporary, from the parent is profound. Prolonged separation during the first several years is thought to be more significant in terms of future physical, social, and emotional growth than at any subsequent age. When interacting with parents of a terminally ill toddler, the parents should be assisted in dealing with their feelings and encouraged to remain as near to the child as possible. It is also important to maintain as normal an environment as possible to retain ritualism.

The community health nurse is providing an educational session to a group of community members at a local high school regarding the issue of organ donation. A member of the group asks the nurse, "How old does someone have to be to provide consent for organ donation?" Which response should the nurse make? 1. "Written consent is never required to become a donor." 2. "A donor must be 18 years of age or older to provide consent." 3. "A person can sign papers to become a donor at 16 years of age." 4. "The family is responsible for decision making about organ donation at the time of death."

2. "A donor must be 18 years of age or older to provide consent." Rationale: Any person 18 years of age or older may become an organ donor by written consent. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent's organs. Therefore options 1, 3, and 4 are incorrect.

The nurse is caring for a client who is terminally ill. When assessing the client, the nurse recognizes which as the most common distress symptom near the end of life? 1. Pain 2. Anxiety 3. Depression 4. Withdrawal

2. Anxiety Rationale: Anxiety is the most common distress symptom near the end of life. Anxiety is an uneasy feeling whose cause is not easily identified. Pain, depression, and withdrawal may occur but are not the most common distress symptom.

The nurse monitors a terminally ill client for which physical signs of approaching death? Select all that apply. 1. Increased appetite 2. Loss of consciousness 3. Loss of bowel control 4. Loss of bladder control 5. Decreased blood pressure 6. Decreased tactile sensation

2. Loss of consciousness 3. Loss of bowel control 4. Loss of bladder control 5. Decreased blood pressure 6. Decreased tactile sensation Rationale: Physical signs of approaching death include decreased appetite/thirst, decreased blood pressure, loss of consciousness, loss of bowel and bladder control, and decreased tactile sensation.

The nurse is caring for a terminally ill client who is experiencing delirium. When caring for this client, the nurse should take which action? 1. Provide a dark room. 2. Provide a well-lighted room. 3. Reorient the client every 8 hours only. 4. Withhold benzodiazepines and sedatives.

2. Provide a well-lighted room. Rationale: Delirium may occur during the last days of life. Nursing management of a terminally ill client experiencing delirium includes providing a room that is quiet, well lighted, and familiar to reduce the effects of delirium; reorienting the dying client to client, place, and time with each; and administering prescribed benzodiazepines and sedatives as needed.

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests no autopsy be performed. Which response to the family is most appropriate? 1. "The decision is made by the medical examiner." 2. "An autopsy is mandatory for any client who is DOA." 3. "I will contact the medical examiner regarding your request." 4. "It is required by federal law. Tell me why you don't want the autopsy done?"

3. "I will contact the medical examiner regarding your request." Rationale: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.

A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation? 1. Assessing lung sounds 2. Monitoring temperature 3. Administering intravenous (IV) fluids 4. Performing range-of-motion exercises to the extremities

3. Administering intravenous (IV) fluids Rationale: Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore, the client who was previously dehydrated with medications to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. The nurse should prepare to infuse IV fluids as prescribed and continue to monitor urine output. Options 1, 2, and 4 will not maintain viability of the kidneys.

The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the *emotional* needs of the client and spouse? 1. Allow family members to name the infant. 2. Encourage the client to talk about the dead fetus. 3. Allow the client and the spouse to hold the infant. 4. Assess the client's and the spouse's perception of the event.

4. Assess the client's and the spouse's perception of the event. Rationale: The initial intervention in planning to meet the emotional needs of the client and her spouse is to assess their perception of the event. Although options 1, 2, and 3 are likely to be components of the plan of care, the initial intervention in planning is to assess the perception of the event.

The hospice nurse visits a client who is dying of ovarian cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's 'sweet 16' birthday party, I'll be ready to die." Which phase of coping is this client experiencing? 1. Anger 2. Denial 3. Bargaining 4. Depression

3. Bargaining Rationale: Denial, bargaining, anger, depression, and acceptance are recognized stages that a client facing a life-threatening illness experiences. Bargaining identifies a behavior in which the individual is willing to do anything to avoid loss or change the prognosis or fate. Anger also may be a first response to upsetting news, and the predominant theme is "Why me?" or the blaming of others. Denial is expressed as shock and disbelief and may be the first response to hearing bad news. Depression may be manifested by hopelessness, weeping openly, or remaining quiet or withdrawn.

The nurse recognizes that which intervention is unlikely to facilitate effective communication between a dying client and family? 1. The nurse encourages the client and family to identify and discuss feelings openly. 2. The nurse assists the client and family in carrying out spiritually meaningful practices. 3. The nurse makes decisions for the client and family to relieve them of unnecessary demands. 4. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

3. The nurse makes decisions for the client and family to relieve them of unnecessary demands. Rationale: Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communications. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 4 is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgmental. The correct option describes the nurse removing autonomy and decision-making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. This is an ineffective intervention, which could impair communication further.

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1.Discourage reminiscing. 2.Make the decisions for the family. 3.Encourage expression of feelings, concerns, and fears. 4.Explain everything that is happening to all family members. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know that they will not be abandoned by the nurse.

3.Encourage expression of feelings, concerns, and fears. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know that they will not be abandoned by the nurse. Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action? 1. Agree to act as a witness. 2. Call the health care provider (HCP). 3. Ask another nurse to serve as a witness. 4. Ask the client who might be available to serve as a witness.

4. Ask the client who might be available to serve as a witness. Rationale: A living will addresses the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the client who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as a witness. There is no reason to call the HCP.

The nurse is caring for a terminally ill adolescent client. When caring for this client the nurse should implement which intervention? 1. Comply with the client's wishes at all times. 2. Encourage the client to be dependent on hospital staff. 3. Refuse to answer questions related to impending death. 4. Encourage the client to maintain maximum self-control.

4. Encourage the client to maintain maximum self-control. Rationale: Interventions appropriate when caring for a terminally ill adolescent include avoiding alliances with either the parent or child, structuring hospital admission to allow for maximum self-control and independence, and answering the adolescent's questions honestly. Complying with the client's wishes at all times is not therapeutic.

A hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's wife states, "I don't understand why he needs morphine. He tells me he's not in pain." What should the nurse include in the explanation of the purpose of the morphine? 1. It reduces the secretions in the bronchi. 2. It causes dilation of the bronchial smooth muscles. 3. It relieves pain, which helps to reduce the dyspnea. 4. It helps to reduce anxiety and oxygen consumption.

4. It helps to reduce anxiety and oxygen consumption. Rationale: Dyspnea is a terrifying and yet common symptom in clients who are near death. The use of opioids is considered standard treatment for dyspnea in clients who are near death. It helps to help reduce dyspnea by reducing anxiety, thus reducing the consumption of oxygen and altering the client's perception of dyspnea. Morphine does not reduce secretions or cause dilation of smooth muscles in the bronchi. Although morphine does relieve pain, this client is not experiencing any pain.

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do-not-resuscitate (DNR) order. What is the nurse's priority action? 1. Prepare the client for intubation and mechanical ventilation. 2. Talk to the family about the client's right to change his mind. 3. Administer an anti-anxiety medication to the client to ease his breathing. 4. Notify the health care provider that the client is rescinding the DNR order.

4. Notify the health care provider that the client is rescinding the DNR order. Rationale: COPD cannot be cured. End-of-life issues are important for clients and families to understand; however, the client always has the right to rescind the decision as long as he or she is mentally competent. The nurse needs the health care provider to reverse the DNR prescription on the chart. The health care provider also needs to be informed about the conflict between the client and his family. Option 1 is incorrect because the decision to take this action is determined by the health care provider. Option 2 is incorrect because the health care provider should handle this. The action identified in option 3 can help but could alter the client's mental capacity to make decisions.