Chapter 11: Palliative Care at End of Life My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 11: Palliative Care at End of Life

Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. The nurse documents this finding as

a.

agonal breathing.

b.

apneustic breathing.

c.

death-rattle respirations.

d.

Cheyne-Stokes respirations.

ANS: D

Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. The death rattle is caused by accumulation of mucus in the airways, causing wet-sounding respirations. Agonal breathing has a very slow and irregular rate and rhythm. Apneustic respirations are irregular and gasping.

DIF: Cognitive Level: Comprehension REF: 156

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

2. A 21-year-old is dying after an automobile accident. The family members want to donate the patients organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when

a.

the patient is flaccid and unresponsive.

b.

CPR is ineffective in restoring heartbeat.

c.

the patient is apneic and without brainstem reflexes.

d.

respiratory efforts cease and no apical pulse is audible.

ANS: C

The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead.

DIF: Cognitive Level: Comprehension REF: 155

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. The nurse explains to the family that these symptoms

a.

will continue to increase until death finally occurs.

b.

are a normal response before these functions decrease.

c.

indicate a reflex response to the slowing of other body systems.

d.

may be associated with an improvement in the patients condition.

ANS: B

An increase in heart and respiratory rate may occur before the slowing of these functions in the dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement, and it would be inappropriate for the nurse to indicate this to the family. The changes in pulse and respirations are not reflex responses.

DIF: Cognitive Level: Comprehension REF: 156

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. A patient who has been diagnosed with metastatic cancer and has a poor prognosis plans a trip across the country to settle some issues with my sisters and brothers. The nurse recognizes that the patient is manifesting the psychosocial response of

a.

restlessness.

b.

yearning and protest.

c.

anxiety about unfinished business.

d.

fear of the meaninglessness of ones life.

ANS: C

The patients statement indicates that there is some unfinished family business that the patient would like to address before dying. Restlessness is frequently a behavior associated with an inability to express emotional or physical distress, but this patient does not express distress and is able to communicate clearly. There is no indication that the patient is protesting the prognosis, or that there is any fear that the patients life has been meaningless.

DIF: Cognitive Level: Application REF: 157

TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

5. The spouse of a patient with terminal lung cancer visits daily and cheerfully talks with the patient about vacation plans for the next year. When the nurse asks about any concerns, the spouse says, Im busy at work, but otherwise things are fine. An appropriate nursing diagnosis is

a.

ineffective coping related to lack of grieving.

b.

anxiety related to complicated grieving process.

c.

caregiver role strain related to feeling overwhelmed.

d.

hopelessness related to knowledge deficit about cancer.

ANS: A

The wifes behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The wife does not appear to feel overwhelmed, hopeless, or anxious.

DIF: Cognitive Level: Application REF: 156-157 | 161

TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity

6. As the nurse admits a patient with severe heart failure to the hospital, the patient tells the nurse, If my heart or breathing stop, I do not want to be resuscitated. Which action is best for the nurse to take?

a.

Ask if these wishes have been discussed with the health care provider.

b.

Place a Do Not Resuscitate (DNR) notation in the patients care plan.

c.

Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed.

d.

Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently.

ANS: A

A health care providers order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patients request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patients wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patients current concern with possible resuscitation.

DIF: Cognitive Level: Application REF: 159-160

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

7. A patient who is very close to death is very restless and keeps repeating, I am not ready to die. Which action is best for the nurse to take?

a.

Remind the patient that no one feels ready for death.

b.

Sit at the bedside and ask if there is anything the patient needs.

c.

Insist that family members remain at the bedside with the patient.

d.

Tell the patient that everything possible is being done to delay death.

ANS: B

Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual patients concerns. Telling the patient that everything is being done does not address the patients fears about dying, especially since the patient is likely to die soon. Family members may not feel comfortable staying at the bedside of a dying patient; the nurse should not insist they remain there.

DIF: Cognitive Level: Application REF: 161-164

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

8. A patient in a hospice program is experiencing continuous, increasing amounts of pain. The nurse caring for the patient plans the scheduling of opioid pain medications to provide

a.

around-the-clock routine administration of analgesics.

b.

PRN doses of medication whenever the patient requests.

c.

enough pain medication to keep the patient sedated and unaware of stimuli.

d.

analgesic doses that provide pain control without decreasing respiratory rate.

ANS: A

The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs. Patients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate.

DIF: Cognitive Level: Application REF: 162 TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

9. When caring for a patient with lung cancer in a home hospice program, it is important for the nurse to

a.

discuss cancer risk factors and appropriate lifestyle modifications.

b.

encourage the patient to discuss past life events and their meaning.

c.

accomplish a thorough head-to-toe assessment several times a week.

d.

educate the patient about the purpose of chemotherapy and radiation.

ANS: B

The role of the hospice nurse includes assisting the patient with the important end-of-life task of finding meaning in the patients life. Frequent head-to-toe assessments are not needed for hospice patients and may tire the patient unnecessarily. Patients admitted to hospice forego curative treatments such as chemotherapy and radiation for lung cancer; discussion of cancer risk factors and therapies is not appropriate.

DIF: Cognitive Level: Application REF: 154-155 | 162

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

10. A hospice nurse who has become very close to a terminally ill patient and family is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?

a.

Contact a grief counselor as soon as possible.

b.

Cry along with the patients family members.

c.

Leave the home as quickly as possible to allow the family to grieve privately.

d.

Consider whether working in hospice is desirable since patient losses are common.

ANS: B

It is appropriate for the nurse to cry and express sadness in other ways when a patient dies, and the family is likely to feel that this is therapeutic. Contacting a grief counselor, leaving the family to grieve privately, and considering whether hospice continues to be a satisfying place to work are all appropriate actions as well, but the nurses initial action at this time should be to share the grieving process with the family.

DIF: Cognitive Level: Application REF: 165

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

11. A patient who is in the clinic for an immunization tells the nurse, My mother died 4 months ago, and I just cant seem to get over it. Im not sure it is normal to still think about her every day. Which nursing diagnosis is most appropriate?

a.

Hopelessness related to inability to resolve grief

b.

Complicated grieving related to unresolved issues

c.

Anxiety related to lack of knowledge about normal grieving

d.

Chronic sorrow related to ongoing distress about loss of mother

ANS: C

The patient should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal for months or years after a death. The other nursing diagnoses imply that the patients grief is unusual or pathologic, which is not the case.

DIF: Cognitive Level: Application REF: 156-157 TOP: Nursing Process: Diagnosis

MSC: NCLEX: Psychosocial Integrity

12. The family member of a dying patient tells the nurse, Mother doesnt really respond any more when I visit. I dont think she knows that I am here. Which response by the nurse is appropriate?

a.

You may need to cut back your visits for now to avoid overtiring your mother.

b.

Withdrawal may sometimes be a normal response when preparing to leave life.

c.

It will be important for you to stimulate your mother as she gets closer to dying.

d.

Many patients dont really know what is going on around them at the end of life.

ANS: B

Withdrawal is a normal psychosocial response to approaching death. Dying patients may maintain the ability to hear while not being able to respond. Stimulation will tire the patient and is not an appropriate response to withdrawal in this circumstance. Visitors are encouraged to be present with the patient, talking softly and making physical contact in a way that does not demand a response from the patient.

DIF: Cognitive Level: Application REF: 157 | 161

TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

13. Which of these patients is most appropriate for the nurse to refer to hospice care?

a.

A 60-year-old with lymphoma whose children are unable to discuss issues related to dying

b.

A 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse

c.

A 28-year-old with AIDS-related dementia who needs palliative care and pain management

d.

A 56-year-old with advanced liver failure whose family members can no longer care for him or her at home

ANS: C

Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life. Patients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice patients.

DIF: Cognitive Level: Application REF: 154-155

OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

14. A terminally ill patient is admitted to the hospital. Which action should the nurse include in the initial plan of care?

a.

Determine the patients wishes regarding end-of-life care.

b.

Emphasize the importance of addressing any family issues.

c.

Discuss the normal grief process with the patient and family.

d.

Encourage the patient to talk about any fears or unresolved issues.

ANS: A

The nurses initial action should be to assess the patients wishes at this time. The other actions may be implemented if the patient or the family express a desire to discuss fears, understand the grief process, or address family issues, but they should not be implemented until the assessment indicates that they are appropriate.

DIF: Cognitive Level: Application REF: 156-157

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Psychosocial Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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