Chapter 19 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 19

Question 1

Type: MCSA

The ICU nurse caring for a patient at the end of life understands that limitation of care refers to a decision:

1. To stop all measures, including pain medication

2. To exclude all but immediate family members from the patients room

3. Not to initiate one or more interventions

4. To stop one or more therapies after they had been initiated

Correct Answer: 3

Rationale 1: Stopping an already started therapy is referred to as withdrawal.

Rationale 2: Limiting family members has nothing to do with limiting care to a patient.

Rationale 3: According to Copnell, limitation occurs when the decision is made not to institute a medical therapy because the therapy is unlikely to benefit the patient.

Rationale 4: Stopping an already started therapy is referred to as withdrawal.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-1: Describe the four categories defined by Copnell by which death occurs in the ICU.

Question 2

Type: MCSA

The decision has been made to not start needed dialysis on a patient in the intensive care unit. According to Copnell (2005), this decision would fall under which category of ICU deaths?

1. Failed CPR

2. Withdrawal

3. Brain death

4. Limitation

Correct Answer: 4

Rationale 1: When the death occurs despite all efforts by clinicians, it is called failed CPR.

Rationale 2: Withdrawal is the category in which a therapy has been stopped after a decision was made that the therapy was not beneficial to the patient.

Rationale 3: Brain death occurs when validation has shown that the brainstem lacks functioning.

Rationale 4: Limitation refers to the decision to not initiate one or more interventions, such as ventilation, intubation, dialysis, enteral feedings, or vasopressors.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-1: Describe the four categories defined by Copnell by which death occurs in the ICU.

Question 3

Type: MCMA

A nurse might elect to have a family present during CPR on a critically ill patient because it is likely to have which benefits?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Staff members are reminded of the patients personhood.

2. The family may realize the seriousness of the patients illness and understand the gravity of the situation.

3. Fewer lawsuits occur when the family members see the care given by the health care team.

4. The family may provide comfort and support to the patient.

5. The family can understand the expenses needed with the multitude of equipment used in critical care.

Correct Answer: 1,2,4

Rationale 1: By keeping the family at the bedside, the humanness of the patient is increased by the staff.

Rationale 2: By experiencing the CPR event, the family can see what really occurs and fantasy views or nightmares about death are minimized by the reality of the event.

Rationale 3: Lawsuits may or may not be decreased by having the family at the bedside.

Rationale 4: Patients after receiving CPR have reported comfort and support.

Rationale 5: Costs are not on the minds of the family at this point in the health care process.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-2: Evaluate the advantages and disadvantages of family presence during CPR.

Question 4

Type: MCSA

When planning to allow a family to be at the bedside during CPR, the nurse should anticipate which possible outcome based on reports from post-CPR patients?

1. The family will be unhappy after seeing the pain and suffering caused by CPR.

2. The patient will feel comforted and supported by his familys presence.

3. The family will be overwhelmed by the confusion and busyness of the events.

4. The patient will be frustrated because of not being able to speak to the family.

Correct Answer: 2

Rationale 1: Although pain and suffering may be a part of the CPR process, the family did not report the CPR efforts as such because it was an attempt to save the patient.

Rationale 2: Research has shown that based on reports from post-CPR patients, the familys presence gave support and comfort, and patients felt less fear.

Rationale 3: Although feelings of being overwhelmed or unhappy may be a part of the CPR process, the family did not report the CPR efforts as such because it was an attempt to save the patient.

Rationale 4: Although intubated or aware of the patients inability to speak, the feelings of comfort and support given by the family were reported as beneficial.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-2: Evaluate the advantages and disadvantages of family presence during CPR.

Question 5

Type: MCSA

What does the nurse have a legal responsibility to prevent if family members are present while CPR is delivered to a patient?

1. Post-traumatic stress syndrome of family members from viewing CPR

2. Breach of confidentiality about the patients medical information during CPR

3. Family vendetta for perceived unskilled or less efficient staff during CPR

4. Patients lack of privacy and physical exposure during CPR

Correct Answer: 2

Rationale 1: This is not a staff concern about family presence during CPR.

Rationale 2: Confidentiality and HIPAA require specific guidelines for the release of information to family. The concern for accidental leaking of this information during a CPR event could be quite high. Therefore, this concern would be an issue that needs specific planning and open communication with the family to make sure they understand why some information cannot be shared. Verbal and written permission from the patient cannot always be obtained in ICU prior to a CPR event; therefore, a conflict might arise where a breach of confidentiality might occur.

Rationale 3: This is not a staff concern about family presence during CPR.

Rationale 4: This is not a staff concern about family presence during CPR.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-2: Evaluate the advantages and disadvantages of family presence during CPR.

Question 6

Type: MCSA

When using the mnemonic in-or-out as a guideline for evaluating family presence during CPR, what would the nurse include during the R step?

1. Identify the relationship to the patient and the family decision maker.

2. Explain the rationale for health outcomes and management options.

3. Assess the familys reason for wanting to be present in the room.

4. React to data collected during the family discussion.

Correct Answer: 1

Rationale 1: During the R step relationships to the patient are identified and clarified. The family decision maker is also identified.

Rationale 2: The health outcomes and management options are explained in step O (for outcome).

Rationale 3: Assessing the familys reasoning and their comprehension of being present is a part of step U (for understanding).

Rationale 4: Reacting to discussion findings is step T (for time to take action).

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-3: Discuss best practices for nurses when speaking with a bereaved family.

Question 7

Type: MCSA

When caring for a bereaved family member, the nurse would avoid which inappropriate action?

1. Offer privacy and a listening ear to the family before speaking.

2. Avoid technical, hospital, or medical terminology when explaining conditions or treatments.

3. Offer clichs, such as she lived a good life, to make the family feel better.

4. Use direct eye contact and offer comfort by touching.

Correct Answer: 3

Rationale 1: This is an appropriate action by the nurse to express caring for the bereaved family.

Rationale 2: This is an appropriate action by the nurse to express caring for the bereaved family.

Rationale 3: Clichs do not offer comfort and may result in an inaccurate perception by the family. Just listening and offering self will allow the family members to express their feelings in a nonjudgmental manner. The nurses role is to help the grieving process by allowing the family to express their feelings (not the nurses).

Rationale 4: This is an appropriate action by the nurse to express caring for the bereaved family.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-3: Discuss best practices for nurses when speaking with a bereaved family.

Question 8

Type: MCSA

How would the nurse explain brain death to a family member? Brain death is:

1. Damage to the brain so extensive that the brain is no longer functional and function cannot be restored by medical therapies

2. Brain tissue that is lacking blood supply so it cannot perform some of its normal functions

3. Electrical malfunction of brain tissue so that it does not control breathing properly

4. When one lobe of the brain is traumatized or bruised and is trying to repair itself

Correct Answer: 1

Rationale 1: The definition of brain death is the irreversible loss of brain function that includes the brainstem.

Rationale 2: Brain death is not just a decreased blood supply; other causes may be present to cause irreversible loss of function as well.

Rationale 3: Electrical control of effective breathing may be one issue, but it does not include the irreversible aspect of the damage present. Breathing can be controlled by other means if the brainstem is still functioning.

Rationale 4: Repair is not an option when the damage is irreversible.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-4: List the criteria for death by neurological criteria (brain death).

Question 9

Type: MCSA

A patient in the intensive care unit is being evaluated for brain death. Which finding is an indication of brain death?

1. Absence of all motor responses to noxious stimuli

2. No respiratory effort when the patient is off the ventilator for 4 minutes with a pCO2 of 49

3. Absence of a cough reflex with nasotracheal stimulation

4. Pupils that are 3 mm and respond to light

Correct Answer: 3

Rationale 1: This assesses the presence and degree of a coma.

Rationale 2: Eight minutes and a pCO2 of 60 are required to determine apnea.

Rationale 3: The absence of reflexes demonstrates that higher brain functions have ceased.

Rationale 4: This is a part of the coma level assessment and alone will not validate the degree of brain function that is present or absent.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-4: List the criteria for death by neurological criteria (brain death).

Question 10

Type: MCMA

Which reflexes will the nurse assess to determine brainstem response in a patient being evaluated for brain death?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. PERLA

2. Oculovestibular

3. Corneal

4. Oculocephalic

5. Moro

Correct Answer: 1,2,3,4

Rationale 1: Absence of brainstem reflexes is determined by pupils 4 mm or larger that do not respond to light.

Rationale 2: Brainstem response can be determined by assessing the oculovestibular reflex.

Rationale 3: Brainstem response can be determined by assessing the corneal reflex.

Rationale 4: Brainstem response can be determined by assessing the oculocephalic reflex.

Rationale 5: Moro reflex is seen soon after birth and disappears with the development of the infant. It is also called the startle reflex that creates a flexion of the thighs and knees and a fanning out of the arms, as if trying to embrace someone.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-4: List the criteria for death by neurological criteria (brain death).

Question 11

Type: MCSA

When attempting to establish a relationship and enter a dialogue with the family of a dying patient, the nurse would:

1. Identify with the family when they have concerns by saying, I have questioned how a physician could believe that also. Ill argue with her about it.

2. Speak more than the family because silence may be difficult for them to tolerate.

3. Demonstrate respect for the family by saying, Im impressed with how involved you have been with the patient during his illness.

4. Begin by saying, I know exactly how you must be feeling.

Correct Answer: 3

Rationale 1: The nurse would not contradict or put down other health care providers but recognize patient concerns by saying something such as: I hear you saying that you dont feel you are being heard by the physicians. Id like to make certain you have a chance to voice all your concerns.

Rationale 2: The nurse would maintain a higher ratio of family member-to-health care provider speaking time; therefore, listening, asking clarifying questions, and tolerating silence are important skills for nurses.

Rationale 3: The nurse would demonstrate respect for family members by saying something such as: Im so impressed by how involved you have been with your father throughout his illness; and also by assuming that the family members are operating in what they believe to be the patients best interests unless there is proof to the contrary.

Rationale 4: The nurse does not know how the family must be feeling. This would not be appropriate for the nurse to say to the family.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-7: Discuss the needs of families of dying patients.

Question 12

Type: MCSA

Which question would be most appropriate for the nurse to ask a son who is his fathers health care proxy to help to clarify the fathers end-of-life wishes?

1. Did he ever speak to your mother about his wishes?

2. When did your father complete his advance directive?

3. Would you tell me in his own words what he said he wanted done at the end of his life?

4. Who else was present during the discussion?

Correct Answer: 3

Rationale 1: This would not help clarify the patients end-of-life wishes.

Rationale 2: This would not help clarify the patients end-of-life wishes.

Rationale 3: This would help clarify the patients end-of-life wishes.

Rationale 4: This would help clarify the patients end-of-life wishes.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5: Explain possible ways to discuss limiting of further therapy such as instituting a Do Not Attempt Resuscitate (DNAR) order with a patient and/or patients surrogate decision maker.

Question 13

Type: MCSA

When applying the substituted judgment standard for decision making, the nurse is asking the health care proxy to make decisions based on what the:

1. Family would like done under these circumstances

2. Spouse would like done under these circumstances

3. Proxy could imagine the patient wants for him- or herself

4. Health care providers feel is appropriate.

Correct Answer: 3

Rationale 1: This is not how the substituted judgment standard is implemented.

Rationale 2: This does not explain the standard from which decisions are made by the health care proxy.

Rationale 3: This is the correct definition of substituted judgment, in which the proxy decides what the patient might desire for end-of-life care. The success of this approach may vary with the proxys ability to see the situation from the patients point of view.

Rationale 4: What the health care providers feel should not be a factor in the decision-making process.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-6: Compare and contrast substituted judgment and the best interests standard for decision making for an incapacitated patient.

Question 14

Type: MCSA

When applying both substituted judgment and best interest standards to end-of-life decision making for a patient, the nurses primary role is to:

1. Tell the proxy what should be done in the best interest of the patient.

2. Establish trust and confidence with the family.

3. Be an advocate and decision maker based on hospital interests.

4. Promote effective communication and decrease conflict.

Correct Answer: 4

Rationale 1: Telling the proxy what to do does not allow for individual freedom of choice in the management of care based on the patients wishes. Health care providers should give options and realistic outcomes but leave the decision making to the proxy and/or family.

Rationale 2: Just establishing trust and building confidence in the health care staffs care will not include what the patients wishes are. Trust and confidence are important to open communication, but they are not the end process. Getting an understanding of the patients desires should be the ultimate goal of the communication process.

Rationale 3: Patient care is not based on hospital interests. Nursing is focused on the patients individual needs and concerns. Allowing the proxy to take these considerations into the decision-making process will allow maximum effect to meet the patients end-of-life needs.

Rationale 4: During decision-making processes, the health care teams goal is to maximize communication and to minimize conflicts in the best interest of the patient based on what the patient would want if able to express his own desires.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-6: Compare and contrast substituted judgment and the best interests standard for decision making for an incapacitated patient.

Question 15

Type: MCMA

The nurse should set which goals when planning care for the family of a dying ICU patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Encourage family members to talk about their feelings and concerns.

2. Establish trust between the family and the members of the health care team.

3. Identify and respect the familys cultural and religious beliefs or practices.

4. Establish respect for family choices and support their decisions.

5. Establish a sympathetic approach in response to family members feelings.

Correct Answer: 1,2,3,4

Rationale 1: This is an appropriate goal when planning care for the family of a dying ICU patient.

Rationale 2: This is an appropriate goal when planning care for the family of a dying ICU patient.

Rationale 3: Individuality of culture and religious beliefs should be incorporated into the plan of care.

Rationale 4: This is an appropriate goal when planning care for the family of a dying ICU patient.

Rationale 5: Empathy, not sympathy, should be included in the plan of care. Showing an understanding of the situation and respect for the familys feelings will allow open communication and maximum understanding while the family deals with the situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-7: Discuss the needs of families of dying patients.

Question 16

Type: MCSA

Which approach would the nurse avoid when caring for the family of a dying patient?

1. Repeating information frequently to make sure the information is being understood fully

2. Reaffirming the bad news but allowing time to listen to their responses

3. Being honest and sincere but sensitive to the familys needs

4. Encouraging a quick decision-making process to decrease the amount of time required to get past the painful part of dealing with the death

Correct Answer: 4

Rationale 1: This action will improve communication and minimize conflicts between staff and family.

Rationale 2: This action will improve communication and minimize conflicts between staff and family.

Rationale 3: This action will improve communication and minimize conflicts between staff and family.

Rationale 4: Rushing the family to a quick decision is not wise and may cause resentment once the situation is better understood or accepted. Frequent repeating and allowing time to process all options are desired for the best outcomes.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-7: Discuss the needs of families of dying patients.

Question 17

Type: MCSA

According to Morse (2001), what two patterns of behavior may a family use when expressing their feelings or emotions related to the death of their loved one?

1. Denial and grieving

2. Enduring and suffering

3. Hostility and acceptance

4. Anger and bargaining

Correct Answer: 2

Rationale 1: These are not patterns of behavior identified by Morse.

Rationale 2: Enduring and suffering are phases of the grief process that indicate the best approach for the nurse to use to help the family move forward through their grief. The nurses response is based on the phase being exhibited by the family member at the time of the encounter. In the enduring phase the nurse needs to respect the family members physical space by not touching or hugging that individual at this time. The family member has not acknowledged the full impact of the situation and is attempting to control his or her emotions and the situation. In the second phase (suffering), the acknowledgment has occurred and the family member is emotionally responding to the loss. Suffering must be experienced before the person can move forward. Positioning, touching, and sharing are acceptable in the suffering phase.

Rationale 3: These are not patterns of behavior identified by Morse.

Rationale 4: These are not patterns of behavior identified by Morse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-7: Discuss the needs of families of dying patients.

Question 18

Type: MCSA

According to Morse (2001) the nurse should anticipate family members of a dying patient to display which behavior before they are ready to move on and face the reality of the situation?

1. Denial

2. Anger

3. Suffering

4. Enduring

Correct Answer: 3

Rationale 1: This is a term that Kubler-Ross uses to describe the grieving process.

Rationale 2: This is a term that Kubler-Ross uses to describe the grieving process.

Rationale 3: Suffering (according to Morse) is required before the family can move forward. In this phase the reality of the situation is accepted.

Rationale 4: Enduring is the first phase and does not acknowledge the loss at this point.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-7: Discuss the needs of families of dying patients.

Question 19

Type: MCMA

What can the nurse allow the family to do when trying to meet the familys need to be helpful to a dying patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Reposition the patient.

2. Activate the patient-controlled analgesia if the patient grimaces or has pain.

3. Talk or read to the patient to show that they are present in the room.

4. Moisten the patients lips and mouth.

5. Comfort or soothe the patient through touch or speech.

Correct Answer: 1,3,4,5

Rationale 1: This action can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse.

Rationale 2: Delegating the administration of pain medication through a patient-controlled device is not a nursing action that can be delegated to a family member. Medication is administered by licensed personnel only. Families do not have the understanding, education, or license to administer meds. Even if the family does have a license, the care of the patient is legally the responsibility of the staff.

Rationale 3: This action can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse.

Rationale 4: This action can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse.

Rationale 5: This action can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-7: Discuss the needs of families of dying patients.

Question 20

Type: MCMA

If a dying patient is being provided with IV hydration, the nurse would assess for which problems?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A decrease in urine output

2. An increase in nausea and possible vomiting

3. An increased likelihood of dyspnea

4. Development of pitting edema in the extremities

5. Irregular heart rhythm

Correct Answer: 1,3,4

Rationale 1: Although some patients experienced improved sedation when they were hydrated, most experienced discomfort from fluid retention manifested as urinary retention.

Rationale 2: Although some patients experienced improved sedation when they were hydrated, most experienced discomfort from fluid retention manifested as edema, ascites, incontinence, urinary retention, pleural effusion, or pulmonary secretions.

Rationale 3: Although some patients experienced improved sedation when they were hydrated, most experienced discomfort from fluid retention manifested as pleural effusion or pulmonary secretions.

Rationale 4: Although some patients experienced improved sedation when they were hydrated, most experienced discomfort from fluid retention manifested as edema.

Rationale 5: The use of intravenous fluids in the dying patient will not increase the onset of an irregular heart rhythm.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-8: Describe collaborative management of patients symptoms at the end of life.

Question 21

Type: MCSA

Which approach to controlling pain, nausea, and dyspnea should the nurse use for pharmacological management at the end of a patients life?

1. Administer medication based only on the severity of symptoms that are observed in the patient.

2. Administer prophylactic medication aggressively as symptoms arise to maintain comfort.

3. Administer medications only at the familys request as the patients health care proxy.

4. Withhold all medication when other therapies are withheld.

Correct Answer: 2

Rationale 1: The severity of symptoms may not be clearly observed because pain and nausea are subjective symptoms, which are normally reported by the patient and not objectively observed by the nurse.

Rationale 2: Medication should be given aggressively to control and minimize symptoms. Prophylactic doses should be given to minimize the peaks and troughs of blood levels.

Rationale 3: The family cannot act as a proxy for medication needs. They can only express the patients wishes, but it is nursing judgment that decides medical management.

Rationale 4: Comfort at the end of life is the goal for the health care staff. Pain medication and other medical therapies are not withheld when other therapies are withdrawn. Often the doses are continually increased to maintain the comfort until the end.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-8: Describe collaborative management of patients symptoms at the end of life.

Question 22

Type: MCMA

When caring for a patient at the end of life, the nurse decides which therapies to continue based on whether the intervention will:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Keep the family happy.

2. Reduce the workload of the staff.

3. Enhance the patients functional status.

4. Lessen the patients emotional, psychological, or spiritual distress.

5. Promote relief of the patients symptoms.

Correct Answer: 3,4,5

Rationale 1: The patient, not the family, is the focus of the care.

Rationale 2: The patient, not the staff, is the focus of the care.

Rationale 3: This is a factor used to base decision of nursing management during the end-of-life care.

Rationale 4: This is a factor used to base decision of nursing management during the end-of-life care.

Rationale 5: This is a factor used to base decision of nursing management during the end-of-life care.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-8: Describe collaborative management of patients symptoms at the end of life.

Question 23

Type: MCSA

Which is the most appropriate intervention for the nurse attempting to meet the spiritual needs of a patient at the end of life?

1. Answer questions about the meaning of life, hope, and purpose of life based on the nurses understanding.

2. Explain the role of suffering as the nurse sees it.

3. Discuss ethical decision making with the patient to clarify his desires.

4. Encourage, respect, and participate when comfortable in the patients and familys cultural or spiritual practices.

Correct Answer: 4

Rationale 1: The patient is not asking for the nurses beliefs; the patient is trying to sort out what he believes.

Rationale 2: A spiritual counselor or chaplain or priest should be consulted to help the patient explore the meanings within his own life events. If the patient asks the nurse what he or she believes, then the nurse should begin by asking what the patient believes so he or she can support or explore these questions further.

Rationale 3: Ethical decision-making processes should not be a topic of discussion for patients at the end of life. Exploring their views and allowing the patients to talk about their issues should be the most comfort when they are dealing with their own death. Adding guilt to their already heavy burden during the dying process is inappropriate.

Rationale 4: If not contraindicated by the nurses own beliefs, the nurse can participate and encourage the practices that are spiritually or culturally comforting for the patient and family. If the nurse cannot participate based on her own beliefs, then it is her responsibility to find clergy, chaplain, or staff that can support these practices.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-8: Describe collaborative management of patients symptoms at the end of life.

Question 24

Type: MCSA

According to the American Nurses Association and the American Association of Critical-Care Nurses, a nurses primary duty to the patient is to:

1. Allow a comfortable death.

2. Do no harm.

3. Base all care on cost-benefit ratio analysis.

4. Minimize emotional distress in the family of a dying patient.

Correct Answer: 2

Rationale 1: This focuses only on the dying patient and not to all patients that nurses provide care on a daily basis.

Rationale 2: According to both the Nursing Practice Act and professional organizations such as the ANA and AACN, the goal for all patients is to do no harm.

Rationale 3: Cost-benefit ratios are for considering budgeting and continuing education presentations, but it is not the primary duty of the nurse. Preventing and doing no harm are the priority obligations of a nurse.

Rationale 4: Assisting the family during the end-of-life care is one of the goals of health care management, but it is not the priority obligation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-9: Explain sources of conflict at the end of life.

Question 25

Type: MCSA

When un-resolvable conflicts are present among health care team and family members concerning futile treatment of a patient, who has the legal right to decide the management plan?

1. The patients family or health care proxy determines the outcome.

2. The empowered nurse specialist coordinates the discussion among family members.

3. The hospitals ethics board dictates the final resolution.

4. The physician decides based on the hospitals ethics boards recommendation, the patients desires, and any written advance directives.

Correct Answer: 4

Rationale 1: These individuals do not have the legal right to decide.

Rationale 2: This individual does not have the legal right to decide.

Rationale 3: The primary physician (who is assigned to the case) has the final authority to decide the outcome in a futile treatment case. The recommendation of the ethics board will be taken into consideration to continue or withdraw therapy based on facts and options for each individual patient. The physician has the right to follow or ignore the recommendation from the ethics board but it is usually followed..These individuals do not have the legal right to decide; the recommendation from the ethics board is an option, not a mandate.

Rationale 4: The primary physician (who is assigned to the case) has the final authority to decide the outcome in a futile treatment case. The recommendation of the ethics board will be taken into consideration to continue or withdraw therapy based on facts and options for each individual patient. The physician has the right to follow or ignore the recommendation from the ethics board but it is usually followed. These individuals do not have the legal right to decide; the recommendation from the ethics board is an option, not a mandate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-9: Explain sources of conflict at the end of life.

Question 26

Type: MCSA

How should the nurse plan to manage sedation and pain medication when a dying client is to be terminally weaned or extubated?

1. Stop all ongoing sedative infusions at least an hour before extubation.

2. Observe the patient and adjust medication dosages every hour.

3. Provide an anticipatory dose of morphine and initiate an ongoing morphine infusion.

4. Initiate medication therapy to control dyspnea but plan to stop it in the event of hypotension.

Correct Answer: 3

Rationale 1: Anticipatory dosing of morphine sulfate is used prior to weaning or extubation. The usual dose is 5 to 10 mg IV or if the patient has been receiving morphine, two to three times the patients usual bolus dose.

Rationale 2: If the patient is displaying symptoms indicative of discomfort then the morphine dose should be titrated up slowly every 5 to 15 minutes with the goal of eliminating tachypnea, coughing or choking, agitation, excessive movement of the head and torso, diaphoresis, and grimacing.

Rationale 3: Anticipatory dosing of morphine sulfate is used prior to weaning or extubation. The usual dose is 5 to 10 mg IV or if the patient has been receiving morphine, two to three times the patients usual bolus dose. Initiation of an ongoing morphine infusion, usually at a rate of 50% of the bolus dose/hour, immediately following the anticipatory bolus dose.

Rationale 4: Hypotension and decreased level of consciousness are anticipated side effects and should not result in a reduction in the dose of morphine.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-8: Describe collaborative management of patients symptoms at the end of life.

Question 27

Type: MCMA

A patient in the critical care unit has died as a result of failed CPR. The nurse knows that this term means:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Death occurred despite all efforts by health care providers.

2. The patient died suddenly after traumatic injuries.

3. The patient died after receiving maximum care for weeks.

4. The patient has no brainstem functioning.

5. The patient died after dialysis was cancelled.

Correct Answer: 1,2,3

Rationale 1: Failed CPR is the term used to identify a death that occurs despite all efforts on the part of clinicians.

Rationale 2: Failed CPR includes patients who die suddenly following traumatic injuries.

Rationale 3: Failed CPR includes patients who die after receiving maximum support for days or even weeks.

Rationale 4: Death that occurs following demonstration of lack of brainstem functioning is brain death and not failed CPR.

Rationale 5: Death that occurs following a decision not to initiate one or more interventions such as dialysis is known as limitation because a decision is made not to institute a medical that is unlikely to benefit the patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-1: Describe the four categories defined by Copnell by which death occurs in the ICU.

Question 28

Type: SEQ

The nurse is helping a family decide to stay with a patient during cardiopulmonary resuscitation. Place in order the steps the nurse will take when helping the family decide.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Nurse introduces self to the family

Choice 2. Nurse explains the patients current status.

Choice 3. Nurse explains the possibly outcome from cardiopulmonary resuscitation.

Choice 4. Nurse asks who the decision maker is in the relationship with the patient.

Choice 5. Nurse provides the family with options.

Choice 6. Nurse asks the family member if they have any questions.

Correct Answer: 1,2,3,4,5,6

Rationale 1: This is the first step that the nurse would take.

Rationale 2: This is the second step that the nurse would take.

Rationale 3: This is the third step that the nurse would take.

Rationale 4: This is the fourth step that the nurse would take.

Rationale 5: This is the fifth step that the nurse would take.

Rationale 6: This is the sixth step that the nurse would take.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-2: Evaluate the advantages and disadvantages of family presence during CPR.

Question 29

Type: MCMA

Which actions would assist a family to recover after learning of the death of their family member in the intensive care unit?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Offer time for the family to be alone in private.

2. Offer to contact the chaplain for the family.

3. Offer time for the family to stay with the patient before being removed from the unit.

4. Asking the family to wait until the mortician has arrived before seeing the patient.

5. Directing the family to the social workers office.

Correct Answer: 1,2,3

Rationale 1: Offering private time helps the family recover after learning of the death of a family member.

Rationale 2: This helps the family recover after learning of the death of a family member.

Rationale 3: This helps the family recover after learning of the death of a family member.

Rationale 4: This does not help the family recovering after learning of the death of a family member.

Rationale 5: The social worker should come to the unit and not send the family to find the social worker after learning of the death of a family member.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-3: Discuss best practices for nurses when speaking with a bereaved family.

Question 30

Type: MCMA

A critically ill patient in the intensive care unit is being evaluated for brain death. What will be assessed in this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Presence of coma

2. Absence of pupil response

3. Apnea lasting for 8 minutes

4. Absence of corneal reflex

5. Urine output less than 5 mL/hr

Correct Answer: 1,2,3,4

Rationale 1: Coma is determined by the lack of motor responses or grimacing to noxious stimuli.

Rationale 2: Absence of brainstem reflexes is determined by pupils that do not respond to light.

Rationale 3: Apnea is identified by removing the patient from the ventilator for approximately 8 minutes and placing on 100% oxygen by T piece. The patient is observed to determine that there are no respiratory movements.

Rationale 4: Absence of brainstem reflexes is determined by the absence of a corneal reflex.

Rationale 5: Urine output is not used to establish brain death.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-4: List the criteria for death by neurological criteria (brain death).

Question 31

Type: MCMA

The family of a dying patient in the intensive care unit does not want a do not attempt resuscitation order. What can the nurse do to assist the family in seeing the value of this order?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Explain that other medical interventions will not be stopped.

2. Explain that comfort is the goal instead of a cure.

3. Explain that the patient will not receive less care.

4. Explain that the patient will be transferred out of the intensive care unit soon.

5. Explain that all medical care will be restricted going forward.

Correct Answer: 1,3

Rationale 1: Nurses should emphasize to patients and families that consent to a DNAR order does not imply consent to limit other medical interventions.

Rationale 2: Nurses should emphasize to patients and families that consent to a DNAR order does not imply a decision to switch to a goal of comfort rather than cure.

Rationale 3: Consenting to a DNAR does not imply that the patient will receive less care.

Rationale 4: Consenting to a DNAR order does not mean that the patient will be transferred out of the intensive care unit.

Rationale 5: Consenting to a DNAR order does not mean that all medical care will be restricted going forward.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-5: Explain possible ways to discuss limiting further therapy such as instituting a Do Not Attempt Resuscitation (DNAR) order with a patient and/or patients surrogate decision maker.

Question 32

Type: MCMA

The daughter of a critically ill patient is having difficulty making care decisions. The nurse suggests the daughter utilize the best interest approach which includes:

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Determining what would be in the best interest of the patient

2. Objectively examining the patients quality of life and amount of function

3. Imagining him- or herself as the patient and determine what he or she would want for care

4. Asking the physician to make the decision regarding ongoing care needs

5. Notifying all family members of the patients status and making a group decision regarding care

Correct Answer: 1,2

Rationale 1: In the best interests standard, the health care proxy makes a decision based on what is in the best interest of the patient.

Rationale 2: In the best interests standard, the health care proxy makes a decision based on objectively determining the patients body integrity and function.

Rationale 3: In the substituted judgment standard, the health care proxy imagines him- or herself as the patient in the particular situation and determines what the patient would want.

Rationale 4: This is not the best interests standard.

Rationale 5: This is not the best interests standard.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-6: Compare and contrast substituted judgment and the best interests standard for decision making for an incapacitated patient.

Question 33

Type: MCMA

The spouse of a dying critically ill patient is demonstrating suffering. What actions can the nurse take to help the spouse at this time?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Establish and maintain eye contact with the spouse.

2. Hug the spouse.

3. Reply with therapeutic responses to the spouses statements.

4. Convey sympathy to the spouse.

5. Leave the spouse alone in the room with the patient.

Correct Answer: 1,2,3,4

Rationale 1: This is an action that the nurse can take to help the suffering spouse.

Rationale 2: Touching is an action that the nurse can take to help the suffering spouse.

Rationale 3: Appropriate use of verbal responses is an action the nurse can take to help the suffering spouse.

Rationale 4: Sharing in the experience through the use of sympathy is an action the nurse can take to help the suffering spouse.

Rationale 5: This is not an action for the nurse to take to help the suffering spouse.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-7: Discuss the needs of families of dying patients.

Question 34

Type: MCMA

Which of these assessment findings would support a dying patient a 3 on The Comfort Scale?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient is drowsy.

2. The patient is anxious.

3. The patients heart rate is elevated 1 to 3 times.

4. The patient is very anxious.

5. The patient is coughing and choking.

Correct Answer: 1,2,3

Rationale 1: This would be rated as a 3 on the comfort scale.

Rationale 2: This would be rated as a 3 on the comfort scale.

Rationale 3: This would be rated as a 3 on the comfort scale.

Rationale 4: This would be rated as a 4 on the comfort scale.

Rationale 5: This would be rated as a 5 on the comfort scale.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-8: Describe collaborative management of patients symptoms at the end of life.

Question 35

Type: SEQ

The family of a dying patient is demonstrating conflict about the patients ongoing care needs. The nurse plans to use the evidence-based mnemonic to help the patient and family. Place in order the steps the nurse will take when using this mnemonic.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. The nurse will name the emotion.

Choice 2. The nurse will state understanding of the emotion.

Choice 3. The nurse will demonstrate respect.

Choice 4. The nurse supports the family and patient.

Choice 5. The nurse helps the family and patient explore possibilities.

Correct Answer: 1,2,3,4,5

Rationale 1: This is the first step in the implementation of the mnemonic NURSE.

Rationale 2: This is the second step in the implementation of the mnemonic NURSE.

Rationale 3: This is the third step in the implementation of the mnemonic NURSE.

Rationale 4: This is the fourth step in the implementation of the mnemonic NURSE.

Rationale 5: This is the fifth step in the implementation of the mnemonic NURSE.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-9: Explain sources of conflict at the end of life.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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