Chapter 43 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 43

Question 1

Type: MCSA

During a home visit, an older male client tells the nurse that his wife died 3 years ago. What did the nurse observe as an indication that this client is experiencing complicated grief?

1. The client has an album of photographs of his wife open on the living room table.

2. He tells the nurse that his wife was an awful cook and that he has eaten better meals since she died.

3. He indicates that he sends his laundry out to be done because he had never figured out how the washer works.

4. He shows the nurse his wifes craft room that remains just as she left it before she died.

Correct Answer: 4

Rationale 1: Showing photographs of the deceased is a normal response to grief.

Rationale 2: Talking about good and bad points of the deceased is a normal response to grief.

Rationale 3: Sending out the laundry to be done is a healthy response to a problem that this client identified.

Rationale 4: Leaving the deceased wifes craft room and belongings intact for over 3 years is considered outside the normal limits of the grief process.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe types and sources of losses.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 990

Question 2

Type: MCSA

The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best nursing diagnosis problem statement for this family?

1. Anticipatory Grieving

2. Dysfunctional Grieving

3. Hopelessness

4. Caregiver Role Strain

Correct Answer: 1

Rationale 1: Grieving prior to the actual loss is termed anticipatory grieving.

Rationale 2: There are no assessment findings in the question that indicate dysfunctional grieving.

Rationale 3: There are no assessment findings in the question that indicate hopelessness.

Rationale 4: This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Describe types and sources of losses.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 990

Question 3

Type: MCSA

The nurse is counseling a family in which a member is terminally ill. The family has children of varying ages. What should the nurse teach the family about the reactions of children to death?

1. Toddlers perceive death as irreversible and unnatural.

2. Preschool children view death as a spiritual release.

3. At about age 9, children begin to understand that death is inevitable.

4. Adolescents tend to have better outcomes than adults after a loss.

Correct Answer: 3

Rationale 1: Toddlers fear abandonment.

Rationale 2: Preschoolers view death as reversible.

Rationale 3: At about age 9, childrens concept of death matures and most understand that death is an inevitable part of life.

Rationale 4: Adults generally have better outcomes than adolescents when confronted with death.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Discuss factors affecting a grief response.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 996

Question 4

Type: MCSA

The nurse is assigning support personnel to assist the families of clients who have died in dealing with the stress related to the loss of their family members. Which family would the nurse screen as at highest risk for complicated grief? The family of a client who

1. died after a long battle against cancer.

2. died after developing diabetes-induced renal failure.

3. was killed in the robbery of a bank.

4. died from chronic heart disease.

Correct Answer: 3

Rationale 1: The client who died of cancer does not meet the criteria as well as the murdered client.

Rationale 2: The client who died of renal failure does not meet the criteria as well as the murdered client.

Rationale 3: Although all families are different and all families can respond to grief differently, research supports a greater potential for complicated grief in families whose loved one died suddenly, violently, or unexpectedly. Of the options given, the client who was murdered best fits all three situations.

Rationale 4: The client who died of heart disease had been ill for some time and does not meet the criteria as well as the murdered client.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Discuss factors affecting a grief response.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 990

Question 5

Type: MCSA

The nurse critically evaluates various models of grief used for terminally ill clients and their families. What should the nurse recognize when applying these models to individual cases?

1. The Kbler-Ross model is primarily used to describe anticipatory grief.

2. No clear timetables exist, nor are there clear-cut stages of grief.

3. The models serve as clear and definitive predictors of grief behaviors.

4. There is strong research proving that these models are not useful for many dying clients.

Correct Answer: 2

Rationale 1: Kbler-Ross describes all stages of grief and grieving.

Rationale 2: Although the models of grief are useful in guiding nursing care of clients who are experiencing loss, there are no clear-cut stages of grief, nor are there exact timetables.

Rationale 3: None of the models are clear or definitive predictors of grief behaviors.

Rationale 4: These models are useful for many dying clients.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify measures that facilitate the grieving process.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 992

Question 6

Type: MCMA

A client hospitalized for injuries from a motor vehicle crash is diagnosed with higher brain death. What findings support this clients diagnosis?

Standard Text: Select all that apply.

1. Episodic coughing

2. No cephalic reflexes

3. Not breathing spontaneously

4. Inconsistent cardiac function on the heart monitor

5. Electroencephalogram showed no activity for 30 minutes

Correct Answer: 2, 3, 5

Rationale 1: Episodic coughing might be a reflex or an attempt to clear the airway. This is not a manifestation of higher brain death.

Rationale 2: Evidence of higher brain death includes absence of cephalic reflexes.

Rationale 3: Evidence of higher brain death includes apnea.

Rationale 4: Inconsistent cardiac function on the heart monitor indicates the client is still alive.

Rationale 5: Evidence of higher brain death includes absence of cephalic reflexes, apnea, and an isoelectric electroencephalogram for at least 30 minutes.

Global Rationale: Evidence of higher brain death includes an isoelectric electroencephalogram for at least 30 minutes.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. List clinical signs of impending and actual death.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 997

Question 7

Type: MCSA

A client is diagnosed with a terminal illness and is demonstrating anxiety. What intervention can the nurse use to help the client at this time?

1. Explore the clients history with other stressful life events and how successful coping was at that time.

2. Teach the family that while talking with the client about death and dying is permissible, they should not allow the client to dwell on death.

3. Supply information about the clients disease process and the expected trajectory of death only on a need-to-know basis.

4. Encourage early pharmaceutical intervention with antianxiety and sedative medications.

Correct Answer: 1

Rationale 1: It is most helpful for the nurse to know how the client has dealt with previous stressful life events so that support of positive coping mechanisms can occur. The client who has received a terminal diagnosis needs to discuss the future and the implications of the diagnosis.

Rationale 2: The need for discussion and the amount of time needed will vary from client to client, so dwelling is an inappropriate descriptor.

Rationale 3: The client must be given facts about the disease process and projected trajectory so that final business and relationships can be addressed.

Rationale 4: Early use of antianxiety and sedative medications is not appropriate because these medications can adversely affect the clients ability to think clearly about the future.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify measures that facilitate the grieving process.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 1000

Question 8

Type: MCSA

A client who has AIDS tells the nurse, I dont know why I should even keep trying. This disease is so horrible and so many people die from it. It will get me, too. The nurse recognizes this statement as being

1. an indication of hopelessness that should be further evaluated for treatment.

2. a simple statement of the facts regarding AIDS.

3. common and expected in those facing the end of life.

4. proof that the client is accepting the facts of the illness and impending death.

Correct Answer: 1

Rationale 1: This statement reflects hopelessness. Hopelessness is not an expected feeling at end of life and can and should be treated. Despite the inevitability of death, the goal is for the client to continue to express hope of some nature. This hope might take the form of short-term completion of goals prior to death, for peacefulness at the time of death, or for attainment of the individuals personal belief about the afterlife.

Rationale 2: This is not a simple statement of the facts regarding AIDS.

Rationale 3: Feelings of hopelessness are not common and expected in those facing the end of life.

Rationale 4: Even though death is inevitable, the client should continue to express hope of some nature.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 3. Identify clinical symptoms of grief.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 997

Question 9

Type: MCSA

The client tells the nurse that she has been having problems sleeping since her boss died unexpectedly 3 weeks ago. She confides that she and the boss had been having a secret extramarital affair for years. The nurse recognizes that the sleeping difficulty is most likely a result of which type of grief?

1. Abbreviated

2. Chronic

3. Disenfranchised

4. External

Correct Answer: 3

Rationale 1: Abbreviated grieving is grieving that is brief, but genuinely felt.

Rationale 2: This clients grief is not yet chronic, as only 3 weeks have passed.

Rationale 3: This client is unable to grieve openly for her lost relationship, as extramarital affairs are not socially sanctioned.

Rationale 4: External grieving is not a recognized type of grief response.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe types and sources of losses. 3. Identify clinical symptoms of grief.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 990

Question 10

Type: MCMA

The nurse is working with a father and his three children, ages 10, 14, and 17. The mother recently died after a long illness. The children are doing poorly in school, and the father is having a difficult time keeping up with household chores. He has recently taken on a second job to help pay his late wifes hospital bills. Which nursing diagnoses should the nurse consider in planning care for this family?

Standard Text: Select all that apply.

1. Anticipatory Grieving

2. Impaired Family Processes

3. Impaired Adjustment

4. Caregiver Role Strain

5. Hopelessness

Correct Answer: 2, 3, 4, 5

Rationale 1: Anticipatory grief is experienced in advance of the event, such as the wife who grieves before her ailing husband dies.

Rationale 2: There may be numerous nursing diagnoses that should be investigated in planning care for this grieving family. This list may not be all inclusive, as problems with sleep, nutrition, self-concept, and role adjustment are common following the long illness and death of a loved one.

Rationale 3: There may be numerous nursing diagnoses that should be investigated in planning care for this grieving family. This list may not be all inclusive, as problems with sleep, nutrition, self-concept, and role adjustment are common following the long illness and death of a loved one.

Rationale 4: There may be numerous nursing diagnoses that should be investigated in planning care for this grieving family. This list may not be all inclusive, as problems with sleep, nutrition, self-concept, and role adjustment are common following the long illness and death of a loved one.

Rationale 5: There may be numerous nursing diagnoses that should be investigated in planning care for this grieving family. This list may not be all inclusive, as problems with sleep, nutrition, self-concept, and role adjustment are common following the long illness and death of a loved one.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 1. Describe types and sources of losses. 3. Identify clinical symptoms of grief.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 995

Question 11

Type: MCSA

During the bath, the client suddenly says, I am not going to get well. I think I am going to die. What response given by the nurse is most appropriate?

1. Lets think of something more cheerful.

2. You are doing so well; dont talk like that.

3. What makes you think you are dying?

4. Whatever is meant to be will happen.

Correct Answer: 3

Rationale 1: Lets think of something more cheerful is changing the subject.

Rationale 2: You are doing so well, dont talk like that is offering false reassurance and devaluing the clients concern.

Rationale 3: The nurse should ask what it is that makes the client think about dying. This allows the nurse to collect and evaluate data before making a further response.

Rationale 4: Whatever is meant to be will happen is being fatalistic and devaluing the clients concerns.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe the process of helping clients die with dignity.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 997

Question 12

Type: MCSA

The client has a documented advance health care directive that indicates that no resuscitative measures should be employed in the event of a respiratory or cardiac arrest. The client begins to exhibit severe dyspnea and air hunger and says, Please do something, I cant breathe. What action should be taken by the nurse?

1. Offer the client comfort measures until death occurs.

2. Call the clients physician for direction.

3. Initiate resuscitative measures.

4. Check the medical record to ascertain the terms of the directive.

Correct Answer: 3

Rationale 1: Just offering comfort measures until the client dies is ignoring the clients wishes.

Rationale 2: There is no need to call the physician for direction, as the client has clearly given the nurse direction.

Rationale 3: This client has the right to change decisions about resuscitation, and has asked for help. The nurse should initiate resuscitative measures.

Rationale 4: The nurse should have already known the terms of the directive and would not have time to seek clarification at this point.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. List clinical signs of impending and actual death.

MNL Learning Outcome: 2.3.1. Implement advance directives in the care of the client at end-of-life.

Page Number: 1000

Question 13

Type: MCMA

A client with end-stage renal disease knows that he is dying but refuses to talk about it with his spouse. At times the spouse talks with the nursing staff about the clients condition but adamantly refuses to discuss death with the client. What will be the outcomes of this situation?

Standard Text: Select all that apply.

1. Client has dignity

2. Client has privacy

3. Client can finalize affairs

4. Client can plan own funeral

5. Client burdened with no one to confide in

Correct Answer: 1, 2, 5

Rationale 1: With mutual pretense, the client, family, and health care personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject. Mutual pretense permits the client a degree of dignity.

Rationale 2: With mutual pretense, the client, family, and health care personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject. Mutual pretense permits the client a degree of privacy.

Rationale 3: With open awareness the client will have the ability to finalize affairs.

Rationale 4: With open awareness the client can participate in the planning of his own funeral.

Rationale 5: With mutual pretense, the client, family, and health care personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject. Mutual pretense places a heavy burden on the dying person, who then has no one in whom to confide.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Describe the process of helping clients die with dignity.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 998

Question 14

Type: MCSA

The family of a young adult client who has recently been diagnosed with a rapidly progressing terminal illness tells the nurse, This cannot be happening. There must be some mistake in the testing. What should be the nurses first step in assisting this family?

1. Provide structure and continuity to promote feelings of security.

2. Examine the nurses own feelings to ensure denial is not shared.

3. Offer spiritual support.

4. Allow the family to express sadness.

Correct Answer: 2

Rationale 1: This would be appropriate to do after the nurse first addresses the potential issue of self-denial of the situation.

Rationale 2: The nurse must first self-examine feelings to ensure that the nurses behaviors do not demonstrate denial of the situation.

Rationale 3: This would be appropriate to do after the nurse first addresses the potential issue of self-denial of the situation.

Rationale 4: This would be appropriate to do after the nurse first addresses the potential issue of self-denial of the situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe the role of the nurse in working with families or caregivers of dying clients.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 991

Question 15

Type: MCSA

A client who has just been diagnosed with a slowly progressive terminal illness asks the nurse about the availability of hospice services. What information should the nurse share with this client?

1. When clients are designated as terminally ill, they are automatically assigned to hospice care.

2. Hospice services are generally reserved for those who have a life expectancy of 6 months or less.

3. Only those clients with private insurance can receive hospice benefits.

4. Provision of hospice services is reserved only for those who refuse other palliative treatments.

Correct Answer: 2

Rationale 1: Clients are not automatically assigned to hospice.

Rationale 2: Hospice services are generally provided only to those who are expected to live less than 6 months. Those clients whose conditions improve after receiving hospice care may be removed from those services.

Rationale 3: Medicare does provide hospice benefits.

Rationale 4: The client may receive both hospice and other palliative care treatments.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe the process of helping clients die with dignity.

MNL Learning Outcome: 2.3.2. Differentiate between hospice and palliative care.

Page Number: 1001

Question 16

Type: MCSA

The nurse is caring for a child who is dying. What is the most important communication strategy for the nurse to use at this time?

1. Talk to the child at the appropriate level of understanding.

2. Be totally open and honest with the child.

3. Avoid discussing death with the child.

4. Encourage the family to talk with the child about the impending death.

Correct Answer: 1

Rationale 1: Although it is very important to be open and honest with the child and may be appropriate to encourage the family to talk with the child about impending death, the most important strategy is to talk with the child at the appropriate level of understanding. Without recognition of this concept, none of the other options will be effective. The nurse should not avoid discussing death with the child if the child brings up the subject.

Rationale 2: Although it is very important to be open and honest with the child and may be appropriate to encourage the family to talk with the child about impending death, the most important strategy is to talk with the child at the appropriate level of understanding. Without recognition of this concept, none of the other options will be effective. The nurse should not avoid discussing death with the child if the child brings up the subject.

Rationale 3: Although it is very important to be open and honest with the child and may be appropriate to encourage the family to talk with the child about impending death, the most important strategy is to talk with the child at the appropriate level of understanding. Without recognition of this concept, none of the other options will be effective. The nurse should not avoid discussing death with the child if the child brings up the subject.

Rationale 4: Although it is very important to be open and honest with the child and may be appropriate to encourage the family to talk with the child about impending death, the most important strategy is to talk with the child at the appropriate level of understanding. Without recognition of this concept, none of the other options will be effective. The nurse should not avoid discussing death with the child if the child brings up the subject.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify measures that facilitate the grieving process.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 1003

Question 17

Type: MCSA

The nurse is caring for a client whose family does not want to tell him that he is dying. What is the nurses best action according to these wishes?

1. Arrange an encounter with the client and tell him the truth.

2. Change the subject when the client asks about his impending death.

3. Tell the family that the patient has the right to know that he is dying.

4. Talk to the family about the situation and their concerns.

Correct Answer: 4

Rationale 1: The nurse should not talk with the client before discussing the situation with the family.

Rationale 2: The nurse should not change the subject if the client asks about impending death, but should not encourage such an encounter before discussing the situation with the family.

Rationale 3: The nurse should discuss the reasons why the family does not want the client to be aware of impending death before offering advice.

Rationale 4: In this situation, the best and first thing the nurse should do is talk with the family about what is happening and what their concerns are. The nurse should investigate religious, cultural, and family traditions regarding telling the client about impending death.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe the role of the nurse in working with families or caregivers of dying clients.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 998

Question 18

Type: MCSA

The nurse who is providing postmortem care for a client sees that the client is wearing a ring. What is the most important action regarding this observation?

1. Remove the ring and give it to the family.

2. Call the presence of the ring to the attention of the funeral director.

3. Tape the ring to the clients finger.

4. Document fully whatever action is taken.

Correct Answer: 4

Rationale 1: The ring should not be removed. The nurse should let the family know that the ring is on the client.

Rationale 2: The nurse could do this if the funeral director arrives and the nurse is still in attendance caring for the client.

Rationale 3: Theoretically, all jewelry should be removed; in some instances, a ring may be taped to the finger. This may or may not be done, depending upon the circumstances.

Rationale 4: Depending upon the circumstances and what kind of ring it is, the nurse might take any of these actions. The most important action is to document what occurred.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe nursing measures for care of the body after death.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 1003

Question 19

Type: MCSA

A client recovering from back surgery is seen crying softly in bed. Upon assessment, the nurse learns that the client has been told of the future inability to perform certain sports, activities, and employment types because of the surgery. The nurse interprets this clients reaction as a response to which type of loss?

1. Situational loss

2. Anticipatory loss

3. Psychological loss

4. Developmental loss

Correct Answer: 1

Rationale 1: The loss of functional ability because of acute illness or injury is a situational loss.

Rationale 2: An anticipatory loss is experienced before the loss actually occurs.

Rationale 3: Psychological losses are often perceived losses in that they are not directly verified, such as the loss of independence or freedom.

Rationale 4: Losses that occur in the process of normal development, such as retirement from a career or the death of aged parents, are developmental losses.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe types and sources of losses.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 989

Question 20

Type: MCSA

An older client has just relocated from home to an assisted living facility. The nurse is concerned because the client has been withdrawn and is crying periodically throughout the day. What type of loss is this client demonstrating?

1. External objects

2. Familiar environment

3. Loved ones

4. Psychological

Correct Answer: 2

Rationale 1: Loss of external objects includes the loss of inanimate objects that have importance to the person. The client might be experiencing this type of loss; however, there is not enough information to determine whether personal belongings were not also relocated to the assisted living facility with the client.

Rationale 2: Separation from an environment and people who provide security can result in a sense of loss, such as in the client who has relocated from home to an assisted living facility.

Rationale 3: The client was relocated to an assisted living facility. There is no information to suggest that the client is experiencing a loss of a loved one.

Rationale 4: Psychological losses are often perceived losses in that they are not directly verified, such as with the loss of independence or freedom. The client who has moved from home to an assisted living facility might have this type of loss; however, it is not the primary loss in this case.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe types and sources of losses.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 989

Question 21

Type: MCMA

A client with terminal cancer of the lung complains of being short of breath with bilateral crackles and wheezes, despite oxygen at 4 L via nasal cannula and diuretic therapy. What nursing interventions are appropriate for this client?

Standard Text: Select all that apply.

1. Move the client to a room closer to the nurses desk for closer observation.

2. Help the client assume a position lying on the right side.

3. Place a fan in the room to move air around the client.

4. Change the clients oxygen therapy to a non-rebreathing mask.

5. Elevate the head of the clients bed to a Fowlers position.

6. Consider use of a p.r.n. morphine sulfate order.

Correct Answer: 3, 5, 6

Rationale 1: The client does not need to be moved to a room closer to the nurses station.

Rationale 2: Lateral positions are appropriate for unconscious clients but not for those who are conscious.

Rationale 3: Placement of a fan to circulate air might relieve shortness of breath.

Rationale 4: Conscious clients who are short of breath do not tolerate oxygen therapy by mask.

Rationale 5: Elevating the head of the bed might relieve shortness of breath.

Rationale 6: Use of morphine sulfate might relieve shortness of breath.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Describe the process of helping clients die with dignity.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 1002

Question 22

Type: MCMA

The nurse is providing postmortem care for a client whose family would like to view the body before it is transported to the morgue. What interventions are necessary for this preparation?

Standard Text: Select all that apply.

1. Provide a total bed bath.

2. Place absorbent pads beneath the body.

3. Remove dentures.

4. Dress the client in street clothes.

5. Place a pillow under the head.

6. Tape the eyelids closed.

Correct Answer: 2, 5

Rationale 1: A total bed bath is not necessary.

Rationale 2: The nurse should place absorbent pads beneath the body.

Rationale 3: Dentures should be inserted.

Rationale 4: The client should be dressed in a clean gown.

Rationale 5: The nurse should place a pillow under the head.

Rationale 6: The eyelids should be held in place until they stay closed, and should not be taped.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe nursing measures for care of the body after death.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 1003

Question 23

Type: SEQ

The spouse of a deceased client is working through the stages of grief. If the nurse applies Martocchios five clusters of grief to this situation, the spouse would progress through the clusters in which order?

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

Choice 1. Reorganization and restitution

Choice 2. Yearning and protest

Choice 3. Identification in bereavement

Choice 4. Shock and disbelief

Choice 5. Anguish, disorganization, and despair

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

Rationale 1: Martocchios five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution.

Rationale 2: Martocchios five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution.

Rationale 3: Martocchios five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution.

Rationale 4: Martocchios five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution.

Rationale 5: Martocchios five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Discuss selected frameworks for identifying stages of grieving.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 992

Question 24

Type: MCMA

The nurse determines that a client, after learning of the death of a close family member, is demonstrating normal signs of grief. What did the nurse assess in this client?

Standard Text: Select all that apply.

1. Crying

2. Weakness

3. Inability to sleep

4. No appetite

5. Inability to concentrate on conversations

Correct Answer: 1, 3, 4, 5

Rationale 1: Crying is considered a normal manifestation of grief.

Rationale 2: Weakness is not a normal manifestation of grief.

Rationale 3: Inability to sleep is considered a normal manifestation of grief.

Rationale 4: Loss of appetite is considered a normal manifestation of grief.

Rationale 5: Difficulty concentrating is considered a normal manifestation of grief.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify clinical symptoms of grief.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 992

Question 25

Type: MCMA

The nurse is concerned that a client is experiencing complicated grieving after the unexpected death of a son. The nurse most likely assessed

Standard Text: Select all that apply.

1. the clients denying the sons death.

2. depression.

3. sudden weight loss because of not eating.

4. crying.

5. verbalizing the desire to not live anymore.

Correct Answer: 1, 2, 3, 5

Rationale 1: Complicated grieving might be characterized by extended time of denial.

Rationale 2: Complicated grieving might be characterized by depression.

Rationale 3: Complicated grieving might be characterized by severe physiological symptoms such as sudden weight loss because of not eating.

Rationale 4: Crying is considered a normal manifestation of grief.

Rationale 5: Complicated grieving might be characterized by suicidal thoughts such as verbalizing the desire not to live anymore.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify clinical symptoms of grief.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 990

Question 26

Type: MCMA

When observing an older clients response upon learning of the death of a close family friend, the nurse realizes that the significance of the loss to the client is dependent upon which factors

Standard Text: Select all that apply.

1. Importance of the person to the client

2. Amount of changes that will occur because of the loss

3. The clients beliefs

4. The clients values

5. The clients socioeconomic status

Correct Answer: 1, 2, 3, 4

Rationale 1: The importance of the lost person to the client affects the significance of the loss.

Rationale 2: The degree of change required because of the loss affects the significance of the loss.

Rationale 3: The clients beliefs affect the significance of the loss.

Rationale 4: The clients values affect the significance of the loss.

Rationale 5: The clients socioeconomic status does not affect the significance of the loss.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Discuss factors affecting a grief response.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 993

Question 27

Type: MCMA

The nurse is planning care to help a client work through the grieving process. What would be appropriate to include in this plan of care?

Standard Text: Select all that apply.

1. Listen to the client.

2. Clarify and reflect the clients feelings.

3. Reassure the client that all will be well.

4. Be silent.

5. Provide advice to the client.

Correct Answer: 1, 2, 4

Rationale 1: The skills most relevant to situations of loss and grief are those of effective communication, such as active listening.

Rationale 2: The skills most relevant to situations of loss and grief are those of effective communication, such as clarifying and reflecting the clients feelings.

Rationale 3: Actions that are less helpful to clients experiencing loss and grief include those that give unwarranted reassurance.

Rationale 4: The skills most relevant to situations of loss and grief are those of effective communication, such as using silence.

Rationale 5: Actions that are less helpful to clients experiencing loss and grief include giving advice.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Identify measures that facilitate the grieving process.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 995

Question 28

Type: MCMA

The nurse is providing emotional support to a client who just learned the outcome of a biopsy. What actions will be the best for the nurse to provide at this time?

Standard Text: Select all that apply.

1. Encourage the client to resume normal activities on a schedule that promotes physical and psychological health.

2. Use therapeutic communication techniques.

3. Offer choices that promote client autonomy.

4. Provide information about community resources or support groups.

5. Acknowledge the grief of the client.

Correct Answer: 2, 3, 4, 5

Rationale 1: Encouraging the client to resume normal activities on a schedule that promotes physical and psychological health would be appropriate to facilitate grief work, but would not provide emotional support.

Rationale 2: Therapeutic communication techniques let the client know that the nurse acknowledges the clients feelings.

Rationale 3: Offering choices that promote autonomy helps the client have a sense of some control at a time when much control might not be possible.

Rationale 4: Providing information about community resources or support groups provides the client with sources of additional information.

Rationale 5: Acknowledging the grief of the client is helpful when providing emotional support.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify measures that facilitate the grieving process.

MNL Learning Outcome: 2.3.3. Implement assessment strategies to determine emotional response to grief and end-of-life care.

Page Number: 995

Question 29

Type: MCSA

A terminally ill client is demonstrating gurgling respirations. The nurse realizes that this client is

1. improving.

2. experiencing pain.

3. trying to talk.

4. nearing death.

Correct Answer: 4

Rationale 1: The death rattle does not mean the client is improving.

Rationale 2: The death rattle does not mean that the client is experiencing pain.

Rationale 3: The death rattle does not mean that the client is trying to talk.

Rationale 4: A clinical manifestation of impending death is noisy breathing. This is often referred to as the death rattle, and is due to collecting of mucus in the throat.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. List clinical signs of impending and actual death.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 999

Question 30

Type: MCMA

The nurse determines that a terminally ill client is nearing death. What did the nurse assess to make this clinical decision?

Standard Text: Select all that apply.

1. Diarrhea

2. Muscle spasms

3. Slow, weak pulse

4. Decreased blood pressure

5. Cyanosis of the extremities

Correct Answer: 3, 4, 5

Rationale 1: Diarrhea is not a clinical manifestation of impending death.

Rationale 2: Muscle spasms are not a clinical manifestation of impending death.

Rationale 3: A slow, weak pulse is a clinical manifestation of impending death.

Rationale 4: Decreased blood pressure is a clinical manifestation of impending death.

Rationale 5: Cyanosis of the extremities is a clinical manifestation of impending death.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. List clinical signs of impending and actual death.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 999

Question 31

Type: MCSA

While caring for a client who is approaching death, the nurse notices the clients facial expression of extreme sadness. What should the nurse do?

1. Leave the client alone.

2. Provide physical care to increase comfort.

3. Acknowledge the clients expression, and ask whether the client would like to talk about her feelings.

4. Offer to provide pain medication.

Correct Answer: 3

Rationale 1: Leaving the client alone does not acknowledge the clients feelings or support the clients emotional needs at this time.

Rationale 2: Providing physical care to increase comfort might not be what the client needs at this time.

Rationale 3: The nurse should establish a communication relationship that shows concern for and commitment to the client. Communication strategies include describing observations and asking whether the client would like to talk about feelings.

Rationale 4: Offering to provide pain medication assumes the client is in pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify measures that facilitate the grieving process.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 1000

Question 32

Type: MCMA

The spouse of a dying client is sitting quietly in the clients room, looking at the floor. What can the nurse do to help the client and spouse during this time?

Standard Text: Select all that apply.

1. Encourage the spouse to move closer to the client, if desired.

2. Permit the spouse to sit alone.

3. Leave the spouse and client in the room alone together as much as possible.

4. Recommend that the spouse return home to get some rest.

5. Suggest the spouse read to the client, if desired.

Correct Answer: 1, 3, 5

Rationale 1: The dying and the family must be allowed as much privacy as they desire in order to meet their needs for physical and emotional intimacy.

Rationale 2: The nurse should not ignore the spouse.

Rationale 3: The dying client and the family must be allowed as much privacy as they desire in order to meet their needs for physical and emotional intimacy.

Rationale 4: The nurse should not recommend that the spouse return home to get rest.

Rationale 5: Family members should be encouraged to participate in the physical care of the dying person as much as they wish to and are able. The nurse can suggest they assist with bathing, speak or read to the client, and hold hands.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify measures that facilitate the grieving process.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 1002

Question 33

Type: MCMA

The family members of a client who has just died want to spend time with the client. What should the nurse do to prepare the client for the family?

Standard Text: Select all that apply.

1. Check the clients religion to make sure care is in compliance with religious expectations.

2. Remove equipment from the room.

3. Permit the family to view the client before postmortem care is done.

4. Change the linens.

5. Place the client in a natural body position.

Correct Answer: 1, 2, 4, 5

Rationale 1: Because care of the body can be influenced by religious law, the nurse should check the clients religion and make every attempt to comply.

Rationale 2: It is important to make the environment as clean and pleasant as possible, so equipment should be removed from the room.

Rationale 3: The nurse should not permit the family to view the client before cleaning and care are provided.

Rationale 4: It is important to make the environment as clean and pleasant as possible, so the linens should be changed.

Rationale 5: It is important to make the environment as clean and pleasant as possible, so the clients position should appear natural and comfortable.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Describe the role of the nurse in working with families or caregivers of dying clients.

MNL Learning Outcome: 2.3.4. Use the nursing process to provide care to the client at the end of life and during postmortem care.

Page Number: 1002

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