medical surgical nursing 1st edition by janice hoffman and nancy sullivan · 2018-09-20 · medical...

Medical Surgical Nursing 1st edition by Janice

Hoffman and Nancy Sullivan

Chapter 5: Palliative Care and End-of-Life Issues

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. A competent older adult patient has a living will that expresses the patient’s desire to avoid resuscitation and heroic life support measures. The patient’s family, however, is not supportive of this directive and plans to contest the living will. Which nursing action is appropriate based on the current situation?

1) Notify the hospital attorney.

2) Contact the Social Services department.

3) Place the document on the patient’s medical record.

4) Explain to the patient that the conflict could invalidate the document.

____ 2. The nurse is providing care for a Catholic patient who has suffered a massive cerebral

hemorrhage and is not expected to survive. Which intervention by the nurse is most appropriate?

1) Contact a priest to deliver the Sacrament of the Sick.

2) Make plans for the family to wash the body after death.

3) Contact a rabbi so that the patient can participate in prayer.

4) Discuss the need to cremate the patient, as burial is not accepted in this faith.

____ 3. The nurse is caring for a terminally ill patient and family members. The family has been tearful and sad since the terminal diagnosis was given. Which should be the nurse’s focus when planning care?

1) Hopelessness

2) Caregiver role strain

3) Anticipatory grieving

4) Complicated grieving

____ 4. The nurse is providing care to a patient who is diagnosed with terminal lung cancer. The patient is lying in the supine position with noisy wet respirations noted and is not breathing well. The patient has a living will which designates the implementation of comfort measures. Which action by the nurse is appropriate?

1) Withhold all care until the patient dies.

2) Provide the patient with pain medication as ordered.

3) Ask the family what they want to be done for the patient.

4) Reposition the patient to a lateral position, with the head elevated as tolerated.

____ 5. The nurse is caring for a dying child who is being treated with comfort measures only. Which nursing action supports the primary goal for this patient?

1) Assess and medicate, as ordered, for any signs and symptoms of distress.

2) Maintain a busy schedule for child and family members.

3) Keep the child entertained so she does not think about dying.

4) Ensure that a good relationship is maintained with the family.

____ 6. The parents of a child with terminal cancer ask the nurse that the child not be told that he will not recover. The child asks the nurse if he is dying. What should the nurse do at this time?

1) Ignore the child’s question and change the subject.

2) Tell the child he is dying and offer to stay with him.

3) Suggest a meeting with the health-care team and the parents.

4) Offer to bring in the child life therapist to help explain the situation.

____ 7. An older school-age child is brought to the emergency department (ED) after a car accident. The parents witness and stare at the resuscitation scene unfolding before them. The child is not

responding to the resuscitative efforts after 30 minutes. Which is the best communication strategy for the nurse to use in this situation?

1)Ask the parents to leave until the child has stabilized.

2)Ask the parents to stand at the foot of the cart to watch.

3)Discuss with the parents whether they would like resuscitative efforts to be continued at this point.

4)Inform the parents that resuscitative efforts have not been effective and are not beneficial to the child.

____ 8. An adolescent patient with terminal cancer tells the nurse that she does not want to continue treatment, even though her parents are planning for her to participate in a study trial that involves aggressive chemotherapy. Which action by the nurse is the most appropriate?

1)Tell her not to worry, that she knows her parents want the best for her.

2)Tell the patient that the decision is her parents’ and she has to participate in the study.

3)Notify the adolescent that she can make her own decisions no matter what her parents want.

4)Request that the parents and daughter meet together with the health-care team to discuss options and the implications of various choices.

____ 9. The nurse is providing care for a patient receiving curative care who is experiencing chronic pain due to cancer. Which type of care should the nurse plan for upon discharge for this patient?

1) Home health care

2) Palliative care

3) Hospice care

4) Rehabilitative care

____ 10. The nurse is assessing the patient for palliative care. When assessing the social domain, which should the nurse include?

1) Financial concerns

2) Pain

3) Depression

4) Spiritual concerns

____ 11. The nurse is assessing the patient for palliative care. When assessing the physical domain, which should the nurse include?


2) Pain

3) Depression


____ 12. The nurse is assessing the patient for palliative care. When assessing the psychosocial and psychiatric domain, which should the nurse include?


2) Pain

3) Depression


____ 13. The nurse is assessing the patient for palliative care. When assessing the cultural domain, which question should the nurse include?

1) “Do you have any financial concerns regarding your care?”

2) “Are you currently experiencing pain?”

3) “Are you experiencing any depression or anxiety?”

4) “Do you have any specific dietary preferences that affect your care?”

____ 14. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which medication should the nurse tell the family to administer for this patient if delirium occurs?

1) Morphine

2) Haloperidol

3) Diphenhydramine

4) Docusate

____ 15. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which medication should the nurse tell the family to administer to treat the patient’s pain?

1) Morphine

2) Haloperidol

3) Diphenhydramine

4) Docusate

____ 16. The nurse is educating the family of a patient who is receiving hospice care due to a terminal illness. Which benzodiazepine medication should the nurse tell the family to administer to treat the patient if hyperactive delirium occurs?

1) Morphine

2) Haloperidol

3) Diphenhydramine

4) Lorazepam

____ 17. The nurse is providing care to a patient who is approaching death. Which family member statement regarding the physical and psychological changes associated with death is reflective of the late stage?

1) “A loss of appetite often occurs during this stage.”

2) “Respirations may sound loud and wet during this stage.”

3) “I might notice that he will begin to sleep more during this stage.”

4) “Confusion or disorientation may begin to occur during this stage.”

____ 18. The nurse is providing care to a patient who is approaching death. Which family member statement regarding the physical and psychological changes associated with death is reflective of the middle stage?

1) “A loss of appetite often occurs during this stage.”

2) “Respirations may sound loud and wet during this stage.”

3) “I might notice that he will begin to sleep more during this stage.”

4) “Confusion or disorientation may begin to occur during this stage.”

____ 19. Which response by the nurse indicates the use of reflective reasoning when communicating with the family of a patient who is in the process of dying?

1) “I can see this is difficult for you.”

2) “Thank you for taking such good care of your mother.”

3) “Your mother is experiencing quite a bit of pain at the moment.”

4) “A social worker will be able to answer all the questions that you have.”

____ 20. Which concept exemplifies a well-managed death experience for a terminal patient and family members?

1) Allowing the patient to die alone

2) Withholding pain medication to decrease addiction

3) Encouraging a lengthy dying process to allow for goodbyes

4) Preparing the patient and the family for the process of dying

____ 21. Which is a team action that nurses can employ as a stress-reducing strategy?

1) Practicing yoga on a daily basis

2) Journaling feelings related to patient care

3) Engaging in aerobic exercise several times per week

4) Sending a bereavement card to the family of a patient who recently passed

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 22. Which factors can create moral distress for nurses? Select all that apply.

1) Supportive management staff

2) Low stress patient environment

3) High technology patient care situations

4) Cultural differences with the patient population

5) Resource pressures when providing patient care

____ 23. The nurse is providing care to a patient who is diagnosed with terminal lung cancer. Which clinical manifestations indicate imminent death? Select all that apply.

1) Diaphoresis

2) Increased cardiac output

3) Decreased blood pressure

4) Tachycardia followed by bradycardia

5) An increase in the volume of Korotkoff’s sounds

____ 24. The wife of a patient with end-stage chronic obstructive pulmonary disease (COPD) tells the nurse that she wishes her husband were eligible for hospice care but she thinks that hospice is only available for cancer patients and would require a change in health-care providers. Which responses by the nurse are appropriate? Select all that apply.

1) Inform her that hospice care is very expensive.

2) Inform her that a diagnosis of cancer is not required for hospice care.

3) Inform her that all hospice programs provide care 24 hours per day, 7 days per week

4) Inform her that her husband can retain his provider when transitioning to hospice care.

5) Inform her that her husband is not eligible for hospice care with the current diagnosis of COPD.

____ 25. The nurse is providing care to a terminal patient who is experiencing delirium. Which should the nurse assess prior to administering haloperidol to this patient? Select all that apply.

1) Last stool

2) Blood pressure

3) Respiratory rate

4) Bladder distention

5) Medication regimen

____ 26. Which statement from the nurse to family members is appropriate to encourage the participation of providing physical care to the patient during the dying process? Select all that apply.

1) “You can bring in pictures of the family to comfort your loved one.”

2) “Apply lip balm to your loves one’s mouth if you feel the lips are dry.”

3) “You can massage your loved one’s arms and legs to provide comfort.”

4) “Bring in music that your loved one likes to listen to with headphones.”

5) “Your child can call your loved one if you don’t want to expose him to this process.”

____ 27. A terminal patient has opted to stop treatment. The family, however, believes the patient is no longer competent to make this decision. Which data supports that the patient is capable of making this treatment decision? Select all that apply.

1) The patient is aware of the current date and location.

2) The patient does not want to be a burden on the family.

3) The patient communicates the decision with the health-care team.

4) The patient understands the nature and consequences of treatment.

5) The patient states the benefits and risks associated with the treatment.

Chapter 5: Palliative Care and End-of-Life Issues

Answer Section

MULTIPLE CHOICE

1.ANS:3

Chapter number and title: 5, Palliative Care and End-of-Life Issues

Chapter learning objective: Analyzing the nursing care priorities for patients near the end of life

Chapter page reference: 051

Heading: Domain 8: Ethical and Legal Aspects of Care

Integrated Processes: Nursing Process – Implementation

Client Need: Safe and Effective Care Environment – Management of Care

Cognitive level: Application [Applying]

Concept: Critical Thinking; Legal

Difficulty: Moderate

Feedback

1There is no need to notify the hospital attorney at this time.

2If there are concerns about the authenticity of the document, the Social Services department or the unit supervisor will need to be contacted.

3This patient is competent; therefore, the wishes of the client take priority. The document should be placed on the patient’s medical record and the health-care provider notified.

4A lack of support by the family, or a plan to contest, does not invalidate the document legally.

PTS: 1 CON: Critical Thinking | Legal

2.ANS:1


Chapter learning objective: Listing the domains of palliative care


Heading: Domain 5: Spiritual, Religious, and Existential Aspects of Care


Client Need: Psychosocial Integrity


Concept: Spirituality


Feedback

1In the Catholic faith, it is common to receive the Sacrament of the Sick from a priest in order to receive spiritual strength and prepare for death.

2Making plans for the family to wash the body after death is appropriate for a patient who is Muslim, not Catholic.

3Contacting a rabbi would be appropriate for a Jewish, not Catholic, patient.

4Cremation is not preferred over burial in the Catholic faith.

PTS: 1 CON: Spirituality

3.ANS:3


Chapter learning objective: Developing communication and support strategies for family members

Chapter page reference: 050-051

Heading: Family Support

Integrated Processes: Nursing Process – Planning



Concept: Grief and Loss


Feedback

1There are no assessment findings that indicate complicated grieving or hopelessness.

2This reaction is typical of family members, so there is no indication that the family is exhibiting caregiver role strain.

3Grieving prior to the actual loss is termed anticipatory grieving.

4There are no assessment findings that indicate complicated grieving or hopelessness.

PTS:1CON:Grief and Loss

4.ANS:1




Heading: Symptom Management


Client Need: Physiological Integrity – Basic Care and Comfort




Feedback

1“Comfort measures only” indicates that the patient does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide patient comfort is intensified and maintained through the end stages of the patient’s life.

2The nurse did not note the patient had any verbal or nonverbal signs or symptoms of pain, so medicating the patient for pain is not appropriate.

3Asking the family what they want to be done is inappropriate when a patient has written a living will.

4Repositioning the patient from the supine position to a lateral position with the head elevated as tolerated would be the first step to address the patient’s symptoms. The nurse may need to medicate the patient with an anticholinergic agent to dry the secretions if ordered. If not ordered, the patient may need to contact the health-care provider to get an order for this type of medication for comfort measures.


5.ANS:1

Ans: 1










Feedback

1The major goal for the dying child is to promote comfort and keep the child symptom-free.

2A dying child does not have the energy to maintain a busy schedule.

3Keeping the child entertained is good, but the pediatric patient needs to voice her feelings about death and dying.

4Maintaining a good relationship is important but not a major goal for the child’s

care. PTS:1CON:Grief and Loss

6.ANS:3










Feedback

1Avoiding the subject is not an option. Changing the subject or ignoring the child is not appropriate.

2Telling the child he is dying would be going against the parents’ wishes.

3Offering to set up a meeting with the health-care team to discuss the parents’ fears and concerns about telling their child the truth is the best action by the nurse.

4The nurse should explain that the parents will talk to the child about this. The child has asked the nurse, but because the child is a minor, the nurse must consult with the parents first. Legally they cannot talk to the child.


7.ANS:4





Integrated Processes: Communication and Documentation





Feedback

1This is not an effective communication strategy in this situation.

2This is not an effective communication strategy in this situation.

3When asking to withhold therapy such as cardiopulmonary resuscitation, it is helpful to indicate that

the therapy is not effective in reversing overwhelming illness or brain damage.

4Care must be used in how the parents are asked to withdraw therapies. An effective communication strategy is to inform the parents that an intervention was initiated to give the child the best chance of recovery, but it has not been effective and is not beneficial to the child.


8.ANS:4








Concept: Grief and Loss; Legal


Feedback

1Telling her not to worry does not address the problem.

2This is not an accurate statement from the nurse.

3This is not an accurate statement from the nurse.

4Adolescents with a serious medical condition are more capable of making treatment decisions than most teenagers. However, the Patient Self- Determination Act of 1990 limits the legal rights of individuals younger than 18 to make their own health-care decisions. If the adolescent states a desire to withdraw from or refuse treatment, her parents and health-care team should discuss the reasons for her decision and help her understand the implications of her decision and any treatment alternatives that may influence her choice.

PTS: 1 CON: Grief and Loss | Legal

9.ANS:2


Chapter learning objective: Discussing the meaning of palliative care and hospice care


Heading: Palliative Care

Integrated Processes: Nursing Process – Planning



Concept: Comfort


Feedback

1Home health care provides skilled care to patients who are home bound. This is not the best choice for the patient.

2Palliative care is a specialized form of care that focuses on relief of pain and other symptoms and stress associated with a severe illness.

3Hospice care focuses on the care of a terminally patient with less than 6 months to live.

4Rehabilitative care provides rehab services for patients who require strengthening after hospitalization.

PTS: 1 CON: Comfort

10.ANS:1




Heading: Domain 4: Social Aspects of Care

Integrated Processes: Nursing Process – Assessment



Concept: Assessment


Feedback

1Assessing the patient’s financial concerns is included when conducting an assessment for the social aspects related to palliative care.

2Assessing the patient’s pain is included when conducting an assessment for the physical aspects of palliative care.

3Assessing the patient for depression is included when conducting an assessment for the psychosocial and psychiatric aspects of palliative care.

4Assessing the patient for spiritual concerns is included when conducting an assessment for the spiritual, religious, and existential aspects of palliative care.

PTS: 1 CON: Assessment

11.ANS:2




Heading: Domain 2: Physical Aspects of Care




Concept: Assessment


Feedback


2Assessing the patient’s pain is included when conducting an assessment for the physical aspects

of palliative care.




12.ANS:3




Heading: Domain 3: Psychological and Psychiatric Aspects of Care




Concept: Assessment


Feedback






13.ANS:4




Heading: Domain 6: Cultural Aspects of Care




Concept: Assessment; Diversity


Feedback



3Assessing the patient for depression or anxiety is included when conducting an assessment for the psychosocial and psychiatric aspects of palliative care.

4Assessing the patient for dietary preferences that may affect care is included when conducting an assessment for the cultural aspects of palliative care.

PTS: 1 CON: Assessment | Diversity

14.ANS:2





Integrated Processes: Teaching and Learning





Feedback

1Morphine is an opiate administered to treat the patient’s pain, not delirium.

2Haloperidol is a drug that is administered to treat delirium that can occur at the end of life.

3Diphenhydramine is an anticholinergic agent administered to dry the patient’s secretions, not to treat delirium.

4Docusate is a stool softener used to treat constipation, not delirium.


15.ANS:1










Feedback

1Morphine is an opiate administered to treat the pain that patients may experience at the end of life.

2Haloperidol is a drug that is administered to treat delirium, not pain, that can occur at the end of life.

3Diphenhydramine is an anticholinergic agent administered to dry the patient’s secretions, not to treat pain.

4Docusate is a stool softener used to treat constipation, not pain.


16.ANS:4










Feedback

1Morphine is an opiate administered to treat the pain that patients may experience at the end of life.

2Docusate is a stool softener used to treat constipation, not delirium.

3Diphenhydramine is an anticholinergic agent administered to dry the patient’s secretions, not to treat delirium.

4Lorazepam, a benzodiazepine, is administered for a patient who is experiencing hyperactive delirium at the end of life.


17.ANS:2




Heading: Domain 7: Care of the Imminently Dying


Client Need: Physiological Integrity – Physiological Adaptation

Cognitive level: Analysis [Analyzing]


Difficulty: Hard

Feedback

1A loss of appetite often occurs during the early stage of the physical and psychological changes that occur prior to death.

2Respirations often sound loud and wet during the late stage of the physical and psychological changes that occur prior to death.

3Sleeping more often occurs during the early stage of the physical and psychological changes that occur prior to death.

4Confusion or disorientation often occurs during the middle stage of the physical and psychological changes that occur prior to death.


18.ANS:4









Difficulty: Hard

Feedback

1A loss of appetite often occurs during the early stage of the physical and psychological changes that occur prior to death.

2Respirations often sound loud and wet during the late stage of the physical and psychological changes that occur prior to death.

3Sleeping more often occurs during the early stage of the physical and psychological changes that occur prior to death.

4Confusion or disorientation often occurs during the middle stage of the physical and psychological changes that occur prior to death.


19.ANS:1








Concept: Communication; Grief and Loss


Feedback

1The use of reflective listening often helps the family process the dying experience. Making a statement such as acknowledging that the experience is difficult is a response by the nurse that exemplified reflective listening.

2This is not an example of reflective listening.



PTS: 1 CON: Communication | Grief and Loss

20.ANS:4





Integrated Processes: Caring


Cognitive level: Comprehension [Understanding]


Difficulty: Easy

Feedback

1A well-managed death experience includes a patient who does not die alone but in the presence of loved ones or caretakers.

2Appropriate symptom management, including pain management, is included in a well-managed death experience. The risk for addiction is not an issue.

3A prolonged dying experience should be avoided even if the patient is unable to say goodbye to loved ones.

4A well-managed death experience includes preparing the patient, and family members, for what to expect during the process of dying.


21.ANS:4


Chapter learning objective: Identifying nursing self-care strategies


Heading: Nurse Self-Care




Concept: Nursing Roles

Difficulty: Easy

Feedback

1Yoga is an individual, not team, self-care activity.

2Journaling feelings is an individual, not team, self-care activity.

3Engaging in aerobic exercise is an individual, not team, self-care activity.

4Sending a bereavement card to the family of a patient who has recently passed is a team action nurses can employ as a stress-reducing strategy.

PTS:1CON:Nursing Roles

MULTIPLE RESPONSE

22.ANS:3, 4, 5


Chapter learning objective: Explaining moral distress in end-of-life issues


Heading: Ethical Implications and Moral Distress





Difficulty: Easy

Feedback

1.This is incorrect. An unsupportive, not supportive, management staff leads to moral distress for nurses.

2.This is incorrect. A high, not low, stress environment leads to moral distress for nurses.

3.This is correct. High technology patient care situations often lead to moral distress for nurses.

4.This is correct. Cultural differences between the nurse and the patient population often lead to moral distress for nurses.

5.This is correct. Resource pressures when providing patient care often lead to moral distress for nurses.


23.ANS:1, 3, 4









Difficulty: Easy

Feedback

1.This is correct. Peripheral circulation decreases, leading to diaphoresis; clammy, cool skin; and changes in skin coloring.

2.This is incorrect. Decreased cardiac output results from bradycardia and hypotension.

3.This is correct. The heart rate and blood pressure decrease, resulting in decreased cardiac output, which is a sign of imminent death.

4.This is correct. The heart rate might initially increase as hypoxia develops; then the heart rate and blood pressure decrease, resulting in decreased cardiac output.

5.This is incorrect. A change in pulse pressure and a decrease in the volume of Korotkoff’s sounds indicate imminent death.


24.ANS:2, 4


Chapter learning objective: Discussing the meaning of palliative care and hospice care


Heading: Domain 1: Structure and Process of Care






Feedback

1.This is incorrect. Hospice care is often less expensive than conventional care in the last six months of life.

2.This is correct. In addition to clients who are diagnosed with cancer, a variety of clients qualify for hospice care.

3.This is incorrect. Hospice teams visit clients intermittently, although they are available 24/7 for support and care.

4.This is correct. Hospice reinforces the client-primary physician relationship by advocating office or

home visits.

5.This is incorrect. In addition to clients who are diagnosed with cancer, a variety of clients qualify for hospice care. A diagnosis of end-stage COPD is often a qualifier for hospice care.


25.ANS:1, 4, 5








Concept: Grief and Loss; Assessment


Feedback

1.This is correct. The last noted stool should be assessed to determine if constipation may be causing the delirium prior to medicating with the prescribed drug.

2.This is incorrect. The nurse would not assess the patient’s blood pressure to determine the cause of delirium.

3.This is incorrect. The nurse would not assess the patient’s respiratory rate to determine the cause of the delirium.

4.This is correct. Bladder distention is often a cause for delirium; therefore, the nurse should assess for this prior to administering the prescribed drug.

5.This is correct. Certain medications are known to cause delirium; therefore, the nurse should assess the patient’s medication regimen prior to administering the prescribed drug.

PTS: 1 CON: Grief and Loss | Assessment

26.ANS:2, 3









Difficulty: Hard

Feedback

1.This is incorrect. While bringing pictures is an appropriate suggestion, this does not allow the family to participate in the physical care of the patient during the dying process.

2.This is correct. The lips of a patient who is experiencing the process of dying often become dry; therefore, the application of lip balm is an appropriate suggestion to allow the family to participate in the physical care of this patient.

3.This is correct. A patient who is dying often experiences pain that can be remedied by massage; therefore, suggesting this to the family allows them to participate in the physical care of this patient.

4.This is incorrect. While bringing music for the patient to listen to is appropriate, this addresses the patient’s psychosocial, not physical, needs.

5.This is incorrect. Suggesting that a child call the dying patient is appropriate; however, this addresses the psychosocial, and not physical, needs of the patient and family.


27.ANS:3, 4, 5









Difficulty: Easy

Feedback

1.This is incorrect. While this data supports that the patient is alert and oriented it does not indicate the patient’s decisional capacity.

2.This is incorrect. The patient stating that he or she does not want to be a burden on the family is not data that supports the patient’s decisional capacity.

3.This is correct. Being able to communicate a decision with the health-care team supports the patient’s decisional capacity.

4.This is correct. Understanding the nature and the consequences of treatment supports the patient’s decisional capacity.

5.This is correct. Stating the benefits and risks associated with the treatment supports the patient’s decisional capacity.


medical surgical nursing 1st edition by janice hoffman and nancy sullivan · 2018-09-20 · medical...

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