Medical Surgical Nursing 3rd Australian Edition by LeMone -Test Bank

Chapter 11: Palliative Care at End of Life
Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. The nurse documents this finding as
a. agonal breathing.
b. apneustic breathing.
c. death-rattle respirations.
d. Cheyne-Stokes respirations.

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

DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

2. A 21-year-old is dying after an automobile accident. The family members want to donate the patient’s organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when
a. the patient is flaccid and unresponsive.
b. CPR is ineffective in restoring heartbeat.
c. the patient is apneic and without brainstem reflexes.
d. respiratory efforts cease and no apical pulse is audible.

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

DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

3. A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. The nurse explains to the family that these symptoms
a. will continue to increase until death finally occurs.
b. are a normal response before these functions decrease.
c. indicate a reflex response to the slowing of other body systems.
d. may be associated with an improvement in the patient’s condition.

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

DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

4. A patient who has been diagnosed with metastatic cancer and has a poor prognosis plans a trip across the country “to settle some issues with my sisters and brothers.” The nurse recognizes that the patient is manifesting the psychosocial response of
a. restlessness.
b. yearning and protest.
c. anxiety about unfinished business.
d. fear of the meaninglessness of one’s life.

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

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity

5. The spouse of a patient with terminal lung cancer visits daily and cheerfully talks with the patient about vacation plans for the next year. When the nurse asks about any concerns, the spouse says, “I’m busy at work, but otherwise things are fine.” An appropriate nursing diagnosis is
a. ineffective coping related to lack of grieving.
b. anxiety related to complicated grieving process.
c. caregiver role strain related to feeling overwhelmed.
d. hopelessness related to knowledge deficit about cancer.

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

DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
MSC: NCLEX: Psychosocial Integrity

6. As the nurse admits a patient with severe heart failure to the hospital, the patient tells the nurse, “If my heart or breathing stop, I do not want to be resuscitated.” Which action is best for the nurse to take?
a. Ask if these wishes have been discussed with the health care provider.
b. Place a “Do Not Resuscitate” (DNR) notation in the patient’s care plan.
c. Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed.
d. Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently.

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

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment

7. A patient who is very close to death is very restless and keeps repeating, “I am not ready to die.” Which action is best for the nurse to take?
a. Remind the patient that no one feels ready for death.
b. Sit at the bedside and ask if there is anything the patient needs.
c. Insist that family members remain at the bedside with the patient.
d. Tell the patient that everything possible is being done to delay death.

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

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

8. A patient in a hospice program is experiencing continuous, increasing amounts of pain. The nurse caring for the patient plans the scheduling of opioid pain medications to provide
a. around-the-clock routine administration of analgesics.
b. PRN doses of medication whenever the patient requests.
c. enough pain medication to keep the patient sedated and unaware of stimuli.
d. analgesic doses that provide pain control without decreasing respiratory rate.

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

DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment

9. When caring for a patient with lung cancer in a home hospice program, it is important for the nurse to
a. discuss cancer risk factors and appropriate lifestyle modifications.
b. encourage the patient to discuss past life events and their meaning.
c. accomplish a thorough head-to-toe assessment several times a week.
d. educate the patient about the purpose of chemotherapy and radiation.

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

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

10. A hospice nurse who has become very close to a terminally ill patient and family is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?
a. Contact a grief counselor as soon as possible.
b. Cry along with the patient’s family members.
c. Leave the home as quickly as possible to allow the family to grieve privately.
d. Consider whether working in hospice is desirable since patient losses are common.

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

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment