ch17.doc

[Osborn] chapter 17

Learning Objectives [Number and Title] Learning Objective 1 Review ethical theories that influence decisions in end-of-life

care.Learning Objective 2 Define advance directives and their role in end-of-life care.Learning Objective 3 Compare and contrast pharmacological and

nonpharmacological therapies used for relief of pain at end of life.

Learning Objective 4 Discuss beliefs surrounding death held by various cultures and religions.

Learning Objective 5 Identify the need for interdisciplinary collaboration in planning end-of-life care.

Learning Objective 6 Identify the role of hospice during end-of-life care.Learning Objective 7 Review the principles of palliative care.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

1. Several visitors are in the room of a terminally ill patient. The health care provider enters the room to discuss the plan of care for the patient. Which of the following should be done to ensure the patient’s privacy?

1. Ask the patient which individuals he or she would like to have stay in the room.

2. Sit down next to the patient and discuss the plan.3. Ask the other patient in the room to increase the volume of the television.4. Stand at the foot of the patient’s bed and tell all present the best course of

action.

Correct Answer: Ask the patient which individuals he or she would like to have stay in the room.

Rationale: The health care provider should ask the patient which individuals he or she would like to have stay in the room. Individuals have a right to privacy, and caregivers have a duty to respect the confidentiality of patient information. Any discussion regarding the patient’s diagnoses, consultation, examination, and treatment should be conducted discreetly. The health care provider should not assume that everyone in the room is supposed to hear the plan of care, nor should the health care provider ask the patient’s roommate to increase the volume of the television to drown out the discussion. Sitting next to the patient does not necessarily ensure privacy.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Safe, Effective Care EnvironmentLO: 1


2. A nurse recognizes that the purpose of palliative care is to provide comprehensive care focused on:

1. Alleviating suffering and promoting quality of life.2. Decreasing pain and prevention of medical complications.3. Controlling side effects of illness while postponing death.4. Withdrawing all medical care to allow natural death.

Correct Answer: Alleviating suffering and promoting quality of life.

Rationale: The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and promoting quality of life. Medical complications can be controlled but not prevented. The purpose is not specifically to postpone death. Withdrawing all medical care would be inappropriate, as it would cause more suffering.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Safe, Effective Care EnvironmentLO: 1


3. A terminal patient with a fulminating leg wound needs surgery, yet there is no guarantee the patient will survive the procedure. The nurse realizes that which of the following actions would support the ethical principle of beneficence?

1. Do not conduct the surgery and determine other treatment approaches.2. Conduct the surgery.3. Explain that the surgery is needed and every effort will be done to keep the

patient alive.4. Tell the patient that offering surgery was an error and that treatment will be

done with medications and therapy.

Correct Answer: Do not conduct the surgery and determine other treatment approaches.

Rationale: Beneficence means to do or promote good. It is different from nonmaleficence, or the duty to not inflict harm. It is sometimes difficult when caring for patients to distinguish between preventing harm and providing benefit. The surgery should not be conducted and other treatment options should be determined; when the duty not to inflict harm conflicts with the duty to provide benefit, there is support for the view that the obligation not to injure others is greater than the obligation to benefit them. Patients at the end of their lives may be vulnerable to harm when they receive unwanted or unnecessary interventions, are overtreated with technological interventions that serve only to prolong dying, and when treatments are withdrawn without their consent or agreement. The surgery should not be done with the promise of keeping the patient alive. The statement that the offer of surgery was a mistake should not be made to the patient.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Safe Effective Care EnvironmentLO: 1


4. A patient tells the nurse that he has a paper that outlines everything that he does and does not want to be done regarding his health should he be unable to make his own health care decisions. The nurse realizes this patient is describing:

1. Advance directives.2. A will.3. A durable power of attorney.4. A care plan.

Correct Answer: Advance directives.

Rationale: Advance directives are a part of the Patient Self-Determination Act and provide directives and directions regarding the amount and degree of care the patient would want in the event he is unable to communicate. A will is created to direct survivors as to what to do with the person’s possessions after death. A durable power of attorney is a mechanism for the patient to appoint an individual who is responsible for making health care decisions for the patient if the patient is incapacitated. A care plan identifies care that the patient is to receive.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Safe, Effective Care EnvironmentLO: 2


5. The family of an incapacitated patient desires one course of treatment that is against the decisions of the person with durable power of attorney. What should the nurse do?

1. Provide care according to the decisions of the person with durable power of attorney.

2. Ask the physician to talk with the family and the person with durable power of attorney.

3. Follow the family’s desires.4. Tell the person with durable power of attorney that he has to get the family’s

consent.

Correct Answer: Provide care according to the decisions of the person with durable power of attorney.

Rationale:The nurse should provide care according to the decisions of the person with durable power of attorney. A durable power of attorney for health care allows the patient to appoint a decision maker in the case of future incapacity. The durable power of attorney specifically states which powers the patient gives to the surrogate decision maker, and those decisions are to be followed even when in conflict with family members’ desires. The appointed person responsible for making medical decisions does not need consent from other family members or friends.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Safe, Effective Care EnvironmentLO: 2


6. A competent terminally ill client has completed a living will that expresses the desire to avoid resuscitation and heroic life support measures. The family members are not supportive of this directive. Which of the following actions by the nursing staff is most appropriate when family members share with staff that they are not supportive of the client’s decision?

1. Facilitate a discussion regarding the directives between the client and family. 2. Contact the social services department to revisit the issue with the client.3. Clarify the legality of the document with the hospital attorney.4. Explain to the family that the conflict with the client’s wishes could invalidate

the document.

Correct Answer: Facilitate a discussion regarding the directives between the client and family.

Rationale: Facilitating a discussion regarding the directives between the client and family is the correct option since it allows for discussion of the client’s wishes with all interested parties being present. The client is competent, so his or her directives will take priority. It is not necessary to contact social services or the attorney. The client’s living will is not invalidated by a conflict with the family’s concerns.

Cognitive Level: ApplyingNursing Process: ImplementationClient Needs: Safe, Effective Care EnvironmentLO: 2


7. A nurse is providing an in-service on do-not-resuscitate (DNR) orders to a group of newly hired graduate nurses. Which of the following statements made by one of the group members indicates to the nurse a need for further teaching?

1. “Do-not-resuscitate orders are a form of euthanasia.”2. “My nursing license is safe as long as I follow facility polices regarding a

DNR.”3. “A do-not-resuscitate order is an example of a client’s right to autonomy.”4. “Do-not-resuscitate orders may be rescinded if the client wishes.”

Correct Answer: “Do-not-resuscitate orders are a form of euthanasia.”

Rationale: Do-not-resuscitate orders are not a form of euthanasia, and this statement would indicate the need for follow-up by the nurse conducting the in-service. The other responses indicate an understanding of DNR orders.

Cognitive Level: ApplyingNursing Process: EvaluationClient Need: Safe, Effective Care EnvironmentLO: 3


8. A dying patient is having a build-up of carbon dioxide in the blood. Which of the following interventions would help make this patient more comfortable?

1. Allow the build-up of carbon dioxide to continue.2. Provide oxygen.3. Raise the head of the bed.4. Place the patient in a side-lying position.

Correct Answer: Allow the build-up of carbon dioxide to continue.

Rationale:Allowing hypoxia is the fastest path to unconsciousness with the least amount of agitation. Withdrawal of some treatments may actually assist the patient to be more comfortable. The patient should not be provided with oxygen nor should the head of the bed be elevated. Placing the patient in a side-lying position may or may not help with the patient’s comfort.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Psychosocial IntegrityLO: 3


9. The nurse is preparing an analgesic infusion for a cancer patient who is in pain and is nearing the end of life. Which of the following should the nurse do to ensure this patient’s comfort?

1. Titrate the medication to help with pain relief and not hasten the dying process.

2. Use Meperidine for the infusion.3. Contact the pharmacy for the correct dose to provide the patient.4. Limit the amount of medication infused.

Correct Answer: Titrate the medication to help with pain relief and not hasten the dying process.

Rationale: The nurse should titrate the medication to reduce the patient’s pain but not hasten the dying process. Meperidine is not recommended for pain because it could cause seizures. The patient may have been receiving pain medication for cancer treatment and may have some tolerance to the medication. There is no set dosage for pain medications at the end of life.



10. A patient is experiencing delirium. Which of the following groups of medication should the nurse consider administering to help decrease delirium?

1. Neuroleptics 2. Opioids 3. Benzodiazapines 4. NSAIDs (nonsteroidal anti-inflammatory drugs)

Correct Answer: Neuroleptics

Rationale: Neuroleptics such as Haldol help decrease symptoms of delirium. Opioids and benzodiazepines can worsen signs of delirium. NSAIDs are helpful to treat inflammation, pain, and fever rather than delirium.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 4


11. A patient of the Jewish faith died on a Friday evening. The nurse realizes this patient most likely will be buried:

1. On Sunday.2. On Saturday.3. After 2 or 3 days.4. Only after the completion of the autopsy.

Correct Answer: On Sunday.

Rationale:In the Jewish faith, the Sabbath is observed from sundown on Friday until sundown on Saturday. Since the patient died on Friday, the first available day to bury the patient will be on Sunday. A requirement to wait 2 or 3 days to bury the patient is not a part of the Jewish faith. Autopsy is forbidden in the Jewish faith. If an autopsy is required, it should be limited to essential organs or systems. All body parts must be returned for burial.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Psychosocial IntegrityLO: 4


12. The family of a Vietnamese patient is grieving after the death of their family member. Which of the following will the family most likely plan to do at the time of the patient’s death?

1. Wash the body of the deceased family member.2. Shout at the nurse to leave them alone to grieve.3. Stare at anyone who comes into the patient’s room.4. Place a special amulet on the patient’s body.

Correct Answer: Wash the body of the deceased family member.

Rationale:The family may want to wash the body of the deceased person because the body is highly respected. In the Vietnamese culture, a loud voice is a sign of disrespect, and avoiding eye contact is a sign of respect. The Chinese place special amulets or cloths on the body of a deceased person.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Psychosocial Integrity LO: 4


13. A client of American Indian descent suffers a massive cerebral hemorrhage and is not expected to survive. Which of the following interventions by the nursing staff would be appropriate when attempting to observe this client’s religious and cultural traditions?

1. Provide the family’s spiritual healer with privacy for death rituals. 2. Offer the family unlimited access to their dying family member.3. Discuss the possibility of transferring the client home for the death.4. Make it possible for the family to assist in the care of the dying family

member.

Correct Answer: Provide the family’s spiritual healer with privacy for death rituals.

Rationale: Providing the family’s spiritual healer with privacy for death rituals is appropriate since American Indian end-of-life practices are often guided by these tribal members. The remaining options do not reflect traditional American Indian death practices.

Cognitive Level: Applying Nursing Process: PlanningClient Need: Safe, Effective Care Environment LO: 5


14. A patient tells the nurse that he has to go home to die because he cannot afford to pay for the hospital care. The nurse realizes this patient would benefit from the aid of which of the following providers?

1. Social worker2. Physician3. Spiritual advisor4. Pharmacist

Correct Answer: Social worker

Rationale: Interdisciplinary collaboration means the knowledge and expertise of health care providers, nurses, social workers, spiritual counselors, dietitians, aides, and volunteers are all brought together to help meet the patient’s and family’s needs. The patient is concerned with financial arrangements, which could best be addressed by the social worker.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Psychosocial Integrity LO: 5


15. A terminally ill patient has been discharged to go home, but the patient lives alone and has limited resources. Which of the following is the most appropriate action by the nurse?

1. Coordinate a meeting with the physician, social worker, and other health professionals to facilitate the postdischarge care for this patient.

2. Suggest to the health care provider that the patient stay in the hospital.3. Instruct the patient to return to the emergency department at the first sign of

distress.4. Locate a skilled nursing facility that could accept the patient.

Correct Answer: Coordinate a meeting with the health care provider, social worker, and other health professionals to facilitate the postdischarge care for this patient.

Rationale: Interdisciplinary collaboration means the knowledge and expertise of health care providers, nurses, social workers, spiritual counselors, dietitians, aides, and volunteers are all brought together to help meet the patient’s needs. The patient lives alone and is terminally ill and will need assistance with coordination of care and resources. Due to the patient’s financial concerns, the nurse should not plan to transfer the patient to a skilled facility nor suggest that the patient be kept in the hospital. The nurse should not simply discharge the patient with the instructions to return to the emergency department if in distress.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Safe, Effective Care Environment LO: 5


16. A client hospitalized for diagnostic cancer testing reports an intense fear of dying from cancer. Which of the following responses by the nurse would be most appropriate?

1. “What has your doctor told you about your condition?” 2. “There is no indication from the testing that you are going to die.”3. “Most forms of cancer are treatable and have good recovery rates.” 4. “What makes you feel that you are going to die now?”

Correct Answer: “What has your doctor told you about your condition?”

Rationale: Asking the client, “What has your doctor told you about your condition?” is the correct option because it facilitates an opportunity for the nurse to have a discussion with the client related to the client’s concerns. Until the nurse understands the client’s knowledge of his or her condition, the other responses are premature.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Psychological IntegrityLO: 6


17. The brother of a terminally ill client states, “I’ll donate a million dollars to the hospital if they cure my brother.” The nurse realizes this statement is indicative of which phase of Kubler-Ross’s loss stages?

1. Bargaining2. Denial3. Anger4. Acceptance

Correct Answer: Bargaining

Rationale: Bargaining is an attempt to postpone or in some way affect the reality of the loss. The brother is not expressing denial or acceptance and does not appear to be angry.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Psychosocial IntegrityLO: 6


18. A client who is a recent widow states, “I wanted to ask him for a divorce and then he died.” The nurse realizes this client is at risk for:

1. A dysfunctional grief reaction.2. Accelerated grief reaction.3. A typical grief reaction process.4. Psychosomatic disorders.

Correct Answer: A dysfunctional grief reaction.

Rationale: A dysfunctional grief reaction is one that is affected by factors that interfere with a successful grieving reaction, such as an ambivalent relationship with the deceased. The client’s comment is not indicative of either a typical grief reaction process or an accelerated grief reaction. There is no indication the client is at risk for a psychosomatic disorder. Cognitive Level: ApplyingNursing Process: DiagnosisClient Need: Psychosocial IntegrityLO: 6


19. A patient asks the nurse what it means to have hospice care at home. Which of the following is the most correct response to this patient?

1. “Hospice makes sure that you are comfortable at home.”2. “Hospice care helps cure your illness.”3. “Hospice care is for patients who will be sick for longer than a year.”4. “Hospice care means your physical needs will be met.”

Correct Answer: “Hospice makes sure that you are comfortable at home.”

Rationale: Hospice care focuses on comfort care versus curative care. Hospice care includes an interdisciplinary team of health care providers including physicians, nurses, social workers, spiritual counselors, dieticians, home health aides, and volunteers. The care plan includes both the patient and family/caregiver as the unit of care, and the care plan is written to meet their values and goals. Patients receiving hospice care are generally defined as those patients who have a prognosis of 6 months or less if their terminal disease runs a normal course.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Psychosocial Integrity LO: 7


20. A dying patient tells the nurse that he is disappointed in how his life has gone and is anxious about dying. Which of the following would be beneficial for this patient?

1. Determine if this patient is eligible for hospice care.2. Ask the physician for an increase in pain medication.3. Facilitate an earlier discharge to home.4. Discuss options to transfer this patient to a skilled facility.

Correct Answer: Determine if this patient is eligible for hospice care.

Rationale: This patient is demonstrating existential suffering, which includes hopelessness, disappointment, remorse, and death anxiety. Hospice addresses suffering at all levels and realizes that relieving suffering is critical to achieving a “good death.” There is no evidence to suggest this patient would benefit from an increase in pain medication. This patient may or may not be stable enough to return to home. There is no evidence to suggest this patient needs to be admitted to a skilled facility.



21. While discussing the discharge of a terminally ill client, the client’s wife asks for information concerning arranging for hospice care. What initial action by the nurse is most appropriate?

1. Provide the client’s wife with a list of contact numbers for hospice agencies.2. Assist the family with making contact with a hospice prior to discharge.3. Determine the client’s life expectancy to decide when contact with hospice is

appropriate.4. Explain to the wife that hospice care is effective only when death is imminent.

Correct Answer: Provide the client’s wife with a list of contact numbers for hospice agencies.

Rationale: Providing the client’s wife with a list of contact numbers for hospice agencies is the correct option because it initiates the process of identifying the most appropriate care agency, and may lead to assisting the family in making contact with the agency. It is not necessary to determine life expectancy before providing the contact information the wife has requested. Hospice care is effective prior to imminent death.

Cognitive Level: Applying Nursing Process: ImplementationClient Need: Safe, Effective Care Environment LO: 7


22. A patient with a chronic illness asks the nurse if the new medication is going to cure his disease. Which of the following is the nurse’s best response?

1. “It will help you be more comfortable. I don’t think it’s going to cure the disease.”

2. “Of course it’s going to cure the disease.”3. “If you believe it will cure the disease, then it will.”4. “I don’t think it’s going to help or hurt at this time.”

Correct Answer: “It will help you be more comfortable. I don’t think it’s going to cure the disease.”

Rationale: In palliative care, the nurse needs to be honest with the patient and therefore explain that the medication will help with comfort, but will not cure. The nurse should not approach care as curative, as this could rob the patient of time and closure at the end of life. The nurse has no way of knowing the effect of the medication as far as helping or hurting the patient’s illness.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Psychosocial Integrity LO: 8


23. The nurse is planning palliative care for a patient with severe atherosclerotic disease. Which of the following would be of the highest priority for this patient?

1. Pain and symptom management2. Financial resource utilization3. Tolerance of physical activity4. Redesign of the patient’s home to support assistive devices

Correct Answer: Pain and symptom management

Rationale: When providing care to patients in a palliative care program, targeted interventions are common and include pain and symptom management, end-of-life care planning, and interventions to support the patient’s psychosocial and spiritual needs. Finances, physical activity, and home environment are not a high priority at this time.



24. Which of the following nursing interventions follows the principles of palliative care?

1. Talk to the patient about plans for funeral arrangements.2. Encourage physical therapy to restore prior level of functioning.3. Talk to the patient about the possibility of becoming an organ donor.4. Facilitate a consult to promote weight gain.

Correct Answer: Talk to the patient about plans for funeral arrangements.

Rationale: Palliative care needs focus on pain and symptom management, end-of-life planning, and psychosocial as well as spiritual needs. Encouraging end-of-life planning such as funeral plans would be very appropriate. Encouraging weight gain is not necessary, and attempting to return to a prior level of functioning is not the goal. Organ donation is only possible when a patient experiences brain death on life support. This is also not the goal in hospice care.



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life care

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plan of care

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health care provider

purpose of palliative

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principles of palliative