End-of-Life Care

1. The home health nurse encourages the older adult to file an advance directive to indicate:

a.
the degree of intervention desired for life support.
b.
who is to manage medical decisions in case of debilitating illness.
c.
who will manage finances in case of debilitating illness.
d.
the mortuary to be used in the case of death.

ANS: A

Advance directives indicate the degree of interventions desired for life support in the case of a terminal illness.

DIF: Cognitive Level: Analysis REF: 244 OBJ: 1

TOP: Advance Directives KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

2. The patient is attempting to make an informed decision about whether to have a life-extending treatment done. The essential piece of information that is significant in the decision is:

a.
whether the quality of life will improve after the procedure is done.
b.
the cost of the treatment.
c.
the amount of time treatment will take.
d.
whether insurance will cover the cost of treatment.

ANS: A

Whether the quality of life will be improved by treatment is the most significant piece of information for making the decision. The consideration about the cost and time involved with the treatment can be addressed after the decision about the treatment has been made.

DIF: Cognitive Level: Analysis REF: 245 OBJ: 2

TOP: Life-Extending Treatments KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

3. The totally competent 76–year-old female with terminal cancer is fatigued and tearful about the ineffectiveness of her treatment. She tells the nurse that she wishes she had never started it but now feels obligated to continue. The nurse explains that:

a.
once treatment has begun, the doctor should decide about any changes.
b.
she may change her mind about treatment at any time.
c.
decisions about treatment should be made by the person who is her medical power of attorney.
d.
cessation of treatment will shorten her life.

ANS: B

Competent patients can change their minds about treatment options or advance directive options at any time.

DIF: Cognitive Level: Application REF: 245 OBJ: 2

TOP: Treatment Cessation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

4. Professional health care providers may neglect to educate patients about end-of-life care because they:

a.
fear that patients will perceive that they are giving up.
b.
do not want to influence the patient in any decision.
c.
want to keep up the patient’s morale.
d.
believe that death is a personal failure on their part.

ANS: D

Professional health care providers frequently neglect mentioning end-of-life provisions because they believe that death is a personal failure.

DIF: Cognitive Level: Application REF: 245 OBJ: 3

TOP: Caregiver Attitudes KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

5. The home health nurse is firm with an 86–year-old man with terminal illness that he needs to file an advance directive to:

a.
demonstrate understanding of his imminent death.
b.
comply with most hospital policies.
c.
clarify treatment protocols.
d.
spare his family the burden of making end-of-life decisions.

ANS: D

The filing of advance directives relieves the family of making those decisions at a more stressful time. It also gives back control over terminal care to the terminally ill person.

DIF: Cognitive Level: Application REF: 244 OBJ: 1

TOP: Advance Directives KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

6. The nurse is aware that hospice care can be made available to terminal patients who:

a.
have a life expectancy of only 12 months.
b.
are Medicaid-qualified.
c.
agree to palliative measures.
d.
are hospitalized.

ANS: C

Hospice is a Medicare-funded program for the provision of palliative care for persons who have 6 months or less life expectancy. The service is extended to qualified persons at home, in a long-term care facility, or in the hospital.

DIF: Cognitive Level: Application REF: 246 OBJ: 5

TOP: Hospice Care KEY: Nursing Process Step: Planning

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

7. The dying patient with terminal liver cancer says to the nurse, “I’m going to take a long time to die, aren’t I? I’m going to get sicker and weaker every day.” The nurse’s best response would be:

a.
“Your type of cancer is usually fatal in 4 to 6 months.”
b.
“I don’t want to hear this kind of negative talk. Make use of the time you have.”
c.
“We have many medications that can make you feel better.”
d.
“What concerns you the most about dying?”

ANS: D

Using an open-ended question but being honest about terminal illness creates an interpersonal environment for effective communication.

DIF: Cognitive Level: Analysis REF: 248 OBJ: 4

TOP: Communication KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

8. The distraught wife of a terminally ill patient complains to the nurse, “My husband has not been shaved, and he has that miserable gown on instead of his own pajamas. Don’t you people care about things like that?” The nurse’s best response would be:

a.
“I delayed his morning care because he was sleeping comfortably. I’ll complete his care now that he’s awake.”
b.
“We’re running late today and I have six other patients to care for. What do you want?”
c.
“Of course we care! Someone will come to do his care before lunch.”
d.
“I’m sorry you feel we’re doing such a poor job. I’m doing my best.”

ANS: A

Listening to criticism without defensiveness and giving a prompt response to requests with an explanation shows the nurse’s concern for meeting the needs of the dying person and of the distressed family members.

DIF: Cognitive Level: Application REF: 247 OBJ: 4

TOP: Communication KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

9. When the nurse becomes tearful at the death of a patient, the nurse should:

a.
leave the room so that the family will not witness the unprofessional behavior.
b.
touch the hand of the daughter and say, “We’ll miss your dad.”
c.
become occupied with rearranging a floral bouquet until emotions are under control.
d.
discontinue the oxygen, turn off the IV, and say, “I’m sorry for your loss.”

ANS: B

Showing that the nurse is experiencing a loss also helps the family deal with their grief. Showing empathetic emotion is not unprofessional. Automatic phrases such as “sorry for your loss” seem insincere.

DIF: Cognitive Level: Application REF: 248 OBJ: 4

TOP: Communication KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

10. The nurse notes that a cardiovascular sign of impending death is:

a.
Cheyne-Stokes respiration.
b.
bounding pulse.
c.
bluish mottling of extremities.
d.
widening pulse pressure.

ANS: C

As death approaches, there is vasoconstriction to the extremities to keep blood going to the heart and brain. This causes mottling of the extremities. Bounding pulse and widening pulse pressure are not seen in the dying person. Cheyne-Stokes respirations are changes seen in the respiratory system, not the cardiovascular system.

DIF: Cognitive Level: Application REF: 252 OBJ: 6

TOP: Cardiovascular Changes of Approaching Death

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. The nurse emphasizes that the objective of pain control for the dying patient is to:

a.
keep the patient unconscious and relaxed to avoid the perception of pain.
b.
delay medication until the patient reports that the pain is intense.
c.
find a control level that reduces pain but allows the patient to interact.
d.
eradicate pain completely.

ANS: C

Finding a level of pain control that allows the patient to participate in care and communicate with family is the goal of pain control. Analgesics given before pain becomes intense can keep pain at a moderate level. Completely eradicating pain is usually not realistic.

DIF: Cognitive Level: Comprehension REF: 251 OBJ: 6

TOP: Pain Control KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The daughter of a dying patient is distressed about oversedation related to her mother’s receiving 2 mg of morphine sulfate every hour. The nurse clarifies that this small dose of morphine is helpful in controlling the end-of-life symptom of:

a.
dyspnea.
b.
pain.
c.
hallucinations.
d.
fatigue.

ANS: A

Administering frequent, small doses of morphine sulfate is standard protocol to reduce end-of-life air hunger. One dose is not enough for euthanasia.

DIF: Cognitive Level: Application REF: 253 OBJ: 6

TOP: Dyspnea KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. To reduce the threat of aspiration in the unconscious patient who is near death, the nurse should:

a.
perform deep tracheal suctioning of the patient every hour.
b.
place the patient in a side-lying position, with the head turned to the side.
c.
slightly elevate the foot of the bed, with the patient in a supine position.
d.
give the patient only thickened fluids.

ANS: B

Side-lying is a safe position for reducing the threat of aspiration. The supine position is not appropriate for aspiration reduction. Frequent suctioning is stressful to the patient, and fluids are never attempted for an unconscious patient.

DIF: Cognitive Level: Application REF: 254 OBJ: 6

TOP: Aspiration KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. The nurse questions the order for a bulk-forming laxative for the person who is near death because the patient would need a minimum fluid intake of _____ mL to tolerate this type of drug.

a.
1000
b.
1500
c.
2000
d.
2500

ANS: C

To prevent a bowel obstruction from bulk-forming laxatives, the patient must have a fluid intake of at least 2000 mL a day.

DIF: Cognitive Level: Knowledge REF: 254 OBJ: 6

TOP: Bulk-Forming Laxative KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmaceutical Therapies

15. When the dying patient becomes delirious, the nurse encourages the family to:

a.
leave the room and wait outside until the delirium clears.
b.
hold the patient’s hand, but say nothing, because hearing stays intact until death.
c.
remain near the bed and speak to the patient in loud tones to stimulate the patient.
d.
touch the patient, call the patient by name, and speak in reassuring tones.

ANS: D

Touching, calling by name, and speaking in a calm and reassuring manner frequently cause the symptoms of delirium to abate and are beneficial to the delirious patient.

DIF: Cognitive Level: Comprehension REF: 255 OBJ: 6

TOP: Delirium KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

16. Because of diminished vision in the person who is dying, caregivers should:

a.
keep lights bright to increase visual acuity.
b.
stand slightly away from the bed and identify themselves before speaking.
c.
keep all lights on in the room, day and night.
d.
come close to the bed and stand directly in front of the patient.

ANS: D

Putting oneself directly in front of the patient, as close as possible, helps the patient with diminished vision identify the speaker.

DIF: Cognitive Level: Application REF: 255 OBJ: 6

TOP: Diminished Vision KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

1. The nurse is aware that end-of-life planning is often neglected because __________. (Select all that apply.)

a.
there is a clear procedure to follow
b.
people are uncomfortable talking about death
c.
young people do not see the need for end-of-life planning
d.
end-of-life planning is a relative new concept
e.
many persons are not really sure what they want to do

ANS: B, C, D, E

The options are so numerous that there is not any one clear line of action to follow. End-of-life planning is a relatively new concept that the older generation did not experience in their youth. Persons are reluctant to talk about death issues, especially young persons, who do not see the need.

DIF: Cognitive Level: Analysis REF: 243-244 OBJ: 1

TOP: End-of-Life Planning KEY: Nursing Process Step: Planning

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

2. The holistic caregiver will bring to end-of-life care the ability to __________. (Select all that apply.)

a.
communicate and respond to the patient’s concerns about death
b.
embrace the value of palliative care rather than curative care
c.
help the patient and family face loss and grieve in anticipation of loss
d.
encourage the patient to focus on wellness and recovery
e.
collaborate with other professionals for patient support

ANS: A, B, C, E

The focus of palliative care is not recovery.

DIF: Cognitive Level: Application REF: 247 OBJ: 3

TOP: Palliative Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

3. The nurse reminds the 70-year-old male patient who has signed an advance directive that copies of the form should be __________. (Select all that apply.)

a.
given to the person who has been named as his power of attorney for medical decisions
b.
posted in his home for emergency personnel
c.
placed in his file in his physician’s office
d.
filed with the hospital of his choice
e.
given to his spiritual advisor

ANS: A, B, C, D

The spiritual advisor is not usually considered an appropriate recipient for a copy of the advance directive. It should only be given to those who will be directly involved with health choices and require this information.

DIF: Cognitive Level: Application REF: 244-245 OBJ: 3

TOP: Advance Directives KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

4. The nurse lists the benefits of filing an advance directive, which are that this document __________. (Select all that apply.)

a.
is legally binding
b.
remains in effect until the family changes it
c.
prevents last-minute confusion about the wishes of the patient
d.
prevents violation of end-of-life choices
e.
clarifies end-of-life issues for the family

ANS: A, C, D, E

The family cannot alter an advance directive made by a patient. It is a legally binding document that clarifies and prevents violation of end-of-life choices of the patient and can only be altered by the patient.

DIF: Cognitive Level: Application REF: 244 OBJ: 2

TOP: Advance Directives KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

5. The nurse is sensitive to the fact that a person’s perceptions about end-of-life care are dependent on __________. (Select all that apply.)

a.
age
b.
gender
c.
cultural background
d.
caregivers
e.
life experiences

ANS: A, B, C, E

The caregivers are there to be supportive. A person’s attitude about end-of-life care is affected by his or her age, gender, cultural background, religious affiliations, and life experiences.

DIF: Cognitive Level: Comprehension REF: 245 OBJ: 1

TOP: End-of-Life Attitudes KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

6. The charge nurse on an oncology unit encourages the staff to complete a values clarification exercise to identify __________. (Select all that apply.)

a.
their own values
b.
values that influence care decisions
c.
values that must be abandoned or changed
d.
values that may cause an ethical dilemma
e.
negative values

ANS: A, B, D

A value clarification exercise neither designates any value as negative nor suggests that any value be abandoned. The exercise is to help persons gain insight into their own value system.

DIF: Cognitive Level: Comprehension REF: 245 OBJ: 3

TOP: Values Clarification KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

7. The nurse considers the provisions of palliative care, which are to __________. (Select all that apply.)

a.
treat symptoms of pain, dyspnea, and nausea
b.
promote acceptance of death
c.
provide CPR
d.
monitor mechanical ventilation machines
e.
enable the patient to have a better quality of life

ANS: A, B, E

Providing mechanical ventilation equipment and performing CPR are not aspects of palliative care.

DIF: Cognitive Level: Comprehension REF: 247 OBJ: 3

TOP: Palliative Care KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

8. To meet the changing needs of the dying person, interservice collaboration is necessary among __________. (Select all that apply.)

a.
medical professionals
b.
social workers
c.
clergy
d.
transportation services
e.
dieticians

ANS: A, B, C, E

The dying person’s needs change as their physical processes decline. Communication and collaboration among specialty services are necessary. Transportation services are not in the basic care collaboration.

DIF: Cognitive Level: Comprehension REF: 247 OBJ: 6

TOP: Collaboration KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

9. To show willingness to spend time with a dying patient and encourage communication, the nurse should __________. (Select all that apply.)

a.
address the patient by name at every opportunity
b.
use direct questions to inquire about the patient’s concerns relative to health and end-of-life issues
c.
complete care with a minimum of conversation to encourage questions from the patient
d.
provide empathetic touching during care to show concern
e.
sit down in the room to converse with patient

ANS: A, D, E

Use of direct questions, which only allow a “yes” or “no” answer from the patient, does not generate communication, nor does limited conversation from the caregiver.

DIF: Cognitive Level: Application REF: 247 OBJ: 4

TOP: Communication KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

10. The nurse shares the information that the benefits of dehydration for persons near death are __________. (Select all that apply.)

a.
better gas exchange because of reduction of fluid in the lungs
b.
decreased need to suction because of reduction of respiratory secretions
c.
improved bowel elimination because of reduced bulk in the stool
d.
decreased pain related to release of endorphins
e.
improved drug distribution via the circulating volume

ANS: A, B, D

Bowel elimination and drug distribution are both reduced when the patient is dehydrated.

DIF: Cognitive Level: Analysis REF: 253-254 OBJ: 6

TOP: Dehydration KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. A resident in the long-term care facility has just expired at 2 AM, and the family is on the way to say their last goodbyes. Before the arrival of the family, the nurse should __________. (Select all that apply.)

a.
remove equipment (e.g., IV poles and tubing, feeding tubes, oxygen equipment)
b.
dress the resident in a clean gown and cover him or her with a clean sheet
c.
remove dentures
d.
apply a diaper to catch draining body fluids
e.
provide privacy by drawing the curtain or moving the other resident to an unoccupied room

ANS: A, B, D, E

Removing the dentures give the face an unnatural appearance. All the other activities are appropriate to prepare the resident and environment after death.

DIF: Cognitive Level: Application REF: 255-256 OBJ: 6

TOP: After-Death Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

12. While working with the bereaved at the time of death, the nurse should __________. (Select all that apply.)

a.
review the stages of dying with them
b.
ensure privacy
c.
observe cultural and spiritual preferences
d.
legally pronounce the death
e.
allow the bereaved to express their feelings

ANS: B, C, E

Reviewing the stages of dying should have been addressed before the death. The physician is the individual who legally pronounces the death. Assuring privacy will allow the bereaved to say final farewells and grieve. Observing cultural and spiritual preferences will prevent the bereaved from being offended.

DIF: Cognitive Level: Application REF: 255 OBJ: 7

TOP: Bereavement KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. The role(s) of the nurse while working with the bereaved include __________. (Select all that apply.)

a.
guidance
b.
resource
c.
advocacy
d.
support
e.
spiritual counseling

ANS: A, B, C, D

Individuals are brought in as requested to meet the spiritual needs of the bereaved. The role of the nurse includes guiding the bereaved as to what needs to be done, serving as a resource for information related to death and dying, being an advocate for the deceased and their family to make requests known related to cultural and spiritual preferences, and supporting the need for privacy and emotional release at the time of death.

DIF: Cognitive Level: Comprehension REF: 245-246 OBJ: 7

TOP: Bereavement KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

COMPLETION

1. The hospice nurse explains that dying in peace without pain and with dignity in a supportive care environment is defined as a(n) _________ death.

ANS: good

DIF: Cognitive Level: Application REF: 245-246 OBJ: 2

TOP: Definition of a “Good” Death KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation