Nokea
A patient who is in the clinic for an immunization tells the nurse, 'My mother died 4 months ago, and I just can't seem to get over it. I'm not sure it is normal to still think about her every day.' Which of the following nursing diagnoses is most appropriate?
- A. Ineffective role performance related to depression
- B. Complicated grieving related to emotional disturbance (death of loved one)
- C. Anxiety related to unmet needs (lack of knowledge about normal grieving)
- D. Impaired mood regulation related to loneliness
Correct Answer: C
Rationale: The patient should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal for months or years after a death. The other nursing diagnoses imply that the patient's grief is unusual or pathological, which is not the case.
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A terminally ill patient is admitted to the hospital. Which of the following actions should the nurse include in the initial plan of care?
- A. Determine the patient's wishes regarding end-of-life care.
- B. Emphasize the importance of addressing any family issues.
- C. Discuss the normal grief process with the patient and family.
- D. Encourage the patient to talk about any fears or unresolved issues.
Correct Answer: A
Rationale: The nurse's initial action should be to assess the patient's wishes at this time. The other actions may be implemented if the patient or the family express a desire to discuss fears, understand the grief process, or address family issues, but they should not be implemented until the assessment indicates that they are appropriate.
The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which of the following terms should the nurse use to document this finding?
- A. Agonal breathing
- B. Apneustic breathing
- C. Death rattle respirations
- D. Cheyne-Stokes respirations
Correct Answer: D
Rationale: 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.
The nurse is caring for a young adult who is dying after an automobile accident. The family members want to donate the patient's organs and ask the nurse how the decision when death has occurred is made. Which of the following is the basis for the nurses' response to the family in this situation?
- A. The patient is flaccid and unresponsive.
- B. The patient is experiencing respiratory acidosis and is on a ventilator.
- C. The patient is unconscious with no brain stem activity.
- D. Respiratory efforts cease and no apical pulse is audible.
Correct Answer: C
Rationale: Death is the permanent loss of capacity for consciousness and all brain stem functions. This may result from permanent cessation of circulation or catastrophic brain injury. In the context of death determination, permanent refers to loss of function that cannot resume spontaneously and will not be restored through intervention. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead.
The nurse is planning for an end-of-life care discussion with a newly admitted patient who is terminally ill and has decided to use the NURSE protocol during the difficult conversation to respond to patient and/or family emotions. Which of the following terms describes the 'E' in the NURSE protocol?
- A. Experimentation
- B. Exploration
- C. Empathy
- D. Emotion
Correct Answer: B
Rationale: Nurses may use several approaches to difficult conversations that share common features. Suggested approaches are 'ask-tell-ask,' 'tell me more,' responding to emotions with the NURSE protocol (naming, understanding, respecting, supporting, and exploring).
A patient who is very close to death is very restless and keeps repeating, 'I am not ready to die.' Which of the following actions should the nurse 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.
Correct Answer: B
Rationale: 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 possible is being done to delay death 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.