Nokea
The nurse is providing hospice care to a patient who is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. Which of the following is the basis for the nurses' response about these symptoms?
- A. They will continue to increase until death finally occurs.
- B. They are a normal response before these functions decrease.
- C. They indicate a reflex response to the slowing of other body systems.
- D. They may be associated with an improvement in the patient's condition.
Correct Answer: B
Rationale: 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.
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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.' Which of the following nursing diagnoses is appropriate?
- A. Ineffective denial related to threat of unpleasant reality
- B. Anxiety related to threat to current status
- C. Caregiver role strain related to inexperience with caregiving
- D. Hopelessness related to persistent stress
Correct Answer: A
Rationale: The spouse's behaviour and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The spouse does not appear to feel overwhelmed, hopeless, or anxious about the partner's impending death.
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.
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 family member of a patient who is dying tells the nurse, 'Mother doesn't really respond any more when I visit. I don't think she knows that I am here.' Which of the following responses by the nurse is most appropriate?
- A. You may need to cut back your visits for now to avoid overtiring your mother.
- B. Withdrawal may sometimes be a normal response when preparing to leave life.
- C. It will be important for you to stimulate your mother as she gets closer to dying.
- D. Many patients don't really know what is going on around them at the end of life.
Correct Answer: B
Rationale: Withdrawal is a normal psychosocial response to approaching death. Dying patients may maintain the ability to hear while not being able to respond. Stimulation will tire the patient and is not an appropriate response to withdrawal in this circumstance. Visitors are encouraged to be 'present' with the patient, talking softly and making physical contact in a way that does not demand a response from the patient.
The nurse is caring for a patient in a hospice palliative care program who is experiencing continuous, increasing amounts of pain. Which of the following time schedules should the nurse implement for the administration of opioid pain medications?
- 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.
Correct Answer: A
Rationale: 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.