Deck 19: Care of the Icu Patient at the End of Life

Question 1

When planning to allow a family to be at the bedside during CPR, the nurse should anticipate which possible outcome based on reports from post-CPR patients?
1) The family will be unhappy after seeing the pain and suffering caused by CPR.
2) The patient will feel comforted and supported by her family's presence.
3) The family will be overwhelmed by the confusion and busyness of the events.
4) The patient will be frustrated because of not being able to speak to the family.

Answer 1

2
Explanation: 1. Although pain and suffering may be a part of the CPR process, the family did not report the CPR efforts as such because they were an attempt to save the patient.
2. Research has shown that based on reports from post-CPR patients, the family's presence gave support and comfort, and patients felt less fear.
3. Although feelings of being overwhelmed or unhappy may be a part of the CPR process, the family did not report the CPR efforts as such because they were an attempt to save the patient.
4. Although the patient may be intubated or unable to speak, the feelings of comfort and support given by the family were reported as beneficial.

Question 2

When applying both substituted judgment and best interest standards to end-of-life decision making for a patient, what is the nurse's primary role?
1) Tell the proxy what should be done in the best interest of the patient.
2) Establish trust and confidence with the family.
3) Be an advocate and decision maker based on hospital interests.
4) Promote effective communication and decrease conflict.

Answer 2

4
Explanation: 1. Telling the proxy what to do does not allow for individual freedom of choice in the management of care based on the patient's wishes. Health care providers should give options and realistic outcomes but leave the decision making to the proxy and/or family.
2. Just establishing trust and building confidence in the health care staff's care will not include what the patient's wishes are. Trust and confidence are important to open communication, but they are not the end process. Getting an understanding of the patient's desires should be the ultimate goal of the communication process.
3. Patient care is not based on hospital interests. Nursing is focused on the patient's individual needs and concerns. Allowing the proxy to take these considerations into the decision-making process will allow maximum effect to meet the patient's end-of-life needs.
4. During decision-making processes, the health care team's goal is to maximize communication and to minimize conflicts in the best interest of the patient based on what the patient would want if able to express his own desires.

Question 3

What should the nurse do when attempting to establish a relationship and enter a dialogue with the family of a dying patient?
1) Identify with the family when they have concerns by saying, "I have questioned how a physician could believe that also. I'll argue with her about it."
2) Speak more than the family because silence may be difficult for them to tolerate.
3) Demonstrate respect for the family by saying, "I'm impressed with how involved you have been with the patient during his illness."
4) Begin by saying, "I know exactly how you must be feeling."

Answer 3

3
Explanation: 1. The nurse should not contradict or put down other health care providers but recognize patient concerns by saying something such as, "I hear you saying that you don't feel you are being heard by the physicians. I'd like to make certain you have a chance to voice all your concerns."
2. The nurse should maintain a higher ratio of family member-to-health care provider speaking time; therefore, listening, asking clarifying questions, and tolerating silence are important skills for nurses.
3. The nurse should demonstrate respect for family members by saying something such as, "I'm so impressed by how involved you have been with your father throughout his illness," and also by assuming that the family members are operating in what they believe to be the patient's best interests unless there is proof to the contrary.
4. The nurse does not know how the family must be feeling. This would not be appropriate for the nurse to say to the family.

Question 4

According to Morse, the nurse should anticipate that family members of a dying patient will display which behavior before they are ready to move on and face the reality of the situation?
1) Denial
2) Anger
3) Suffering
4) Enduring

Question 5

Which approach should the nurse avoid when caring for the family of a dying patient?
1) Repeating information frequently to make sure the information is being understood fully
2) Reaffirming the bad news but allowing time to listen to the family's responses
3) Being honest and sincere but sensitive to the family's needs
4) Encouraging a quick decision-making process to decrease the amount of time required to get past the painful part of dealing with the death

Question 6

According to Morse, what two patterns of behavior may a family use when expressing their feelings or emotions related to the death of their loved one?
1) Denial and grieving
2) Enduring and suffering
3) Hostility and acceptance
4) Anger and bargaining

Question 7

When caring for a bereaved family member, the nurse should avoid which inappropriate action?
1) Offer privacy and a listening ear to the family before speaking.
2) Avoid technical, hospital, or medical terminology when explaining conditions or treatments.
3) Offer clichés, such as "she lived a good life," to make the family feel better.
4) Use direct eye contact and offer comfort by touching.

Question 8

Which question would be most appropriate for the nurse to ask a son who is his father's health care proxy to help clarify the father's end-of-life wishes?
1) "Did he ever speak to your mother about his wishes?"
2) "When did your father complete his advance directive?"
3) "Would you tell me in his own words what he said he wanted done at the end of his life?"
4) "Who else was present during the discussion?"

Question 9

The nurse should set which goal when planning care for the family of a dying ICU patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Encourage family members to talk about their feelings and concerns.
2) Establish trust between the family and the members of the health care team.
3) Identify and respect the family's cultural and religious beliefs or practices.
4) Establish respect for family choices and support their decisions.
5) Establish a sympathetic approach in response to family members' feelings.

Question 10

When using the mnemonic "in-or-out" as a guideline for evaluating family presence during CPR, what should the nurse include during the "R" step?
1) Identify the relationship to the patient and the family decision maker.
2) Explain the rationale for health outcomes and management options.
3) Assess the family's reason for wanting to be present in the room.
4) React to data collected during the family discussion.

Question 11

A patient in the intensive care unit is being evaluated for brain death. Which finding is an indication of brain death?
1) Absence of all motor responses to noxious stimuli
2) No respiratory effort when the patient is off the ventilator for 4 minutes with a pCO₂ of 49
3) Absence of a cough reflex with nasotracheal stimulation
4) Pupils that are 3 mm and respond to light

Question 12

The decision has been made to not start needed dialysis on a patient in the intensive care unit. According to Copnell (2005), this decision would fall under which category of ICU deaths?
1) Failed CPR
2) Withdrawal
3) Brain death
4) Limitation

Question 13

A nurse might elect to have a family present during CPR on a critically ill patient because it is likely to have which benefits? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Staff members are reminded of the patient's personhood.
2) The family may realize the seriousness of the patient's illness and understand the gravity of the situation.
3) Fewer lawsuits occur when the family members see the care given by the health care team.
4) The family may provide comfort and support to the patient.
5) The family can understand the expenses needed with the multitude of equipment used in critical care.

Question 14

When applying the "substituted judgment" standard for decision making, on what basis is the nurse asking the health care proxy to make decisions?
1) Based on what the family would like done under these circumstances
2) Based on what the spouse would like done under these circumstances
3) Based on what the proxy could imagine the patient wants for him- or herself
4) Based on what the health care providers feel is appropriate

Question 15

How should the nurse explain "brain death" to a family member?
1) Damage to the brain so extensive that the brain is no longer functional, and function cannot be restored by medical therapies
2) Brain tissue that is lacking blood supply so it cannot perform some of its normal functions
3) Electrical malfunction of brain tissue so that it does not control breathing properly
4) When one lobe of the brain is traumatized or bruised and is trying to repair itself

Question 16

What should the nurse allow the family to do when trying to meet the family's need to be helpful to a dying patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Reposition the patient.
2) Activate the patient-controlled analgesia if the patient grimaces or has pain.
3) Talk or read to the patient to show that they are present in the room.
4) Moisten the patient's lips and mouth.
5) Comfort or soothe the patient through touch or speech.

Question 17

A terminally ill patient in the ICU agrees to limitation of care. What should the nurse interpret this type of care to mean?
1) To stop all measures, including pain medication
2) To exclude all but immediate family members from the patient's room
3) Not to initiate one or more interventions
4) To stop one or more therapies after they had been initiated

Question 18

If a dying patient is being provided with IV hydration, the nurse should assess for which problem? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) A decrease in urine output
2) An increase in nausea and possible vomiting
3) An increased likelihood of dyspnea
4) Development of pitting edema in the extremities
5) Irregular heart rhythm

Question 19

Which reflex should the nurse assess to determine brainstem response in a patient being evaluated for brain death? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) PERLA
2) Oculovestibular
3) Corneal
4) Oculocephalic
5) Moro

Question 20

What does the nurse have a legal responsibility to prevent if family members are present while CPR is delivered to a patient?
1) Posttraumatic stress syndrome of family members from viewing CPR
2) Breach of confidentiality about the patient's medical information during CPR
3) Family vendetta for perceived unskilled or less efficient staff during CPR
4) Patient's lack of privacy and physical exposure during CPR

Question 21

When caring for a patient at the end of life, on what basis should the nurse decide to continue therapies? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) The therapies will keep the family happy.
2) The therapies will reduce the workload of the staff.
3) The therapies will enhance the patient's functional status.
4) The therapies will lessen the patient's emotional, psychological, or spiritual distress.
5) The therapies will promote relief of the patient's symptoms.

Question 22

Which assessment finding indicates a dying patient is in need of additional comfort measures? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) The patient is moaning.
2) The patient is anxious.
3) The patient's heart rate is elevated one to three times.
4) The patient is sleeping.
5) The patient is gasping for air.

Question 23

Which actions would help a family to recover after learning of the death of their family member in the intensive care unit? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Offer time for the family to be alone in private.
2) Offer to contact the chaplain for the family.
3) Offer time for the family to stay with the patient before being removed from the unit.
4) Ask the family to wait until the mortician has arrived before seeing the patient.
5) Direct the family to the social worker's office.

Question 24

The nurse is helping a family decide to stay with a patient during cardiopulmonary resuscitation. Place in order the steps the nurse will take when helping the family decide. Choice
1) Nurse introduces self to the family. Choice
2) Nurse explains the patient's current status. Choice
3) Nurse explains the possible outcome from cardiopulmonary resuscitation. Choice
4) Nurse asks who the decision maker is in the relationship with the patient. Choice
5) Nurse provides the family with options. Choice 6. Nurse asks the family members if they have any questions.

Question 25

Which approach to controlling pain, nausea, and dyspnea should the nurse use for pharmacological management at the end of a patient's life?
1) Administer medication based only on the severity of symptoms that are observed in the patient.
2) Administer prophylactic medication aggressively as symptoms arise to maintain comfort.
3) Administer medications only at the family's request as the patient's health care proxy.
4) Withhold all medication when other therapies are withheld.

Question 26

When unresolvable conflicts are present among health care team and family members concerning futile treatment of a patient, who has the legal right to decide the management plan?
1) The patient's family or health care proxy determines the outcome.
2) The empowered nurse specialist coordinates the discussion among family members.
3) The hospital's ethics board dictates the final resolution.
4) The physician decides based on the hospital's ethics board's recommendation, the patient's desires, and any written advance directives.

Question 27

A patient in the critical care unit has died as a result of failed CPR. How should the nurse interpret this phrase? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Death occurred despite all efforts by health care providers.
2) The patient died suddenly after traumatic injuries.
3) The patient died after receiving maximum care for weeks.
4) The patient has no brainstem functioning.
5) The patient died after dialysis was canceled.

Question 28

How should the nurse plan to manage sedation and pain medication when a dying client is to be terminally weaned or extubated?
1) Stop all ongoing sedative infusions at least 1 hour before extubation.
2) Observe the patient and adjust medication dosages every hour.
3) Provide an anticipatory dose of morphine and initiate an ongoing morphine infusion.
4) Initiate medication therapy to control dyspnea, but plan to stop it in the event of hypotension.

Question 29

A terminally ill patient is anxious and having difficulty breathing. Which medication should the nurse anticipate being prescribed for this patient?
1) Fentanyl
2) Morphine
3) Diazepam
4) Lorazepam

Question 30

A critically ill patient in the intensive care unit dies after specific therapy has been stopped. Which action demonstrates the withdrawal of a therapy? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Application of a CPAP device
2) Discontinuation of enteral feedings
3) Initiation of patient-controlled analgesia
4) Cessation of hemodialysis for chronic renal failure
5) Removal of chest tubes for bilateral pleural effusion

Question 31

Which is the most appropriate intervention for the nurse attempting to meet the spiritual needs of a patient at the end of life?
1) Answer questions about the meaning of life, hope, and purpose of life based on the nurse's understanding.
2) Explain the role of suffering as the nurse sees it.
3) Discuss ethical decision making with the patient to clarify his desires.
4) Encourage, respect, and participate when comfortable in the patient's and family's cultural or spiritual practices.

Question 32

A critically ill patient in the intensive care unit is being evaluated for brain death. What will be assessed in this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Presence of coma
2) Absence of pupil response
3) Apnea lasting for 8 minutes
4) Absence of corneal reflex
5) Urine output less than 5 mL/hr

Question 33

According to the American Nurses Association and the American Association of Critical-Care Nurses, what is the nurse's primary duty to the patient?
1) Allow a comfortable death.
2) Do no harm.
3) Base all care on cost-benefit ratio analysis.
4) Minimize emotional distress in the family of a dying patient.

Question 34

A patient with end-stage renal disease and severe cardiomyopathy deteriorates after every hemodialysis treatment. The health care provider asks if hemodialysis treatments should be continued, to which the spouse responds by asking when the patient is going to be well enough to return home. What does the spouse's statement indicate?
1) The patient wants to die at home.
2) The spouse wants to take the patient home.
3) The patient wants the treatments to continue.
4) The spouse misunderstands the patient's condition.

Question 35

The family of a dying patient is demonstrating conflict about the patient's ongoing care needs. The nurse plans to use the evidence-based mnemonic to help the patient and family. Place in order the steps the nurse will take when using this mnemonic. Choice
1) The nurse will name the emotion. Choice
2) The nurse will state understanding of the emotion. Choice
3) The nurse will demonstrate respect. Choice
4) The nurse supports the family and patient. Choice
5) The nurse helps the family and patient explore possibilities.

Question 36

The family of a dying patient in the intensive care unit does not want a "do not attempt resuscitation" order. What should the nurse do to assist the family in seeing the value of this order? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Explain that other medical interventions will not be stopped.
2) Explain that comfort is the goal instead of a cure.
3) Explain that the patient will not receive less care.
4) Explain that the patient will be transferred out of the intensive care unit soon.
5) Explain that all medical care will be restricted going forward.

Question 37

The nurse case manager schedules a meeting with the family of a critically ill patient who is not responding to renal replacement therapy. If using the SPIKES approach, in which order should the nurse discuss the patient's health status with the family? Choice 1: Ensure privacy.
Choice 2: Speak in simple terms.
Choice 3: Develop a strategic plan.
Choice 4: Respond empathetically.
Choice 5: Assess the family's perception of the situation.
Choice 6: Ask how much information the family wants to know.

Question 38

The spouse of a dying critically ill patient is demonstrating suffering. What action should the nurse take to help the spouse at this time? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Establish and maintain eye contact with the spouse.
2) Hug the spouse.
3) Reply with therapeutic responses to the spouse's statements.
4) Convey sympathy to the spouse.
5) Leave the spouse alone in the room with the patient.

Question 39

The daughter of a critically ill patient is having difficulty making care decisions. The nurse suggests the daughter utilize the best-interest approach, which includes which of the following items? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Determining what would be in the best interest of the patient
2) Objectively examining the patient's quality of life and amount of function
3) Imagining herself as the patient and determining what she would want for care
4) Asking the physician to make the decision regarding ongoing care needs
5) Notifying all family members of the patient's status and making a group decision regarding care