Deck 3: Palliative and End-Of-Life Care

Question 1

An 80-year-old female sustained a serious closed head injury following a fall.Family has decided to forgo placing the patient on mechanical ventilation and will not allow neurosurgery,electing to "let nature take its course." The nurse is very upset by this decision,thinking that the patient has a strong chance of a good quality of life following standard interventions.What nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)The nurse should try to persuade the family to allow treatment.
B)The nurse should be certain the family understands treatment options.
C)The nurse should transfer care to another nurse.
D)The nurse should ask the family to consider naming a legal guardian for the patient.
E)The nurse should contact hospital administration regarding legal action.

Answer 1

The nurse should be certain the family understands treatment options.
The nurse should transfer care to another nurse.

Question 2

The wife of a patient in the ICU says to the nurse,"I don't think my husband can get well.I wonder if we are doing the right thing keeping him on the breathing machine.Maybe we should just stop all of this.Would that be wrong?" Which responses by the nurse are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)"I think you are correct.I will contact the medical team."
B)"Once we put a patient on the ventilator it is very complicated to stop the treatment."
C)"I'll schedule a conference with your husband's care team so we can talk about options for his care."
D)"When recovery is unlikely it is considered ethical to discontinue treatments."
E)"The decision to discontinue treatment is made by the physician team."

Answer 2

"I'll schedule a conference with your husband's care team so we can talk about options for his care."
"When recovery is unlikely it is considered ethical to discontinue treatments."

Question 3

Which statements made by nurses who care for terminally ill patients demonstrate their understanding of the principle of double effect of pain management? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)"Since my patient's liver is damaged I must double the amount of pain medication administered."
B)"The medication I just gave my patient for pain could hasten his death."
C)"I must be careful that I don't administer enough pain medication to affect my patient's breathing."
D)"Using two classes of pain medications is more effective than using only one class."
E)"Pain medications can have both positive and negative effects."

Answer 3

"The medication I just gave my patient for pain could hasten his death."
"Pain medications can have both positive and negative effects."

Question 4

A family has given consent for organ donation for a patient who has been declared brain dead.The family is visiting the room for the first time since giving this consent.Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Explain that the mechanical ventilator is helping the patient continue to breathe.
B)Speak to the patient in a normal tone of voice.
C)Explain why the cardiac monitor continues to show a heart rate and ECG tracing.
D)Refer to the patient in terms of being dead.
E)Explain that intravenous lines and medications are being given to protect organ function.

Question 5

A patient has decided to forgo additional treatments for her terminal disease.The patient has presented a valid living will.The family is unhappy and tells the nurse they think the patient made the decision because of her depression.What response by the nurse is indicated?

A)"You need to let her make her own decisions."
B)"Do you think if we talked to her she would change her mind?"
C)"My role is to assure your loved one's wishes are followed."
D)"You need to talk to her physician about revising the do not resuscitate order."

Question 6

The nurse manager of an ICU is concerned about unit stress levels after there have been several "bad" deaths in the last month.Which statements,made by staff members,would validate need for concern? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)"Please assign this patient to someone else.I am sick of the family."
B)"Wow,we have had a bad month."
C)"I'll take the heart attack in pod 2 if you assign the postop bypass in pod 4 to someone else."
D)"I'll be glad to care for two patients if you will assign any new admits to someone else."
E)"Maybe when the moon changes our luck will change with it."

Question 7

The wife of a critically ill patient asks the nurse for help in making end-of-life care decisions for her husband.What action by the nurse is indicated?

A)Encourage the wife to recall any discussions with her husband about his wishes.
B)Encourage the wife to discontinue aggressive medical treatments as soon as possible.
C)Tell the wife what most other families have done in similar situations in the past.
D)Refer the wife to social services for information about end of life.

Question 8

A patient in the ICU is seriously ill following surgery for a ruptured gallbladder.Palliative care is being considered.Which statements,made by family members,would the nurse evaluate as potential barriers to providing palliative care? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)"I know she is really sick,but modern medicine can work miracles."
B)"I am so concerned that she is in pain."
C)"I just know the new antibiotic will turn her around."
D)"I think we should consider transferring her to a bigger hospital."
E)"She isn't eating enough."

Question 9

Nurses working on an ICU are showing signs of severe stress following several months of high census with many patient deaths and negative outcomes.What interventions should the nurse manager implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Make certain staff members are taking lunch and rest breaks throughout the shift.
B)Do an audit on the medical records of patients with negative outcomes to identify which nurses have provided much of their care.
C)Use unit discretionary funds to purchase healthy snacks for the unit breakroom.
D)Ask nurses to develop a new staffing system to allow more time off.
E)Provide coverage so that staff can attend regular debriefing sessions.

Question 10

The day shift nurse reports that a patient who is terminally ill has been restless but denies pain.The last PRN pain medication was administered 14 hours ago.What nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Reposition the patient to make him more comfortable.
B)Discuss acceptable levels of discomfort with the patient.
C)Administer pain medication along with the patient's other standard medications.
D)Ask the family if they think the patient is in pain.
E)Ask the patient to describe how he is feeling today.

Question 11

A committee of nurse managers is creating hospital protocol using guidelines from the National Consensus Project (NCP)Domains of Palliative Care.Which statements indicate that the nurses have good understanding of these domains? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)"The ethical aspects of palliative care will be outlined in a separate document."
B)"The protocols should take cultural concerns into consideration."
C)"Specific end-of-life protocols should follow guidelines written by a different consensus group."
D)"Physical aspects of care will be a primary issue in these protocols."
E)"The protocol should indicate that we refer any social issues to social service experts."

Question 12

A terminally ill patient has developed delirium since admission to the ICU.Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Collaborate with the physician to eliminate any medications that have the side effect of delirium.
B)Collaborate with the physician regarding the administration of haloperidol or ziprasidone.
C)Restrain the patient to prevent injury.
D)Avoid confrontation by "going along" with the patient's hallucinations.
E)Use objects like the television or newspapers to help maintain patient orientation.

Question 13

The family and medical team has decided to withdraw life-sustaining therapy.Which nursing interventions are indicated in preparation for this action? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Remove as much equipment as possible from the bedside to allow more room for visitors.
B)Inform the family that they will be brought to the room after death has occurred.
C)Remain in the room and watch the bedside monitor for documentation of time of death.
D)Provide patient hygiene measures prior to the initiation of withdrawal protocols.
E)Meet with the care team to discuss which medications and invasive equipment can be removed prior to initiating withdrawal.

Question 14

The physician providing care for a terminally ill patient orders an MRI of the patient's abdomen.The nurse does not think this treatment is necessary.How should the nurse respond to the physician who requested this test? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)"Will the benefits of this test outweigh the discomfort of transferring the patient to the MRI machine?"
B)"How will the results of this test change what we are doing for the patient?"
C)"I don't see the purpose of this test."
D)"We won't be able to schedule the MRI until the order is countersigned by the patient's surgeon."
E)"Has the family approved of us doing this testing?"

Question 15

A patient has been comatose and in the intensive care unit since having a stroke four days ago.Palliative care interventions were formally initiated yesterday.The nurse would evaluate that these strategies were effective if which situations occur? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)The family begins to ask questions about requesting a do-not-resuscitate order.
B)The need for a family meeting has been eliminated.
C)The patient is less restless.
D)The primary physician and neurologist consult agree that the patient's prognosis is grim.
E)The patient's daughter asks that the nurse not allow the patient's ex-husband to visit.

Question 16

A patient is extremely nauseated the day after receiving chemotherapy.The nurse would collaborate with the physician for which intervention to treat this nausea? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Placement of a nasogastric tube
B)Temporary nothing by mouth (NPO)status
C)Initiation of a serotonin receptor blocking medication
D)Initiation of a bowel motility agent
E)Initiation of a glucocorticoid medication

Question 17

A patient in the ICU is a candidate for palliative care.The patient is a widower with several siblings and children,but no one has legal power of attorney.Which steps should be made as planning for palliative care progresses? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)The oldest child should be designated as the primary decision maker.
B)The oldest of the patient's siblings should be designated as the primary decision maker.
C)A guardian,who may or may not be a family member,should be assigned.
D)The hospital's ethics committee should be consulted.
E)The patient's physician should be designated as the primary decision maker.

Question 18

A patient has just been declared dead following a massive myocardial infarction.The family is gathering in the waiting room.Which nursing interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Explain that an organ procurement representative will be in shortly to speak to the family.
B)Ask the family to move to a different area to wait for additional family to arrive.
C)Accompany family members as they go to the patient's room.
D)Assist the family with logistical and emotional support.
E)Call the hospital chaplain to come and speak to the family.

Question 19

During a patient care conference a nurse mentions that palliative care strategies seem to be helping the patient rest.The patient's daughter says,"I don't want you to give up on my father getting well.I don't want him in palliative care." What education should the nurse provide?

A)"We do palliative care on all of the patients on this unit."
B)"Palliative care interventions can be provided along with curative efforts."
C)"At this point,you should realize that your father is not going to get well."
D)"Hospice is not the same as palliative care."

Question 20

A patient has decided to explore palliative care.After this decision is announced,the nurse notices that not all the disciplines of the healthcare team seem to be supportive of the decision.What action by the nurse is indicated?

A)Contact the physician to report the discrepancies in the plan of care.
B)Discuss the patient's wishes in the next multidisciplinary meeting.
C)Develop a plan of care and distribute it to the other disciplines of the healthcare team.
D)Advise the patient to contact the social services department.