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?

Accepted Answer

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?

Accepted Answer

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?

Accepted Answer

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?

Accepted Answer

1. This is a term that Kübler-Ross uses to describe the grieving process.
2. This is a term that Kübler-Ross uses to describe the grieving process.
3. Suffering (according to Morse) is required before the family can move forward. In this phase, the reality of the situation is accepted.
4. Enduring is the first phase and does not yet acknowledge the loss.

Question 5

Which approach should the nurse avoid when caring for the family of a dying patient?

Accepted Answer

1. This action will improve communication and minimize conflicts between staff and family.
2. This action will improve communication and minimize conflicts between staff and family.
3. This action will improve communication and minimize conflicts between staff and family.
4. Rushing the family to a quick decision is not wise and may cause resentment once the situation is better understood or accepted. Frequent repeating and allowing time to process all options lead to the best outcomes.

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?

Accepted Answer

1. These are not patterns of behavior identified by Morse.
2. Enduring and suffering are phases of the grief process that indicate the best approach for the nurse to use to help the family move forward through their grief. The nurse's response is based on the phase being exhibited by the family member at the time of the encounter. In the enduring phase, the nurse needs to respect the family member's physical space by not touching or hugging that individual at this time. The family member has not acknowledged the full impact of the situation and is attempting to control his or her emotions and the situation. In the second phase (suffering), the acknowledgment has occurred and the family member is emotionally responding to the loss. Suffering must be experienced before the person can move forward. Positioning, touching, and sharing are acceptable in the suffering phase.
3. These are not patterns of behavior identified by Morse.
4. These are not patterns of behavior identified by Morse.

Question 7

When caring for a bereaved family member, the nurse should avoid which inappropriate action?

Accepted Answer

1. This is an appropriate action by the nurse to express caring for the bereaved family.
2. This is an appropriate action by the nurse to express caring for the bereaved family.
3. Clichés do not offer comfort and may result in an inaccurate perception by the family. Just listening and offering self will allow the family members to express their feelings in a nonjudgmental manner. The nurse's role is to help the grieving process by allowing the family to express their feelings (not the nurse's).
4. This is an appropriate action by the nurse to express caring for the bereaved family.

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?

Accepted Answer

1. This would not help clarify the patient's end-of-life wishes.
2. This would not help clarify the patient's end-of-life wishes.
3. This would help clarify the patient's end-of-life wishes.
4. This would not help clarify the patient's end-of-life wishes.

Question 9

The nurse should set which goal when planning care for the family of a dying ICU patient? Select all that apply.

Accepted Answer

1. This is an appropriate goal when planning care for the family of a dying ICU patient.
2. This is an appropriate goal when planning care for the family of a dying ICU patient.
3. Individuality of culture and religious beliefs should be incorporated into the plan of care.
4. This is an appropriate goal when planning care for the family of a dying ICU patient.
5. Empathy, not sympathy, should be included in the plan of care. Showing an understanding of the situation and respect for the family's feelings will allow open communication and maximum understanding while the family deals with the situation.

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?

Accepted Answer

1. During the "R" step, relationships to the patient are identified and clarified. The family decision maker is also identified.
2. The health outcomes and management options are explained in step "O" (for outcome).
3. Assessing the family's reasoning and their comprehension of being present is a part of step "U" (for understanding).
4. Reacting to discussion findings is step "T" (for time to take action).

Question 11

A patient in the intensive care unit is being evaluated for brain death. Which finding is an indication of brain death?

Accepted Answer

1. This assesses the presence and degree of a coma.
2. Eight minutes and a pCO2 of 60 are required to determine apnea.
3. The absence of reflexes demonstrates that higher brain functions have ceased.
4. This is a part of the coma level assessment and alone will not validate the degree of brain function that is present or absent.

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?

Accepted Answer

1. When the death occurs despite all efforts by clinicians, it is called failed CPR.
2. Withdrawal is the category in which a therapy has been stopped after it has been decided that the therapy was not beneficial to the patient.
3. Brain death occurs when validation has shown that the brainstem lacks functioning.
4. Limitation refers to the decision to not initiate one or more interventions, such as ventilation, intubation, dialysis, enteral feedings, or vasopressors.

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.

Accepted Answer

1. By keeping the family at the bedside, the humanness of the patient is increased in the eyes of the staff.
2. By experiencing the CPR event, the family can see what really occurs and fantasy views or nightmares about death are minimized by the reality of the event.
3. Lawsuits may or may not be decreased by having the family at the bedside.
4. After receiving CPR, patients have reported receiving comfort and support from family members.
5. Costs are not on the minds of the family at this point in the health care process.

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?

Accepted Answer

1. This is not how the substituted judgment standard is implemented.
2. This does not explain the standard from which decisions are made by the health care proxy.
3. This is the correct definition of "substituted judgment," in which the proxy decides what the patient might desire for end-of-life care. The success of this approach may vary with the proxy's ability to see the situation from the patient's point of view.
4. What the health care providers "feel" should not be a factor in the decision-making process.

Question 15

How should the nurse explain "brain death" to a family member?

Accepted Answer

1. The definition of brain death is the irreversible loss of brain function that includes the brainstem.
2. Brain death is not just a decreased blood supply; other causes may be present to cause irreversible loss of function as well.
3. Electrical control of effective breathing may be one issue, but it does not include the irreversible aspect of the damage present. Breathing can be controlled by other means if the brainstem is still functioning.
4. Repair is not an option when the damage is irreversible.

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.

Accepted Answer

1. This action can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse.
2. Delegating the administration of pain medication through a patient-controlled device is not a nursing action that can be delegated to a family member. Medication is administered by licensed personnel only. Families do not have the understanding, education, or license to administer meds. Even if the family does have a license, the care of the patient is legally the responsibility of the staff.
3. This action can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse.
4. This action can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse.
5. This action can be delegated to the family once the process has been explained, supervised, and evaluated by the nurse.

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?

Accepted Answer

1. Stopping an already started therapy is referred to as "withdrawal."
2. Limiting family members has nothing to do with limiting care to a patient.
3. According to Copnell, limitation occurs when the decision is made not to institute a medical therapy because the therapy is unlikely to benefit the patient.
4. Stopping an already started therapy is referred to as "withdrawal."

Question 18

If a dying patient is being provided with IV hydration, the nurse should assess for which problem? Select all that apply.

Accepted Answer

1. Although some patients experienced improved sedation when they were hydrated, most experienced discomfort from fluid retention manifested as urinary retention.
2. Although some patients experienced improved sedation when they were hydrated, most experienced discomfort from fluid retention manifested as edema, ascites, incontinence, urinary retention, pleural effusion, or pulmonary secretions.
3. Although some patients experienced improved sedation when they were hydrated, most experienced discomfort from fluid retention manifested as pleural effusion or pulmonary secretions.
4. Although some patients experienced improved sedation when they were hydrated, most experienced discomfort from fluid retention manifested as edema.
5. The use of intravenous fluids in the dying patient will not increase the onset of an 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.

Accepted Answer

1. Absence of brainstem reflexes is determined by pupils 4 mm or larger that do not respond to light.
2. Brainstem response can be determined by assessing the oculovestibular reflex.
3. Brainstem response can be determined by assessing the corneal reflex.
4. Brainstem response can be determined by assessing the oculocephalic reflex.
5. Moro reflex is seen soon after birth and disappears with the development of the infant. It is also called the startle reflex that creates a flexion of the thighs and knees and a fanning out of the arms, as if trying to embrace someone.

Question 20

What does the nurse have a legal responsibility to prevent if family members are present while CPR is delivered to a patient?

Accepted Answer

1. This is not a staff concern about family presence during CPR.
2. Confidentiality and HIPAA require specific guidelines for the release of information to family. The concern for accidental leaking of this information during a CPR event could be quite high. Therefore, this concern would be an issue that needs specific planning and open communication with the family to make sure they understand why some information cannot be shared. Verbal and written permission from the patient cannot always be obtained in ICU prior to a CPR event; therefore, a conflict might arise where a breach of confidentiality might occur.
3. This is not a staff concern about family presence during CPR.
4. This is not a staff concern about family presence during CPR.

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