Nursing Critical Care Questions Chapter 4

Chapter 04: Palliative and End-of-Life Care MULTIPLE CHOICE 1. A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam 1 to 2 mg IV as needed (prn). The patient has received no lorazepam during this course of illness. What is the most appropriate nursing intervention to control agitation? a. Administer fentanyl (Duragesic) 25 mg IV bolus. b. Administer midazolam 2 mg IV now. c. Increase the rate of the morphine infusion by 50%. d. Request an order for a paralytic agent. ANS: Midaz am 2 mg IV is an appropriate loading dose for a patient who is benzodiazepine naïve and ex riencing agitation during withdrawal of life support. Fentanyl treats pain and morph e controls pain. Paralytic agents are not warranted. DIF: OBJ: TOP: MSC: ognitive Level: Analysis escribe nursing interventions to support the patient and family during the end-of-life stage. ursing Process Step: Implementation CLEX: Physiological Integrity 2. A 75-y r-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and has req has ap states was be and th a. Eu b. Pa c. W d. W red ventilatory support since the time of the stroke. The primary health care provider oached the spouse regarding placement of a permanent feeding tube. The spouse t the patient never wanted to be kept alive by tubes and personally didn’t want what g done. After holding a family conference with the spouse, the medical team concurs eeding tube is not placed. What term would be used to describe this situation? anasia ative care drawal of life support holding of life support ANS: Because the tube feeding had not been placed in the care of this patient, this scenario is an example of withholding of life support. Withholding of life support does not constitute euthanasia. Withdrawal of life support involves discontinuation of previously established therapies in a terminally ill patient. DIF: Cognitive Level: Understand OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment 3. What were the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT)? a. Clear communication is typical in the relationships between most patients and healthcare providers. b. Critical care units often meet the needs of dying patients and their families. c. Disparities exist between patients’ care preferences and actual care provided. d. Pain and suffering of patients at end of life is well controlled in the hospital. ANS: Dispar health patient hospit es and lack of communication are common in the relationships between patients and e providers. Critical care units are often poorly equipped to meet the needs of dying The SUPPORT study demonstrated that pain and suffering is widespread in . DIF: gnitive Level: Knowledge OBJ: scuss concepts of end-of-life care, including palliative care; communication and conflict resolut ; withholding or withdrawing therapy; and psychological support of the patient, family membe and healthcare providers. TOP: Nursing Process Step: Assessment MSC: CLEX: Safe and Effective Care Environment 4. A state ent that provides a legally recognized description of an individual’s desires regarding care at a. Ad b. Gu c. He d. Po ANS: Legall are adv health files le design is an in incapa DIF: OBJ: TOP: e end of life is referred to as what? nce directive dianship ad item hcare proxy r of attorney ecognized documents that provide guidance on an individual’s end-of-life choices nce directives. Advance directives include living wills, durable power of attorney for re, and healthcare surrogate designations. A guardianship ad litem is a parent who l action on the behalf of a child. A healthcare proxy is an individual who is legally ed through statute to make decisions for an incapacitated person. A power of attorney vidual who is, through filing of legal papers, authorized to act on the behalf of an ated person in legal matters. gnitive Level: Comprehension scribe ethical and legal concerns related to end-of-life care. rsing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 5. A 65-y r-old patient with a history of metastatic lung carcinoma has been unresponsive to chemo availab the po This is a. Me b. Pa c. Te d. Wi ANS: erapy. The medical team has determined that there are no additional treatments that will prolong life or improve the quality of life in any meaningful way. Despite prognosis, the patient continues to receive chemotherapy and full nutrition support. n example of what end-of-life concept? cal futility ative care inal weaning drawal of treatment Medical futility is a situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patient’s health status. Palliative care focuses on symptom relief and is not limited to the dying. Terminal weaning refers to withdrawal of artificial ventilation interventions. Withdrawal of treatment refers to removal of established therapies in a terminally ill patient. DIF: Cognitive Level: Understand OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 6. What should a designated healthcare surrogate base healthcare decisions on? a. Personal beliefs and values b. Recommendations of family members and friends c. Recommendations of the physician and healthcare team d. Wishes previously expressed by the patient ANS: Healt sugge shoul recom e surrogates attempt to have decisions match the wishes of the patient. Although ns of family and friends may provide insight into patient desires, actual decisions based upon known patient wishes. The physician and healthcare team may provide ndations, but decisions should be based upon the patient’s wishes. DIF: OBJ: TOP: gnitive Level: Analysis scribe ethical and legal concerns related to end-of-life care. rsing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 7. Whic atement made by a staff nurse identifying guidelines for palliative care would need correc ? a. B nursing care is a critical element in palliative care management. b. C mon conditions that require palliative management are nausea, agitation, and sl disturbance. c. Pa tive care practices are reserved for the dying client. d. Pa tive care practices relieve symptoms that negatively affect the quality of life of atient. ANS: The purpose of palliative care is to relieve negative symptoms that affect the quality of life of a patient. Palliative care is an integral part of every injured or ill patient’s care. Basic nursing care, including repositioning, skin care, and provision of a peaceful environment, promote comfort. These conditions all commonly require palliative care techniques. DIF: Cognitive Level: Analysis OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment 8. Which statement is true regarding the impact of culture on end-of-life decision making? a. African-Americans prefer more conservative, less invasive care options during the end of life. b. Caucasians prefer aggressive and more invasive care options during the end of life. c. Culture and religious beliefs may affect end-of-life decision making. d. Perspectives regarding end-of-life care are similar between and within religious groups. ANS: Religi decisi Africa prefer within s doctrines, ethnicity, and cultural beliefs have profound impact on end-of-life s. Americans prefer more aggressive and invasive end-of-life care options. Caucasians ss aggressive care options at the end of life. Perspectives on end-of-life care vary nd between religious groups. DIF: TOP: ognitive Level: Analysis ursing Process Step: Assessment OBJ: Discuss cultural considerations in end-of-life care. MSC: NCLEX: Psychosocial Integrity 9. What he most critical element of effective early end-of-life decision making? a. Co rol of distressing symptoms such as nausea, anxiety, and pain. b. Ef ctive communication between the patient, family, and healthcare team th ghout the course of the illness. c. Or nizational support of palliative care principles. d. Re cation the dying patient from the critical care unit to a lower level of care. ANS: The fa end-o Early and fa dimen staffin family the ne princi re of clinicians, family members, and patients to openly discuss prognoses, fe wishes, and preferences contributes to care conflicts such as in the Schiavo case. cussion of end-of-life wishes is required to promote positive outcomes for the patient ly, and actually should predate illness. Even though symptom control is a significant on of palliative care, it is not involved in initial end-of-life decision making. Adequate and facility policies that support the dying patient are critical but should not impact ecision making. The patient should be cared for in an environment that best supports s of the patient and family. Even though organizational support of palliative s is important, it should not drive individual decision making. DIF: OBJ: resolu memb MSC: ognitive Level: Analysis scuss concepts of end-of-life care, including palliative care; communication and conflict n; withholding or withdrawing therapy; and psychological support of the patient, family and healthcare providers. TOP: Nursing Process Step: Assessment CLEX: Psychosocial Integrity 10. A pati appro a. A in b. A m c. H d. H ANS: t with end-stage heart failure is experiencing considerable dyspnea. What is the ate pharmacological management of this symptom? inistration of 6 mg of midazolam and initiation of a continuous midazolam ion. inistration of morphine, 5 mg IV bolus, and initiation of a continuous hine infusion. ly increases of the midazolam (Versed) infusion by 100% dose increments. ly increases of the morphine infusion by 100% dose increments. Morphine is an excellent agent to control the symptom of dyspnea. A 5-mg IV bolus and initiation of a morphine drip is an appropriate initial intervention to control dyspnea. Initial dosing of midazolam should be 2 to 4 mg, and more is indicated for anxiety. The morphine dose should be titrated incrementally by 50% dose increases. Midazolam is indicated for management of dyspnea and is titrated incrementally by 50% dose increases. DIF: OBJ: TOP: MSC: Cognitive Level: Application Describe nursing interventions to support the patient and family during the end-of-life stage. Nursing Process Step: Implementation NCLEX: Physiological Integrity 11. Which statement is consistent with societal views of dying in the United States? a. Dying is viewed as a failure on the part of the system and providers. b. Most Americans would prefer to die in a hospital to spare loved ones the burden of care. c. People die of indistinct, complex illness for which a cure is always possible. d. The purpose of the healthcare system is to prevent disease and treat symptoms. ANS: Death manag Ameri distinc health viewed as a failure by society and healthcare providers that results in aggressive ment of disease, even in unfavorable situations. Research has indicated that most ns would prefer to die at home. There is a commonly held belief that people die of iseases, implying that a cure is possible. There is a commonly held belief that the e system exists to treat illness, disease, and injury and to “save” lives. DIF: gnitive Level: Comprehension OBJ: scuss concepts of end-of-life care, including palliative care; communication and conflict resolut ; withholding or withdrawing therapy; and psychological support of the patient, family membe and healthcare providers. TOP: Nursing Process Step: Assessment MSC: CLEX: Safe and Effective Care Environment 12. Which ursing intervention would need to be corrected on a care plan for a patient in order to be con tent with the principles of effective end-of-life care? a. Co rol of distressing symptoms such as dyspnea, nausea, and pain through use of ph macological and nonpharmacological interventions b. Lim ation of visitation to reduce the emotional distress experienced by family me bers c. Pa nt and family education on anticipated patient responses to withdrawal of the py d. Pro sion of spiritual care resources as desired by the patient and family ANS: Active involvement of family is a critical dimension of end-of-life care. Family members should have access to the patient and inclusion in care to the degree they desire. Limitation of visitors is not consistent with effective end-of-life care practices. Control of distressing symptoms is a dimension of end-of-life care. Family education and anticipatory guidance are critical elements of end-of-life care. Meeting the emotional and psychological needs of the patient and family through provision of spiritual resources and bereavement care is a critical element of end-of-life care. DIF: Cognitive Level: Analysis OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage. TOP: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 13. In which situation would a healthcare surrogate or proxy assume the end-of-life decision-making role for a patient? a. When a dying patient requires extensive heavy sedation, such as benzodiazepines and narcotics, to control distressing symptoms b. When a dying patient who is competent requests to withdraw treatment against the wishes of the family c. When a dying patient who is competent requests to continue treatment against the recommendations of the healthcare team d. When a dying patient who is competent is receiving prn treatment for pain and anxiety ANS: A pati medic surrog medic family situati findin t who requires heavy sedation, such as IV infusions of pain medications or anxiolytic ons, would not be competent to make healthcare decisions. A healthcare proxy or e would be required in this situation. A patient who is deemed competent by the team may be responsible for healthcare decisions even if these are not consistent with eliefs. A surrogate would not assume decision-making responsibilities in this . A healthcare team member who cannot support decisions would be responsible for n alternative care provider who could support the patient’s wishes. DIF: OBJ: TOP: ognitive Level: Analysis escribe ethical and legal concerns related to end-of-life care. ursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment 14. Which atement is true regarding the effects of caring for dying patients on nurses? a. At ndance at funerals is inappropriate and will only create additional stress in nu es who are already at risk for burnout. b. Ca ng for dying patients is an expected part of nursing and will not affect the em ea c. M pa d. Pr re ional health of the nurse if he or she maintains a professional approach with patient and family. nurses who work with dying patients are able to balance care needs of nts with personal emotional needs. ision of aggressive care to patients for whom they believe it is futile may t in personal ethical conflicts and burnout for nurses. ANS: Burnout may occur when nurses must provide aggressive care to patients for whom they believe it is futile or when care choices made by patients and/or surrogates differ from those of clinicians. Attendance at funerals may relieve emotional strain in some situations. Meeting the emotional needs of patients and families often requires that the nurse invest emotionally while providing care. Maintaining a professional, healthy distance and being human when working with the dying is a difficult task that requires a great deal of balancing. DIF: Cognitive Level: Analysis OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 15. The family is considering withdrawing life-sustaining measures from the patient. The nurse knows that ethical principles for withholding or withdrawing life-sustaining treatments include which of the following? a. Any treatment may be withdrawn and withheld, including nutrition, antibiotics, and blood products. b. Doses of analgesic and anxiolytic medications must be adjusted carefully and should not exceed usual recommended limits. c. Life-sustaining treatments may be withdrawn while a patient is receiving paralytic agents. d. The goal of withdrawal and withholding of treatments is to hasten death and thus relieve suffering. ANS: Any tr produc surrog dose o the po patien diseas tment that is used to sustain life, including nutrition, fluids, antibiotics, blood , and respiratory support, may be withdrawn in consultation with the patient and/or e provided that the patient has been deemed terminal or persistently vegetative. Any nxiolytics or analgesics may be used to relieve suffering, although these may have ntial to hasten death. Life-sustaining treatment should not be withdrawn while the s receiving paralytic treatments. Death occurs as a consequence of the underlying and the goal of care is to relieve suffering, not hasten death. DIF: OBJ: TOP: ognitive Level: Understand escribe ethical and legal concerns related to end-of-life care. ursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment 16. The pa ent’s significant other is terrified by the prospect of removing life-sustaining treatm nurse a. “It b. “It fro c. “It un d. “W ts from the patient and asks why anyone would do that. What explanation should the ovide? to save you money so you won’t have such a large financial burden.” ill preserve limited resources for the hospital so other patients may benefit them.” to discontinue treatments that are not helping and may be very mfortable.” have done all we can for your wife and any more treatment would be futile.” ANS: The goal of withdrawal of life-sustaining treatments is to remove treatments that are not beneficial and may be uncomfortable. DIF: Cognitive Level: Application OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 17. All of the patient’s children are distressed by the possibility of removing life-support treatments. The child who is most upset tells the nurse, “This is the same as killing! I thought you were supposed to help!” What response would the nurse provide to the family? a. “This is a process of allowing death to occur naturally after the injuries that were sustained in a serious accident.” b. “The hospital would never allow us to do that kind of thing.” c. “Let’s talk about this calmly, and I will explain why assisted suicide is appropriate in this case.” d. “Your parent lived a long and productive life.” ANS: Forgoi life-sustaining treatments is not the same as active euthanasia or assisted suicide. Killing s an action causing another’s death, whereas allowing dying is avoiding any interve ion that interferes with a natural death following illness or trauma. DIF: ognitive Level: Application OBJ: scuss concepts of end-of-life care, including palliative care; communication and conflict resolut ; withholding or withdrawing therapy; and psychological support of the patient, family membe and healthcare providers. TOP: Nursing Process Step: Implementation MSC: CLEX: Safe and Effective Care Environment 18. To pre the nu a. Do tre b. Th c. DN tre d. Th res nt any unwanted resuscitation after life-sustaining treatments have been withdrawn, should ensure that what intervention has been implemented? ot-resuscitate (DNR) orders are written before discontinuation of the ments. amily is not allowed to visit until the death occurs. orders are written as soon as possible after the discontinuation of the ments. change-of-shift report includes the information that the patient is not to be citated. ANS: DNR o ders should be written before withdrawal of life support; this will prevent any unfort ate errors in unwanted resuscitation during the time period between initiation of withdr wal and the actual death. DIF: OBJ: TOP: MSC: ognitive Level: Application escribe ethical and legal concerns related to end-of-life care. ursing Process Step: Implementation CLEX: Safe and Effective Care Environment 19. The pa ent’s spouse is very upset because the patient, who is near death, has dyspnea and restles a. Re b. Op c. Inc d. Inc ess. The nurse explains what options to decrease the discomfort? iratory therapy treatments id medications given as needed ntive spirometry treatments ased hydration. ANS: Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow). DIF: Cognitive Level: Application OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20. The patient’s partner, experiencing anticipatory grieving, tells the nurse, “I don’t see any point in continuing to visit at the bedside, since it’s like I’m not even here.” What is the nurse’s best response to the partner’s statement? a. “You’re right, there is no awareness of anything going on now.” b. “Unresponsiveness doesn’t mean the sense of hearing is gone and there is a benefit from you being present.” c. “I’ll call you if the patient begins responding again.” d. “Why don’t you check to see if any other family member would like to visit?” ANS: The pa option ay still be able to hear despite appearing to be nonresponsive. None of the other de a benefit for the continued presence of the partner. DIF: OBJ: TOP: ve Level: Application e nursing interventions to support the patient and family during the end-of-life stage. Process Step: Planning MSC: NCLEX: Psychosocial Integrity 21. Which a. W the b. Ea be c. On d. W following statements about comfort care is accurate? ng and withdrawing life-sustaining treatment are distinctly different in f the legal community. edure should be evaluated for its effect on the patient’s comfort before lemented. atient can determine what constitutes comfort care for him or her. ing life-sustaining treatments is considered euthanasia in most states. ANS: The go the pa omfort care is to provide treatments that do not cause pain or other discomfort to DIF: OBJ: resolut membe MSC: ve Level: Comprehension concepts of end-of-life care, including palliative care; communication and conflict hholding or withdrawing therapy; and psychological support of the patient, family healthcare providers. TOP: Nursing Process Step: N/A : Psychosocial Integrity MULTIPLE 1. Which a. Co b. Di c. Di d. Ti e. Ti NSE ntions may be included during “terminal weaning”? (Select all that apply.) extubation following ventilator withdrawal uation of artificial ventilation but maintenance of the artificial airway uation of anxiolytic and pain medications f ventilator support based upon blood gas determinations f ventilator support to minimal levels based upon patient assessment of co ANS: “Terminal weaning” may include titration of ventilator support to minimal levels, removal of the ventilator with maintenance of the artificial airway, and complete extubation. Pain and anxiolytic medications may be required to control dyspnea and anxiety that may accompany ventilator withdrawal. Blood gas determinations would be used in therapeutic ventilator management. DIF: OBJ: TOP: MSC: Cognitive Level: Analysis Describe nursing interventions to support the patient and family during the end-of-life stage. Nursing Process Step: Implementation NCLEX: Physiological Integrity 2. Which therapeutic interventions may be withdrawn or withheld from the terminally ill client? (Select all that apply.) a. Antibiotics b. Dialysis c. Nutrition d. Pain medications e. Repositioning and hygiene ANS Any end o thera may Dign prov at is life sustaining may be withheld from a terminally ill patient during the treatments include nutrition, dialysis, fluids, antibiotics, respiratory support, cations, and blood products. Any dose of analgesic or anxiolytic medication revent suffering and should not be withdrawn. e maintained during the course of dying. This would include ongoing c nursing care and comfort. DIF: OBJ: TOP: Level: Analysis hical and legal concerns related to end-of-life care. ocess Step: Assessment MSC: NCLEX: Physiological Integrity 3. Whic who appl a. C b. A a c. F d. L e. R c ons can the nurse use to facilitate communication with patients and families ocess of making decisions regarding end-of-life care options? (Select all that on of uniform messages from all healthcare team members plan of care that is developed collaboratively by the patient, family, e team f continuity of care through accurate shift-to-shift and transfer reports time for families to express feelings in order to control family grief e patient and family that they will not be abandoned as the goals of m aggressive treatment to comfort care ANS Effective and consistent communication between the patient, family, and healthcare team members is required to promote positive outcomes during end-of-life care. Family members should be provided ample time to express feelings in order to improve the level of satisfaction and prevent dysfunctional bereavement patterns. DIF: OBJ: TOP: MSC: Cognitive Level: Analysis Describe nursing interventions to support the patient and family during the end-of-life stage. Nursing Process Step: Implementation NCLEX: Psychosocial Integrity 4. Palliation care includes what goals? (Select all that apply.) a. Pain relief b. Nausea relief c. Psychological support d. Withdrawal of life-support interventions e. Withholding tube feedings ANS: Palliati patient DIF: OBJ: resoluti membe MSC: 5. When which a. Un b. Un c. Ro d. Clo e. Par s relieving symptoms that may have a negative effect on the family or the evel: Analysis ncepts of end-of-life care, including palliative care; communication and conflict ding or withdrawing therapy; and psychological support of the patient, family thcare providers. TOP: Nursing Process Step: Implementation hysiological Integrity palliative care, the nurse must keep in mind that the family may include owing? (Select all that apply.) e partners of same sex e partners of opposite sex ANS: The definition of family varies and may include unmarried life partners of the same or opposite sex, close friends, and other close individuals who have no legal relationship with the patient. DIF: Cognitive Level: Understand OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage. TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity