31: End-of-Life Care

Multiple Choice

1. The nurse is caring for a patient who just died. Which action does the nurse take first to determine if the patient is an organ or tissue donor?

a. Delegate the task to nursing assistive personnel (NAP).

b. Determine the patient’s legal representative.

c. Request a copy of the patient’s driver’s license.

d. Ask the spouse to sign an organ donation consent.

ANS: B

The nurse needs to determine if patient is an organ/tissue donor. Federal law mandates that family members be given a chance to authorize organ/tissue donation. The nurse should then call the organ/tissue request and procurement team (consult agency policy). Discussing organ donation and obtaining consent are tasks that the nurse cannot delegate because they require clinical judgment and critical thinking skills and are usually done by a special team. A copy of the patient’s driver’s license can be impractical or impossible to obtain soon enough to donate viable organs; generally the family knows the patient’s wishes about organ donation. If the spouse is the patient’s legal representative, he or she can provide consent.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. Apply oxygen with a face mask. b. Ask the family to leave the room. c. Speak to the patient calmly and softly. d. Administer extra pain medication.

2. The family of the patient receiving hospice care is at the bedside expecting an imminent death. They become upset when the patient suddenly becomes restless and disoriented. Which action by the nurse is most appropriate?

ANS: C

Restlessness and agitation are common patient assessments as death approaches and are part of the body’s preparation for death. The nurse explains that the upsetting behavior occurs frequently in the dying process and provides actions for the family to implement. For restlessness and agitation, the family can massage the hands or feet or play soothing music. Oxygen by face mask can increase patient distress and impair any ability to communicate. The nurse avoids asking the family to leave the room. The nurse explains that the patient’s behavior is very common, reflective more of the dying process than actual distress. The nurse administers pain medication according to the prescription and clinical judgment.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. Place a rolled-up towel under the patient’s chin. b. Stuff the mouth with cotton to maintain the facial contour. c. Tell the family to take the dentures to the funeral home. d. Ask the family what they want to do about this situation.

3. During postmortem care, the patient’s family says that the patient didn’t have his dentures to place in his mouth. Which action does the nurse take at this time?

ANS: A

If there are no dentures to place in the mouth after death, a rolled-up towel will help keep the patient’s mouth positioned appropriately, if this action is culturally acceptable. Cotton is not used by the nurse to maintain the patient’s mouth position. The dentures are easiest to place in the mouth immediately after death. It could be hours to several days until the patient’s body is taken to the funeral home, depending on whether an autopsy is done or not. The nurse should know what to implement regarding this situation.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. Maintain a darkened, cool room. b. Elevate the head of the bed. c. Catheterize the patient frequently. d. Provide warm, soothing liquids.

4. The patient is in the final stage of dying. Which action does the nurse implement?

ANS: B

The nurse elevates the head of the bed as tolerated to facilitate breathing; in addition, the patient looks more comfortable slightly elevated in bed, which can be comforting to the family. The nurse does not alter the temperature of the room unless requested to. The patient may be more relaxed if the lighting is dim rather than brightly lit. Because urine production slows significantly as death approaches, urinary catheters are usually unnecessary. Patients eat less and less as death approaches; simple items such as ice chips, a teaspoon of tea, or an ice pop are usually sufficient.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. Ask about the patient’s cultural or spiritual practices. b. Remove tubes and lines before they become difficult to remove. c. Cover the patient and transfer the body to the morgue. d. Remove the old patient identification (ID) band and apply a new one.

5. The nurse provides postmortem care for an unfamiliar patient. Which approach should the nurse use to best care for the body after death?

ANS: A

To best prepare the patient’s body after death, the nurse should exercise cultural sensitivity by inquiring about cultural or spiritual practices that the patient or family desires and implementing the practices to the best of the nurse’s ability. If family members are present, they often assume the responsibility for these rituals. Depending on the circumstances surrounding the death and on state law, the nurse may be required to leave all equipment and supplies in place. The nurse must check before removing any tubes or lines. He or she implements proper postmortem care for any patient, which includes much more than covering the patient with a sheet. The nurse leaves the original patient ID band to ensure patient identification in the morgue. The postmortem kit usually contains additional tags for patient identification.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. It eliminates all adverse symptoms. b. It improves the patient’s quality of life. c. It increases the daily caloric and fluid intake. d. It improves the amount of activity tolerated.

6. The nurse is caring for a patient who is dying but is receiving palliative care. What reason should the nurse give to the patient’s family for this type of care?

ANS: B

Palliative care focuses on symptom management, including pain control, to improve the quality of the patient’s life up to death. Palliative care is not curative and does not eliminate all adverse symptoms; it does not necessarily increase the daily caloric and fluid intake nor is its focus to improve the patient’s activity tolerance.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Planning a. Allowing the family members to wash and prepare the patient’s body b. Helping the family arrange for burial of the body c. Communion and prayers by the hospital minister d. Discussion of the finality of death

7. The nurse is caring for a Hindu patient receiving hospice care. Which does the nurse expect to facilitate for the family when the patient dies?

ANS: A

Hindu family members take an active role in preparing the body of a family member after death. Cremation, not burial, is traditional. Most likely the family will request the presence of a Brahmin priest who may chant prayers. A belief in reincarnation is held by those of the Hindu religion.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Planning a. Keep the head of the bed lowered. b. Provide regular hygiene and skin care. c. Reduce the amount of analgesics given. d. Encourage the patient to eat frequently.

8. The nurse plans nonpharmacological comfort measures for a patient who is dying. What activity by the nurse is most appropriate?

ANS: B

Patients near death can be incontinent; thus the nurse provides hygiene and skin care to enhance his or her appearance, provide comfort, and maintain dignity. Unless the patient is unable to tolerate it, the nurse keeps him or her in semi-Fowler’s position to facilitate breathing. The nurse administers adequate pain relief around-the-clock for the dying patient. Often eating increases discomfort in dying patients, so the nurse does not encourage feeding, but responds to the patient’s request for fluids or food.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. Hospice care b. A combination of hospice care and palliative care c. Palliative care d. Experimental curative therapy with hospice care

9. The nurse wants to provide specialized nursing care for a patient with a serious degenerative illness that is not life threatening but for which there is no cure. Which approach would the nurse use in the care of this patient?

ANS: C

The nurse knows that palliative care enhances the quality of life for the patient at any time during serious illness and is helpful with a long-term chronic illness. Hospice care is holistic patient care that helps the patient and family prepare for death. A combination of hospice care and palliative care would be used for a patient who is dying. When a patient enters hospice care, there are no further attempts to cure; rather the focus is on relief of adverse symptoms and promotion of the best quality of life possible for the remaining time a patient has.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Planning a. Understand that grief can begin long before the patient dies. b. The family needs to say good-bye to the patient. c. Update the family on every patient change. d. Provide a list of the area funeral homes and available services.

10. The nurse is caring for a patient who is dying. What action by the nurse facilitates family grieving?

ANS: A

Grief is a process that often begins before a patient dies. Survivors grieve as they anticipate a loss and continue to feel the grief after the patient dies. The nurse provides support, resources, information, and comfort based on the family’s needs and desires. He or she usually allows the family to visit at will when a patient is near death so that the family can and processing the events. Individuals process death and grieve in many different ways, and not everyone wants an opportunity to say good-bye; however, if a family member wishes to do so, the nurse facilitates the family’s wishes. The nurse avoids becoming involved in the decision about the funeral home and declines to offer an opinion about available businesses; however, he or she can provide an area telephone book and a telephone for the family.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. Provide hygienic care, including hair care, in their presence. b. Tell the family to ask any questions that they have about the patient. c. Place patient valuables in the body bag to go with the body to the morgue. d. Share other families’ past experiences of grief so they know they are not alone.

11. The family wants to see their family member who has just died. What actions does the nurse take when the family comes to visit?

ANS: B

When a family suffers a loss, grief can make it difficult to gather coherent thoughts and questions. The nurse should let the family know that they can ask questions when they are ready. The patient should have already been cleaned, including having the hair combed and dentures placed if present, unless that is not culturally acceptable. Any patient valuables should be given to the patient’s family. The focus is on the family experiencing the loss, not other families.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. “I will go into a hospice bed.” b. “I will no longer focus on a cure.” c. “My pain-management program will change.” d. “My physician team will change.”

12. The nurse is explaining to the patient the transition phase from palliative care to hospice care. Which statement by the patient indicates a good understanding of the process?

ANS: B

As a patient’s condition changes, the goals of care may shift away from curing an illness to care completely focused on symptom management and maintaining the highest possible quality of life. Ideally, patients who receive palliative care would move seamlessly into hospice care when they no longer benefit from curative treatments. They do not necessarily go to a hospice bed, and their pain-management program may change but it may stay the same initially. The physician team may also be the same.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Evaluation a. Tell the family they shouldn’t try to force food and fluid on the patient. b. Tell the family that it’s the patient’s right to refuse food and fluids. c. Explain to the family that loss of interest in food and fluid is normal at the end of life. d. Explain to the family that blood flow to the intestines decreases and eating is not desired.

13. The family of a dying patient is distressed that their loved one does not want to eat or drink and is constantly asking the patient to eat or drink something. What response by the nurse is best?

ANS: D

Near the end of life, as blood flow diminishes to all areas of the body, anorexia develops because the intestines are no longer working properly. Eating and drinking can cause discomfort and patients often refuse oral intake. While all options are correct statements, the best option is the one that explains the reason behind their loved one’s action to the family.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. “They were ordered by the provider so I have to give them.” b. “I don’t know but I can find out and let you know.” c. “Constipation causes abdominal discomfort so we try to prevent it.” d. “You don’t want the patient to get constipated, do you?”

14. The family of a dying patient asks the nurse “Why bother giving the patient laxatives and stool softeners now?” What response by the nurse is best?

ANS: C

Constipation can lead to abdominal distention and discomfort, so nursing care attempts to prevent it from occurring. Opioids, decreased food and fluid intake, and limited activity all can contribute to constipation before the blood flow to the intestines is impaired. The nurse understands why all medications are being given, but if he or she truly does not know the answer to a question, the correct response is to admit it, say you will find out, and say you will let the person asking know. Implying that the family member does not care about possible constipation is rude and demeaning.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. “The patient was in pain before so it’s wise to assume the pain is still present.” b. “These medications are ordered to be given around-the-clock.” c. “This is a standing palliative care medication routine.” d. “Opioids help with breathing and restlessness, making the family feel better.”

15. A patient with bone cancer and severe pain is nearing the end of life and is now unresponsive. The nurse continues to administer round-the-clock opioid analgesics. What does the nurse explain to the nursing student about this activity?

ANS: A

Just because the patient cannot express his or her views does not mean the patient is not in pain. The disease causing the severe pain has not gotten better, so there is no reason to think the patient’s pain has gone. Having a constant blood level of the medication helps maintain consistent pain control. The nurse will continue to give the pain medication around-the-clock. Telling the student that they are ordered this way does not give the student any useful information. Treatments are individualized in both palliative and hospice care. Opioids can help with breathing difficulties and restlessness, but the intervention is based on patient, not family, need.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. Raises the head of the bed 30 degrees. b. Closes the patient’s eyes. c. Ties the hands together over the abdomen. d. Replaces the patient’s dentures in the mouth.

16. The nurse and nursing assistive personnel are collaborating to perform post-mortem care on a recently deceased patient. What action by the NAP requires the nurse to intervene?

ANS: C

The weight of the arms and hands across the body causes tissue damage, so the nurse intervenes to correct the NAP. The other actions are appropriate.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation

Multiple Response

1. The nurse is explaining the similarities between palliative care and hospice care to the family of a patient. Which statements indicate a need for further education? (Select all that apply.)

a. Palliative care is used for patients nearing the end of their life.

b. Palliative care is only for those patients who are terminally ill.

c. Patients who are receiving palliative care continue treatments aimed at cure.

d. Patients are active participants in their care and decisions.

e. Patients are cared for by an interdisciplinary team.

ANS: A, B

The following are similarities between palliative care and hospice care: Prioritize for quality of life and relief from pain and other distressing symptoms. Integrate the physical, psychological, social, and spiritual dimensions into the care plan. Affirm life and regard dying as a normal process. Involve the patient and family as active participants in all decisions and care. Rely on the expertise of an interdisciplinary team for planning and implementing care. Appropriate for all patients, regardless of diagnosis, age, or setting.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Evaluation a. Swabbing mouth with alcohol-containing mouthwash b. Applying nonpetroleum lip balm when lips are dry c. Wiping mouth out with moist toothette or cloth every 2 hours d. Applying antifungal balm to patient’s tongue and gums e. Brush the patient’s teeth once a day

2. The nurse is caring for a dying patient and delegates hourly oral care to the nursing assistive personnel. What actions does the NAP perform? ( Select all that apply.)

ANS: B, C

The NAP provides oral care by using nonpetroleum lip balm to dry lips and moist toothettes or washcloths to wipe out the patient’s mouth. Alcohol-containing mouthwashes will hasten drying of mucus membranes. Antifungal balm is a medication, applied by the nurse. The patient needs oral hygiene more than once a day and may or may not include brushing the teeth, depending on if the patient has teeth and if it causes too much discomfort.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation a. Coca-Cola b. Milkshake c. Orange juice d. Chicken broth e. Ice chips

3. A patient on hospice care has been nauseated for two days, but now feels better and wishes to drink a little fluid. What fluid would the nurse bring the patient?

ANS: D, E

As nausea subsides, patients tolerate clear liquids best. The nurse would avoid any caffeinated liquids, milk, and fruit juices. Chicken broth or ice chips would be the best alternative.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Implementation

Matching

Match the symptoms seen near the end of life with an appropriate intervention.

a. Raise the head of the bed.

b. Use light blankets.

c. Gentle massage.

d. Give frequent hygiene.

e. Hold hand and speak quietly.

1. Bluish extremities

2. Unresponsiveness

3. Restlessness

4. Incontinence

5. Labored breathing

1. ANS: B DIF: Cognitive Level: Applying

OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation

MSC: Bluish extremities are often cool or cold and covering them with light blankets is comforting.

2. ANS: E DIF: Cognitive Level: Applying

OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation

MSC: Holding the patient's hand and speaking quietly is appropriate as the patient may still be able to hear.

3. ANS: C DIF: Cognitive Level: Applying

OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation

MSC: Restlessness is often relieved by gentle massage, soothing music, and dim lighting.

4. ANS: D DIF: Cognitive Level: Applying

OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation

MSC: The incontinent patient may require frequent hygiene and the nurse would assess if the patient is becoming exhausted from this activity. If so, or if the skin is excoriated, an indwelling urinary catheter may be preferred.

5. ANS: A DIF: Cognitive Level: Applying

OBJ: NCLEX: Psychosocial Integrity TOP: Nursing Process: Implementation a. May wish to face the east as they are dying. b. A family member may stay with the body until burial. c. A peaceful environment at the time of death is preferred. d. Rituals of confession or anointing the sick may occur. e. Only the family should wash the body after death. 6.

MSC: Elevating the head of the bed often helps with alterations in breathing. The nurse also administers pain medication and anxiolytics.

Match the religious faith with a common practice.

6. ANS: B DIF: Cognitive Level: Understanding

OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring

MSC: After death of a Jewish patient a family member may remain with the body until the burial has occurred.

7. ANS: C DIF: Cognitive Level: Understanding

OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring

MSC: A peaceful environment is optimal for Buddhists so if the patient is awake, he or she can meditate or contemplate their death.

8. ANS: A DIF: Cognitive Level: Understanding

OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring

MSC: A Muslim may wish to face Mecca, which is in the east, as they are dying.

9. ANS: E DIF: Cognitive Level: Understanding

OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring

MSC: Only the family of a Hindu patient who has died should touch the body and they are responsible for washing and preparing it.

10. ANS: D DIF: Cognitive Level: Understanding

OBJ: NCLEX: Psychosocial Integrity TOP: Integrated Process: Caring

MSC: Some Christian rituals near the time of death include rituals of confession and anointing of the sick.