CHPT 16

MOSTLY CASE STUDIES

100

Scenario: A 45-year-old client has just been diagnosed with a terminal stage of ALS. During the assessment, the client’s spouse is seen crying in the hallway, stating, "I can't imagine my life without them. I feel like I'm already losing them." The spouse also reports having trouble sleeping and a loss of appetite since the diagnosis was shared.

Rationale: The spouse is experiencing ___ __, which occurs when a person knows a loss is going to occur in the future. 

The physical symptoms reported (sleep alterations, loss of appetite) are common symptoms of grief. 

The nurse’s priority is to ____ ____ ___ by reassuring the grieving person that their loss is important and understood, providing a quiet presence, and listening as they speak about their pain

.

• Rationale: The spouse is experiencing anticipatory grief, which occurs when a person knows a loss is going to occur in the future. 
• The physical symptoms reported (sleep alterations, loss of appetite) are common symptoms of grief. 
• The nurse’s priority is to validate the loss by reassuring the grieving person that their loss is important and understood, providing a quiet presence, and listening as they speak about their pain.

200

Scenario: A patient with end-stage renal failure says to the nurse, "If I can just make it to my daughter’s wedding in three months, I promise I will be the best patient and never complain about the dialysis again". 

• Rationale: The patient is in the ___ ___. This stage is characterized by the wish for an ___ ___ __ or relief from pain, often based on the experience that "good behavior" is rewarded. The patient is attempting to "make a deal" to reach a specific milestone.

• Rationale: The patient is in the Bargaining stage. This stage is characterized by the wish for an extension of life or relief from pain, often based on the experience that "good behavior" is rewarded. The patient is attempting to "make a deal" to reach a specific milestone.

300

Scenario: Mrs. Rodney is in a palliative care unit with metastatic breast cancer. She is receiving scheduled morphine but is grimacing and holding her body rigid. Her daughter asks the nurse, "Aren't you worried that giving her more morphine will make her die faster?". 

• Rationale: The nurse should explain that there is no ___ __ __ or reaching __ ___ _____when narcotics are increased in response to pain in a dying patient. Research suggests that increasing opioid dosages in terminal patients does not hasten death, cause loss of consciousness, or lead to addiction. Furthermore, ___ ___ controls pain more successfully than PRN (as needed) dosing, as it is easier to prevent severe pain than to curtail it once it has begun.

Rationale: The nurse should explain that there is no risk of addiction or reaching a safety limit when narcotics are increased in response to pain in a dying patient

. Research suggests that increasing opioid dosages in terminal patients does not hasten death, cause loss of consciousness, or lead to addiction

. Furthermore, scheduled dosing controls pain more successfully than PRN (as needed) dosing, as it is easier to prevent severe pain than to curtail it once it has begun

.

400

Scenario: A dying patient has developed noisy, rattling respirations, often referred to as the "death rattle".

 The family is distressed by the sound and is also concerned that the patient is "starving to death" because they have stopped eating and drinking.

FILL OUT THE FOLLOWING RATIONALE:

Rationale: For the "death rattle," the nurse should explain that the patient is usually unaware of the secretions and that __ __ __ on their side or elevating the head of the bed is more effective than suctioning, which can be distressing. Regarding nutrition and hydration, the nurse should clarify that __ results in less distress and ___ for the dying patient. Withholding fluids is often more comforting because decreased intake is a natural part of the body slowing down; additionally, the breakdown of body fat during starvation can act as a natural ___ ____.

Rationale: For the "death rattle," the nurse should explain that the patient is usually unaware of the secretions and that positioning the patient on their side or elevating the head of the bed is more effective than suctioning, which can be distressing. Regarding nutrition and hydration, the nurse should clarify that dehydration results in less distress and pain for the dying patient. Withholding fluids is often more comforting because decreased intake is a natural part of the body slowing down; additionally, the breakdown of body fat during starvation can act as a natural pain reliever

500

Scenario: A patient with advanced COPD is tired of frequent hospitalizations and "aggressive treatments" like intubation. They want to focus on staying at home and being comfortable but are not quite ready to "give up" on all medical interventions. 

fill in the rationale

• Rationale:___ ____is appropriate here, as it is not exclusive to end-of-life care and can be used at any___ of a ___ ___ to optimize the quality of life by relieving symptoms and stress. This aligns with the ___ ___ ___ ___, specifically the right to participate in their care and its planning, as well as the right to be treated as a ___ __ ___. The focus of palliative care is to transition from a curative focus to a focus on ___ __ ___.

HINT *Which care model is most appropriate for this patient, and which "Right of the Dying Patient" supports their choice to refuse aggressive measures?

• Rationale: Palliative care is appropriate here, as it is not exclusive to end-of-life care and can be used at any stage of a serious illness to optimize the quality of life by relieving symptoms and stress. This aligns with the Rights of the Dying Patient, specifically the right to participate in their care and its planning, as well as the right to be treated as a person until death. The focus of palliative care is to transition from a curative focus to a focus on quality of life.

SHES GONE

100

A patient with terminal breast cancer tells the nurse, "If I can just live long enough to see my grandson graduate, I will be ready to go." According to Kübler-Ross, which stage of coping is this patient experiencing?

A.Denial

B.Acceptance

C.Anger

D.Bargaining

D.Bargaining

This stage involves a wish for the extension of life or relief from pain, often expressed as a 'deal' for 'good behavior' or reaching a milestone.

200

The family of a dying patient is distressed by the 'noisy, rattling' sounds of the patient's respirations. Which nursing intervention is most appropriate for managing this symptom, known as the 'death rattle'?

A. Positioning the patient on their side or elevating the head of the bed

B. Increasing the oxygen flow via non-rebreather mask

C. Administering high doses of intravenous fluids to thin secretions

D. Frequent deep suctioning of the secretions

A. Positioning the patient on their side or elevating the head of the bed

Proper positioning helps secretions drain or settle, which may reduce the noise of respirations and improve comfort.

300

A nurse is caring for a patient at the end of life who has developed kidney impairment. According to the medication guidelines for this condition, which opioid should the nurse expect to be listed as 'DO NOT USE'?

A.Oxycodone

B.Fentanyl

C.Meperidine

D.Methadone

C.Meperidine

This medication is specifically contraindicated for patients with kidney impairment due to the risk of toxicity from its metabolites.

400

The family of a terminally ill patient expresses concern that providing morphine for pain will 'make him die faster.' Which response by the nurse is based on clinical evidence?

A.We will stop the morphine if his respiratory rate drops below 12 breaths per minute.

B.Pain medication is only given when the patient is within minutes of death to avoid complications.

C.There is no risk of addiction or reaching a safety limit when narcotics are increased for end-of-life pain.

D.Morphine actually stimulates the heart and can prolong the patient's life slightly.

C. There is no risk of addiction or reaching a safety limit when narcotics are increased for end-of-life pain.

The focus of palliative care is comfort; research shows that appropriately titrated doses for pain do not hasten death.

500

Which term describes the state of having suffered a loss, specifically the loss of a person through death?

A. Anticipatory grieving

B.Grief

C.Bereavement

D.Closure

C. Bereavement

This term refers specifically to the state or condition caused by the death of a loved one.

THEY BOUGHT THE FARM

100

When educating a family about the benefits of 'patient-endorsed intake' and dehydration at the end of life, which physiological benefit should the nurse mention?

A.Decreased edema and fewer episodes of incontinence

B.Increased urine output to prevent bladder infections

C.Improved alertness and cognitive function

D.Enhanced effectiveness of oral medications

A.Decreased edema and fewer episodes of incontinence

Reduced fluid intake results in less fluid accumulation in tissues and less urine production, increasing overall comfort.

200

According to the WHO Three-Step Ladder for Pain Relief, what is the appropriate first step for managing a patient's pain?

A.Immediately administer a strong opioid to prevent the cycle of pain

B.Start with nonopioid drugs with or without an adjuvant therapy

C.Administer PRN (as needed) doses only to avoid sedation

D.Use nonpharmacologic methods exclusively until they no longer work

 B. Start with nonopioid drugs with or without an adjuvant therapy

The ladder begins with the least invasive/potent options and progresses to stronger medications as needed.

300

A nurse is assessing a patient for 'anticipatory grieving.' Which situation best illustrates this concept?

A.A patient with a terminal diagnosis starting to mourn their own future life.

B.A woman crying at her husband's funeral two days after his death.

C.A nurse feeling emotional after a patient they cared for passes away.

D.A family member feeling trapped in a stage of grief one year after a loss.

A. A patient with a terminal diagnosis starting to mourn their own future life.

This occurs when a person knows a loss is coming and begins the grieving process before the event occurs.

400

The 'Rights of the Dying Patient' (Box 16.3) includes which of the following?

A.The right to receive aggressive life-prolonging treatments against a physician's advice

B.The right to be told what to believe spiritually by the medical staff

C.The right to have pain controlled and be treated as a human being until death

D.The right to have all medical records shared with any inquiring relative

C.The right to have pain controlled and be treated as a human being until death

Maintaining dignity and managing pain are fundamental rights for all terminal patients.

500

A nurse observes a dying patient experiencing hallucinations and an altered mental status. Which is the most appropriate initial nursing action?

A. Immediately administer a strong sedative to stop the hallucinations

B. Encourage the family to speak to the patient in quiet tones while remaining calm

C. Tell the patient their hallucinations are not real to help reorient them

D. Restrict all visitors to prevent further overstimulation of the patient

B. Encourage the family to speak to the patient in quiet tones while remaining calm

Providing a soothing environment and involving the family in a gentle way helps manage the patient's distress during delirium.

HEAVENS NO

100

Which stage of Kübler-Ross's theory is marked by a sense of great loss, mourning lost family and possessions, and a feeling of hopelessness?

Depression

200

In the 'Acceptance' stage of dying, what is the typical emotional and physical state of the patient?

The patient has found peace, the struggle is over, and there is often a withdrawal from social contact.

300

What are the three cardinal findings used to define brain death?

Coma, absence of brain stem reflexes, and apnea.

400

How does 'loss' differ from 'grief' in clinical terminology?

Loss is the event of no longer possessing an object or person; grief is the emotional reaction to that loss.

500

According to the standards of care for the terminally ill, what should be a major goal of treatment?

Maintaining pain control.

BIG BRAIN

100

According to the World Health Organization (WHO) Three-Step Ladder for Pain Relief, what is the first step for mild pain? 

HINT*PG-218

Change to an opioid designated for moderate to severe pain with nonopioid and/or adjuvant therapy.

200

True or False: Suctioning is highly effective at clearing secretions in a dying patient.

False (it is often not effective in clearing secretions and can be upsetting).

300

According to Box 16.3, what is one right of the dying patient regarding their environment?

The right to die in familiar surroundings or to die with dignity.

400

A patient asks, "Why me?" and expresses resentment toward the nursing staff. According to Kübler-Ross, which stage of coping is this?

Anger

500

In the 'Acceptance' stage of dying, what is the typical emotional and physical state of the patient?

The patient has found peace, the struggle is over, and there is often a withdrawal from social contact