Palliative and End Of Life
RN is caring for a client on hospice care. Which of the following findings should the nurse identify as a manifestation of impending death?
a. pale yellow urine
b. increased blood pressure
c. decreased strength of peripheral pulses
d. tightening of the facial muscles
C. decreased strength of peripheral pulses
Rationale
a. dark, concentrated urine and decreased output is a sign of impending death
b. decreased blood pressure is a sign
d. decreased muscle tone is a sign
A 68-year-old client with a history of Chronic Obstructive Pulmonary Disease (COPD) is admitted to the hospital with increasing shortness of breath and productive cough. The client is receiving oxygen at 2 liters per minute via nasal cannula. Which of the following interventions should the nurse implement to promote effective breathing? (Select all that apply)
A. Encourage the client to drink at least 2-3 liters of fluids per day.
B. Position the client in a high Fowler's position.
C. Administer bronchodilators as prescribed.
D. Teach the client pursed-lip breathing techniques.
E. Reduce the client's oxygen flow rate to 1 liter per minute.
F. Restrict the client’s fluid intake to less than 1 liter per day.
Correct Answers:
A. Encourage the client to drink at least 2-3 liters of fluids per day.
B. Position the client in a high Fowler's position.
C. Administer bronchodilators as prescribed.
D. Teach the client pursed-lip breathing techniques.
Rationale:
A. Encourage the client to drink at least 2-3 liters of fluids per day: This helps to thin secretions, making them easier to expectorate.
B. Position the client in a high Fowler's position: This position facilitates easier breathing by allowing maximum lung expansion.
C. Administer bronchodilators as prescribed: Bronchodilators help to open airways, improving airflow and gas exchange.
D. Teach the client pursed-lip breathing techniques: This technique helps to slow down the exhalation phase and keeps the airways open longer, improving ventilation.
E. Reduce the client's oxygen flow rate to 1 liter per minute: Reducing oxygen flow is inappropriate without a specific order; it can lead to hypoxia.
F. Restrict the client’s fluid intake to less than 1 liter per day: Restricting fluids is contraindicated as it can lead to dehydration and thicker secretions.
A nurse is caring for a 45-year-old client who has been admitted to the psychiatric unit with suicidal ideation. During the initial assessment, the client states, "I don't see the point of living anymore. I just want to end it all." Which of the following responses by the nurse is most appropriate?
A. "You have a lot to live for, things will get better."
B. "I'm sorry you're feeling this way. Can you tell me more about what you're experiencing?"
C. "You shouldn't think like that. Think about your family."
D. "Have you tried talking to your friends about how you feel?"
B. "I'm sorry you're feeling this way. Can you tell me more about what you're experiencing?"
Rationale:
B. "I'm sorry you're feeling this way. Can you tell me more about what you're experiencing?": This response uses therapeutic communication by showing empathy and encouraging the client to express their feelings, which can help the nurse understand the depth of the client's distress and plan appropriate interventions.
A nurse is educating a client about the body's response to stress. The nurse explains that when a stressful situation occurs, the hypothalamus releases corticotropin-releasing factor (CRF), which triggers the activation of the sympathetic nervous system (SNS). Which of the following physiological changes should the nurse expect to occur during the "fight or flight" response?
A. Decreased heart rate and blood pressure
B. Constriction of bronchial airways and pupil constriction
C. Increased blood glucose levels and dilation of bronchial airways
D. Decreased cardiac output and pupil constriction
C. Increased blood glucose levels and dilation of bronchial airways
Rationale:
C. Increased blood glucose levels and dilation of bronchial airways: During the "fight or flight" response, the sympathetic nervous system releases norepinephrine, epinephrine, and dopamine, which cause several physiological changes: increased blood glucose levels to provide energy, and dilation of bronchial airways to enhance oxygen intake.
A nurse is using the SAD PERSONS scale to assess a 65-year-old client for suicide risk. The following factors are identified:
Using the SAD PERSONS scale, the nurse calculates the client’s score to be 5. Based on the score, which of the following is the nurse's best action?
A. Discharge the client home with appropriate follow-up care.
B. Admit the client to the hospital for closer observation.
C. Schedule a follow-up appointment within the next week.
D. Provide outpatient therapy and home care instructions.
Correct Answer:
B. Admit the client to the hospital for closer observation
Correct Answer:
B. Admit the client to the hospital for closer observation
Rationale:
The SAD PERSONS scale assigns one point for each risk factor present, and the total score helps determine the appropriate level of care:
A score of 3 to 6 suggests that the client requires admission or discharge with appropriate follow-up. Given that the client scored a 5, admission to the hospital for closer observation is the most appropriate action to ensure safety and provide immediate intervention.
A. Discharge the client home with appropriate follow-up care: This is not appropriate for a score of 5, as the client is at moderate risk and needs closer monitoring.
C. Schedule a follow-up appointment within the next week: While follow-up care is important, a score of 5 warrants more immediate intervention, not just a scheduled appointment.
D. Provide outpatient therapy and home care instructions: Outpatient therapy is not sufficient for a client with a moderate suicide risk; they require more immediate support, such as inpatient care.
A nurse is caring for a client who has stage IV heart failure. The client has crackles in his lungs and is experiencing fluid overload. Which of the following medications should the nurse plan to administer to the client?
a. scopolamine
b. amoxicillin/clavulanate
c. furosemide
d. lorazepam
C. Furosemide.
Rationale Furosemide is a diuretic which reduces the workload of the heart along with the congestion and excess fluid. This allows the client to breathe easier.
An 80-year-old client with a history of asthma presents to the emergency department with complaints of wheezing, shortness of breath, and chest tightness. Which of the following medications should the nurse anticipate administering first to relieve the client’s acute symptoms?
A. Montelukast
B. Albuterol
C. Fluticasone
D. Theophylline
B. Albuterol
Rationale:
B. Albuterol: Albuterol is a short-acting beta-agonist (SABA) that works quickly to relax bronchial smooth muscle and relieve acute asthma symptoms such as wheezing, shortness of breath, and chest tightness. It is the first-line treatment for an asthma exacerbation.
A. Montelukast: Montelukast is a leukotriene receptor antagonist used for long-term control and prevention of asthma symptoms but not for acute relief.
C. Fluticasone: Fluticasone is an inhaled corticosteroid used for long-term control of asthma. It helps reduce inflammation but is not effective for immediate relief of acute symptoms.
D. Theophylline: Theophylline is a long-acting bronchodilator used for chronic asthma management but is not typically used for immediate relief of acute symptoms.
A nurse is assessing a 68-year-old client with depression using the SAD PERSONS Scale. The client has the following characteristics: male gender, history of depression, single, and recently lost his job. He also reports a lack of social support and has previously attempted suicide. Based on the SAD PERSONS Scale, which of the following is the nurse's priority action?
A. Refer the client to outpatient therapy
B. Immediately implement a suicide watch
C. Schedule a follow-up appointment in one week
D. Encourage the client to engage in social activities
Correct Answer:
B. Immediately implement a suicide watch
An 80-year-old client is admitted to the hospital following a fall at home. During the assessment, the nurse identifies several factors that may contribute to the client’s stress. Which of the following are potential stressors for this older adult client? Select all that apply.
A. Loss of independence due to decreased mobility after the fall
B. Increased financial burden from medical expenses related to the fall
C. Family support system that has increased involvement after the fall
D. Fear of future falls and further physical decline
E. Retirement and loss of social interactions with peers
Correct Answers:
A. Loss of independence due to decreased mobility after the fall
B. Increased financial burden from medical expenses related to the fall
D. Fear of future falls and further physical decline
E. Retirement and loss of social interactions with pe
A 68-year-old patient with advanced lung cancer is discussing care options with the nurse. The patient expresses a desire to focus on comfort and quality of life rather than curative treatments. Which of the following statements by the nurse best differentiates hospice care from palliative care?
A. "Hospice care is for patients who are expected to live for more than six months, while palliative care can be provided at any stage of a serious illness."
B. "Palliative care provides support for patients and families, focusing on relieving symptoms and improving quality of life, while hospice care is only for patients who are no longer seeking curative treatment."
C. "Both hospice and palliative care require a referral from a primary care physician."
D. "Hospice care includes aggressive treatments to cure the illness, whereas palliative care focuses solely on pain management."
B. "Palliative care provides support for patients and families, focusing on relieving symptoms and improving quality of life, while hospice care is only for patients who are no longer seeking curative treatment."
A nurse is caring for a 55-year-old client recently diagnosed with obstructive sleep apnea (OSA). Which of the following is the nurse's priority intervention?
A. Educate the client on weight loss and exercise
B. Instruct the client to avoid alcohol and sedatives before bedtime
C. Refer the client for a Continuous Positive Airway Pressure (CPAP) titration study
D. Teach the client about the importance of maintaining a sleep diary
C. Refer the client for a Continuous Positive Airway Pressure (CPAP) titration study
Rationale:
C. Refer the client for a Continuous Positive Airway Pressure (CPAP) titration study: The priority intervention for a client with obstructive sleep apnea is to ensure they receive appropriate treatment to prevent further complications. CPAP is the first-line treatment for OSA, as it keeps the airway open during sleep and significantly reduces apnea episodes. A titration study is necessary to determine the correct pressure settings for the CPAP machine.
A 78-year-old client with a history of major depressive disorder is admitted to the hospital due to severe depression. The client reports feeling hopeless, has poor appetite, and mentions, "I just don't see any point in going on." What is the nurse's priority action?
A. Encourage the client to participate in group therapy sessions.
B. Assess the client for suicidal ideation and a specific plan.
C. Contact the client’s family to provide emotional support.
D. Administer prescribed antidepressant medication.
B. Assess the client for suicidal ideation and a specific plan.
Rationale
B. Assess the client for suicidal ideation and a specific plan: The nurse's priority is to ensure the safety of the client. Assessing for suicidal ideation and the presence of a specific plan is crucial to determine the immediate risk and need for intervention to prevent self-harm.
A nurse is educating a client about the different types of stressors that can impact their health. Which of the following examples would be classified as a psychological (emotional) stressor?
A. A client experiences pain following a surgical procedure.
B. A client feels anxious and worried about an upcoming job interview.
C. A client is exposed to loud noises in a busy emergency room.
D. A client experiences an increase in blood pressure after running a marathon.
B. A client feels anxious and worried about an upcoming job interview.
Rationale:
B. A client feels anxious and worried about an upcoming job interview: This is a psychological (emotional) stressor, as it involves emotional responses to an event interpreted as negative or threatening, such as anxiety about a job interview.
The nurse is assessing a patient who is receiving hospice care. Which of the following clinical signs and symptoms may indicate that the patient is approaching the end of life? (Select all that apply.)
A. Decreased urine output
B. Increased appetite and fluid intake
C. Cheyne-Stokes respirations
D. Increased periods of wakefulness and activity
E. Coolness and mottling of extremities
F. Disorientation and confusion
A. Decreased urine output
C. Cheyne-Stokes respirations
E. Coolness and mottling of extremities
F. Disorientation and confusion
A nurse is assessing a client who is suspected of having sleep apnea. Which of the following symptoms should the nurse expect to find? (Select all that apply)
A. Excessive daytime sleepiness
B. Loud snoring
C. Hypertension
D. Night sweats
E. Morning headache
F. Increased appetite
A. Excessive daytime sleepiness B. Loud snoring C. Hypertension E. Morning headache
Rationale:
A. Excessive daytime sleepiness: Clients with sleep apnea often experience excessive daytime sleepiness due to interrupted sleep at night.
B. Loud snoring: Loud snoring is a common symptom of sleep apnea, caused by partial blockage of the airway during sleep.
C. Hypertension: Sleep apnea can lead to increased blood pressure due to repeated episodes of low oxygen levels during sleep.
E. Morning headache: Morning headaches are common in sleep apnea patients, often due to fluctuations in oxygen and carbon dioxide levels during sleep.
D. Night sweats: While night sweats can occur, they are not a primary manifestation of sleep apnea and could be related to other conditions.
F. Increased appetite: Increased appetite is not typically associated with sleep apnea; in fact, some individuals might experience weight gain due to fatigue and reduced physical activity.
A 75-year-old client is brought to the clinic by their family due to increasing cognitive impairment and hallucinations. The family reports that the client has fluctuations in attention and alertness, often seeming confused and disoriented. The client also exhibits signs of parkinsonism such as rigidity and bradykinesia. Which of the following findings would most likely support a diagnosis of Lewy body dementia?
A. Memory loss without fluctuations in cognitive function
B. Gradual onset of symptoms over several years
C. Presence of visual hallucinations and parkinsonian features
D. Predominantly language impairment with preserved memory
C. Presence of visual hallucinations and parkinsonian features
Rationale:
C. Presence of visual hallucinations and parkinsonian features: Lewy body dementia is characterized by visual hallucinations, parkinsonian motor symptoms (such as rigidity and bradykinesia), and fluctuations in cognitive function and alertness. These symptoms are key indicators for diagnosing Lewy body dementia.
A. Memory loss without fluctuations in cognitive function: Memory loss without cognitive fluctuations is more typical of Alzheimer's disease rather than Lewy body dementia.
B. Gradual onset of symptoms over several years: While Lewy body dementia can have a gradual onset, the presence of specific symptoms like visual hallucinations and parkinsonian features is crucial for diagnosis.
D. Predominantly language impairment with preserved memory: This description is more consistent with frontotemporal dementia rather than Lewy body dementia, which is characterized by a broader range of cognitive impairments including attention, executive function, and visual-spatial abilities.
An 82-year-old client, who has recently retired and lost their spouse, presents to the clinic with complaints of fatigue, difficulty sleeping, and increased irritability. The client expresses feelings of sadness and reports that they "can't cope with all the changes" in their life. During the assessment, the nurse notices the client is withdrawing from social activities and not engaging in previously enjoyed hobbies. Which of the following is the most likely cause of the client’s symptoms?
A. Psychological stress due to life changes
B. Physiological stress from a chronic medical condition
C. Medication side effects related to a recent prescription change
D. Cognitive decline from an undiagnosed neurodegenerative disease
Correct Answer:
A. Psychological stress due to life changes
Rationale:
A. Psychological stress due to life changes: The client’s symptoms, including sadness, fatigue, difficulty sleeping, irritability, and withdrawal from social activities, are common signs of psychological stress triggered by significant life changes, such as retirement and the loss of a spouse. These events can cause emotional distress, leading to symptoms of depression or stress.
A nurse is providing care to a patient with advanced heart failure who is receiving palliative care. The patient expresses feelings of fear and uncertainty about the future. Which of the following responses by the nurse demonstrates effective therapeutic communication?
A. "Don't worry, everything will be fine."
B. " Can you tell me more about what you're feeling?"
C. "You should focus on the positive aspects of your life right now."
D. "Let's discuss the treatment options that are still available to you."
B. "It's normal to feel scared about what lies ahead. Can you tell me more about what you're feeling?"
Rationale:
An 82-year-old client with a history of Chronic Obstructive Pulmonary Disease (COPD) is admitted to the hospital with acute respiratory distress. The client's oxygen saturation is 88%, respiratory rate is 28 breaths per minute, and they are using accessory muscles to breathe. What is the nurse's priority action?
A. Administer albuterol via nebulizer
B. Obtain a stat arterial blood gas (ABG) analysis
C. Increase the oxygen flow rate to 5 liters per minute via nasal cannula
D. Position the client in high Fowler's position
Correct Answer:
D. Position the client in high Fowler's position
Rationale:
D. Position the client in high Fowler's position: The immediate priority is to help the client breathe more effectively. Positioning the client in high Fowler's position can maximize lung expansion and ease the work of breathing.
A nurse is assessing two clients for suicide risk using the SAD PERSONS Scale. Review the following information for each client and determine which client is more at risk for suicide.
Client A:
Client B:
Based on the SAD PERSONS Scale, which client is at greater risk for suicide, and what should be the nurse’s priority action?
A. Client A; implement a suicide watch
B. Client A; refer to outpatient therapy
C. Client B; schedule a follow-up appointment
D. Client B; encourage engagement in social activities
A. Client A; implement a suicide watch
Client A has multiple high-risk factors:
Client B has fewer high-risk factors:
An older adult client is admitted to the hospital and is observed to repeatedly say, "I don't need any help; I'm perfectly fine," despite having significant difficulty with daily activities such as dressing and bathing. Which defense mechanism is the client demonstrating?
A. Denial
B. Rationalization
C. Projection
D. Repression
Correct Answer:
A. Denial
Rationale:
A. Denial: The client is refusing to acknowledge or accept the reality of their limitations, which is characteristic of the defense mechanism denial. This allows the client to avoid the emotional discomfort of accepting their need for help.
B. Rationalization: Rationalization involves justifying or explaining undesirable behaviors to avoid emotional discomfort, but the client is not making excuses for their actions in this scenario.
C. Projection: Projection involves attributing negative thoughts or feelings onto someone else, which is not seen in this situation.
D. Repression: Repression involves the unconscious forgetting of painful or uncomfortable memories, but the client is actively denying their current limitations rather than suppressing past experiences.