ATI Comprehensive Exit Exam

1. A patient’s father died a week ago. Both the patient and the patient’s spouse talk about the death. The patient’s spouse is experiencing headaches and fatigue. The patient is having trouble sleeping, has no appetite, and gets choked up most of the time. How should the nurse interpret these findings as the basis for a follow-up assessment? a. The patient is dying and the spouse is angry. b. The patient is ill and the spouse is malingering. c. Both the patient and the spouse are likely in denial. d. Both the patient and the spouse are likely grieving. ANS: D Both are likely grieving from the loss of the patient’s father. Symptoms of normal grief include headache, fatigue, insomnia, appetite disturbance, and choking sensation. Different people manifest different symptoms. There is no data to support the spouse is angry or malingering. There is no data to support the patient is dying or ill. Denial is assessed when the person cannot accept the loss; both talked about the loss. MULTIPLE RESPONSE 1. A nurse is documenting end-of-life care. Which information will the nurse include in the patient’s electronic medical record? (Select all that apply.) a. Reason for the death b. Time and date of death c. How ethically the family grieved d. Location of body identification tags e. Time of body transfer and destination 1 ANS: B, D, E Documentation of end-of-life care includes the following: time and date of death, location of body identification tags, time of body transfer and destination and personal articles left on and secured to the body. Reason for the death is not appropriate; this is a medical judgment and not a nursing judgment. How ethically the family grieved is judgmental and does not belong in the chart. We must remain open to the varying views and beliefs of grieving that are in contrast to our own in order to best support and care for our patients and their families.