Nurs 4704 Exam 4 Questions With Complete Solutions
The nurse is caring for an unresponsive terminally ill patient
who has 20-second periods of apnea followed by periods of deep
and rapid breathing. Which action would the nurse take?
a. Suction the patient's mouth.
b. Administer oxygen via face mask.
c. Document the patient's respiratory pattern.
d. Place the patient in high Fowler's position.
c. Document the patient‘s respiratory pattern
Cheyne-Stokes respirations are characterized by periods of
apnea alternating with deep and
rapid breaths. This respiratory pattern is expected in the last
days of life and is not position-dependent. There is also no need
for supplemental oxygen by using a face mask or suctioning the
patient.
The nurse is caring for a dying adolescent patient who is
comatose. The patient's parents are interested in organ donation
and ask the nurse how the healthcare providers determine brain
death. Which response by the nurse accurately describes brain
death determination?
a. ―If CPR does not restore a heartbeat, the brain cannot
function any longer.
b. ―Brain death has occurred if there is not any breathing or
,brainstem reflexes.
c. ―Brain death has occurred if a person has flaccid muscles
and does not awaken.
d. ―If respiratory efforts cease and no apical pulse is audible,
brain death is present.
b. ―Brain death occurs if there is no breathing or brainstem
reflexes.
The diagnosis of brain death is based on the irreversible loss of
all brain functions, including
brainstem functions that control respirations and brainstem
reflexes. The other descriptions
describe other clinical manifestations associated with death but
are insufficient to declare a
patient brain dead.
A patient in hospice is manifesting a decrease in all body system
functions except for a heart rate of 124 beats/min and a
respiratory rate of 28 breaths/min. Which statement would be
accurate for the nurse to make to the patient's family?
a. ―These vital signs will continue to increase until death
finally occurs.
b. ―These vital signs demonstrate the body's ability to
compensate and heal.
c. ―These vital signs are an expected response now but will
slow down later.
d. ―These vital signs may indicate an improvement in the
patient's condition.
,c. ―These vital signs are an expected response now but will
slow down later.
An increase in heart and respiratory rate may occur before the
slowing of these functions in a
dying patient. Heart and respiratory rate typically slow as the
patient progresses further
toward death. In a dying patient, high respiratory and pulse rates
do not indicate improvement
or compensation, and it would be inappropriate for the nurse to
indicate this to the family.
A patient who has been diagnosed with inoperable lung cancer
and has a poor prognosis plans a trip across the country ―to
settle some issues with family members. The nurse recognizes
that the patient is manifesting which psychosocial response?
a. Protesting the unfairness of death
b. Anxiety about unfinished business
c. Fear of having lived a meaningless life
d. Restlessness about the uncertain prognosis
b. Anxiety about unfinished business
The patient's statement indicates that there is some unfinished
family business that the patient
would like to address before dying. There is no indication that
the patient is protesting the
prognosis, feels uncertain about the prognosis, or fears that life
has been meaningless.
, A patient with terminal cancer is being admitted to a family-
centered inpatient hospice. The patient's spouse visits daily and
cheerfully talks with the patient about wedding anniversary
plans for the next year. When the nurse asks about any concerns,
the spouse says, ―I'm busy at work, but otherwise things are
fine. Which issue would the nurse identify as a concern in
working with the patient's spouse?
a. Fear
b. Anxiety
c. Hopelessness
d. Difficulty coping
d. Difficulty coping
The spouse's behavior and statements indicate the absence of
anticipatory grieving, which
may lead to impaired adjustment as the patient progresses
toward death. The spouse does not
appear to feel fearful, hopeless, or anxious.
As the nurse admits a patient in end-stage renal disease to the
hospital, the patient tells the nurse, If my heart or breathing stop,
I do not want to be resuscitated. Which action should
the nurse take first?
a. Place a ―Do Not Resuscitate‖ (DNR) notation in the patient's
care plan.
b. Invite the patient to add a notarized advance directive in the
health record.
c. Advise the patient to designate a person to make future health
The nurse is caring for an unresponsive terminally ill patient
who has 20-second periods of apnea followed by periods of deep
and rapid breathing. Which action would the nurse take?
a. Suction the patient's mouth.
b. Administer oxygen via face mask.
c. Document the patient's respiratory pattern.
d. Place the patient in high Fowler's position.
c. Document the patient‘s respiratory pattern
Cheyne-Stokes respirations are characterized by periods of
apnea alternating with deep and
rapid breaths. This respiratory pattern is expected in the last
days of life and is not position-dependent. There is also no need
for supplemental oxygen by using a face mask or suctioning the
patient.
The nurse is caring for a dying adolescent patient who is
comatose. The patient's parents are interested in organ donation
and ask the nurse how the healthcare providers determine brain
death. Which response by the nurse accurately describes brain
death determination?
a. ―If CPR does not restore a heartbeat, the brain cannot
function any longer.
b. ―Brain death has occurred if there is not any breathing or
,brainstem reflexes.
c. ―Brain death has occurred if a person has flaccid muscles
and does not awaken.
d. ―If respiratory efforts cease and no apical pulse is audible,
brain death is present.
b. ―Brain death occurs if there is no breathing or brainstem
reflexes.
The diagnosis of brain death is based on the irreversible loss of
all brain functions, including
brainstem functions that control respirations and brainstem
reflexes. The other descriptions
describe other clinical manifestations associated with death but
are insufficient to declare a
patient brain dead.
A patient in hospice is manifesting a decrease in all body system
functions except for a heart rate of 124 beats/min and a
respiratory rate of 28 breaths/min. Which statement would be
accurate for the nurse to make to the patient's family?
a. ―These vital signs will continue to increase until death
finally occurs.
b. ―These vital signs demonstrate the body's ability to
compensate and heal.
c. ―These vital signs are an expected response now but will
slow down later.
d. ―These vital signs may indicate an improvement in the
patient's condition.
,c. ―These vital signs are an expected response now but will
slow down later.
An increase in heart and respiratory rate may occur before the
slowing of these functions in a
dying patient. Heart and respiratory rate typically slow as the
patient progresses further
toward death. In a dying patient, high respiratory and pulse rates
do not indicate improvement
or compensation, and it would be inappropriate for the nurse to
indicate this to the family.
A patient who has been diagnosed with inoperable lung cancer
and has a poor prognosis plans a trip across the country ―to
settle some issues with family members. The nurse recognizes
that the patient is manifesting which psychosocial response?
a. Protesting the unfairness of death
b. Anxiety about unfinished business
c. Fear of having lived a meaningless life
d. Restlessness about the uncertain prognosis
b. Anxiety about unfinished business
The patient's statement indicates that there is some unfinished
family business that the patient
would like to address before dying. There is no indication that
the patient is protesting the
prognosis, feels uncertain about the prognosis, or fears that life
has been meaningless.
, A patient with terminal cancer is being admitted to a family-
centered inpatient hospice. The patient's spouse visits daily and
cheerfully talks with the patient about wedding anniversary
plans for the next year. When the nurse asks about any concerns,
the spouse says, ―I'm busy at work, but otherwise things are
fine. Which issue would the nurse identify as a concern in
working with the patient's spouse?
a. Fear
b. Anxiety
c. Hopelessness
d. Difficulty coping
d. Difficulty coping
The spouse's behavior and statements indicate the absence of
anticipatory grieving, which
may lead to impaired adjustment as the patient progresses
toward death. The spouse does not
appear to feel fearful, hopeless, or anxious.
As the nurse admits a patient in end-stage renal disease to the
hospital, the patient tells the nurse, If my heart or breathing stop,
I do not want to be resuscitated. Which action should
the nurse take first?
a. Place a ―Do Not Resuscitate‖ (DNR) notation in the patient's
care plan.
b. Invite the patient to add a notarized advance directive in the
health record.
c. Advise the patient to designate a person to make future health
