Chapter 09: Palliative Care at End of Life || WELL-
ENLIGHTENED Q&A; 100% CORRECT!!
1. The nurse cares for a terminally ill patient who has 20-second periods of apnea followed
by periods of deep and rapid breathing. Which action by the nurse would be most
appropriate?
a. Suction the patient.
b. Administer oxygen via face mask.
c. Place the patient in high Fowlers position.
d. Document the respirations as Cheyne-Stokes. correct answers ANS: D
Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and
rapid breaths. Cheyne-Stokes respirations are expected in the last days of life. There is also
no need for supplemental oxygen by face mask or suctioning the patient. Raising the head of
the bed slightly and/or turning the patient on the side may promote comfort. There is no need
to place the patient in high Fowlers position.
DIF: Cognitive Level: Apply (application) REF: 131
TOP: Nursing Process: Assessment
2. The nurse cares for an adolescent patient who is dying. The patients parents are interested
in organ donation and ask the nurse how the decision about brain death is made. Which
response by the nurse is most appropriate?
a. Brain death occurs if a person is flaccid and unresponsive.
b. If CPR is ineffective in restoring a heartbeat, the brain cannot function.
c. Brain death has occurred if there is no breathing and certain reflexes are absent.
d. If respiratory efforts cease and no apical pulse is audible, brain death is present. correct
answers ANS: C
The diagnosis of brain death is based on 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.
DIF: Cognitive Level: Apply (application) REF: 131
TOP: Nursing Process: Assessment
, 3. A hospice patient is manifesting a decrease in all body system functions except for a heart
rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patients
family member, is most
appropriate?
a. These symptoms will continue to increase until death finally occurs.
b. These symptoms are a normal response before these functions decrease.
c. These symptoms indicate a reflex response to the slowing of other body systems.
d. These symptoms may be associated with an improvement in the patients condition. correct
answers ANS: B
An increase in heart and respiratory rate may occur before the slowing of these functions in
the 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, and it would be inappropriate for the nurse to indicate this to the family. The
changes in pulse and respirations are not reflex responses.
DIF: Cognitive Level: Apply (application) REF: 132
TOP: Nursing Process: Implementation
4. 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 sisters and brothers. The nurse
recognizes that the patient is manifesting which psychosocial response to death?
a. Restlessness
b. Yearning and protest
c. Anxiety about unfinished business
d. Fear of the meaninglessness of ones life correct answers ANS: C
The patients statement indicates that there is some unfinished family business that the patient
would like to address before dying. Restlessness is frequently a behavior associated with an
inability to express emotional or physical distress, but this patient does not express distress
and is able to communicate clearly. There is no indication that the patient is protesting the
prognosis, or that there is any fear that the patients life has been meaningless.
DIF: Cognitive Level: Apply (application) REF: 132
TOP: Nursing Process: Assessment
5. The spouse of a patient with terminal cancer 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, Im busy at work, but otherwise things are fine. Which nursing
diagnosis is most appropriate?
ENLIGHTENED Q&A; 100% CORRECT!!
1. The nurse cares for a terminally ill patient who has 20-second periods of apnea followed
by periods of deep and rapid breathing. Which action by the nurse would be most
appropriate?
a. Suction the patient.
b. Administer oxygen via face mask.
c. Place the patient in high Fowlers position.
d. Document the respirations as Cheyne-Stokes. correct answers ANS: D
Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and
rapid breaths. Cheyne-Stokes respirations are expected in the last days of life. There is also
no need for supplemental oxygen by face mask or suctioning the patient. Raising the head of
the bed slightly and/or turning the patient on the side may promote comfort. There is no need
to place the patient in high Fowlers position.
DIF: Cognitive Level: Apply (application) REF: 131
TOP: Nursing Process: Assessment
2. The nurse cares for an adolescent patient who is dying. The patients parents are interested
in organ donation and ask the nurse how the decision about brain death is made. Which
response by the nurse is most appropriate?
a. Brain death occurs if a person is flaccid and unresponsive.
b. If CPR is ineffective in restoring a heartbeat, the brain cannot function.
c. Brain death has occurred if there is no breathing and certain reflexes are absent.
d. If respiratory efforts cease and no apical pulse is audible, brain death is present. correct
answers ANS: C
The diagnosis of brain death is based on 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.
DIF: Cognitive Level: Apply (application) REF: 131
TOP: Nursing Process: Assessment
, 3. A hospice patient is manifesting a decrease in all body system functions except for a heart
rate of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patients
family member, is most
appropriate?
a. These symptoms will continue to increase until death finally occurs.
b. These symptoms are a normal response before these functions decrease.
c. These symptoms indicate a reflex response to the slowing of other body systems.
d. These symptoms may be associated with an improvement in the patients condition. correct
answers ANS: B
An increase in heart and respiratory rate may occur before the slowing of these functions in
the 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, and it would be inappropriate for the nurse to indicate this to the family. The
changes in pulse and respirations are not reflex responses.
DIF: Cognitive Level: Apply (application) REF: 132
TOP: Nursing Process: Implementation
4. 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 sisters and brothers. The nurse
recognizes that the patient is manifesting which psychosocial response to death?
a. Restlessness
b. Yearning and protest
c. Anxiety about unfinished business
d. Fear of the meaninglessness of ones life correct answers ANS: C
The patients statement indicates that there is some unfinished family business that the patient
would like to address before dying. Restlessness is frequently a behavior associated with an
inability to express emotional or physical distress, but this patient does not express distress
and is able to communicate clearly. There is no indication that the patient is protesting the
prognosis, or that there is any fear that the patients life has been meaningless.
DIF: Cognitive Level: Apply (application) REF: 132
TOP: Nursing Process: Assessment
5. The spouse of a patient with terminal cancer 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, Im busy at work, but otherwise things are fine. Which nursing
diagnosis is most appropriate?
