1. Which are direct causes of death? (Select all that d.

Complete relief of only distressing physical

apply) symptoms.
a. GI bleeding
5. To qualify for hospice benefits, a criterion for
b. Heart failure
admission is that the patient's prognosis must be
c. Respiratory failure
limited to what amount of time?
d. Shock
e. Kidney failure a. 2 weeks or less
2. The terminally ill patient has an advance directive b. 3 months or less
living will, which states that she does not want heroic
measures such as cardiopulmonary resuscitation (CPR) c. 6 months or less
and intubation. She also has a do not resuscitate order d. 1 year or less
in her chart written by the provider. As the patient
nears death, her daughter tells the hospice nurse that 6. Which statements about the assessment of a
she wants everything possible done to save her terminally ill patient are true? (Select all that apply)
mother's life. What is the nurse's best action? a. Assess only the patient; do not include the family's
a. Call a code and bring the crash cart to the patient's perception of the patient's symptoms.
bedside. b. When the patient is unable to communicate, there is
b. Inform the health care provider of this change in the no need to assess symptoms of distress any longer.
plan of care. c. Assess patients who are unable to communicate
c. Respect the patient's wishes and ask the chaplain to distress by observing for objective signs of discomfort.
stay with the daughter. d. Assess the patient for dyspnea, agitation, nausea, and
d. Inform the daughter that further interventions are vomiting only.
futile. e. Identify alternative methods to assess for symptoms
3. Which statement regarding the approach to of distress.
hospice/end-of-life care is correct? f. The family can help identify patient habits and
a. Hospice programs only include provision of care in preferences, which may aid in the overall assessment.
the home? 7. Which symptom is most distressing and feared by
b. Admission to hospice is involuntary and directed by a terminally ill patients?
health care provider's order. a. Difficulty breathing
c. The focus is on facilitating quality of life just for the b. Confusion
dying patient. c. Pain
d Loss of consciousness
d. An interdisciplinary team approach is used for the
care of the patient and family. 8. The terminally ill patient is nearing death. His wife
expresses concern that he has no appetite and eats
4. A patient receiving nursing care in a home hospice very little. What is the nurse's best response to this
program can expect which kind of care? concern?
a. The use of high-technology equipment such as a. Teach the patient's wife about the risk of aspiration
ventilators until time of death. and explain that loss of appetite is normal when a
b. Around-the-clock skilled direct nursing patient care patient nears death.
until time of death. b. Encourage the patient's wife to feed the patient as
c. Pain and symptom management that will achieve the much as he will take to maintain adequate nutrition.
best quality of life.
c. Request that the health care provider order a dietary 12. Which statements about pain management in a
nutrition consult to include foods that the patient patient who is dying are true? (Select all that apply)
prefers.
a. The patient's pain may come from many areas.
d. Keep fluids and finger foods at the bedside for easy
b. Patients who are dying should discontinue long-
access whenever the patient is hungry or thirsty.
acting opioids.
Rationale: When family members understand that the
c. Alternative therapies have been shown to be useful
client is not suffering from hunger and is not "starving
when integrated into a pain management plan of care.
to death," they may allow the client to determine when,
what, or if to eat. Often, as death approaches, d. When using massage for patients with cancer, deep
metabolic needs decrease and clients do not feel the pressure is the preferred method.
sensation of hunger. Forcing them to eat frustrates the
client and the family. e. Aromatherapy, massage, music therapy, and
therapeutic touch are a few alternative therapies that
9. The terminally ill patient who is near death has loud, have been shown to be useful.
wet respirations that are disturbing to the family.
Which interventions by the nurse are appropriate at 13. Which action is an example of active euthanasia for
this time? (Select all that apply) a dying patient?

a. Position the patient on her side. a. Removal of a patient from a mechanical ventilator

b. Place a small towel under her mouth. b. Discontinuing intravenous fluids

c. Use oropharyngeal suctioning to remove the c. Withdrawal of telemetry heart monitoring

secretions. d. Administering a large dose of intravenous morphine
d. Administer an ordered anticholinergic drug to dry up 14. A nurse cares for a dying client. Which
the secretions. manifestation of dying should the nurse treat first?
e. Teach family members how to use the suctioning a. Anorexia
device whenever needed. b. Pain
c. Nausea
10. The most common treatment of pain in a terminally d. Hair loss
ill patient is administration of which kind of therapy?
Rationale: Only symptoms that cause distress for a
a. Opioids dying client should be treated. Such symptoms include
pain, nausea and vomiting, dyspnea, and agitation.
b. Steroids
These problems interfere with the client's comfort. Even
c. Nonsteroidal anti-inflammatory agents when symptoms, such as anorexia or hair loss, disturb
the family, they should be treated only if the client is
d. Radiation treatments
distressed by their presence. The nurse should treat the
11. While caring for a patient of the orthodox Jewish client's pain first.
faith who is dying, what cultural concept should the
15. A nurse plans care for a client who is nearing end
nurse keep in mind?
of life. Which question should the nurse ask when
a. Traditionally, Jewish cultures are male-dominated. developing this client's plan of care?

b. Expression of grief is open, especially among women. a. "Is your advance directive up to date and notarized?"

c. An autopsy after death will not be permitted. b. "Do you want to be at home at the end of your life?"

d. Family members are likely to avoid visiting the c. "Would you like a physical therapist to assist you with
terminally ill family member. range-of-motion activities?"
d. "Have your children discussed resuscitation with your not as therapeutic because they justify or minimize the
health care provider?" client's response.

Rationale: When developing a plan of care for a dying 18. After teaching a client about advance directives, a
client, consideration should be given for where the nurse assesses the client's understanding. Which
client wants to die. Advance directives do not need to statement indicates the client correctly understands
be notarized. A physical therapist would not be involved the teaching?
in end-of-life care. The client should discuss
a. "An advance directive will keep my children from
resuscitation with the health care provider and children;
selling my home when I'm old."
do-not-resuscitate status should be the client's decision,
not the family's decision. b. "An advance directive will be completed as soon as
I'm incapacitated and can't think for myself."
16. A nurse is caring for a client who has lung cancer
and is dying. Which prescription should the nurse c. "An advance directive will specify what I want done
question? when I can no longer make decisions about health
care."
a. Morphine 10 mg sublingual every 6 hours PRN for
pain level greater than 5 d. "An advance directive will allow me to keep my
money out of the reach of my family."
b. Albuterol (Proventil) metered dose inhaler every 4
hours PRN for wheezes Rationale: An advance directive is a written document
prepared by a competent individual that specifies what,
c. Atropine solution 1% sublingual every 4 hours PRN for
if any, extraordinary actions a person would want taken
excessive oral secretions
when he or she can no longer make decisions about
d. Sodium biphosphate (Fleet) enema once a day PRN personal health care. It does not address issues such as
for impacted stool the client's residence or financial matters.

Rationale: Pain medications should be scheduled 19. A nurse is caring for a dying client. The client's
around the clock to maintain comfort and prevent spouse states, "I think he is choking to death." How
reoccurrence of pain. The other medications are should the nurse respond?
appropriate for this client.
a. "Do not worry. The choking sound is normal during
17. A client tells the nurse that, even though it has the dying process."
been 4 months since her sister's death, she frequently
b. "I will administer more morphine to keep your
finds herself crying uncontrollably. How should the
husband comfortable."
nurse respond?
c. "I can ask the respiratory therapist to suction
a. "Most people move on within a few months. You
secretions out through his nose."
should see a grief counselor."
d. "I will have another nurse assist me to turn your
b. "Whenever you start to cry, distract yourself from
husband on his side."
thoughts of your sister."
Rationale: The choking sound or "death rattle" is
c. "You should try not to cry. I'm sure your sister is in a
common in dying clients. The nurse should acknowledge
better place now."
the spouse's concerns and provide interventions that
d. "Your feelings are completely normal and may will reduce the choking sounds. Repositioning the client
continue for a long time." onto one side with a towel under the mouth to collect
secretions is the best intervention. The nurse should not
Rationale: Frequent crying is not an abnormal response.
minimize the spouse's concerns. Morphine will assist
The nurse should let the client know that this is normal
with comfort but will not decrease the choking sounds.
and okay. Although the client may benefit from talking
Nasotracheal suctioning is not appropriate in a dying
with a grief counselor, it is not unusual for her to still be
client.
grieving after a few months. The other responses are
20. The nurse is teaching a family member about concerns related to discontinuation of therapy. How
various types of complementary therapies that might should the nurse respond?
be effective for relieving the dying client's anxiety and
a. "I understand your concerns, but in this state,
restlessness. Which statement made by the family
discontinuation of care is not a form of active
member indicates understanding of the nurse's
euthanasia."
teaching?
b. "You will need to talk to the provider because I am
a. "Maybe we should just hire an around-the-clock sitter
not legally allowed to participate in the withdrawal of
to stay with Grandmother."
life support."
b. "I have some of her favorite hymns on a CD that I
c. "I realize this is a difficult decision. Discontinuation of
could bring for music therapy."
therapy will allow the client to die a natural death."
c. "I don't think that she'll need pain medication along
d. "There is no need to worry. Most religious
with her herbal treatments."
organizations support the client's decision to stop
d. "I will burn therapeutic incense in the room so we medical treatment."
can stop the anxiety pills."
Rationale: The nurse should validate the family's
Rationale: Music therapy is a complementary therapy concerns and provide accurate information about the
that may produce relaxation by quieting the mind and discontinuation of therapy. The other statements
removing a client's inner restlessness. Hiring an around- address specific issues related to the withdrawal of care
the-clock sitter does not demonstrate that the client's but do not provide appropriate information about their
family understands complementary therapies. purpose. If the client's family asks for specific
Complementary therapies are used in conjunction with information about euthanasia, legal, or religious issues,
traditional therapy. Complementary therapy would not the nurse should provide unbiased information about
replace pain or anxiety medication but may help these topics.
decrease the need for these medications.
23. A nurse admits an older adult client to the hospital.
21. A nurse assesses a client who is dying. Which Which criterion should the nurse use to determine if
manifestation of a dying client should the nurse assess the client can make his own medical decisions? (Select
to determine whether the client is near death? all that apply.)

a. Level of consciousness a. Can communicate his treatment preferences

b. Respiratory rate b. Is able to read and write at an eighth-grade level

c. Bowel sounds c. Is oriented enough to understand information

provided
d. Pain level on a 0-to-10 scale
d. Can evaluate and deliberate information
Rationale: Although all of these assessments should be
performed during the dying process, periods of apnea e. Has completed an advance directive
and Cheyne-Strokes respirations indicate death is near.
24. A nurse teaches a client's family members about
As peripheral circulation decreases, the client's level of
signs and symptoms of approaching death. Which
consciousness and bowel sounds decrease, and the
manifestations should the nurse include in this
client would be unable to provide a numeric number on
teaching? (Select all that apply.)
a pain scale. Even with these other symptoms, the nurse
should continue to assess respiratory rate throughout a. Warm and flushed extremities
the dying process. As the rate drops significantly and
breathing becomes agonal, death is near. b. Long periods of insomnia

22. An intensive care nurse discusses withdrawal of c. Increased respiratory rate

care with a client's family. The family expresses d. Decreased appetite
e. Congestion and gurgling 28. What is the nurse's role in a patient that chooses
death with dignity?
Rationale: Common physical signs and symptoms of
approaching death including coolness of extremities, A.Provide information about the pros and cons of death
increased sleeping, irregular and slowed breathing rate, with dignity
a decrease in fluid and food intake, congestion and
B.Influence the patient decision
gurgling, incontinence, disorientation, and restlessness.
C.Being a witness
25. Which of the following statements about Values
clarification tools would indicate need for further D.Advocate for the patient's wishes and continue to
education? perform unbiased care
A.Value clarification tools are helpful in analyzing 29. The hospice nurse is caring for a patient who is
underlying biases that may impact thoughts about and actively dying. When the patient's respirations become
behavior toward others. loud and wet, the caregiver expresses fear that the
patient is in respiratory distress.
B. As nurses, they can be used to identify how our
values and beliefs may impact patient care when faced What is the appropriate nursing action? (Select all that
with situations that may present ethical dilemmas. apply.)
C.A patient assessment tool used upon admission to A.Immediately administer oxygen
emergency care.
B.Reposition the patient onto one side
D.Exercises developed by the National Abortion
Federation to clarify values related to abortion, views C.Administer an anticholinergic drug as ordered
about the role of health care providers, as well as case D.Contact 9-1-1
studies used to identify and examine potential biases.
E.Provide the caregiver with reassurance that this is a
26. A new RN graduate is taking care of a patient normal finding in someone who is actively dying
recently diagnosed with cancer. The patient is
discussing his concerns about his medical bills and 30. A competent patient who has been given three
transportation. The nurse learns that the employer months to live expresses the desire to voluntarily stop
fired the patient because the "cancer would slow eating and drinking. Which is the appropriate nursing
down the work flow". What American Disability Act response?
(ADA) title would the nurse inform the patient about? A.Tell the patient that this is unethical.
A. Title IV: Telecommunications B.Disclose the patient's desire to caregivers.
B. Title II: Public Entities and Public Transportation C.Advocate for the patient's choice.
C. Title I: Employment D.Refuse to care for the patient.
D. Tile III: Public Accommodations 31. The family of a dying client being cared for at home
27. What therapies are included in Withdrawal of is requesting information on how best to prepare food.
support? (select all that apply) Which suggestion by the nurse may stimulate
appetite?
A.Speech therapy Rationale: Preparing cool or cold foods may be
tolerated better by the client and thus stimulatea) Eating alone so the client can eat at his own pace and
B.Chemotherapy appetite. Hot foods may have an aroma that
not be hurried
may cause nausea. Clients may enjoy a
C.Hydration mealtime companion making the eating b) Preparing cool or cold foods that may be better
experience more pleasurable. Offering small
D.Mechanical Ventilationportions is appropriate because large, multiple tolerated
portions/choices may shut down the appetite.
E. Physical therapy c) Providing several choices on the plate so that the
Although weight loss may be significant, clients
should have the ability to pick and choose foods client has what may appeal to him
that interest them.