Palliative Care Nursing Quality Care to the End of Life 5th Edition By Marianne Matzo, Deborah Sher

Palliative Care Nursing Quality Care to the End of Life 5th Edition Matzo Test Bank

CHAPTER 1 Palliative Care Nursing Multiple Choice 1. The majority of hospice care is provided in which setting?

A. Hospitals B. Private residences C. Jails D. PC clinics Answer: B Rationale: While hospice occurs in many different settings such as acute care hospital units, PC clinics or ambulatory settings, private practices, and prisons, most hospice care is provided in private residences such as nursing homes, homes, and residential facilities.

2. Which entity is the first professional organization for excellence in the practice of hospice nursing?

A. National Board for Certification of Hospice and Palliative Nurses (NBCHPN) B. Hospice and Palliative Nurses Foundation (HPNF) C. Advancing Expert Care (AEC) D. Hospice and Palliative Care Nurses Association (HPNA) Answer: D Rationale: Incorporated in 1987, the Hospice Nurses Association (HNA) became the first professional nursing organization dedicated to promoting excellence in the practice of hospice nursing. NBCHN is the National Board for Certification of Hospice and Palliative Nurses. HPNF is the Hospice and Palliative Nurses Foundation. In 2014, the HPNA came together with the Hospice and Palliative Nurses Foundation (HPNF) and the Hospice and Palliative Credentialing Center (HPCC) to form a partnership with a synergized mission. The three distinct organizations form Advancing Expert Care (AEC).

3. In 1995, SUPPORT investigators came to which conclusion?

A. Patients with end-of-life care felt they had adequate communication with their healthcare providers.

B. Patients with end of life care were requesting less-aggressive medical treatments.

C. Dying patients require an individual and collective commitment from healthcare providers.

D. Dying patients were reporting moderate levels of pain and needed little increase in medication.

Answer: C Rationale: The “Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment” (SUPPORT; SUPPORT Study Investigators, 1995) investigators believed that improving the end-of-life care for patients required an individual and collective commitment of healthcare providers and that the caregiving processes needed to be reshaped. SUPPORT findings indicated a lack of communication between patients and their providers, particularly

related to EOL preferences, aggressiveness of medical treatments, and a high level of reported pain by seriously ill and dying patients.

4. Which type of disease is a leading cause of death today?

A. Infectious B. Autoimmune C. Chronic D. Acute Answer: C Rationale: People today are living much longer than those of previous eras. The leading causes of death have changed from primarily infectious diseases to chronic illnesses. In 2014, the 10 leading causes of death were heart disease, cancer, chronic lower respiratory diseases, unintentional injuries, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide. These 10 causes of death accounted for 74% of the 2.6 million deaths in 2014.

5.

What is the purpose of the eight domains of palliative care?

A. To reflect national guidelines for quality palliative care B. To correlate palliative care with hospice parameters C. To determine nursing school palliative care learning objectives D. To educate physicians on the benefits of a palliative care

Answer: A Rationale: The domains of quality palliative care are designed to complement the process of improving PC quality. The qualifications of caregivers are determined by the organizations that grant professional credentials and programmatic accreditation. As a specialty organization, the Hospice and Palliative Care Nurses Association has identified the scope and standards of hospice and palliative care nursing and the competencies at all levels of nursing practice, specifically nursing assistants, licensed vocational nurses, professional registered nurses, and advanced practice nurses.

6. In addition to the nurse, which professionals are core members of the palliative care team?

A. Dietician and physical therapist B. Physician and pharmacist C. Physician and nursing assistant D. Physician and social worker Answer: D Rationale: At the very minimum, the interprofessional team includes the physician, nurse, social worker, and clergy. While physical therapists, dieticians, and nursing assistants can play significant roles in the patient’s care, they are not considered part of the minimal team.

7. What is the last step in the advanced practice nurse’s standards for development and implementation of a plan of care?

A. Planning B. Consultation C. Diagnosis D. Evaluation Answer: D Rationale: A specific notation of standards applies only to the advanced practice nurse, especially when creating a plan of care for the patient. The steps involved are assessment, diagnosis, outcome identification, planning, implementation, coordination of care, health teaching and health promotion, consultation, prescriptive authority and treatment, and evaluation.

8. Which situation shows a nurse demonstrating competency in collaboration when providing palliative care?

A. Checking current research on effective pain management when determining the care plan for an end-of-life patient B. Consulting with a dietician when determining the meal plan for a patient with end-stage renal failure C. Providing a list of caregiver support groups to a patient's family members D. Reflecting on actions taken in a care situation and how they may be improved Answer: B Rationale: Interprofessional collaborative practice involves different types of health professionals working together with patients, families, and communities to deliver best practices and best patient outcomes. Practicing evidence-based nursing, being knowledgeable regarding resources to assist patients and families, and evaluating care are nursing competencies but does not reflect interprofessional collaboration.

9. What is the core principle of palliative care?

A. Patient’s family involvement is approved by the healthcare provider.

B. Patient’s care depends primarily on the disease involved.

C. Patient and healthcare provider are the unit of care.

D. Patient and family are the unit of care.

Answer: D Rationale: A core principle of palliative care across the entire disease spectrum and in all settings is that the patient and family constitute the unit of care. The patient and family, rather than the disease, are the primary focus of care. Family-centered care forms the foundation of palliative care philosophy; it addresses the meaning of disease, suffering, life, and death within the context of each family unit.

10. Physical, psychological, spiritual, and social dimensions are part of which conceptual model?

A. Whole-person suffering B. Calkin model of advanced nursing practice C. Systems approach D. Clinical ethics

Answer: A Rationale: Dame Cicely Saunder is the founder of St. Christopher’s Hospice in London. She developed a conceptual model of “whole-person” suffering that has four dimensions: physical, psychological, spiritual, and social. Suffering affects each domain of the bio–psycho–social– spiritual aspects of care. This forms the basis for the description of palliative care nursing practice.

Short Answer 1. What is the difference between palliative care and hospice care?

Model Answer: While there are similarities between palliative care and hospice care, palliative care involves identifying and preventing serious, chronic, or life-threatening illness, and is used along with measures to reverse the illness or prolong life. The focus is pain and symptom relief for the patient, comfort measures, and management of physical, psychological, or spiritual issues that the patient may experience during the illness trajectory.

Palliative care was built on the foundation of Hospice care which is holistic, comprehensive care of the patient and family with serious, life-threatening, and progressive illness. The difference is that patients may be enrolled in Hospice, as a Medicare benefit, only during that last six months before death. Palliative and Hospice care exist on the same continuum of care with palliative care offered earlier in the illness experience. If a patient decides not to enroll in Hospice, Palliative care can also continue through the death of the patient and into the bereavement period of families.

2. Describe three factors that drew national attention to palliative care as it was first emerging as a care specialty.

Model Answer: Billings and Block (1997) identified forces that increased national attention on palliative care. These included growing interest in death and dying; development of hospice programs; increasing integration of pain and symptom management into conventional care; concern about the high cost of dying; increased national focus on pain management; greater attention in medicine to caring rather than curing; national debates on physician-assisted suicide and euthanasia. All of these forces led to increased demand for expert, comprehensive palliative and hospice care.

3. What are at least four standards of nursing practice?

Model Answer: The standards of nursing practice, which are the foundations of palliative care and hospice nursing, include providing age-appropriate and culturally, ethnically, and spiritually sensitive care and support; maintaining a safe environment; educating patients and families to identify appropriate settings and treatment options; assuring continuity of care and transitioning to the next appropriate setting; coordinating care across settings and among caregivers; managing information and protecting confidentiality; communicating promptly and effectively.

4. Discuss ways in which relief of suffering and quality of life can be enhanced for patients receiving palliative care and hospice.

Model Answer: Relief of suffering and quality of life for individuals who are undergoing palliative care or hospice and their families are enhanced by providing effective pain and symptom management; addressing psychosocial and spiritual needs; incorporating cultural values and attitudes in the plan of care; creating a healing environment for a peaceful death; supporting those who are experiencing loss, grief, and bereavement; promoting ethical and legal decision making; advocating for personal wishes and preferences; using therapeutic communication skills in all interactions; facilitating collaborative practice; ensuring access to care and community resources through influencing and developing health and social policy; contributing to improved quality and cost-effective services; creating opportunities and implementing initiatives for palliative education for patients, families, colleagues, and community; and participating in the generation, testing, and evaluation of PC knowledge and practice.

5. Why is certification in hospice and palliative care valuable and important?

Model Answer: Certification in hospice and palliative care means achieving tested and proven competency, increasing knowledge, committing to this specialty, being dedicated to professional development, committing to improved patient outcome, having compensation incentives, gaining recognition, and being an asset to an employer because certification is a recognized quality marker by patients, physicians, providers, quality organizations, insurers, and the federal government.

CHAPTER 2: Palliative Care: Responsive to the Need for Healthcare Reform in the United States Multiple Choice 1. Which statement describes palliative care for a patient recently diagnosed with pancreatic cancer?

A. Patients with a rapidly progressing cancer benefit little from palliative care.

B. Palliative care is offered in the last 6 months of life.

C. Palliative care focuses primarily on disease management D. Palliative care can be provided along with curative treatments.

Answer: D Rationale: Palliative care can be provided in the context of curative treatments, concurrently with symptom alleviation of the disease or its treatment, as well as offering psychological and spiritual support during the illness experience. Palliative care begins at the time of the patient’s diagnosis and continues until the patient’s death, and into the bereavement period for families.

2. The rising cost of healthcare has caused which of the following effects?

A. Palliative care is becoming a structured system of care within mainstream healthcare.

B. The number of patient consultations to palliative care is decreasing.

C. Palliative care is increasing medical expenses. beErSoT f tBreAaN tmKeS ntEoLpL tioEnRs .oC ffeOrM ed.

D. The need to limit the numT Answer: A Rationale: Palliative care is moving into the mainstream of healthcare as a highly structured and organized system of care. Because of the increase in the number of people age 65 and older, more patients are seeking palliative care. Palliative care promotes quality health outcomes, providing added value while lowering health care costs. Palliative care which is comfort and supportive care can be offered along with curative therapies.

3. A patient has just received a diagnosis of rheumatoid arthritis. If the patient receives a palliative care consultation, which outcome is most likely?

A. Care will be shifted from home to hospital.

B. Comprehensive, coordinated care will occur C. Quality of life for family will be unchanged.

D. Laboratory and pharmaceutical costs will increase.

Answer: B Rationale: Palliative care results in fewer hospital days, fewer emergency department or physician office visits, and fewer days in a skilled nursing facility. As more patients wish to remain at home during an illness and to die at home, palliative care allows the shift of care from hospital to home, while providing comprehensive coordinated care across settings. Palliative care increases the quality of life for patients and their families, and reduces the total costs of ICU admissions, lowers the cost per day, lowers the direct costs per admission, and also reduces laboratory costs.

4. Which patient is most likely to have access to quality hospice or palliative care?

A. Jason, who receives outpatient services in rural Tennessee B. Carmine, who has been admitted to a small community hospital in Arizona C. Nancy, who has been admitted to an academic medical center in Massachusetts D. Adele, who receives outpatient services at the VA hospital in Georgia Answer: C Rationale: There is state-to-state and region-to-region variability in accessibility and availability of palliative care. Issues may be due to a shortage of trained professionals in PC, particularly in public and community provider hospitals, which serve Americans who are without healthcare insurance or those who live in geographically isolated areas. PC has grown rapidly in the U.S. healthcare system, with 90% of large hospitals with 300 or more beds now having a PC team.

The number of palliative care programs is highest in the New England (88% of hospitals), Pacific (77% of hospitals), and mid-Atlantic (77% of hospitals) areas and lowest in the west south central (43%) and east south central (42%) states. In contrast, only 26% of for-profit hospitals, 37% of community hospitals, and 54% of public hospitals offer PC. Most veterans receive hospice care (71%), while 52% received palliative care.

5. In which way does voluntary certification in palliative care support healthcare reform?

A. Increases the number of palliative care programs supervised by physicians B. Links palliative care with hospice care in the minds of patients C. Insures that palliative care programs meet the criteria for quality palliative care D. Maintains current reimbursement standards for palliative care Answer: C Rationale: The current voluntary certification in PC, as recommended by the Joint Commission, as well as the expectation for hospitals to achieve Magnet status, supports the mandate for healthcare reform in America and the provision of PC for patients and families. Certification insures that a palliative care program meets the criteria for quality palliative care as identified in the National Quality Forum Consensus Guidelines for Quality Palliative Care.

6. The family of a patient with Alzheimerʼs disease requests an appointment with a palliative care specialist. Which of the four “As” of Maryland’s Blueprint for Success does this demonstrate?

A. Awareness B. Acknowledgment C. Action D. Access Answer: D Rationale: Access is the right, privilege, or ability to make use of resources and information related to palliative and hospice care.

7. Which statement describes palliative care on a global level?

A. Most countries are starting to consider palliative care to be a human right.

B. Palliative care has been well integrated into the healthcare systems of most countries.

C. Funding for palliative care is highly reimbursed in most countries.

D. Palliative care occurs primarily in the home across most countries.

Answer: A Rationale: In many countries, access to PC is being considered a human right, as it ensures the relief of pain and suffering from cruel, inhumane, and degrading treatment. The integration of palliative care into global health care settings is moving forward in many countries but not all countries. The reimbursement of palliative care remains a challenge.

8. Which action by the nurse most empowers the patient?

A. Consulting with the attending physician B. Explaining risks and benefits of treatments C. Discussing the prognosis with family members D. Choosing a plan of care based on research evidence Answer: B Rationale: Explaining risks and benefits of treatments most empowers the patient because the patient is informed of and can make decisions about his or her healthcare accordingly.

9. What role in the nursing profession develops new palliative care knowledge?

A. Nurse researchers B. Nurse educators C. Doctors of Nursing Practice D. Clinical Nurse Leaders Answer: A Rationale: Nurse researchers have the skill to conduct nursing studies and add to the development of knowledge related to palliative care. Doctors of Nursing Practice translate knowledge into practice. Nurse educators and Clinical Nurse Leaders educate nurses and promote the advancement of quality palliative care.

10. Which action by nurses will best integrate palliative care into mainstream healthcare?

A. Establish networks of palliative care providers B. Increase public knowledge of palliative care C. Ensure the funding of palliative care D. Participate in social and political activism for palliative care Answer: B Rationale: Modification of public perceptions of palliative care is central to improving knowledge of, and access to, services, empowering individuals and involving communities in end-of-life care. Nurses, as educators, must focus on achieving a comprehensive knowledge of the public regarding palliative care.

Short Answer 1. Describe the 3-year palliative care/hospice demonstration project implemented by the Centers for Medicare & Medicaid Services under the requirements of the Affordable Care Act of 2010.

Model Answer: This project is designed to allow patients to receive aggressive treatment and palliative/hospice care concurrently. It requires an evaluation of the current hospice eligibility criteria, with the expectation that the current prognosis of 6 months or less to live for patients with advanced illness will be relaxed. Additional project outcomes measured are the cost saving of palliative home healthcare programs and an evaluation of patients’ and families’ quality of life. The project hypothesizes that, compared to usual care, there will be improved survival rates when palliative care is performed along with life-sustaining treatments.

2. What are four positive health outcomes of palliative care?

Model Answer: Studies conclude that palliative care reduces the overuse of marginally effective, ineffective, and unnecessary treatments, and results in fewer hospital readmissions, allowing greater continuity of care and the development of safe transition plans upon initial discharge. Other positive health outcomes of palliative care include better management of pain and other symptoms; emotional, spiritual, and social support of patients and families; better quality of life for patients and families; increased patient/family satisfaction; efficient TiElyS/pTaBtiA ELmLeE handling of time-intensive fam enNt/K teS am etR in. gsC; O beMtter coordination of care; increased specialty-level assistance to attending physicians; support for discharge planning staff; and nurse and physician satisfaction.

3. What roles do healthcare professionals have in promoting healthcare reform, especially in palliative care?

Model Answer: According to Maryland’s Action Plan, healthcare professionals play major roles in the education of patients, families, and communities regarding palliative and hospice care, including advanced care planning. They should develop and implement educational programs (formal and informal) related to palliative and hospice care, and communicate these programs to patients through conversations, healthcare publications, and media/marketing. In addition, healthcare professionals must be educated to ensure adequate staffing of PC programs, particularly given the increase in the number of programs. Medical, nursing, and social work schools are not only integrating PC into their curriculum, but are also creating graduate programs with a focus on PC. In addition, several interprofessional fellowship programs in PC are offered across the country, which reinforce the importance of interprofessional collaboration and teamwork. Healthcare professionals should also actively participate in palliative education and palliative care initiatives by attending national conferences, increase certification and credentialing rates, and make referrals to palliative care services and hospice care. Lastly, healthcare professionals should incorporate the National Quality Forum Preferred Practices of Palliative Care as a standard of care within the institution.

4. What are the most optimal and efficient methods for implementing palliative care on an international level?

Model Answer: To direct the international future of PC, a meeting of clinicians, health economists, researchers, policy makers, and advocates was convened with the identification of seven recommendations. These include sharing definitions of PC; recognizing the strengths and weaknesses of different payment systems; identifying country-specific and international research priorities; determining appropriate economic evaluation methods; evaluating PC costs; supporting interprofessional PC education and training programs; and developing national standards to regulate and determine PC planning and development.

5. What responsibilities do advanced practice nurses have in implementing a palliative care program?

Model Answer: Advanced practice nurses make the case to hospital administration to implement a palliative program and develop the business plan that includes interprofessional resources, feasibility and accessibility, cost control, revenue generation, integration and leveraging of existing services, and decisions regarding the structure and model of the programs. They design the operational plan for the implementation of PC programs, such as space needs, staffing roles and requirements, basic policies and procedures, and projections of patient volumes and program capacity, as well as consideration of financial and strategic planning issues. The hospital’s financial viability, including the value of the program regarding the length of stay at the hospital, daily census, hospital billing revenues, estimated cost savings, and potential coT ntE riS buTtiBoA nsNbKySpE hiL laL nE thR ro.pC y,OaM re outlined. Given their advanced clinical knowledge and expertise related to healthcare systems, advanced practice nurses provide the perspective as to how PC can meet the expectations of quality care within the context of cost effectiveness and reform.

CHAPTER 3: Interprofessional Collaboration Multiple Choice 1. Which patient would benefit most from an interprofessional palliative care team?

A. Janice, who has Crohnʼs disease, is an active member of her synagogue, and lives near her two adult children B. Troy, who has a torn meniscus, is running back for his high school football team, and lives with his parents and three sisters C. Carl, who has hypertension controlled by medication, works long hours as a custodian, and lives by himself D. Ann, who has lupus, has retired from being a research assistant, and is recently widowed and lives by herself Answer: D Rationale: While all patients can benefit from an interprofessional palliative care team, some patients have more resources than others. Of the four patients listed, Ann would benefit the most.

She has a chronic disease that requires pain management and occasional hospitalization. Since she is retired, she may not have supportive friends from work, and since she is recently widowed, she has undergone a great loss.

2. Which example demonstrates interprofessional team care?

A. A patient addicted to alcoT hoElSwThB oA atN teK mSpE tsLsuLiE ciR de., C thO enMreceives a visit from a social worker after going home from the hospital B. A mother on the obstetrical unit whose premature infant is in the NICU receives a visit from the hospital clergy C. An overweight patient, with heart disease who undergoes bypass surgery, receives a referral for a dietician upon discharge to help him lose weight D. An indigent patient with cancer who undergoes chemotherapy and is then referred to a radiologist.

Answer: B Rationale: Quality, comprehensive, whole-person care depends on the integration of curative and palliative care. The mother of a premature infant in the NICU who then receives a visit from the hospital clergy is an example of interprofessional team care. Her spiritual needs are being addressed at the same time that her baby is receiving medical care. All the other examples involve healthcare and healthcare professionals brought in later when they should have been brought in concurrently with the medical care.

3. Which process demonstrates interprofessional practice?

A. Curative methods are used first, then palliative methods.

B. Communication is primarily through the patient’s chart.

C. Integrated plan of care is formulated by many professionals.

D. Family needs are addressed after the plan of care is enacted.

Answer: C Rationale: An interprofessional team approach integrates separate disciplines into a single consultation, discussing the patient history, assessment, diagnosis, intervention, and short- and long-term care management. The goals of care are established by the team, together with the patient and the family, who are involved in making healthcare decisions.

4. Which interprofessional team member usually assesses patient and family physical, emotional, and spiritual needs?

A. Registered nurse B. Chaplain C. Palliative care physician D. Social worker Answer: A Rationale: A registered nurse conducts a comprehensive assessment of patients’ and families’ physical, emotional, and spiritual needs and intervenes through therapeutic presence and communication, use of nursing interventions, and administration of medical treatments to improve the quality of life.

5. Which of the following is an example of good interprofessional communication?

A. Confirming a registered nurse was aware that a patient was being given two prescriptions B. Ensuring physicians communicate with one another and the palliative care nurse about what to prescribe for a patient TuBnA C. Asking the pharmacist to T coEmSm icN atK eS wE itL hL thE eR re.gC istOeM red nurse about what prescriptions a patient should receive D. Having the palliative care nurse inform physicians which prescriptions would be best for a patient Answer: B Rationale: Certain levels of decision making may be made by individual members of the interprofessional team, whereas other levels will require input from the entire team as a whole.

Poor, fragmented decision making results from the failure to include appropriate team members in the decision-making process. Physicians should communicate with one another and the palliative care nurse about what to prescribe for a patient. The registered nurse is not responsible for writing prescriptions. Asking the pharmacist to communicate with the registered nurse about what prescriptions a patient should receive is inappropriate, as is having the palliative care nurse inform physicians what prescriptions they should write.

6. If the interprofessional team leader asks other team members for their expert opinions but develops the plan of care on his or her own and expects the other team members to follow it, what will the result most likely be?

A. Fragmented decision making B. Lack of input C. Lack of innovated problem solving D. Miscommunication of information

Answer: C Rationale: The interprofessional team leader is displaying lack of respect for the knowledge and skills of other team members. This may stifle the creativity and innovative solutions if team members consistently think they are not being listened to. There is no lack of input because the team leader has asked for expert opinions.

7. Which healthcare professional is demonstrating interprofessional competence?

A. A physician who makes sure the nurse sees to the family’s needs while he or she focuses on curative methods B. An advanced care nurse who wants a clergy member on every patient’s team C. A physician who uses the same team model at a new hospital that was used at a previous hospital for continuity D. A registered nurse who asks patients and families regarding their needs and preferences and involves support of the community Answer: D Rationale: Interprofessional competence means following the principles of interprofessional healthcare, which are patient centered and community/population focused rather than profession centered. A registered nurse who wants to restructure her work schedule to do community outreach is community/population focused rather than profession centered. A physician who makes sure the nurse sees to the family’s needs while he or she focuses on curative methods is not looking at the patient holistically, which is a basic tenet of the interprofessional care. An advanced care nurse who wants a clergy member on every patient’s team is not being patient EL centered if the patient does not wT anEt S aT clB erAgN yK mS em beLr.EARp.hCyO siM cian who uses the same team model at a new hospital that was used at a previous hospital for continuity is not being sensitive to the fact that different practice settings may require different team models.

8. What is the key to healthcare reform for providing compassionate, cost-effective, evidencebased healthcare that is individualized for each patient?

A. Interprofessional education B. New laws concerning medical treatments C. Surveys requesting input from patients D. Interprofessional marketing Answer: A Rationale: Interprofessional education is key to developing a workforce of the future that will provide comprehensive, compassionate, cost-effective, continuous, evidence-based healthcare for varying patient populations, families, and communities. Interprofessional marketing can bring awareness about the interprofessional team approach but does not necessarily lead to healthcare reform.

9. Which statement describes the use of an interprofessional team care?

A. It is effective only in large hospitals with many team members.

B. Patients become confused with so many different team members.

C. Team members develop their own discipline specific plan of care.

D. Team members can share leadership for the patient’s best interest.

Answer: D Rationale: Sharing or rotating group leadership is of value in equalizing power and responsibility and acknowledging and appreciating the expertise of all members of the interprofessional group.

This provides new insights; the best thinking of colleagues is valued since there is a sense of shared responsibility in insuring the best patient and family healthcare outcomes.

10. Which statement regarding an interprofessional team is incorrect?

A. Leadership of the team is shared depending on the patient issue.

B. Health professional competencies are unique to their discipline, as well as shared.

C. The plan of care is developed by the champion of the team.

D. Collaboration, coordinated decision making, and conflict avoidance are essential.

Answer: B Rationale: The Center for Advancement of Interprofessional Education (IPE) emphasizes the unique and shared competencies of health professionals, as well as the importance of having a champion of interprofessional collaboration, who may assume a leadership role, but engages all team members. The champion of interprofessional collaboration may be the leader of the interprofessional team, or another healthcare professional may assume that role. Leadership may also change, depending on the patient’s case. An interprofessional team approach integrates separate disciplines into a single consultation, discussing the patient history, assessment, diagnosis, intervention, and short- and long-term care management. A dynamic and outcomeoriented interprofessional team requires collaboration, leadership, coordinated decision making, and conflict resolution.

Short Answer 1. What are the driving forces behind an interprofessional approach to palliative care?

Model Answer: Palliative care requires a comprehensive and holistic approach that cannot be addressed by just one healthcare professional. There is a need to reduce morbidity and mortality rates, improve care coordination, provide patient-centered care, reduce healthcare costs, and enhance group accountability for the quality of healthcare. Healthcare professionals need to work together as a team. This will involve redesigning healthcare education, retraining health professionals already in the workforce, and reforming the overall healthcare system. Research suggests that interprofessional learning is essential for patientcentered, cost-effective, efficient, safer, timelier, and more equitable healthcare. For patients and family members, interprofessional practice can decrease total patient complications, decrease the length of hospital stay, reduce outpatient visits, and reduce mortality rates, including suicide rates.

2. Kacie is 32, married, and the mother of two small children. She was admitted to the hospital with weakness and pain that seemed to come out of the blue. After extensive tests, she has been diagnosed with multiple sclerosis. What would be the advantages of an interprofessional model of care for her?

Model Answer: Based on an interprofessional model of care, leadership, communication, and decision-making means leadership is shared and based on patient and family needs and

goals. Many different healthcare professionals will be brought together to formulate her plan of care. Team members will directly interact with Kacie and her family, share information, provide consultation, and work interdependently together to provide comprehensive, continuous care. The team will likely consist of her physician, palliative care nurse, as well as a physical therapist, an occupational therapist, and pharmacist.

3. What roles does the interprofessional team nurse have in the therapeutic relationship with the patient and other team members?

Model Answer: As a coordinator of care and a core member of the interprofessional team, the nurse has the responsibility of developing therapeutic relationships with the patient and family and among all pertinent members of the team. The goal is to ensure effective and supportive communication and quality patient outcomes. The nurse continually reassesses the goals of the patient and family, and their treatment preferences, and offers support. Often, the physician has had a long-term relationship with the patient and family, and as the needs for traditional medical model of curative care lessen, the physician may feel a sense of loss. The collaborative relationship with the physician may also be a source of support for the physician both personally and professionally. The nurse is also a primary conduit for information, critical assessments, and evaluation of the patient and family goals within the interprofessional team. A critical aspect of palliative care involves the identification and subsequent resolution of often differing goals of the patient, family, or the healthcare team.

The nurse is instrumental in coordinating and implementing a comprehensive family-focused plan of care.

4. An advanced care nurse in a 300-bed hospital located in a mid-sized city has taken note of high dissatisfaction rates from patients regarding their hospital stays. The nurse knows that budget cuts have had much to do with this, and is concerned that this may be a continuing trend. While researching other hospitals that are similar in size that are facing the same issues, the nurse reads about interprofessional team healthcare. The nurse is concerned about how well it could be implemented, given the diverse personalities of the hospital healthcare professionals. What steps could the nurse take as an experiment for interprofessional collaboration?

Model Answer: The nurse could try an interprofessional case study modeled after the one used by a group of eight interprofessional colleagues in the College of Nursing and Health Sciences. This was a reflective process by the group leader that led to the identification of eight steps of the group collaborative process. These include the discussion of the leadership of the group going forward, depending on clinical issue to be addressed; the group process promoting commitment and accountability, such as establishing the best day and time to meet or the use of technology in conducting meetings, as well as strategies for communication through email; shared group responsibility in reviewing the health sciences literature regarding the care of the specific patient population, with each member contributing their findings during a group discussion from their disciplinary perspective; outlining the components of the comprehensive health history and physical examination from an interprofessional perspective and developing case-specific details; reviewing the case findings with identification and prioritization of clinical diagnoses; developing holistic interventions, including discipline-specific and complementary interventions from an

interprofessional perspective to address diagnoses/clinical problems; and involving all team members in the evaluation of health outcomes. This method involved all members contributing equally from their area of expertise instead of using traditional hospital hierarchy.

5. What is necessary to keep the momentum going for healthcare reform through the implementation of interprofessional healthcare teams?

Model Answer: Transformative change in education and clinical practice is needed. It will involve interprofessional networking of colleagues within, across, and beyond the university environment and those within healthcare systems and agencies. Further research on the structure, processes, and outcomes related to interprofessional collaboration is needed as it relates to patients and their families, healthcare providers, and institutional outcomes.

CHAPTER 4: Ethical Aspects of Palliative Care Multiple Choice 1. If a nurse is wondering if removing a terminal patient’s feeding tube was the right action to do, what is the nurse engaged in?

A. Ethics consultation B. Ethical inquiry C. Value clarification D. Moral uncertainty Answer: B Rationale: Ethical inquiry seeks to interpret acts, and to answer such questions as “What is the right thing to do?” includes an evaluation of the moral agent and his or her character, the motive for the act itself, and the effect of the action on others.

2. Which situation is an example of an ethic of caring?

A. A nurse who avoids telling terminal patients to prepare for the end of life so they will remain calm.

B. A nurse who spends an extra few minutes with each patient to find out how he or she is feeling.

C. A nurse who recommends that patients receive palliative care only in the hospital for the best outcome.

D. A nurse who urges patients to request opioids for pain relief since they provide the most analgesia.

Answer: B Rationale: Caring, within the context of an ethics of care, refers to care for, emotional commitment to, and willingness to act on behalf of persons with whom one has a significant relationship. An example of this is a nurse who spends an extra few minutes with each patient to find out how he or she is feeling because the nurse is forming a relationship with these patients.

3. The custodial parent of a terminally ill child in a hospital has requested that the noncustodial parent be prevented from visiting the child. The concern is that the child will become upset.

However, the child has been asking to see the noncustodial parent. The healthcare professionals are trying to decide how to handle the situation. Which concept is involved?

A. Moral analysis B. Value clarification C. Ethics of doing D. Ethics of being Answer: C Rationale: Ethical theories that focus primarily on actions and decisions are considered ethics of doing. Moral analysis is employed to discern all the parameters involved in a decision. Ethical theories that focus on an individual’s character attributes and virtues are considered ethics of

being. Values clarification is a process of self-reflection that helps individuals identify, consider, and articulate the belief, purposes, and attitudes they prize and that drive their actions.

4.

Which situation describes a nurse breaking the fundamental principle of respect for persons?

A. Allowing family to stay in the room with the patient after hospital visiting hours are over B. Questioning whether a patient’s DNR order has been properly documented C. Forgetting to note a dietary allergy in the patient’s chart, which causes an anaphylactic event D. Administering pain medications last to patients on the floor who are on government assistance

Answer: D Rationale: The most fundamental ethical principle within nursing practice is the principle of respect for persons. The first provision in the Code of Ethics for Nurses calls for nurses to “respect the dignity and rights of all human beings regardless of the factors contributing to the person’s health status. The worth of a person is not affected by illness, ability, socioeconomic status, functional status, or proximity to death.” Administering pain medications last to patients on the floor who are on government assistance shows lack of respect for these persons.

5. Melanie has just been diagnosed with early-onset Alzheimerʼs disease. She is terrified about her future and is unsure what do to about her healthcare. Which surrogate decision-making option is the most optimal for Melanie?

A. Writing an advance directive that outlines her wishes EbSeT B. Depending on a family mT em r’B sA suN bK stiStuEteLdLjuEdRg. mC enOt M C. Relying on healthcare professionals to make decisions in her best interest D. Trusting that she will make her own best decisions when she is lucid Answer: A Rationale: There are three standards for surrogate decision making: written advance directives (e.g., living wills), substituted judgment, and best interest. These three standards are ordered so that advance directives have priority over the other two, and substituted judgment has priority over the best-interest standard. The best of all situations is a thoughtfully drafted advance directive applied by a surrogate decision maker who knows the patient’s values and wishes.

6. Jeremy has been living with an aggressive form of leukemia for some time and is currently undergoing chemotherapy. Recently, a nurse making a home healthcare visit said that Jeremy might consider experimental treatments. The survival rate with the experimental treatments is lower than that for chemotherapy, but the side effects are milder. What issue does this present?

A. Duty-based ethics B. Principle of double effect C. Nonmaleficence D. Morality Answer: B Rationale: Any discussion that includes attempts to distinguish between harming and benefiting patients often includes the principle of double effect. The traditional formulation of this principle

stipulates that four conditions be met before an act with both good and bad consequences may be morally justified: The action itself must be good or at least morally indifferent; the individual must sincerely intend only the good effect and not the evil; the evil effect cannot be the means to the good effect; there must be a proportionately valid reason for permitting the evil effect; that is, there must be a favorable balance between the good and the evil effects of the action. Nurses may appeal to this principle in morally difficult situations where it is not possible to benefit a patient by an action without at the same time causing harm.

7. If a nurse is confronted with an ethical dilemma, which approach would be most useful in resolving it?

A. Organize a committee, identify authority figures who can make decisions, notify legal entities B. Consider past actions, present relevant information to patient, have patient make choices C. Gather relevant facts, identify parties involved, identify choices and consequences D. Identify conflicts of ethical principles, give information to authority figures, step away from the situation Answer: C Rationale: Steps that can help resolve an ethical dilemma include reviewing the situation; gathering all relevant facts; identifying the parties or stakeholders involved; identifying relevant legal data; identifying specific conflicts of ethical principles or values; identifying possible choices, their purpose, and their probable consequences to the welfare of the patient; identifying and making use of interprofessional and institutional resources; identifying practical constraints .aCkO to decision making; taking actionTifEySoT uBarAeNthKeSdE ecLisLioEnRm erMor supporting the authorized decision maker; reviewing and evaluating the situation after action is taken.

8. Which consideration demonstrates the primary moral concern for nurses?

A. Whether parents are choosing the correct course of chemotherapy for their child B. Whether parents understand if a medication’s benefit outweighs side effects for their child C. Whether family members understand the end of life is near for their loved one D. Whether family members are initiating life-sustaining treatments too late Answer: B Rationale: Optional or nonburdensome treatments include all medications, treatments, and operations that offer a reasonable hope of benefit and can be obtained and used without excessive expense, pain, or other inconvenience from the patient’s perspective. Extraordinary (or burdensome) treatments are those that are very costly, unusual, difficult or dangerous, or do not offer a reasonable hope of benefit to the patient. What should be of moral concern for nurses is not what the intervention is, but whether the benefits of its continued use outweigh its associated burdens, as determined by the patient or surrogate decision maker.

9. Which concern plays a central role in the debate surrounding assistance in dying?

A. If prescriptions for lethal amounts of medication is the same as withholding food and water B. That increasing numbers of terminal patients will end their lives rather than receive palliative care

C. Negative attitudes that have been directed toward those who choose to end their lives D. A possible cultural shift leading to vulnerable patients perishing too soon Answer: D Rationale: While some individuals benefit from access to lethal prescriptions to control the timing of their death, others are harmed by lack of access, leading to concerns about unintended negative consequences of legalizing and sanctioning this practice. The concern is that allowing healthcare providers to support patients who choose to end their life through legally and professionally sanctioned access to lethal prescription will accelerate a cultural shift that will lead some of the most vulnerable members of society to die too soon.

10. Which statement accurately describes pediatric medical considerations?

A. Minors need to be included in decisions about their care B. Parents have the final say about their infant’s care C. Parents can always choose what type of care their children receive D. Minors cannot override parents’ decisions about what care they receive Answer: A Rationale: Minors have rights to be included in end-of-life decision making, depending on their decision-making capacity and maturity.

Short Answer

.oCrO 1. Describe a situation in whichTaEnS urT seBiA sN exKpS erE ieL nL ciE ngRm alMuncertainty, and a situation in which the nurse is experiencing an ethical dilemma. Explain how these situations are similar, and how they are different.

Model Answer: Moral uncertainty occurs when nurses are uncertain if a moral problem exists, are unsure about its nature, and are unclear which values conflict and which principles might facilitate clarification. An ethical dilemma occurs less frequently and is understood as a situation in which two or more clear ethical principles apply that support mutually inconsistent courses of action. Each alternative course of action can be justified by an ethical rule or principle, but one can choose or satisfy only one course of action at the expense of not satisfying the other. A situation involving moral uncertainly could be a patient who is alcoholic and continues to drink even though the alcohol interferes with potentially lifesaving medication. The moral uncertainty could be in how to address the patient’s drinking and discussing the ramifications, especially if the nurse has values against drinking excessively. A situation involving an ethical dilemma is a nurse who is with a patient who has just been sexually assaulted by a man. The attending physician is male, and the patient is terrified to be touched by him. The patient needs care but refuses to be seen by the physician.

Both situations require the nurse to do self-inquiry, to come up with the best course of action, and to ensure the client’s care and safety. The first situation, however, requires the nurse to examine his or her own morals. The second situation requires the nurse to discern the most ethical solution.

2. Myron is 23 years old and is addicted to heroin. He has been in and out of treatment for his addiction since he was 15 and cannot seem to stay clean. He has lucid moments but is high more often than not. He has just been brought to the emergency room by his parents when they discovered him passed out in his room. As he is being treated for the overdose, the physician notes an orange tint to his skin, mucous membranes, and sclera of his eyes. A liver panel is ordered, and he is tested for hepatitis infection. The physician would like to do further liver testing. What are the steps needed to determine whether Myron is decisionally capable for his own healthcare?

Model Answer: A decisionally capable person is able to understand a proposed intervention (or its termination), deliberate regarding major risks and benefits, make a decision in light of that deliberation, and communicate the choice to others (whether verbally or nonverbally). If Myron is decisionally capable, he should understand the condition for which the intervention is recommended (hepatitis infection and/or cirrhosis of the liver), the nature of the recommended intervention (further liver testing), and the risks and benefits of the recommended intervention and of alternative interventions, including no intervention or treatment. The physician should determine that Myron acknowledges that treatment is recommended, he understands how the proposed treatment or lack of treatment can affect his quality of life, and his decision is not substantially based on a delusional belief.

3. What factors are involved in ensuring that justice is done within cost containment measures for healthcare?

Model Answer: This is a com TpEleSxTisBsA ueN. K InStE heLcLuE rrR en.t C erOa M of cost containment and social injustice, those who are already marginalized and disadvantaged by poverty, chronic or terminal illness, old age, cultural and racial status, or gender may not think they are entitled to life-sustaining procedures. Additionally, in certain political and societal realms, these people may be seen as a drain on resources and entitled to only minimal care. This is a conflict with the basic tenet of nursing, which is respect for all persons, and nurses may feel a great deal of ethical and moral conflict. However, many who advocate for U.S. healthcare reform agree that cost must be considered in the allocation of healthcare resources. There are increasing numbers of people with chronic critical illnesses in the United States. Fairly weighing such costs and associated burdens against benefits requires interprofessional understanding and cooperative effort among all affected parties within society. Caregivers face challenges in reaching ethical decisions that are fair to individual patients while using available resources responsibly and treating comparable cases alike.

4. Jackie is 14 years old and was hit by a car while riding her bicycle. She has been in a persistent vegetative state for over a year. Her parents are trying to come to terms with letting her go and have started talking about letting her die with dignity. Jackie’s nurses and physicians are recommending withdrawing artificial nutrition and hydration. What are ethical considerations of this?

Model Answer: Often the most difficult decisions about withholding treatments are those that involve caring and nurturing interventions, such as providing food and fluids.

“Artificial” or technologically provided nutrition and hydration (ANH) is not the same as oral provision of food and water. Food and water are continued to be offered orally as long as

patients desire them. However, a moral and legal consensus is that ANH is a medical treatment that may be refused or withdrawn on the same grounds as any other medical intervention—whether it is a benefit or a burden. Jackie’s parents and healthcare providers may have ethical difficulties if they are unclear whether continued provision of nutrition is more beneficial or harmful to Jackie. On one hand, continuing to provide ANH is unlikely to achieve the clinical outcome for which it is most often used, namely, to enhance comfort, prolong life, and improve the quality of life. On the other hand, Jackie is still alive, and the basic tenet of humanity and medicine is “do no harm.” Additionally, nurses should know whether their state’s legislative policy restricts or limits parental rights to decide about the administration of ANH, as that will play a role in the decision as well.

5. What resources are available for nurses to assist them in ethical decision making and to help prevent burnout?

Model Answer: Nurses may experience conflict between their own moral values and the values of the profession, and they have the right to remain true to their own conscientious moral and religious beliefs. Although prohibited from compromising legitimate patient choices or imposing their values on others, nurses who are ethically opposed to certain patient interventions will find support for their position in the Code of Ethics for Nurses.

They have the right to withdraw from providing interventions that run counter to their core beliefs, assuming that arrangements can be made for the patient’s safe transfer to the care of another. Conflict inevitably arises between nurses’ roles as caregivers and patient advocates, institutional employees, and clinicians expected to implement physicians’ orders. The nurse LoErR ethicist helps nurses identify T anEdSbT etB teA rN mK anSaE geLm al.dC isO trM ess in the workplace. Ethics consultation help staff identify and understand the specific ethical issues the case raises; improve communication between the patient, family, and healthcare team; provide emotional support to the health team members involved in a difficult case; offer ethically justifiable recommendations for how to resolve an ethical question or dilemma; and improve patient care by preventing patient care decisions that run counter to ethical guidelines and standards.

Multidisciplinary and nursing ethics committees should be available to nurses for case consultation regarding ethical conflicts. Activities such as “Schwartz rounds” and nurse resilience programs proactively address factors that can lead to moral distress and burnout.

Interprofessional ethics rounds also present an opportunity for individuals working in different patient care disciplines to discuss regularly troubling cases that may not require an immediate decision. Such meetings allow for analysis, exploration, and sharing of different points of view. Thus, when ethical problems do occur, a foundation exists to provide guidance about the most effective way to respond.

CHAPTER 5: Legal Aspect of Palliative Care and Advance Care Planning Multiple Choice 1. Which legality makes sure that Cho completely understands all the aspects of the hysterectomy her physician recommends before agreeing to the surgery?

A. Life-sustaining treatment order B. Advance directive C. Informed consent D. Durable power of attorney for healthcare Answer: C Rationale: The fundamental goals of informed consent are patient autonomy and selfdetermination, empowering them to exercise these rights rationally and intelligently. Informed consent means all the benefits and risks of medical procedures have been explained to the patient before the patient makes a decision whether to receive the treatment or not.

2. Which statement describes informed consent regarding children?

A. Children have little sense of autonomy, so parents make healthcare decisions for them.

B. Children younger than adolescents can understand treatment options and the potential end of their lives.

C. School-age children are uT suEaS llyTaBllAoN wK edStE oL haLvE eR th.eCfiO naMl say on whether they will receive treatments.

D. Adolescent children have full autonomy and can make their own healthcare decisions.

Answer: B Rationale: A study by Hinds et al. found that children as young as 10 years dying from brain tumors could understand the potential treatment options and recognize that their death could be the consequence of their decision.

3. Delphina is 67 years old, with a history of strokes, and is on Medicare. She does not want to receive painful or invasive procedures that prolong her life but decrease her quality of life and concerned that her children would override her wishes should she have a medical emergency. According to the Patient Self-Determination Act (PSDA), what is her hospital required to provide her that will help her?

A. An in-person meeting about individual rights concerning advance directives B. Verbal information about rights under state law to have an advance directive C. Written documents about hospital policies regarding advance directives D. Online sites to research how to write an advance directive Answer: C Rationale: The PSDA requires that facilities participating in the Medicare and Medicaid program provide written information to individuals about hospital policies regarding advance directives and about their right to participate in medical decision making and formulate advance directives.

Information about rights under state law to have an advance directive and policies regarding advance directive need to be given in writing, not verbally or as a verbal consultation.

4. Which document causes concern for healthcare providers because it may not allow for advances in medical treatment?

A. Durable power of attorney B. Do-not-resuscitate directive C. Living will D. Medical directive Answer: D Rationale: Healthcare providers voice concern with the accuracy of medical directives because they do not allow for advances in medical treatment or for the patient to change his or her mind about one of the interventions or situations without changing or destroying the directive.

5. In which case do laws allow physicians to prescribe large doses of opioids?

A. Chronic pain B. Intractable pain C. Patient request for the end of life D. Family request for patientʼs end of life Answer: B Rationale: Several states have enacted intractable pain statutes to encourage those who treat patients who are terminally ill anT dE haSvT eB inA trN acKtaSbE leLpL aiE nRto.m CaOnMage the pain without the threat of legal liability if the treatment results in the patient’s death. Chronic pain, patient request for the end of life, and family request for patientʼs end of life are not legally supported reasons for prescription of large doses of opioids.

6. A patient has been left unconscious from a car accident and had never formulated an advance directive. Which entity has the primary legal right to make decisions on the patient’s behalf?

A. Court system B. Healthcare institution C. Family member D. Family lawyer Answer: C Rationale: In 1982, the President’s Commission concluded that family decision making had gained and should be accorded legal acceptance. Motivated by concern over the formal legal status of family decision making in the 1980s, state legislatures recognized and began to regulate it by statute. Since the patient does not have an advance directive, the family lawyer has not been given authority to act on his or her behalf. The healthcare institution and the court system would step in only if no one else is able to act on the patient’s behalf.

7. Which question may be the most beneficial in initiating a discussion with the patient about the end-of-life preparation?

A. “Do you have an advance directive for your future medical care?”

B. “Is it okay to talk with you about your health and future medical care?”

C. “Can we talk about procedures for your future medical care?”

D. “Are you okay with talking about legal aspects of your future medical care?

Answer: B Rationale: The provider asking for permission to discuss the patient’s current condition and possible future medical care displays caring and sensitivity, and is inviting the patient into a discussion about this difficult topic. Asking about an advance directive, procedures, and legal aspects of future medical care may feel abrupt and insensitive to the patient. These types of questions are more utilitarian in approach and can be off-putting.

8. Which is an accurate statement about advance directives?

A. People may think they cause treatment to be withheld unnecessarily.

B. Most patients have them and have given them to their physicians.

C. Emergency admission is the best time to receive information about them.

D. Physicians adhere to them even in conflict with family preferences.

Answer: A Rationale: People may be concerned that once an advance directive is completed and it contains a statement to withhold treatment, providers will devote less attention to their care and may withhold more treatment than was desired. The public has not embraced the use of advance directives, and most Americans do not have one even though surveys demonstrate strong support for them. teE nS anTaBdA vaNnK ceSdEiL reL ctE ivR e. wC itO hM a DNR order and presented it to 9. A patient had previously writT her family and physician. The patient slips into a coma from diabetic complications and her family members are unable to accept the DNR order, forbidding the physician from using it.

What is the most appropriate first step for the physician?

A. Try to resolve the issue with the family members B. Refer the issue to the courts and have it resolved there C. Bring the issue to an ethics committee for discussion D. Think carefully and critically through the ethical issues Answer: D Rationale: Physicians need to think carefully and critically through the ethical issues themselves before they try to resolve disagreements with the patient or family. It is important that this reflection be done first before other actions so that the physician is clear about all the factors involved in the situation.

10. Which resource would best help nurses in enhancing their knowledge of professional moral obligations?

A. American Nurses Association Center for Ethics and Human Rights B. Supreme Court of the United States C. Black’s Law Dictionary D. Joint Commission on Accreditation of Healthcare Organizations Answer: A

Rationale: Ethics rounds, grand rounds, ethics colloquia, courses in basic nursing education, continuing education offerings, and conferences all provide forums for nurses, students, faculty, and clinicians to enhance their ethical and legal awareness. The American Nurses Association Center for Ethics and Human Rights is one rich resource for nurses who seek consultation and ethics information.

Short Answer 1. What are the purposes of natural death acts?

Model Answer: Natural death acts sprang from the belief that medical technology had made possible the artificial prolongation of patients’ lives beyond their natural limits. Another underlying assumption of the acts was that adults in the United States have the right to control decisions about how they live their lives as well as how they die. Natural death acts allow patients to refuse excessive medical care at the end of life. In addition, some natural death acts specifically state that “physicians and nurses should not withhold or unreasonably diminish pain medication for patients in a terminal condition where the primary intent of providing such medication is to alleviate pain and maintain or increase the patient’s comfort.” Most states also include in their natural death act a provision that a person’s right to control his or her healthcare may be exercised by an authorized representative who validly holds the person’s durable power of attorney for healthcare.

2. A young and active couple has not discussed how to handle medical issues, thinking it would be something to worry about T inElaStT erByA eaNrsK. S OE neLoLfEthRe. mCeOxM periences a traumatic and significant brain injury, and the physicians tell the patient’s partner that recovery is unlikely and asks about the patient’s preferred treatment. What factors will the partner need to consider? Why is it likely the partner will have trouble making decisions about the treatment?

Model Answer: In this situation, there is no clear and convincing evidence of what the patient would have wanted, so the partner is being called on to make decisions. The factors that should be taken into account when deciding what is in the patient’s best interest are the level of cognitive functioning, quality of life, treatment options, current level of pain and suffering, likelihood of pain and suffering if treatment is continued versus withdrawn, and benefits and burdens from treatment. Although these factors seem objective, the partner is likely to find the factors difficult to consider, and intense emotions may make it difficult to deliberate carefully. Shapiro (2015) notes that even the most diligent and responsible surrogates experienced a lack of clarity and were unsure about how to weigh the risks and benefits to the patients. It was difficult for the surrogates to extrapolate from incomplete information and to appreciate the uncertainty of a prognosis. Shapiro states that “many surrogates know the right outcome, it is the process that haunts and paralyzes them.”

3. A 74-year-old patient with cancer has been transported to the hospital to be stabilized in the ICU. The patient has an advance directive refusing life-sustaining treatments. The patient’s children arrive to find they cannot talk with him because of his intubation. The physician explains that life-sustaining treatments may be used for the patient, but they are painful and invasive, and it may be time to prepare for the patient’s end of life. The family becomes

upset and comes into conflict over further treatment decisions. What could have been done to help prevent or resolve the emotional anguish of this situation?

Model Answer: Decision about end-of-life care needs to be made in a family context.

Discussion with patients about end-of-life care helps a patient and their family prepare for death. The patient should have made his physician aware of his advance directive, and thoughtful discussions among the patient, his physician, and his children about his choices would have been helpful. The attending physician now has an ethical dilemma about whether to follow the advance directive or to follow the wishes of the patient’s children. Even if the patient had discussed his advance directive with his children, it is still possible they would not be prepared for his end of life and would want life-sustaining treatments performed.

Conflicts among the physician, the patient’s wishes, and his family about his end-of-life care may need to be resolved by the development of consensus about goals for care through listening, thoughtful discussion, multidisciplinary rounds, and ethics consultation.

4. Describe physician orders for life-sustaining treatment (POLST).

Model Answer: Physician orders for life-sustaining treatment (POLST) are not an advance directive. They are a set of medical orders for a patient with a serious, life-threatening condition. The physician discusses predictable future events for a patient with a lifethreatening condition (such as cardiac arrest with severe heart failure) and determines in conjunction with the patient or surrogate how the patient should be treated if/when the events arise. A document is created that specifies the treatment the physician has prescribed. The document is usually brightly T coEloSreTdBsA oN thKatSiE t iLs L eaEsR y. toCidOeMntify, and it accompanies the patient across healthcare settings, ensuring continuity of care. It is designed to provide quick, clear guidance to healthcare providers about the care that the patient desires and the primary healthcare provider has prescribed. The categories for choices on POLST forms vary from state to state. Physicians, after consultation with their patients or surrogates, prescribe either “attempt resuscitation” or DNAR at the start of the document. Other categories on the documents used in most states provide places for the physician to prescribe or to withhold a range of medical interventions from comfort measures only to full treatment, the use of antibiotics, and the administration of artificially administered nutrition.

5. Explain how the nurse is an advocate for a patient’s end-of-life preferences.

Model Answer: As the ANA has stated in its position statement, it is the responsibility of nurses to facilitate informed decision making for patients at the end of life. This responsibility begins when the nurse has a patient consider what would be important to him or her at the end of life, continues with the nurse educating the person about end-of-life care options, and is completed when the nurse advocates for and delivers the type of care the patient desires at the end of her or his life. However, this process of communication about EOL care is not solely the responsibility of the patient and the nurse; it is an interprofessional process that includes at least the physician and family in addition to the patient and nurse. On admission to a healthcare institution, the nurse should ask the patient and family if the patient has an advance directive and, if a directive exists, whether they can produce a copy of the directive. The nurse or another healthcare provider needs to inquire if the patient still wants

the directive to take effect. The nurse may use the directive to help families to understand and follow the choices laid out in the directive for a family member who has become gravely ill and is incapacitated. Often, however, no advance directive exists. When the patient is gravely ill, it is often the nurse who first notices that death is approaching. Clear communication to the family and physician is essential at this time because the family frequently has not considered death as an alternative. If death appears imminent and there has been no decision about end-of-life expectations, nurses may introduce the discussion of withholding or withdrawing life-sustaining interventions, such as CPR, intubation, and ventilation. Most patients and families want to discuss end-of-life care with their nurse, but they need to hear the same message from the patient’s physician. The nurse must be in communication with the physician about the patient’s prognosis and the patient and family’s preferences about end-of-life care. In situations in which death is not imminent, the nurse can assist a surrogate or family member to understand her or his role in the multidisciplinary team and to help make the decision about the patient’s end-of-life care. The nurse must educate the person about what the role of the surrogate entails as well as how important it is.

CHAPTER 6: Culture and Spirituality as Domains of Quality Palliative Care Multiple Choice 1. When a patient has a terminal illness, which aspect informs the nurse the most about how the patient will approach death?

A. Level of education B. Cultural background C. Views of family members D. Type of support system Answer: B Rationale: Cultural background relates to the degree of fatalism or activism in accepting or controlling death, and maintaining hope, as well as to the views of the patient and family about death. Level of education, views of family members, and type of support may play roles in how the patient approaches death, but the core factor is the patient’s cultural background.

2. Qiu is a Chinese American and the patriarch of his family. Qiu is now 84 years old and in end-stage renal failure. What can the nurse expect when approaching him about the end-oflife care?

A. Request for hospice services prEoS gnToB siA s NKSELLER.COM B. Reluctance to discuss the T C. Belief in fighting to the end D. A sense of fatalism Answer: B Rationale: Generally, members of Chinese culture are reluctant to discuss prognosis and diagnosis as they believe discussing end-of-life issues is like wishing death upon the patient, or may lead to hopelessness, especially as terminal illness is not socially accepted. There is also the belief a person’s final days should be characterized by calm and that the patient should not be involved in decision making.

3. If a nurse refrains from casually touching and making direct eye contact with a patient because these actions are considered disrespectful, which principle is being observed?

A. Cultural diversity B. Cultural awareness C. Cultural sensitivity D. Cultural knowledge Answer: C Rationale: Cultural sensitivity requires the recognition of individual attitudes and beliefs and a refinement of communication skills related to active listening, use of silence and touch, conversational distance, language patterns, and the effective use of translators.

4. Which action demonstrates cultural awareness on the part of the nurse?

A. Consider the role of family members in making decisions regarding patient care.

B. Asking a family member to translate medical treatment procedures to the patient C. Being honest with the patient about his or her chances of survival D. Avoiding asking about the patient’s spiritual beliefs because these are private Answer: A Rationale: Consideration should be given to the issue of family involvement in decision making.

Disagreement and conflict between family and healthcare professionals may occur when the family insists on making decisions for patients who have decisional capacity. As healthcare professionals, it is important to identify the key members of the family and involve them in the discussions as desired by the patient.

5. What is the purpose of the nurse asking patients about their degree of ethnic identity, family structure, and beliefs about health and illness?

A. Assess cultural diversity B. Create cultural competencies C. Determine cultural sensitivity D. Conduct cultural assessments Answer: D Rationale: In conducting cultural assessments, there are many areas to be addressed, including asking patients about their Degree of ethnic identity, family structure, and beliefs about health and illness.

6. Jaime explains to her physician that she feels calm in the face of her end of life because she believes she will be transitioning to another plane of existence in the universe. What is Jaime describing?

A. Her religiosity B. Her spirituality C. Her culture D. Her reverence Answer: B Rationale: Throughout a person’s lifetime, and particularly as people age, religion and spirituality assist them to confront their finitude and vulnerability; to uncover meaning, value, and dignity in illness and death; to establish connection with others and a higher life force; and to find hope, love, and forgiveness in the midst of fear and despair. As such, spirituality engenders serenity and transcendence, thereby buffering stress. Religiosity is one means of expressing spirituality. Religiosity refers to beliefs and practices of different faiths and an acceptance of their traditions, such as Catholicism, Eastern perspectives, Islam, Judaism, and Protestantism.

7. What relationship do spirituality and religiosity have with end-of-life care?

A. Patients may use them to assert an indirect form of control B. They are a small part of the patient’s plan of care C. Patients should never substitute them for medical treatment D. They have a slight effect on the despair and isolation patients may feel

Answer: A Rationale: Religiosity or spirituality also facilitates coping with chronic pain, disability, and serious illness by providing an indirect form of control that helps to interrupt the cycle of anxiety and depression. For some individuals, prayer provides a form of control by believing that through prayer they can influence their medical outcome; in contrast, others deliberately turn over to God their health situation. It is essential that the patient’s spirituality and/or religiosity be integrated into the patient’s plan of care because they can be a source of comfort and anxiety relief.

8. How can nurses best help alleviate a patient’s suffering?

A. Assure the patient that family members are unaffected B. Tell the patient that physical pain is the predominate form C. Disclose to the patient personally painful events in a show of empathy D. listen to the feelings and experiences of a patient’s losses and how they found meaning.

Answer: D Rationale: Genuinely listening to the patient navigate through losses to find meaning can help alleviate a patient’s suffering. This builds trust; the patient will not feel alone, can express thoughts of despair, and search for hope.

9. What is the nurse engaged in by asking the patient questions about their faith, their religious community, and whether faith is helping them cope?

A. Spiritual assessment B. Spiritual caregiving C. Spiritual distress D. Spiritual intervention Answer: A Rationale: The nurse is engaged in spiritual assessment to determine what spiritual or religious needs the patient may have.

10. How can hospice and palliative care nurses prevent or alleviate burnout?

A. Research spiritual aspects of other cultures B. Align patientʼs spiritual needs with their own C. Take care of their own spiritual needs D. Keep their spiritual side separate from their work Answer: C Rationale: In caring for people with life-threatening and progressive illness, nurses must remain in tune with their own spiritual needs, healing themselves as well as others.

Short Answer 1. What are the seven themes representing core principles relevant to Native American healthcare identified by Lowe and Struthers (2001)?

Model Answer: The themes include caring, which embodies characteristics of health, relationships, holism, and knowledge, and is characterized as a “partnership in healing”; traditions, which refers to valuing and connection with heritage; respect, which includes characteristics of honor, identity, and strength and refers to the components of presence and compassion; connection, which honors all people, the past, present, and future, harmony with nature, and explores differences and similarities; holism, which includes balance and culture; trust, which is characterized through relationship, presence, and respect; and spirituality, which includes unity, honor, balance, and healing and includes components of touching, learning, and utilizing traditions to recognize oneness and unity.

2. Olivia is a recent graduate of nursing school. In her first week of work at the hospital, Bharat is admitted. Bharat is from India and is now living in the United States with her adult son.

She has had a persistent productive cough, and her respiration has become labored. Olivia comes in one day to discover that Bharat died during the evening. She is horrified to see someone from Bharat’s family tending to her body, and to hear that Bharat will be cremated.

Olivia is confused and thinks that someone should explain how things are done in America.

Which principles of culturally sensitive care would Olivia benefit from?

Model Answer: The first principle is to be knowledgeable about cultural values and attitudes. Healthcare professionals should attend to a patient’s needs in a sensitive, understanding, and nonjudgmental way, and respond with flexibility as much as possible.

Olivia should understand that cultures different from hers have different rituals surrounding death. For Asian Indians, after death, family members should be the only ones to touch the body, and ideally a family meTmEbS erToBf A thNeKsaSmEeLsL exEsRh. ouCldOM clean the body. After the body is cleansed, a cloth is tied under the chin and over the top of the head, and the body is wrapped in red cloth. Embalming and organ donation are prohibited, and there is a preference for cremation. The tenth principle is for health professionals to conduct a self-assessment of their own beliefs about illness and death. For Olivia, this would include how her beliefs influence her attitudes; how culture and religion influence her personal attitudes toward death; what kind of death does she prefer for herself; what efforts does she believe should be made to keep a seriously ill person alive; how their bodies should be disposed of; as well as what rituals they have participated in to honor the dead.

3. Malachi grew up without spiritual or religious instruction and identifies as an agnostic. He is a nurse in a small community hospital. The community has a strong religious presence, with churches of several denominations, a synagogue, and a mosque with a small congregation.

Malachi has been the nurse for several patients as they faced end of life. Each has requested that he pray for him or her, and once a family clasped hands in a prayer circle around their loved one’s hospital bed and asked Malachi to join them. These situations have made Malachi acutely uncomfortable and unsure of what to say. He wants to be respectful but is at a loss for words. What recommendations could be made to Malachi?

Model Answer: Since the spiritual needs of the patient are important, Malachi could talk with his supervisor about the best approaches. He could do a self-evaluation about what he is comfortable doing and saying. Patients at end-of-life care just need to feel their caregivers are present and genuine, and sometimes a touch on the shoulder and a smile are enough. His kindness will show through. He may not need to say anything and just respectfully listen to

the patient and the patient’s family. He could also say something like, “You are in my thoughts and I am here for you.” What he should not do is offer his personal beliefs of agnosticism.

4. How can healthcare professionals help patients discover hope during a serious illness and end-of-life care?

Model Answer: Despite the stage of illness and a situation of poor prognosis, healthcare professionals can provide hope and a positive outlook by discussing goals of care, offering symptom control, providing supportive resources, and promising the patient that they will not abandon her or him. At times, the most important way to provide hope is by listening attentively and being physically present, which convey a sense of value and affirmation of worth. Hope is then gained that the patient will not be abandoned and isolated. Health professionals can help dying patients co-create meaning day by day while emphasizing the importance of bearing witness to the struggles, joys, and hope of the dying person.

5. Describe ways health professionals can be spiritual caregivers for their patients.

Model Answer: During hospitalizations, health professionals may ask if the person would like to speak with the clergy or chaplain or have the opportunity to attend a hospital worship service. Patients may also be asked if they would like someone to pray with or for them or have spiritual reading materials. If a person is not religious or does not want a health professional to address religious issues, spiritual conversations around hope, love, courage, and forgiveness can occur in T thE eS prToB viA deNr–KpSaE tieLnL t rEeR la. tioCnO shMip. Humor also has an effect on the spiritual aspect of healing, as many patients find humor “spiritually uplifting.” Health professionals can also encourage patients to socialize with friends, family, and children, as well as encouraging them to help others, even if only by active listening. Adults can also pass on their legacy to others by recording personal histories, telling stories, and reminiscing about the past. If the person is isolated, the health practitioner can suggest his or her watching spiritual or religious television programs or provide an opportunity to enjoy his or her favorite sacred or secular music, or other forms of art. Healthcare professionals may encourage opportunities for patients to experience nature in whatever ways they can, such as a walk or wheelchair ride in the garden or courtyard, or as they sit outside feeling the air and warmth of the sun. Spiritual uplifting in the present moment can also occur as the practitioner attempts to create meaning and a source of pleasure in the present moment.

CHAPTER 7: Intimacy and Sexual Health Multiple Choice 1. Which statement describes sexual health?

A. Ability of sexual structures to orgasm B. Optimally functioning sexual organs C. Ability to communicate sexual needs and desires D. Physical, emotional, and social aspects of being sexual Answer: D Rationale: One definition of sexual health is the integration of somatic, intellectual, and social aspects of being sexual. The ability of sexual structures to orgasm and optimally functioning sexual organs are only part of sexual health—the somatic aspect. The ability to communicate sexual needs and desires is also only part of sexual health—the intellectual aspect.

2. A patient has been treated for breast cancer and is seeing her physician for a follow-up examination. She has been wondering if it is okay to resume sexual relations with her husband, but instead avoids eye contact with her physician and answers in monosyllables.

What issue is most likely preventing the patient from talking with her physician about sex?

A. She is embarrassed.

B. She would like more privacy.

C. She thinks her physician iT sE toS oTbB usAyN . KSELLER.COM D. She is unsure if her physician is knowledgeable.

Answer: A Rationale: Sexuality assessment is frequently overlooked by palliative care providers when healthcare needs are being assessed. Healthcare professionals may avoid discussion of sexuality because of embarrassment, assuming that the sex life is over due to the disease, lack of knowledge, and lack of time. Patient-reported barriers can include embarrassment, privacy, and environmental factors. The patient’s behavior indicates that she is embarrassed.

3. Which statement most describes conversations between healthcare professionals and their patients about the patients’ sexual issues?

A. Healthcare professionals usually initiate the dialogue.

B. Healthcare professionals may be too embarrassed to discuss these issues.

C. Healthcare professionals are eager to offer their knowledge.

D. Healthcare professionals are willing to set aside time for these issues.

Answer: B Rationale: Healthcare professionals’ barriers to discussing sexuality include embarrassment, misinformed beliefs and assumptions, lack of knowledge, inadequate communication skills, and time constraints. Sexual health is not routinely assessed due to the belief that the patient will bring up the topic if it is a concern; the perception that people are “too sick” to be sexual; lack of their own comfort with the topic; preconceived ideas, attitudes, and values regarding sexuality;

perceived lack of time for this conversation; and the feeling that there are “more important” issues to be addressed.

4. When should the initial assessment of the patient’s sexual needs be made?

A. After healing is complete B. Before the diagnosis C. At the time of diagnosis D. During the course of treatment Answer: C Rationale: The most effective communication addresses the needs of the patient at each stage of his or her illness. The initial assessment should begin when the diagnosis is made and continue throughout the disease process. Communication with cancer patients is delicate in that the disease is both life threatening and potentially treatable or curable, which creates much uncertainty and stress on the patient.

5. Women most likely to report sexual issues are those diagnosed with which type of cancer?

A. Colorectal B. Breast C. Gynecological D. Lung Answer: B Rationale: Hughes et al. (2017) stTuE diS edTsBeA xuNaK l hSeE alLthLoEfRw.oC mO enMdiagnosed with breast cancer versus non-breast-cancer patients, noting that issues of sexual dysfunction are primarily documented in colorectal or gynecological cancer. However, their study found that regardless of demographic variables, women diagnosed with breast cancer were statistically more likely to report sexual problems. Women living with breast cancer typically experience body image issues, permanent menopause resulting from cancer treatments, and aromatase inhibitors that negatively affect sexual expression. Other types of cancer can result in sexual issues, but breast cancer causes the most reporting of sexual issues.

6. What change in sexual health is usually focused on for men?

A. Prostate function B. Sperm production C. Testosterone levels D. Erectile function Answer: D Rationale: Alterations in sexual health for men primarily focus on erectile function. Cancer treatments can interfere with erection by damaging a man’s pelvic nerves, pelvic blood vessels, or hormone balance. Prostate, bladder, and colon cancer are often treated with radiation to the pelvis. The higher the total dose of radiation and the wider the section of the pelvis irradiated, the greater the chance of an erection problem later. Erectile dysfunction (ED) is a common complication of diabetes (secondary to autonomic neuropathy, vascular insufficiency, or psychological factors) in at least half of men over age 50. ED can also occur as a result of cardiovascular disease, hypertension, hypercholesterolemia, smoking, and the abuse of drugs including alcohol. Prostate

function, sperm production, and testosterone levels can also be of concern, but the primary concern is erectile function.

7. A patient is being prepped for laser surgery for cervical cancer. Her respirations increase, and she begins sweating. As the treatment begins, she starts trembling and crying, then yells for the physician to stop while pulling herself away from the physician. What is the patient most likely experiencing?

A. Posttraumatic stress symptoms B. Fear about the prognosis C. Sexual health anxiety D. Pain from the procedure Answer: A Rationale: Posttraumatic stress symptoms (PTSS) can be exemplified by re-experiencing the trauma, avoidance of trauma-related stimuli, and negative alterations of cognition, mood, arousal, and reactivity following exposure to a stressor. It is possible that the patient could be experiencing fear about the prognosis, sexual health anxiety, and pain from the procedure, but her extreme reactions point to PTSS. 8. What characterizes sexuality in those with severe illness?

A. Sexual health concerns vary widely B. Positional modifications are too cumbersome C. Masturbation is used only minimally for sexual gratification oE enSgTagBeAiN nK paSrtEnL erL edEsRe. xuCaO l aMctivity D. Patients feel encouraged tT Answer: A Rationale: Sexual health concerns in those with severe illness vary widely. Some patients are comfortable talking with their healthcare professionals about issues, some are not. There are psychological, physical, and emotional aspects of sexuality that can be traumatized by severe illness, and it is difficult to determine what these will be at the onset of disease.

9. A patient is being treated for testicular cancer and would like to discuss sexual issues with his healthcare professional. Which question should his healthcare professional ask first?

A. Can you describe your issues with erectile dysfunction?

B. What are your concerns about being able to father children?

C. How has your illness affected your emotional intimacy with your partner?

D. What are your worries about your attractiveness to your partner?

Answer: C Rationale: While patients indicate that emotional connections take precedence over physical concerns, healthcare professionals may focus more on whether a patient is capable of having sex and on the impact of illness on menopause, erectile, or fertility status. This perspective offers a medicalized approach to sexuality, which may be different than the patient’s goals. Asking the patient’s concerns for emotional intimacy with his or her partner is a good way to initiate dialog and what is likely foremost in his or her mind.

10. Which method is most effective for healthcare professionals to decrease patient anxiety about sexual issues?

A. Prescribe mindfulness techniques to the patient B. Initiate a conversation with the patient C. Recommend the patient exercise regularly D. Give the patient positive statistics for recovery Answer: B Rationale: Often, medically ineffective and wasteful processes are carried out when the patientʼs need is healthcare provider presence and a sense of being cared about. Patients are vulnerable, and often feel a loss of control in what is happening to their bodies.

Short Answer 1. Describe the Sexual Health Model for palliative care.

Model Answer: The Sexual Health Model identifies 10 broad components posited to be essential aspects of healthy human sexuality. These include talking about sex comfortably, especially sexual values, preferences, attractions, history, and behaviors; cultural influences on sexuality and sense of sexual self; basic knowledge, understanding, and acceptance of sexual anatomy and functioning; sexual healthcare; overcoming challenges to sexual health; body image as an important aspect of sexual health; realistic appreciation of the important role of masturbation and fantasy; positive sexuality including a developmental approach to BaAcN sexual health over the life spaTnE ; iS ntTim yK anSdErL elL atE ioR ns.hC ipOs;Mand spirituality and values, including the assumption of congruence between one’s ethical, spiritual, and moral beliefs and one’s sexual behaviors and values.

2. A patient has been diagnosed with ovarian cancer. Fortunately, it was caught early and her prognosis is good. What factors make her at risk for decreased sexual functioning?

Model Answer: Risk factors for poorer sexual functioning after being diagnosed with gynecological cancer are age, treatment, time since treatment, poor self-esteem/body image, physical symptoms, poor performance status, depression, and anxiety. Ovarian cancer is usually treated with a hysterectomy, oophorectomy, and chemotherapy, which can all affect sexual functioning, through a decrease in estrogen production (resulting in vaginal atrophy, loss of vaginal lubrication, and hot flashes) and loss of sexual interest resulting from changes in body, fatigue, and nausea.

3. A patient has had several axillary lymph nodes removed and is experiencing pain down her arm and up her neck. What recommendations can she be given regarding engaging in sexual activity?

Model Answer: The American Cancer Society has recommendations for patients regarding overcoming nongenital pain. The patient can plan sexual activity for the time of day she feels the least pain. If using pain medicine, she should take it an hour before planned sexual activity, so it will be in full effect during sex. She and her partner can find a position for

touching or intercourse that puts as little pressure as possible on the sore areas, support the sore area, and limit its movement with pillows. If a certain motion is painful, she can choose a position that does not require it or ask her partner to take over the hip movements during intercourse. The patient and her partner should talk about what brings the most pleasure. The patient should be encouraged to focus on her feelings of pleasure and excitement; with this focus, the pain may fade into the background.

4. How do adolescents develop emotionally and intellectually, and how does palliative care affect their sexual development?

Model Answer: Adolescents in palliative care share the same developmental tasks as other adolescents. Cognitive thinking is required to link consequences to behavior; however, in early adolescence, thinking is predominately concrete and long-term consequences are not considered. Abstract thinking begins in middle adolescence; at this point, consequences of behavior begin to be considered. However, under times of stress, the middle adolescent often reverts to concrete thinking. Late adolescence is a time when abstract thinking begins to mature and the consequences of behavior are considered. Here, adolescents are striving for autonomy and peer support. Issues of romance, sexuality, and reproduction are normal developmental tasks and should be given attention by healthcare providers. A life-threatening illness may also compromise the development of body image and self-esteem.

5. A patient is in a hospice facility for congestive heart failure. His partner visits every day with expressions and displays of love and intimacy. The patient and his partner would like to be sexually intimate again since T thEeyST arB eA unNsK urSeEhL ow mR uc.hCtO imMe they have left together. What LE are the barriers to this?

Model Answer: Barriers to sexual expression in the hospice facility include lack of privacy, staff interruptions, and bed size. Additionally, the partner may be concerned about hurting the patient, or that he is too fatigued. The sense of bereavement that the partner knows will happen when the patient dies could be on his mind now, causing him anxiety. Even though sexuality is an integral aspect of palliative care, they may feel a decreased loss of control over this aspect of their relationship. They may be reluctant to discuss possibilities for sexual intimacy with the hospice care workers due to embarrassment.

CHAPTER 8: Family Caregivers Multiple Choice 1. Della, her best friend of 40 years, her sister, and her prayer group would be defined by which category of family?

A. Structural B. Functional C. Symbolic representation D. Group interaction Answer: D Rationale: A category of definitions of family is based on interactions within the family group. It looks at the role of family members, the power dynamics within the family, and how family members relate to one another. This broad category would allow for work-groups or societies to be defined as family, as well as a group of friends who view themselves as a family.

2. Health professionals often make assumptions regarding who will be the family caregiver.

Which statement is most likely assumed?

A. Nancy, who is 49 years old and the eldest of three children, will take care of her mother with Alzheimerʼs disease B. Brad, who is 31 years old, will take care of his children after his wife dies C. Logan, who is 24 years olT dEanSdTm ,w BaArrNieKdS EiLllLtaEkRe .caCreOoMf his niece and nephew when their mother is incarcerated D. Emma, who is 18 years old and not married, will take care of her father with leukemia Answer: A Rationale: Due to cultural and societal expectations, healthcare professionals might tend to assume that Nancy will take care of her mother. Myths about the family may influence the health professionals’ assumptions, beliefs, and expectations related to families and their interactions within the healthcare system. One belief is that children, especially female children, have an obligation to care for chronically ill or impaired family members, especially elders. This expectation is shared by family, medical providers, and cultural norms, irrespective of the burden this places on the individual, and without recognition of their additional family and work responsibilities.

3. Rosalind, who is 78 years old, has been diagnosed with transcient ischemic attacks (TIAs).

The healthcare professionals recommend Rosalind have full-time care of some type. Her niece, Denise, and her husband decide to have Rosalind move in with them. What is Denise likely to experience with this new living situation?

A. Increased reliance on her religious community for support B. Better time management skills C. Need to mask feelings of burden and anxiety D. Increased family time together Answer: C

Rationale: Denise will likely feel the need to mask feelings of burden and anxiety. Caregivers are reluctant to identify themselves as individuals who need support. This reflects the concept of “legitimacy of needs” or “caregiver ambivalence” as they do not want to “bother” professionals or shift attention away from the patient.

4. The qualities of trust, honesty, and sharing are part of what dimension of strength in families?

A. Coping B. Spiritual well-being C. Commitment D. Positive communication Answer: B Rationale: Spiritual well-being is demonstrated by hope, faith, compassion, shared ethical values, and oneness with humankind.

5. What is the purpose of studying models and theories of responses to caregiving?

A. Guide caregiver assessment and interventions B. Create remedial plans for overhauling caregiver culture C. Initiate discussion on caregiver reform D. Determine healthcare responsibilities of caregivers Answer: A Rationale: Theoretical frameworkTsEreSlaTteBdAtN oK faS mEilL yL caEreRg.ivCinOgMcan guide questions for family assessment and the development of family caregiver interventions to alleviate stress.

6. Which approach do caregivers typically receive from healthcare professionals?

A. Support for the caregiver’s emotional and physical needs equal to the patient’s B. Standardized approach of seeing the patient and caregiver as a unit C. Standardized approach of seeing the patient’s needs as more important than the caregiver’s D. Support for the caregiver’s knowledge once the patient has been stabilized Answer: C Rationale: Caregivers typically receive a standardized (“one size fits all”) approach that focuses on the patient’s needs, while the caregiver’s needs are considered secondarily, if at all.

7. Rebekah’s sister had a stroke during the delivery of her second child. The stroke has left her incapacitated. Rebekah is understandably very worried about her sister’s prognosis and has questioned the physicians about all possible treatments. She has also been spending time every evening after work online researching treatments, including alternative therapies.

Rebekah has not spoken much about this with her sister’s husband, or the rest of their family.

What type of communication pattern is Rebekah displaying?

A. Manager B. Carrier C. Partner D. Lone

Answer: D Rationale: With the lone communication pattern, there is great focus on hope of the efficacy of treatments and the lone caregiver attempts to seek treatments for the patient’s condition.

8. What is the primary reason caregivers may suffer from depression, anxiety, and guilt?

A. Lack of support and services B. Failure to access support and services C. Unwillingness to take on the role of caregiver D. Insufficient knowledge about medical conditions Answer: B Rationale: Often caregivers are unaware of resources available to them or simply lack the energy to seek them out. Repeatedly, family caregivers report that information given to care for their loved one is insufficient. Caregivers want to feel a sense of readiness and confidence in their role as a caregiver. When a caregiver is not prepared, they risk suffering from depression, anxiety, guilt, and grief.

9. Why is negotiating expectations usually the most difficult category of interventions for caregivers?

A. Caregivers are unable to recognize key tasks and responsibilities.

B. There are few resources currently available for caregivers.

C. Caregivers often take on more than one person can actually accomplish.

D. There is little recognition that sometimes tough conversations are necessary.

Answer: C Rationale: Caregivers often take on more than one person can actually accomplish. Sometimes they may not be aware of all the factors involved in adding on care for another person in addition to their usual responsibilities.

10. Who should address the needs and concerns of caregivers?

A. All members of the palliative or hospice care team B. The patient’s physician C. Clergy on the palliative or hospice care team D. The patient’s family Answer: A Rationale: The needs and concerns of family caregivers should be addressed by all members of the interprofessional palliative or hospice care team. The patient and the family caregiver should be considered a unit.

Short Answer 1. Describe the typical caregiver in the United States.

Model Answer: The majority of caregivers care for one other adult. Upward of 75% of all caregivers are female and may spend as much as 50% more time providing care than males.

Female caregivers are more likely than male caregivers to provide personal care. Higher-hour

caregivers are, on average, 51.8 years of age. Lower-hour caregivers are on average 48 years of age. Family caregivers increasingly provide care for aging adults, most of whom have one or more chronic conditions and who wish to remain in their own homes and communities.

Other family caregivers belong to the “sandwich generation,” which describes the caregivers sandwiched between caring for elder parents or grandparents and spouse and/or children.

These caregivers are pulled in both directions and often have jobs as well as these dual responsibilities. They are typically middle-aged women who are overwhelmed with responsibility, act out of duty, and neglect themselves because there are competing demands for their time.

2. Carlotta and Roberto have two young children and are in their mid-30s. Carlotta has a brother, Miguel, with Down syndrome and several severe health challenges. When Carlotta’s parents died three years ago, Carlotta and Robert brought Miguel to live with them. Between Roberto working two jobs and Carlotta taking care of the home, children, and Miguel, they wonder sometimes how they are making it through life. How can healthcare professionals support Carlotta and Roberto?

Model Answer: Sometimes the simplest actions and words have the most meaning.

Healthcare professionals can support Carlotta and Roberto by acknowledging the good care they are giving to their children and Miguel, that they understand the stress they may be under, and that healthcare professionals can direct them toward other resources that can help them. Given the strengths of the family, the caregiving experience may also have benefits and possible gains, yet these outcomes have received little attention. Health professionals should not miss the opportuniTtyEtS oT idBenAtN ifyKS thE eL reL wEarRd. sC anOdMsatisfaction that come from the role of caregiving. Studies indicate that family caregivers describe feelings of satisfaction for a job well done, particularly when the patient appreciates and acknowledges their care and support, and when caregivers feel a sense of giving back for the care and nurturing they received themselves. The positive aspects associated with the caregiving experience may act as a buffer against overwhelming burden and traumatic grief. Caregivers who have a positive approach to life are better able to cope with caregiving demands and are motivated to maintain their caregiving role.

3. What are the benefits of performing a caregiver assessment?

Model Answer: Caregiver assessment can be used for determining the eligibility for services and identifying unrecognized or subtle problems that have great impact on successful caregiving. The assessment process also allows for the development of a strong, trusting, and therapeutic relationship between the clinician and the caregivers. The best assessments include all family caregivers as well as the care recipient. Both the patient and the family should be assessed by the same provider in the caregivers’ home or another place where they both feel safe to discuss all aspects of the situation. The first advantage of performing a caregiver assessment is the identification of actual or potential problems such as interpersonal, relational, situational, or financial problems within the caregiving role. The second advantage is the clarification of roles and responsibilities for family members, as well as a clear estimate of the resources available versus those that will be needed to provide the required care. The assessment can also reveal stresses that can be intervened with before they

reach overwhelming and incapacitating anxiety and depression leading to despair. The structured and systematic nature of a good caregiver assessment assures that important aspects will not be missed and that a comprehensive approach is implemented.

4. George and Monica are expecting their fourth child. It is a difficult delivery, and when Sydney is born, the physician notes that Sydney has some issues. Further testing reveals that Sydney has cerebral palsy. George and Monica are overwhelmed with the news and have no idea of how to care for her. How can a family assessment assist them in their new caregiving capacity?

Model Answer: A careful family assessment with George and Monica will identify family strengths and weaknesses that will have an impact on them as caregivers and Sydney. Their relationships should be identified, clustered, and organized in a way that they reflect the priorities and function of George, Monica, and Sydney. Generally, strategies can be successful by addressing four general areas: setting realistic goals, having difficult discussions, finding help, and negotiating expectations.

5. Martha cared for her partner, Janet, through the 10-year-long trajectory of her dementia.

When Janet finally died, Martha managed to make it through her funeral, then collapsed, and was hospitalized with pneumonia. What could have the interprofessional team done to help prevent this?

Model Answer: Beyond words of encouragement and support, which validates the NeKmSbEerLsLoE importance of Martha’s caregT ivEeS r rToB leA ,m f tRh. eC inO teM rprofessional team should have offered their expert advice, advocated for Martha’s well-being, and assisted her in accessing valuable community resources. At the end of Janet’s life, both the palliative care team and the hospice should have provided a lifeline to Martha, as her health was at risk and she became a second-order patient.

CHAPTER 9: Communicating With Seriously Ill and Dying Patients, Their Families, and Their Healthcare Practitioners Multiple Choice 1. Which statement describes communication about the end of life between healthcare professionals and patients?

A. Most patients report physicians discussing it with them.

B. Physicians are more willing than nurses to initiate the discussion.

C. Nurses are more comfortable initiating the discussion than physicians.

D. Families prefer to discuss it after the patient is in hospice.

Answer: C Rationale: Surveys show that nurses tend to be more comfortable initiating discussion about the end of life with patients than physicians are.

2. Which factor is most important when the healthcare professional needs to impart bad news?

A. Absolute honesty B. Preparation ahead of time C. Keeping the recipient from feeling anxiety D. Maintaining the therapeutic relationship Answer: B Rationale: Conveying bad news requires thought and preparation. When preparing for the discussion, the healthcare professional should locate a private place for the discussion, ask the patient to have a family member or friend present, have all information available to explain to the patient, and practice what she or he is planning to say.

3. Joe’s son, Casey, was helping Joe clean out the gutters on the house when Casey fell off the ladder, landing in the driveway and hitting his head. In the emergency room, Casey’s pupils are unresponsive to light and his breathing is irregular and shallow. Despite their best efforts to stabilize him, it soon becomes apparent to the attending physicians that Casey is dying.

Which sentence is the most compassionate way to initiate this conversation with Joe? A. “Joe, due to blunt force trauma, Casey’s reflexes are nonexistent, he’s hypoventilating, and recovery is unlikely.”

B. “Joe, I am sorry, but I have some difficult news for you in that Casey’s recovery is unlikely.”

C. “Joe, I need to talk to you about Casey; is there someone you want to call to have here with you?”

D. “Joe, Casey should have been more careful on that ladder because now he’s seriously injured.”

Answer: B Rationale: “Joe, I am sorry, but I have some difficult news for you in that Casey’s recovery is unlikely” is the most compassionate way to initiate the conversation with Joe. Before actually stating the problem, it is recommended to foreshadow the news in simple language.

4. What is the nurse doing if he or she is identifying and responding to the patient’s and family’s concerns about the patient’s treatments?

A. Opening the relationship B. Structuring the care agreement C. Exploring dying expectations D. Clarifying the problem Answer: D Rationale: There are several components to the phase of clarifying the problem. They include facilitating the patient’s expression of emotions, identifying what the patient and family believe are problems, and identifying and responding to the patient’s and family’s concerns about care.

5. Jai responds to the news that her ovarian cancer is terminal with disbelief, saying, “That can’t be true! I’m only 22. I’m sure that I’ll beat this if I get another round of chemo.” What is the nurse’s most appropriate response?

A. “Well, you might think you can beat this but the chances aren’t good.”

B. “You really need to face reality here. You have to think about what you want to do.”

C. “I know this is difficult to hear when it seemed like the treatments were working.”

D. “It’s difficult to hear but you should live whatever time you have left to the fullest.”

Answer: C Rationale: Denial is a natural response that may be helping Jai deal with her illness and should be respected. The nurse should not argue with Jai, but instead should acknowledge the difficulty in accepting the truth, and suggesTt E aS poTsB sibAlN eK reS asEoL nL foEr R th.e C diOffMiculty, without giving any sense of blame. The best approach is to acknowledge that the news is difficult and understanding why Jai would want to deny it.

6. What is the nurse doing if he or she is initiating a discussion of the patient’s treatment goals?

A. Opening the relationship B. Structuring the care agreement C. Exploring dying expectations D. Clarifying the problem Answer: B Rationale: Structuring and formulating the care agreement means the healthcare team will initiate a discussion of the patient’s treatment goals.

7. Alden was diagnosed with tumors in his lungs and brain. Alden’s palliative care nurse, Shenae, asks him what is most important to him in the time he has left. Alden says he would like to live long enough to see his grandson born. What is Shenae helping Alden do?

A. Explore what dying well means to him B. Deny that the end of life is near C. Form their therapeutic relationship D. Take action toward the end of life Answer: A

Rationale: Nurses should be able to assist a patient to define what she or he believes constitutes dying well or represents a good and timely death. Shenae is helping Alden identify which issue would be most important for him to address so that he might die well.

8. Which statement describes appropriate communication from the nurse to the parents of a dying child?

A. “We need to make some decisions today, so we can get to work planning.”

B. “Stopping treatment now is the right thing to do.”

C. “Let me know when you are ready to talk about some options.”

D. “At least you know your child will be at peace soon.”

Answer: C Rationale: Multiple studies of family members of both dying adults and children have indicated that at least as important as the information provided is the sensitivity with which the information is conveyed. Experienced nurses can assist the parents to understand the issues, express their feelings, and delineate their roles so that the parents can be actively involved in the decision-making process for their children. “Let me know when you are ready to talk about some options” is inviting the parents to start a conversation about their child’s end-of-life care, while allowing the space and time to start coming to terms with it.

9. Terrell and his wife, Lisa, are trying to decide whether it is time to remove Terrell’s mother from life support. He and Lisa decide to talk with the nurse since the physician seems to be busy. They converse with the nurse for a few minutes; then the nurse’s eyes drift to the clock OeMhave lots of options for end-ofon the wall. Finally, she smileTsEaS ndTsBaA ysN, K “DSoEnL ’tLwEoR rr. y.CW life care,” which wraps up the conversation, and she leaves to check on other patients. Which concern are Terrell and Lisa most likely having about Terrell’s mother right now?

A. The hospital has inadequate hospice facilities.

B. They will be unable to have enough time to say goodbye.

C. She will be given too little medication for her pain.

D. She will be abandoned by the healthcare team.

Answer: D Rationale: The nurse is responsible for ensuring that palliative care and end-of-life planning are carried out. It is imperative that the nurse demonstrate, by words and deeds, that the healthcare providers will not abandon the patient after end-of-life choices are made and that, instead, nurses and other healthcare workers will provide the care the patient needs or will teach and assist family members or friends to provide the care and support the patient requires while dying. The nurse did not make time to talk with Terrell and his wife, nor did she suggest another time to sit down and talk with them. Her words most likely came off as rushed and uncaring, even though that may not have been her intent. As a result, Terrell and Lisa are most likely to think Terrell’s mother will be abandoned by the healthcare team.

10. What do bereaved families need most from healthcare professionals when their family member has died?

A. Spiritual counseling B. To be listened to

C. Professional distance D. To be prayed for Answer: B Rationale: Although students and recent graduates often are worried about what they ought to say to the family at this time, bereaved families usually are more in need of someone to listen to them. Thus, one of the major roles of the nurse at this time is active, compassionate listening.

Short Answer 1. Explain how the mnemonic NURSE can be used as an empathetic approach to helping patients sort through feelings after receiving the news that they are dying.

Model Answer: An empathetic approach to helping patients sort through their feelings means the nurse should reflect, name, and legitimize the person’s feelings. The mnemonic NURSE is helpful to uncover and respond to the patient’s or family’s emotions. The mnemonic followed by sample statements for the nurse to use is as follows: Name the emotion: You seem (insert appropriate emotion—e.g., worried).

Understand the emotion: I can see that this is difficult for you.

Respect: I can see that you are trying to .

Support the participants: I (or we) will help you to .

Explore possibilities: Tell me what options you can envision.

2. Angela is 39 years old and has cystic fibrosis. She received a partial lung transplant seven years ago, which worked for quite some time. She is now hospitalized because that lung is failing, and she is finding it more and more difficult to breathe. Angela’s air passageways need quite a bit of suctioning, and each time seems a little bit worse than the last. Angela just feels frail and tired, and has not had much energy or appetite since before she was hospitalized. Her nurse, Javier, comes in to check on her. He asks how she is doing. Angela smiles weakly, and says, “Not too good. Life seems to be slipping by.” Javier responds with, “Well, at least it’s a beautiful day today. You can just look out the window and see the trees in bloom. How uplifting is that!” Angela pauses for a moment, then says, “Well, I’ve already seen a lot of life, but I’m getting so tired. I’m wondering if all this is worth it.” Javier says, “Sure it is! We just need to find the right combination of meds for you and you’ll be sailing out of here. I think you’re just having a down day.” What methods is Javier using to block communication with Angela about the end of life?

Model Answer: Wilkinson identified three groups of nurses who used different methods to block patient communication. These were ignorers, informers, and mixed responders. Javier is mixed responding, which is a combination of ignoring and informing. He has ignored Angela’s cues to talk about the end of life by trying to change the subject and using social chitchat to avoid an emotionally laden conversation. He has been an informer by offering inappropriate advice and/or stating his opinion without being asked to avoid talking with Angela about the end of life.

3. What roles do nurses have in the goal-setting phase of the therapeutic relationship?

Model Answer: Nurses in the goal-setting phase of the therapeutic relationship support patients and families following the physician’s discussion of death and dying and end-of-life goals. The skills they use include taking stock, asking open-ended questions, checking patient understanding, endorsing asking questions, clarifying, and restating. The nurse’s process tasks are tailoring information to the patient’s level of understanding, asking if a discussion of the dying process would be helpful, describing the natural dying process, avoiding jargon and euphemisms, and addressing cultural and religious needs. During this phase, it is essential that the nurse determine not only what treatment the patient believes he or she wants but also what the patient believes will happen if he or she receives the treatment.

4. Toni is 63 years old and Apache. She has lived with lupus most of her life, and in the past few years, she could feel her health unraveling. She is hospitalized and has started to come to terms with the fact that her end of life is near. What responsibilities does the nurse have about Toni’s end of life and Apache customs?

Model Answer: The nurse will need to ask Toni and her family about any Apache end-oflife customs or rituals that provide meaning to them. Because a range of responses occurs within cultural and religious groups, it is essential that the nurse not assume that specific rituals will be of significance to Toni and her family simply because they are Apache. The nurse might want to inquire, “What is your faith or belief? Is there a religious or ethnic community that is a source of support for you? Would you like me to notify the community or arrange for something for yToEuS ?”TOBnAceNtKhS esE eL cuLsE toRm.sCoO r rMituals have been identified, they should be integrated into Toni’s plan of care.

5. Carmichael is a nurse who disagrees with the physician about a patient’s end-of-life care.

What steps can he take to have effective communication with the physician?

Model Answer: To establish effective communication with the physician, crucial elements for Carmichael include assessing the patient by learning the details of the situation and identifying any questions that Carmichael or the patient have prior to contacting the physician; focusing on the patient’s and family’s desires and concerns while identifying their readiness for additional information; identifying medications or interventions that Carmichael and/or the patient believe might be effective, recommending them to the physician, and providing a rationale for their use; and respectfully questioning interventions chosen by the physician with which Carmichael, the patient, or family does not agree.

CHAPTER 10: Health Promotion and Rehabilitation in Palliative Care Multiple Choice 1. Which statement describes the concept of health promotion in palliative care?

A. Primary focus is pain relief.

B. Patients need to rest as much as possible.

C. Incurable disease precludes physical therapy.

D. Communities can provide support.

Answer: D Rationale: Health-promoting palliative care (HPPC) addresses not only the ways in which clinicians support the seriously ill and dying, but also how communities can be more effectively engaged in the care and support of their dying members.

2. Chelsea is developing muscular contractures from lying in bed during her late stage of cancer. Her mother recently read that physical therapy may be able to help alleviate the contractures and give her some relief. Chelsea’s attending physician and nurse are resistant to the physical therapy, saying it will most likely cause her more pain than she is already in.

Which core area of HPPC needs to be addressed?

A. Encouragement of interpersonal reorientation B. Encouragement of reorientation of palliative care services C. Providing education and iT nfEoS rmTaBtiA onNfKoS rw EeLllL-bEeRin.gCOM D. Combatting death-denying policies and attitudes Answer: B Rationale: Encouragement of reorientation of palliative care services needs to be addressed. This involves reorientation from a conventional to a health-promoting approach to Chelsea’s care.

3. Which outcome occurs with viewing palliative and end-of-life care as a whole-person experience?

A. There is an increased focus among physical, psychological, social, and spiritual aspects.

B. Focus is directed more toward the individual than the community.

C. Community perspectives toward illness and death reflect the dominant culture..

D. Death and dying are viewed primarily within a medical framework.

Answer: C Rationale: Viewing palliative and end-of-life care as a whole-person experience means respecting all the domains of human existence—physical, psychological, social, and spiritual.

Therefore, the whole-person experience involves community participation, not just focus on the individual, and community perspectives toward death and dying change.

4. Which activity could a nurse do as a first step toward promoting health in palliative care?

A. Lead support groups for patients and caregivers B. Incorporate research into the caregiving approach C. Support professional development of staff

D. Conduct death education workshops in the community Answer: A Rationale: The micro-individual level of promoting health promotion in palliative care involves the most direct, individualized contact with patients, their caregivers, and their families. It gives nurses a way to begin promoting health in palliative care. Leading a support group for patients and caregivers is an example of this.

5. Louise is 56 years old and has rheumatoid arthritis since she was 32. She has the extremity changes that are typical for the disease, and the exacerbations and treatment have left her with a great deal of weakness. What would be a goal of palliative rehabilitation for her?

A. Increase muscle mass so that she can do the hikes she loved to do in her 40s B. Increase her overall strength so that she can keep the disease from flaring up C. Increase her stamina so that she can travel across the country to visit her daughter D. Increase joint mobility so that she can continue to do activities of daily living Answer: D Rationale: Palliative rehabilitation focuses on maintaining a person’s independence and increasing their quality of life by supporting and enabling them to live as normal a life as possible despite their stage of illness or age. Increasing joint mobility so that she can continue to do activities of daily living is an example of palliative rehabilitation for Louise.

6. At which point should the patient participate in palliative rehabilitation?

A. Before being diagnosed wTitE hS aT dB iseAaN seKSELLER.COM B. Throughout the trajectory of a disease C. Only when feeling weak and unstable D. Only when other treatment options stop working Answer: B Rationale: Palliative rehabilitation is appropriate to start from the time of diagnosis through to the terminal phase of illness. Typically, a patient will not participate in palliative rehabilitation before being diagnosed with a disease. The patient can participate in palliative rehabilitation even if he or she is not feeling weak and unstable, and palliative rehabilitation can occur concurrently with other treatments.

7. Which type of rehabilitation could involve adjusting body positions to prevent further contractures and the use of muscle relaxants to decrease pain and spasm?

A. Preventive B. Restorative C. Supportive D. Palliative Answer: D Rationale: Palliative rehabilitation targets symptoms such as pain, dyspnea, edema, and contractures through positioning, breathing assistance, relaxation, and assistive devices. Ongoing support of families and caregivers continues.

8. Cassidy is 13 years old and living with terminal cancer and has been hospitalized. It has become apparent that medical treatments are no longer working. Her parents, her oncologist, and her nurses have avoided talking with her about end of life, but she has a hunch that may be happening. Cassidy has decided to make memory bracelets out of cording and beads for all the nurses and her friends. What is the best approach for her healthcare team to help her with this goal?

A. Encourage her to commit to following through on making all of them B. Avoid involving her parents since this is a very personal project C. Have her decide how many she can do in a given space of time D. Have her parents buy them instead so she can conserve her energy Answer: C Rationale: In order for Cassidy’s goal to be achievable, she should set short-term goals due to fluctuating functional performance levels and the uncertainty of time. Short-term goals should relate to the completion of activities that are meaningful to Cassidy and enable her to live as normal a life as possible during this period. Her goal to make all the bracelets may not be realistic over time, so encouraging her to commit to following through on making all of them may place undue stress on her. Her parents should be aware of this project so they can support her, and also guide her should the goal become unrealistic.

9. Which condition are nurses most likely to perform rehabilitation intervention for?

A. Reflux disease B. Breathlessness C. Decubitus ulcer D. Indigestion Answer: B Rationale: The most common nursing rehabilitation interventions in palliative care nursing are related to managing a patient’s symptoms of pain, fatigue, and breathlessness. Reflux disease, decubitus ulcers, and indigestion will possibly need rehabilitation intervention, but they are not among the most common conditions.

10. What should be the overall focus when establishing goals for a patient receiving rehabilitative palliative care?

A. Enhance acceptance of the diagnosis B. Eliminate the need for family caregiving C. Maximize the use of palliative care resources D. Enable the patient to live as normal a life as possible Answer: D Rationale: Palliative care patients have progressive illness and require increasing care from caregivers. Acceptance of their diagnosis can occur at anytime during the illness experience and not specifically at the rehabilitative phase. The overall goal for rehabilitative palliative care is to promote the quality of life until death, assisting patients to live as normally as possible.

Short Answer 1. Using information from the Ottawa Charter, what are three strategies healthcare professionals can use to develop personal skills in health-promoting palliative care?

Model Answer: Participation of palliative care organizations in the development of personal skills to deal with issues of illness, dying, death, grief, and loss can involve strategies such as holding conferences that teach healthcare professionals these skills, developing online resources about how to develop these skills, and providing written materials about these skills. It would also be highly valuable for healthcare professionals to evaluate these skills in each through activities such as role playing and giving feedback after observing each other with end-of-life patients. Another responsibility is to gently educate end-of-life patients in these skills and guide them as they navigate through their issues surrounding their end of life.

2. Marjorie and Tariq are two advanced practice nurses who have noted that the caregivers and families of end-of-life patients have been, for the most part, unhappy with how their loved ones have received end-of-life care. They have done their best, but it seems like their hands are tied when it comes to certain hospital policies. Both Marjorie and Tariq have a great deal of experience in end-of-life care and have attended conferences on the topic. Lately, they have been talking about the whole-person approach and were wondering what they could do to change the climate and, ultimately, policies of end-of-life care at the hospital. What steps could they take to do this?

Model Answer: ImplementinTgEhS eaTltB h-ApN roKmSoE tinLgLpEaR lli. atCivOeMcare (HPPC) into the hospital will not happen overnight. Marjorie and Tariq are likely to encounter some resistance from physicians and administration. The first step would be to develop a cohesive description of the whole-person approach with fellow nurses and discuss it with them. As they garner support, they could perhaps form a core group that create an action plan, using existing, effective quality improvement approaches. They need buy-in from the executive management, and a main feature of the action plan would be showing how the whole-person approach increases patient satisfaction and decreases costs. It is important to build within the organization a critical mass of health professionals with knowledge and vision. With a realistic plan for service development that includes a sustainable approach, HPPC could become a realistic goal.

3. Carol is single and living with emphysema. She was diagnosed with it two years ago when she noticed shortness of breath climbing the flight of stairs to her bedroom. She is continuing to work full-time as an office manager but has noticed that she feels tired quite a bit these days. What supportive rehabilitation recommendations would be useful for her?

Model Answer: Supportive rehabilitation recommendations can include modifying her work schedule so that she is no longer working full-time. If possible, she should move her bedroom downstairs so that she does not have to use the stairs. She may need a cane or walker to help her with locomotion. A walk-in shower or tub can also be recommended.

Tasks such as cleaning the house and doing the laundry could be subdivided into smaller sections of shorter duration, so she can conserve her strength in between, or she could look into having someone come in to help her.

4. Corey has been a nurse for six months and still feels like he is “learning the ropes” at the large teaching hospital he works in. Recently, he transferred to the oncology unit, and has discovered that he has an aptitude for working with patients who have cancer. His supervisor, Shawna, has been working with him to enhance his skills, and has just assigned him to talk with a patient about pain management for her bone cancer. Shawna can see how nervous Corey is about this. What recommendations can Shawna give Corey?

Model Answer: Nurses are essential for delivering pain education and evaluating its effectiveness for patients. Corey’s pain education to the patient should address her misconceptions and fears about pain treatments, explain the WHO pain control ladder, and identify pain management goals. Corey should then discuss the patient’s pain with the treating physician and help develop strategies to meet these goals. Corey should give the patient written information to complement the verbal information he gives her; it should contain information on pain management, pain treatments, guidelines for discussing pain with the physician, free space to write down any questions or goals, and a pain scale to document changes in pain intensity with activities of daily living. Since nurses do not always feel confident with administering pain medications for patients with palliative pain needs, Shawna should accompany him as he does this until he feels comfortable.

5. What factors are involved in providing psychosocial support for patients and their families?

Model Answer: Through communication and rapport building with the family, the palliative rehabilitation nurse is able to provide information, give emotional support, and coordinate care for the family’s loved onT e,EtS huTsBenAhNaK ncSinEgLaLpEatRie.nC t’sOrMehabilitation process. Nursing interventions developed for caregivers were found to reduce caregiver burden, improve coping abilities, increase confidence as caregivers, reduce anxiety, and improve marital and family relationships. Nurses can reduce caregiver burden and improve coping abilities by providing education on the nature of the disease and treatment options for the patient; identifying caregivers’ physical, emotional, and supportive needs; and problem solving and evaluating any negative reactions to caregiving. Improving caregiving skills was seen to be an effective way to increase caregivers’ confidence in caring for their loved ones.

Additionally, nurses have been found to play a role in maintaining marital satisfaction, providing family support, and improving couples’ communication in patients with cancer.

Interventions are focused on educating the patient and his or her spouse on symptoms, symptom management, caregiver-related skills, communication techniques, and intimacy expectations.

CHAPTER 11: Loss, Grief, and Bereavement Multiple Choice 1. Which situation is a nurse most likely to encounter when providing end-of-life care?

A. Personal grief experiences have little impact on relating to the patient.

B. Cultural norms of the patient apply only after death.

C. Communication with the patient may be difficult.

D. Focus should be on comfort instead of activities the patient can do.

Answer: C Rationale: Communication may be impaired or even unintelligible in the dying patient. In such circumstances, the nurse needs to inform the patient that the nurse is attempting to understand.

2. There are many theories and studies about grief. What do they all have in common in real life?

A. Stages of grief are sequential.

B. Stages of grief are nonlinear.

C. Resolution of the grief comes at some point.

D. Grief stops when attachment to the deceased stops.

Answer: B Rationale: The commonly recognTizEeS dT stB agAesNoKfSgE riL efL(dEeRn. iaC l, O anMger, bargaining, sadness, acceptance), no matter how they are named or discussed in the various theories and studies, occur in a nonlinear fashion.

3. Ellie has just retired from working as a nurse her entire professional life. Between work, raising a family, and volunteering on her church board, she had little time to do needlework, which is her passion. She had been having trouble seeing for a few months and so made an appointment with her ophthalmologist two weeks after her retirement party. She is devastated to learn she has macular degeneration, making needlework impossible. What is Ellie most likely experiencing from this news?

A. Loss B. Suffering C. Grief D. Bereavement Answer: A Rationale: Loss is being deprived of something or someone. It can be actual, potential, physical, or symbolic. Loss is related to health, function, roles, relationships, and life itself. Suffering is the bearing of pain or distress. Suffering impacts a patient’s body, mind, and spirit. Grief is deep or intense sorrow or distress, particularly arising from bereavement concerning someone with whom a close bond was formed. Bereavement is the state or act of being deprived of a loved one.

4. Which correlation tends to occur regarding relationships and loss?

A. Intimate relationships inspire the most suffering from loss.

B. The longer the relationship, the more the loss and suffering.

C. The significance of the relationship determines loss and grieving.

D. Therapeutic relationships are unlikely to result in loss and grieving.

Answer: C Rationale: The significance of the relationship impacts how the individual will interpret the loss and the accompanying suffering.

5. Which situation is a nurse likely to encounter in performing end-of-life care?

A. The patient’s physician usually knows the patient’s wishes.

B. The nurse needs to advocate for the patient’s wishes.

C. The patient’s care is well coordinated among providers.

D. The nurse needs to keep the patient’s goals from changing.

Answer: B Rationale: The nurse needs to keep abreast of the patient’s treatment wishes (which may change during the dying process) and coordinate care between facilities and providers.

6. Craig is 42 years old and living with acute myeloid leukemia. He is the owner of a gym, and has been fit and athletic his entire life, up until now. He is currently hospitalized while receiving his latest round of chemotherapy, feeling weaker than he has ever felt in his life, and has come to realize that hTe E isSpTroBbA abNlyKS ouEt L ofLtE reR at. mCeO ntMoptions. He had turned the gym management over to his business partner but seldom calls her. The coaches from his gym try to stop in and see him, but he says no. A year ago he had set up a social media page and posted on it regularly. Now he never looks at it. What issue in the living–dying interval is Craig most likely struggling with?

A. Planning remaining time B. Arranging his affairs C. Attending to future care needs D. Confronting loss of identity and self Answer: D Rationale: The living–dying interval occurs from the time death is acknowledged as imminent to the point of the actual death. Craig is struggling with confronting loss of identity and self because he has stepped away from his gym and being an athlete. He has not yet reached the point where he is planning his remaining time. He has already started arranging his affairs by turning his gym over to his business partner, and he has not started thinking about attending to his future care needs yet.

7. Which action by the nurse demonstrates acknowledgment of the importance of significant others at the end of life for the patient?

A. Incorporating significant others into the patient’s care as desired by the significant others B. Focusing primarily on the patient’s needs and secondarily on the significant others’ needs C. Stepping away from significant others in their loss and grief to protect their privacy

D. Recognizing the need to work with both the patient and the significant others Answer: D Rationale: There is interdependence between the patient, the significant others, and the nurse in relation to providing optimal care for the patient with a terminal illness. The nurse can maximize the positive aspects of this interdependence by recognizing and affirming the patient’s significant others, incorporating them into the patient’s care as desired by the patient, and assisting the significant others in their loss, suffering, and grief related to the patient’s dying and death.

8. Which statement describes influences on grief in significant others?

A. Some factors may cause depression instead.

B. Physiological factors are the most predominant.

C. They are best addressed after the patient has died.

D. Addressing them is out of nursing scope of practice.

Answer: A Rationale: Some of the same factors that influence grief may cause depression instead. A way to distinguish between grief and depression is to note if the individual in question is able to experience pleasure. Grieving individuals generally can experience pleasure; depressed individuals often have difficulty experiencing pleasure and may lose morale and hope.

9. Which approach is most appropriate for nurses when helping family members of a terminally ill patient with their grief?

A. Recognizing that a parentT ’sEgS riT efBwAilNl K beSdEeL epLeE rR th. anCaOsMibling’s when a child dies B. Understanding that the child may have the fear for their own well-being when a sibling dies C. Being aware that depression and grief present quite differently in an elderly person D. Having insight that the level of grief for loss of a parent is the same as that for the loss of a child Answer: B Rationale: Grief is a deep and complex issue. If a child loses a sibling, other issues, such as guilt, ambivalence, denial, increased vulnerability, and fear for his own well-being, may arise. When a child dies, siblings can feel grief as deeply as the parent. In the elderly, often depression and grief present quite similarly. If a person loses a parent and loses a child, the loss of the child tends to inspire a deeper level of grief.

10. Josiah is sitting with his brother, Jeremiah, who is in hospice. Jeremiah was born with muscular dystrophy and is now reaching the end of life. Josiah’s grief is palpable, all the more so because the anniversary of his parents’ deaths in a car accident is approaching.

Which action by the nurse would be the most helpful to Josiah right now?

A. Giving him lists of chronic illness organizations he could volunteer for in his brother’s memory B. Checking to see that Josiah has plenty of reading material while by his brother’s bedside C. Staying in the room with Josiah without talking unless he initiates it D. Asking Josiah to speak about what he is feeling about his brother

Answer: C Rationale: Staying in the room with Josiah without talking unless he initiates it is being authentically present for Josiah. Nurses are accustomed to action-oriented, “doing for” interventions. However, when caring for the patient with a terminal illness, the nurse’s role may be less action oriented and more presence oriented. Giving Josiah lists of chronic illness organizations he could volunteer for in his brother’s memory, checking to see that Josiah has plenty of reading material while by his brother’s bedside, and asking Josiah to speak about what he is feeling about his brother are all action-oriented approaches.

Short Answer 1. Describe the differences among mourning, grief, and bereavement.

Model Answer: Mourning, grief, and bereavement often are used interchangeably.

Mourning involves social and cultural factors such as customs and rituals influenced by the community in which the person lives, heritage, and religious beliefs and values. Grief involves the physical, mental, emotional, and spiritual dimensions of a person as he or she responds to loss or the perception of loss. Grief is a part of mourning. Bereavement is also a part of mourning and is the state of having suffered a loss.

2. What recommendations will help nurses who become close to certain terminally ill patients?

Model Answer: Nurses are encouraged to maintain their composure when caring for patients. However, nurses canTbEeSpT roBfeAsN sioKnSaE l aLnL dE stR ill.eCnO gaMge emotionally with the patient and the patient’s family. What they should not do is bring their own emotional needs into the therapeutic relationship. Authentic self-disclosure of feelings by nurses may role model to others a healthy process of acknowledging and resolving the suffering of loss. Nurses need to do honest self-reflection as to why they are disclosing these feelings and to make sure they are not doing so as to get their own emotional needs met. If nurses release emotional stress through crying, they need to be able to direct this into a meaningful and positive experience for the patient and the patient’s family. Peer support groups can be helpful for nurses to work through their grief. When a team is involved, it is helpful to provide an opportunity for staff members to have open communication and to sustain and care for one another. Other recommendations include regular exercise, good nutrition, diversional activities, focus on caring rather than curing, emphasizing the positive dimensions of nurses’ roles, and recalling positive experiences with families.

3. Beatrice is in hospice for end-stage renal failure. She never married nor had children but has several nieces and a nephew who love her very much. They are traveling to be with her, but it will take several days for everyone to arrive. Beatrice is frightened about death, worried that she won’t have enough time to tell her nieces and nephew what she wants to tell them, and what to do about her condo, her pet cats, and her estranged sister. What can the nurse do to ensure that Beatrice has some closure in her personal affairs?

Model Answer: The nurse can conduct an assessment with Beatrice about her end-of-life issues. The questions the nurse can ask include:

How do you view your illness?

What is the meaning of your illness to you?

What fears or concerns do you have regarding your illness?

In what ways are you experiencing loss and suffering?

Are there any unresolved issues or business matters that need to be resolved?

Do you have any specific fears about dying and death in general? About your own dying and death?

What concerns do you have for others now and after your death?

What helps you maintain a sense of hope during difficult times?

The nurse can then help Beatrice with methods and resources for closure with her personal affairs.

4. Lia and Cade are 9-year-old twins. Their 72-year-old grandfather has lived with them and their parents for as long as they remember, and they are all very close. The grandfather dies suddenly from a heart attack. What are the best recommendations to give the parents for the twins about grieving for their grandfather?

Model Answer: Lia and Cade need gentle confirmation and reassurance. Their parents should give Lia and Cade clear and realistic information about what happened to their grandfather. If they want to be there, Lia and Cade should be included in the funeral ceremonies. Even though Lia and Cade’s parents are grieving themselves, they should give the children permission to express their feelings and provide opportunities to do so. As much SE as possible, Lia and Cade’s paTrE enStsTsBhA ouNldKm aiL ntL aiE nR a. stC ruOcM tured schedule and continue individual and family activities. Lia and Cade’s school needs to be notified about what is occurring.

5. How can patient spiritual care be incorporated into nursing practice?

Model Answer: Medical science has limitations, and often patients feel dehumanized during some medical procedures. In addition to addressing comfort needs, patients need assurance that their humanity will be respected and valued. The nursing profession has reawakened to the importance of integrating spiritual care within total patient care. Patients have indicated that their spiritual needs are best met through nurses’ listening to, talking with, supporting their religious practices, and being with them. Even in the midst of suffering through the loss of physical well-being, patients may sense spiritual well-being. Buckwalter (2003) refers to “moments of ministry” or “ministry of the moment” as those times when nurses or others assist patients in a “holy moment of connection,” especially for someone who may be experiencing profound memory loss. If a nurse feels inadequate or uncomfortable assisting dying patients in this area in any way, a pastoral care referral may be indicated. In addition, the patient may desire to have clergy closely involved even if the nurse is comfortable meeting the patient’s spiritual needs.

CHAPTER 12: Holistic Integrative Therapies in Palliative Care Multiple Choice 1. Which statement describes holistic care?

A. It is folk medicine.

B. It less effective than traditional medicine.

C. It can increase a person’s sense of control over illness D. It provides only temporary relief.

Answer: C Rationale: Holism focuses on unity, mutuality, meaning, and the interrelationship of all beings, events, and things. It can help patients participate in their own care. Some aspects of holistic care have been handed down through the ages, but some of them are based on science. Traditional medicine has many benefits, but it is not effective for every disease or condition a patient can have. There are many instances in which holistic care is more effective, such as in helping patients relax. Some benefits of holistic care are temporary, just like some benefits of traditional medicine. However, holistic care can also provide long-term or even life-time relief of symptoms.

2. Who is most likely to use complementary integrative health approaches (CIHAs)?

A. Lindsay, who is 24 and is trying to lose weight B. Martin, who is 19 and phyTsE icS alT lyBfA it NKSELLER.COM C. Gisele, who is 54 and has chronic pain D. Alberto, who is 42 and gets the occasional cold Answer: C Rationale: Many people use CIHAs for many different reasons. The most common reasons for using CIHA are to prevent illness or for overall wellness (77%), to reduce pain or treat painful conditions (73%), to treat a specific health condition (59%), or to supplement conventional medicine (53%). There is also great interest among the chronically ill, those with life-threatening conditions, and those at the end of their lives.

3. Carmen and her physician recently had the difficult conversation about preparing for her end of life. She is distraught and filled with anxiety, which is compounded by chronic pain. The nurse suggests that a complementary integrative healing modality might be helpful for Carmen. Which statement is ethical for the nurse to make to Carmen about trying this approach?

A. “The modality will eliminate your pain.”

B. “The modality may be calming and allow you to rest.”

C. “The modality can increase your chances of extending your life.”

D. “The modality works better than your other medical treatments.”

Answer: B Rationale: “The modality may be calming and allow you to rest” is an ethical statement. CIHA has documented calming influences and some physiological effects. “The modality will eliminate

your pain,” “The modality can increase your chances of extending your life,” and “The modality works better than your other medical treatments” are all unethical statements because they are not true. Some modalities may alter the perception of pain, but they do not eliminate pain. No treatment, whether allopathic or holistic, can guarantee to extend life. Claiming a holistic modality works better than other treatments the patient is receiving undermines the treatment approach. In the healthcare setting, holistic modalities are used to complement, not replace, medical treatments.

4. Which holistic modality has as its primary aim protecting the body from the effects of stress?

A. Relaxation techniques B. Guided imagery C. Music thanatology D. Life review Answer: A Rationale: Relaxation techniques are the basis of many holistic modalities. Relaxation has three aims: (a) as a prevention to protect body organs from unnecessary stress and wear; (b) as a treatment to alleviate stress in numerous conditions, for example, hypertension, tension headache, insomnia, asthma, immune deficiency, panic, and pain; and (c) as a coping skill to calm the mind and to help thinking to become clearer and more effective.

5. Which holistic modality can influence the patient’s mind and body by directly affecting the limbic system?

A. Meditation B. Imagery C. Reiki D. Aromatherapy Answer: D Rationale: Aromatherapy involves the distillation of oils from plants. The advantage of these oils comes from their influence on the limbic system, which coordinates mind and body activity. This system is very sensitive to odors and encodes them into associations and memories, which when awakened alter basic physical functions such as heart rate, blood pressure, breathing, and hormone level.

6. A nurse is helping a patient do a life review. Why would the patient choose this particular holistic modality?

A. To feel that he is vital again B. To feel his experiences have meaning C. To feel connected to the universe D. To more easily transition into his death Answer: B Rationale: Life review provides integration, a feeling that this life was individual and unique.

The client may verbalize sadness as well as achievement, but the objective is to allow a person to see the meaning in his or her life. Feeling vital and connected to the universe, and to more easily

transition into death, can be side benefits of a life review, but the main purpose is for the patient to feel his life had meaning.

7. Alan is receiving end-of-life care and spends most of his time in bed, with occasionally being able to sit in a recliner. He has noticed that the muscles in his back seem to always hurt, and sometimes he has difficulty raising his arms from shoulder tightness. Which holistic modality would have the most direct benefit for Alan?

A. Massage B. Reiki C. Therapeutic touch D. Compassionate touch Answer: A Rationale: Massage can be used for pain reduction, comfort, tension release, prevention of atrophy of muscles and stiffness of joints, and inducing sleep. Reiki and therapeutic touch work with the patient’s energy field, and compassionate touch involves stationary placement of hands on the patient’s body. These holistic modalities may have an effect on Alan’s issues, but massage will have the most direct benefit.

8. A nurse notices that a patient’s family has been bringing in small bags of herbs to one of the patients in hospice. The nurse checks the patient’s chart and sees that only prescription medications are listed in it. Which action should the nurse take?

A. Ignore the herbs because they are most likely ineffective at this stage in the patient’s illness B. Tell the patient to cease taking the herbs immediately and confiscate them C. Ask the patient to disclose what herbs they are because they may interfere with treatment D. Tell the patient that herbs are unregulated, so are illegal in healthcare settings Answer: C Rationale: The nurse should ask the patient to disclose what herbs he or she is taking because they may interfere with treatment. This can be done in a respectful manner. The nurse should not ignore the herbs because there could be deleterious effects or side effects on the patient. The nurse does not have the right to tell the patient to cease taking the herbs immediately and confiscate them. Even though there is little to no regulation of herbs, they are not illegal in healthcare settings.

9. How are holistic modalities meant to be used?

A. To cure common diseases B. To serve as a placebo C. To improve a sense of well-being D. To limit the number of medications prescribed Answer: D Rationale: Holistic modalities address physical, emotional, and spiritual needs of a person. In Western cultures, they are not primarily used to cure common diseases, serve as placebos, or limit the number of medications prescribed.

Complementary, holistic modalities are used most often to improve a sense of well-being by reducing symptoms, such as pain, stress, or anxiety and improving overall quality of life.

10. A nurse is advocating for holistic modalities to be part of palliative care. A physician who is heavily invested in traditional medicine is skeptical that holistic modalities can be of any benefit to patients. What information could the nurse give him that might change his mind?

A. Holistic therapies have been handed down through generations of practitioners.

B. Holistic therapies are aimed toward strengthening the body’s own defenses and healing abilities.

C. Family members and caregivers can be taught simple holistic techniques to use with their loved ones and themselves.

D. Interconnectedness of physical, mental, emotional, environmental, and spiritual aspects of the person is supported by holistic therapies.

Answer: B Rationale: The fact that holistic therapies are aimed toward strengthening the body’s own defenses and healing abilities may appeal to the physician’s traditional medicine mindset.

Short Answer 1. How can nurses help patients heal while dying?

Model Answer: Healing the dying involves regard for relationships and connectedness.

Transcendence implies a sensT eE ofScToB nnAeN ctK ioSnEbL etL wE eeRn.sC elO f aMnd a greater reality. Selftranscendence integrates self with past and future, giving meaning to the present. This caring relationship emphasizes quality rather than length of life. Healing the dying includes palliative care and focuses on all types of relationships. Opportunities and choices allow the dying person to live life to its fullest and, at some point, comfortably forgive, let go, release, and experience a peaceful death. The nurse is in a partnership with the dying client, sharing rather than denying the experience. The focus of nursing care is on providing sacred space and the setting for a calm and peaceful death. The nurse works with the client to foster hope and cultivate an appreciation of the seemingly irrelevant things in life. Learning to appreciate simple occurrences such as a sunset or the joys of life can cultivate a more positive view of life and one’s present experience. Enhancing avenues of support, whether professional, social (family and friends), or support groups, can often facilitate grieving and increase a sense of meaning in illness. Developing unrecognized inner strengths and resources is of great importance to the person who is dying or grieving.

2. Miles is an artist known for painting large, colorful canvases. He is now in the end stages of AIDS and is having difficulty with pain management. Which holistic modality might be the most useful for him?

Model Answer: Guided imagery might be the most useful for Miles because, as an artist, he is highly visual. Imagining is a powerful technique of focusing and directing the imagination.

All the senses are used—vision, sound, smell, taste, movement, position, and touch. Imagery influences attitudes, feelings, behaviors, and anxiety, which can either lead to a sense of hopelessness or promote a perception of well-being that assists in changing opinions about

disease, treatment, and healing potential. Imagery can affect people physically, emotionally, mentally, and biochemically, and the body and mind respond as if the event is actually occurring. Guided imagery has many applications in end-of-life and palliative care, including relaxation, stress reduction, pain relief, symptom management, grief work, and assisting clients to comprehend meaning in their illness experience.

3. An advanced practice nurse would like to start offering healing modalities in the form of touch to end-of-life patients. What benefits of touch should she include when she designs a proposal to present to hospital administration?

Model Answer: In the later stages of life, individuals are often deprived of tender and nurturing physical contact such as being touched in a way that is healing, nourishing, relaxing, and pleasurable. Touch is essential to one’s quality of existence. It provides comfort, warmth, and renewed vitality—a sense of security and assurance that we are not alone. The benefits of touch include increased circulation and mobility, a decrease in pain, increase in vitality, increase in physical functioning, the experience of being nurtured and cared for, a boost in self-esteem, increased motivation to receive and give attention to self and others, energy and emotional release, a sense memory triggering a relaxation response, relief from loneliness and isolation, decreased feelings of abandonment and deprivation, verbal interaction, and calming reassurance and support. It often induces much-needed sleep.

4. What steps can a person preparing for end of life take to die consciously?

.nCdOeM Model Answer: Individuals bTeE coSmTeBaAwNarKeSoE f tLhL eiE r oRw aths in phases, and this awareness can lead to consciousness in dying. Keegan and Drick and Olson identified some tasks for dying consciously. One is to live life fully until death comes and participate in care for as long as possible. Another one is to plan to say good-bye to family and friends, finish things you wanted to do, and make final decisions regarding the last will and testament, the estate, organ donation, and so forth. A third is to participate in emotional and spiritual tasks such as forgiving yourself and others, feeling that life mattered and the world is different because you were here, and knowing and accepting love as one changes. The last is to rehearse the dying process. Through an awareness of dying, learn to diminish the fear of death and to “let go of this life” when it is time to do so. Imagery, relaxation, meditation and prayer can help patients to transcend pain and grief by enabling them to be more peaceful, let go, open their heart, forgive themselves and others. Such holistic modalities also help people to find comfort and peace, and the achievement of closure.

5. James has been working as a nurse in pediatric oncology for almost three years. He is joyful for the patients who are able to overcome cancer and leave the hospitals. However, lately it seems that many more patients than usual have died or are approaching end of life. James has been finding himself having sharp words with other nurses, calling in sick when he was not sick, and feeling a sense of dullness inside when a new patient is admitted to the floor. How can James take care of himself to alleviate the stress from “death overload?”

Model Answer: James can address five areas of self-care. Spiritual self-care involves him asking himself if spirituality is important in his life. What is his relationship with God or a

higher power? Why is he here and what is his purpose? What is his relationship to the universe? Emotional self-care involves him asking if he can identify his emotions. How does he deal with them? Is he usually in control? Can he discuss his emotions? Is he open to others, and does he respect the feelings of others or does he jump to conclusions? When do his emotions get out of control? Physical self-care involves him asking himself what areas of his lifestyle are unhealthy. What can he do to improve his lifestyle? Mental self-care involves him asking himself if he is knowledgeable and strives to continually increase his knowledge.

Is he satisfied with the status quo or is he open to new ideas? What is he doing to stimulate his mind? Relationships self-care involve him asking himself if he is open and honest with himself and others? Does he have satisfying relationships with others? Is he willing to accept the thoughts and feelings of others even though they are different from his own or is he judgmental? Must he have all the control or can he share it? Does he have a balance among work, home, and leisure?

CHAPTER 13: Cancer Multiple Choice 1. Which factor is involved in current cancer care?

A. Palliative care for cancer occurs mostly in hospice.

B. Care is shifting to the interprofessional model of support.

C. The number of cancer cases continues to decrease.

D. Cancer is most frequently diagnosed in later stages.

Answer: B Rationale: Cancer care has evolved in the past 20 years not only as a result of changes in treatment efficacy but also due to the interprofessional model of support currently offered.

Healthcare consumers prefer honest and more complete information pertaining to diagnosis, prognosis, symptom burden, and survival benefits related to treatment. The increasing number of healthcare professionals certified in PC offers more options for the supportive care of cancer than just hospice. Worldwide cancer cases are expected to continue to increase, and cancer is being diagnosed in earlier stages.

2. What are effects of having a palliative care consult?

A. Increased medical costs for facilities because of additional healthcare professionals B. Increased patient and family spiritual and bereavement referrals to other locations C. Increased support for patiT enEtsS, T faB mAilN ieK sS anEdLthLeEoRn. coCloOgM y team D. Reduced need for evidenced-based research into pain management treatments Answer: C Rationale: Palliative care (PC) teams support the clinicians and work closely with a patient population living with a life-threatening disease by providing emotional and educational support.

Evidence suggests that PC teams assisting in cancer care improve patient care and reduce costs to the family and healthcare system. Where multiple clinicians representing different specialties are involved, PC teams provide the hub of communication and specialized spiritual and bereavement support of patients, families, and clinicians that cancer care requires. Having PC providers on the interprofessional team does not reduce the need for evidence-based research into pain management teams.

3. Which type of cancer is most prevalent in children?

A. Leukemia B. Neuroblastoma C. Bone D. Colorectal Answer: A Rationale: Leukemias (mainly acute lymphocytic leukemia) account for approximately 31% of all childhood cancers; brain and nervous system cancers make up about 25% of childhood cancers; while neuroblastoma is the most commonly occurring (6% of all childhood cancer

types) solid tumor outside of the central nervous system. Bone cancer does occur in children but is not as common as leukemia. Colorectal cancer is much more common in adults.

4. Katherine has Stage III breast cancer. Which treatment regimen is she most likely undergoing?

A. Surgery, radiation, and hormonal therapy B. Surgery, chemotherapy, and radiation C. Hormonal therapy and chemotherapy D. Radiation and hormonal therapy Answer: B Rationale: Treatment for Stage III breast cancer (locally advanced tumors) involves a combination of surgery, chemotherapy, and radiation for local control of the tumor and to decrease the risk of distant recurrence. Hormonal therapy is considered the standard of care for treatment of hormone receptor positive breast cancer.

5. Why is colorectal cancer difficult to detect in older adults?

A. They are usually asymptomatic.

B. Few diagnostic methods exist.

C. Symptoms may be attributed to the aging process.

D. Symptoms are diffuse and mimic other diseases.

Answer: C Rationale: Diagnosis of colorectaT lE caS nT ceB rA (CNRKCS) E inLtL heEoRld.eCr O adMult is especially challenging because many of the common symptoms associated with CRC such as constipation, change in bowel patterns, and fatigue may be inaccurately attributed to the aging process. Diagnosis is made through screening to detect polyps and cancer.

6. Which type of comorbidity is a risk factor for any type of cancer?

A. Obesity B. Genetics C. Smoking D. Frailty Answer: D Rationale: Frailty at any age adds a risk factor to cancer morbidity. Anticancer therapies often decrease the patient’s functional level, leading to catabolic syndrome, muscle wasting, and increased risk of infection. Obesity, genetics, and smoking are risk factors for various types of cancer, but frailty is the only risk factor for all types.

7. When should palliative care begin for a patient with cancer?

A. At the time of diagnosis B. At the initiation of chemotherapy C. During discussion of prognosis D. During end of life

Answer: A Rationale: Palliative care is best initiated at the time of a cancer diagnosis, especially for patients with a life-limiting cancer. Many individuals experience symptoms that interfere with quality of life at the time of diagnosis as well as other points in time along the disease trajectory.

8. Which statements represents barriers to pediatric palliative care?

A. Parents have a need to try every available therapy to increase the chance for survival.

B. Parents and physicians recognize the level of suffering C. Parents and physicians understand the difference between palliative care and hospice D. Physicians understand the limitations of cancer therapies Answer: A Rationale: Palliative care health professionals working in the field of pediatrics have reported the parental need to provide every available therapy to their child in order to feel confident they have given their child the best chance for survival. Parents and physicians may not recognize the degree of physical or emotional suffering of a child. They may associate palliative care with hospice care rather than understanding the palliative care can involve not only curative treatments but treatments that alleviate suffering. Many oncologists view death as a failure and therefore attempt cancer therapies that may not prevent death.

9. Which consideration is most important for cancer care of adults?

A. Age is the most useful determinant in prognosis.

B. Older adults with and without disease need the same amount of assistance.

C. All older adults are frail bT yEvS irtTuB eA ofNthKeSirEaL geL. ER.COM D. Functional abilities at any age determine the treatment plan.

Answer: D Rationale: Natural changes associated with age often lead to a greater susceptibility to chronic and acute disease, yet a comprehensive evaluation of the older adult’s comorbidities, cognition, functional status, nutritional status, social supports, psychological state, and personal resolve gives a more accurate definition of age in relation to cancer treatment tolerance. Age itself is not the most useful factor to determine prognosis and consider treatment options for older adults.

Chronological age can be used as a functional status indicator for older adults because it is assumed that adults living with cancer are more likely to need functional assistance than their same-age peers without cancer. The medical literature often refers to a frail individual as someone with poor physiological reserves and a high prevalence of repeated chronic illness requiring multiple hospital admissions.

10. Which action by the healthcare professional most often results in generating hope in the family of a patient with cancer?

A. Giving the patient information about latest medical treatments B. Building a trusting relationship with the patient C. Withholding the prognosis that the patient is terminal D. Making all the decisions about care for the patient

Answer: B Rationale: When physicians establish a compassionate, trusting relationship with the patient, family prognostic disclosure could support hope, even when the prognosis is poor. The palliative team assists caregivers to develop the physical, emotional, and mental reserves that are required to maintain hope, coupling that with the provision of timely, accurate, and honest information on the impending death. Nurses should respond to patient and family concerns with patience and assurance of non-abandonment and an increase in attention to aggressive symptom.

Short Answer 1. Sharon is a nonsmoker, very active physically, a vegetarian who eats only organically grown produce, and drinks ultra-filtered water. She is shocked when she is diagnosed with cancer.

How does cancer develop?

Model Answer: Malignant tumors are produced by a synergy between the accumulation of mutations and tissue changes that support the survival of mutant cells. Factors that cause or facilitate cancer development include chemical mutagens, radiation, free radicals, genomic instability, inherited cancer susceptibility, telomere shortening, and altered cellular environment. Modifiable risk factors such as smoking, diet, physical activity, and weight control can alter cellular environment and influence the proliferation of cancer cells.

Carcinogenesis works in a stepwise progression in which a normal cell undergoes malignant transformation. Steps include tumor initiation, promotion, malignant conversion, and, finally, tumor progression. Occasionally, family members will question the cause of cancer when a loved one is diagnosed; howeT veErS , fT urBthAeN rK inS veEsL tigLaE tioRn.uCsO uaMlly reveals an existential concern that a genetic explanation may not satisfy.

2. Caleb is 69 years old and has been having difficulty urinating lately. He is wondering if it is due to prostate cancer, so he makes an appointment with the nurse at his assisted living facility. What signs and symptoms will the nurse ask him about, and what type of further examinations will Caleb need?

Model Answer: Early and localized stages of prostate cancer generally do not present with symptoms. Hallmark symptoms that occur more frequently in locally advanced stage cancer are usually associated with urinary outlet obstruction: frequent urination, urinary hesitancy, inability to urinate, nocturia, and dysuria. Impotence, painful ejaculation, bloody urine or semen, pain, and stiffness in the lower back, hips, or upper thighs are additional symptoms suggestive of malignancy. Since many of the common symptoms may mimic other conditions, it is common for men to postpone medical consultation. Symptoms of malignant prostate disease usually do not subside, which distinguishes prostate cancer from benign disorders. Digital rectal examination and/or PSA blood test are the most commonly used screening methods for prostate cancer.

3. Explain the differences in disease management for small cell lung cancer (SCLC) and non– small cell lung cancer (NSCLC).

Model Answer: Because SCLC is considered a systemic disease, surgery is not a treatment option. Chemotherapy alone or with radiation is the usual treatment for SCLC with a high rate of early remission but frequent recurrences. NSCLC has more treatment options such as chemotherapy, radiation, surgery, immunotherapy, targeted therapy, and kinase inhibitors.

However, surgical resection remains the only potential curative treatment for patients with NSCLC presenting with surgically resectable disease. Surgery is recommended for all adults with good performance status. Newer surgical techniques, such as the VATS, have provided a minimally invasive approach with similar long-term survival rates. Current treatment options will include surgical resection, systemic therapy, radiation, or combinations of these modalities depending on stage.

4. Kari is 15 years old and recently diagnosed with a rare form of bone cancer. She is undergoing treatment, and her parents and oncologists are cautiously optimistic. Needless to say, her life has been turned upside down. What should healthcare professionals assess in terms of the effects uncertainty, disease, and treatment have on her?

Model Answer: Uncertainty while living with cancer has been identified as a significant aspect of pediatric cancer and a major concern of adolescent and young adult cancer survivors. Treatments can have serious implications through each phase of the patient’s life.

Chemotherapy and radiation therapy can harm developing organs, and surgery can alter normal physical functioning or cause disfigurement. Many survivors of childhood cancer have physical, mental, or emotional limitations resulting from successful anticancer treatment. A major concern is thoughts of suicide. Risk factors associated with a higher significance of suicidal sympT toE mS sT inB clAuN deKySoE unLgLerEaRg. eC atOdM iagnosis, a greater time lapse since diagnosis, and radiation treatments to the head. Add those risk factors to feelings of depression and hopelessness, chronic pain, physical dysfunction, and appearance alterations due to treatment and the data suggest that healthcare professionals should perform a thorough psychosocial assessment upon long-term follow-up of survivors. Survivors with 5 or more years from diagnosis had higher uncertainty related to knowing what to expect for disease recurrence and multiple meanings of communication from doctors.

5. If a patient and his or her family is asking for chemotherapy even though the patient is transitioning to end of life, how should healthcare professionals respond?

Model Answer: A discussion of patient preference for quality and quantity of life with or without chemotherapy is a good start to a palliative treatment discussion. Before chemotherapy is recommended, a definable benefit must be identified, and a straightforward discussion can be initiated by asking patients how much they want to know about their current condition and prognosis. The healthcare professionals should define the words “response” and “cure” because many patients will use these terms interchangeably. Printed resources should be provided that list benefits and adverse reactions to chemotherapy. The patient should be asked about his or her goals for treatment, views on undesirable side effects, and plans for the future. Extending survival time for an upcoming special event may be the benefit that could justify treatment in the patient’s mind. If the patient receives the chemotherapy, the plan should be revisited when the cancer is resistant to chemotherapy.

CHAPTER 14: End-Stage Heart Disease Multiple Choice 1. Which statement is accurate regarding heart failure?

A. It is a curable disease.

B. End of life is difficult to predict.

C. Disease progression usually occurs in a linear fashion.

D. There are usually one or two admissions to the hospital.

Answer: B Rationale: Heart failure is considered a progressive disease which has exacerbations and remissions but eventually the heart fails and it becomes a terminal disease. As such, it is difficult to predict when death will occur. In the final phase, patients and their families experience office visits, hospitalizations, and decreased quality of life despite optimal therapy.

2. Which statement describes end of life for patients with heart failure?

A. Referral rates for hospice and palliative care are high.

B. Referrals to hospice and palliative care tend to occur in the last four weeks of life.

C. Palliative care needs to be incorporated into general care.

D. Healthcare costs are likely to go up with increased use of palliative care.

Answer: C Rationale: Because of the low rate of hospice utilization and pattern of late referrals in end-stage heart disease, there is a need for the infusion of palliative care principles into general care. While a majority of hospice admissions for cardiovascular disease has surpassed admissions for cancer diagnosis, there is still a low referral rate for heart failure patients. Referrals to hospice and palliative care tend to occur in the last two weeks of life. Cardiovascular disease results in hospital admissions and readmissions. Palliative care, with its focus on symptom management and decisional support, has the potential to ameliorate some of the burden of heart failure.

3. What effect does depression have on heart failure?

A. Decreased incidence of clot formation can result from low cytokine levels.

B. Hypertension from increased afterload can result from high cortisol levels.

C. Decreased ventricular filling can result from low serotonin levels.

D. Increased incidence of diabetes mellitus can result from high cytokine levels.

Answer: B Rationale: Depression and anxiety are important as they relate to the pathophysiology of heart failure (HF). Depression may independently worsen HF and increase the risk of death. Cortisol levels are persistently high in patients with depression, which, over time, leads to hypertension caused by increased afterload and an increase in heart rate resulting from decreased ventricular filling time. Proinflammatory cytokines, which are activated in the stress response, reduce the available serotonin, which leads to not only depression but also increased platelet aggregation and ultimately coronary artery occlusion.

4. Which substance is used as a predictor of hospitalization and mortality for heart failure?

A. MR-proADM B. Soluble ST2 C. Galectin 3 D. C-reactive protein Answer: A Rationale: MR-proADM has natriuretic, vasodilatory, and hypotensive effects; is elevated in acute and chronic heart failure; and is used as a predictor of hospitalization and mortality. Two markers, soluble ST2 receptor and Galectin 3, are linked to myocardial remodeling and fibrosis that eventually leads to the myocardial dysfunction and heart failure and may be considered as prognostic markers of heart failure. C-reactive protein, tumor necrosis factor-α (TNF-α), and interleukins 1, 6, 18 are all inflammatory markers that appear to have direct adverse effects on the myocardium through myocyte apoptosis and necrosis.

5. Mary finally went to see her physician after not feeling well for some time. Her physician suspects Mary might be in Stage C of heart failure. Which symptom would have presented first in Mary?

A. Cough B. Abdominal bloating C. Peripheral edema D. Dyspnea Answer: D Rationale: Of Stages A through C, Stage C of heart failure is when patients notice the first signs and symptoms. Dyspnea is typically the first manifestation of heart failure in patients.

6. If the healthcare professional is asking the patient about how well he or she gets around, what activities he or she does, what type of status is being assessed?

A. Cardiac B. Self-care C. Symptom D. Functional Answer: D Rationale: Functional status assessments include asking the patient about ambulation, activity level, self-care ability, oral intake, and level of consciousness.

7. Which type of medication will all patients with heart failure be prescribed?

A. Angiotensin-converting enzyme inhibitor B. Diuretic C. Beta-blocker D. Aldosterone antagonist Answer: C

Rationale: All patients with HF, unless contraindicated, should be prescribed a beta-blocker and one of the following: an angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) or angiotensin receptor blockers with neprilysin inhibitor (ARNI).

8. Joseph has Stage C heart failure and is at his appointment with his cardiologist. When the physician asks Joseph how he has been feeling, Joseph says he has been okay for the most part, but the arthritis in his hip has acted up so he took a couple of aspirin for the pain. Why will the cardiologist tell Joseph to stop taking aspirin?

A. It can cause increased blood pressure.

B. It can cause cardiac depression.

C. It can increase the risk of clot formation.

D. It can stimulate the release of epinephrine.

Answer: A Rationale: Nonsteroidal anti-inflammatory drugs cause sodium retention and peripheral vasoconstriction, as well as decrease efficacy and increase toxicity of diuretics and ACEI. In addition, they increase the risk of bleeding when used with anticoagulants such as warfarin, a drug widely used in this population.

9. Which piece of equipment is designed to synchronize contractions of both sides of the heart?

A. Implantable cardioverter defibrillator B. Biventricular pacemaker C. Left ventricular assist device D. Transthoracic doppler Answer: B Rationale: A biventricular pacemaker provides electrical stimulation that is programmed precisely to synchronize and coordinate the right and left ventricular contraction.

10. Which statement most accurately indicates the relationship between disease management and palliative care in heart failure?

A. Disease management and palliative care are two terms for the same practices.

B. Palliative care is used after disease management runs out of options.

C. Disease management focuses on medical interventions and palliative care focuses on quality of life.

D. Palliative care and disease management occur at the same time to improve the quality of life of a patient and their family caregivers.

Answer: D Rationale: There is a common misperception that disease management and palliative care are synonymous types of care. Disease management can attempt to cure a disease or the lessen its progression. Disease management are treatments targeted at the disease while palliative care improves the physical or psychological symptoms associated with the disease. Disease management does not include all of the domains identified in quality care for people with lifelimiting conditions such as heart failure. For example, the psychological and psychiatric; social,

spiritual, religious, and existential; and cultural aspects of care and care of the patient and patient’s family at the end of life are part of palliative care.

Short Answer 1. Roman is 72 years old and has just been diagnosed with systolic heart failure due to left ventricular hypertrophy. When he asks his cardiologist what that means, the physician answers in medical jargon, leaving Roman quite confused and unsure what to ask next. How can the cardiologist explain heart failure so that Roman understands?

Model Answer: Your heart is made mainly of muscle and when the muscle contracts, it pumps blood out of the heart. Heart failure means that your heart is a slowly failing pump.

There are two sides of the heart, right and left. The right side of the heart pumps blood to the lungs, and the left side of the heart pumps blood out to the rest of the body. Roman, your heart is failing on the left side. The muscle simply is not strong enough to pump enough blood out to meet the needs of the rest of your body. The most common cause is hypertension, or high blood pressure. Because the blood pressure is so high in the artery leading away from your heart, the left side of your heart has had to work extra hard to pump, and it has enlarged but not in a good way. The strain on the muscle in the left side of your heart is now slowly giving out.

2. As part of the interprofessional team, the palliative care (PC) professional would need to perform an assessment on a patient with heart failure. What does this assessment encompass?

Model Answer: A hallmark of quality PC is the assessment of the physical, psychological, social, and spiritual/existential aspects of care. Particular areas for assessment involve a complete physical assessment as well as taking a psychological history and assessing for reaction to the current condition, indicators of distress, family structure and function, strengths and vulnerabilities, caregiving needs, access to community services and resources, and advanced care planning. It should also include a spiritual assessment. Using the acronym FICA, the clinician assesses for faith or belief systems, important influences in the person’s life, community support, and addressing the issues in the person’s healthcare.

3. Why would a patient with heart failure be prescribed digitalis?

Model Answer: Digitalis glycosides, positive inotropic agents, have been a part of the medical regime for patients with heart failure (HF) for over 200 years. These agents are still indicated for use in patients with systolic dysfunction (HFrEF) and ongoing symptoms of HF despite already being on optimum doses of ACEIs or ARBs and BBs. Patients with mild to moderate HF on digoxin experienced a decrease in the progression of HF and had decreased hospital admissions, but had no overall decrease in mortality. Digoxin is also indicated in patients with HF with atrial fibrillation and uncontrolled ventricular response. However, this drug must be used carefully, while monitoring for and preventing digoxin toxicity.

4. Natasha is 56 years old and has been happy leading a sedentary life. Lately, however, she has noticed she is little more short of breath than she used to be and her weight has started to

creep up. One evening her daughter comes to visit and notices how swollen Natasha’s ankles are. It seems excessive, so her daughter insists that Natasha make an appointment with her doctor. After examining Natasha, her doctor insists that she be admitted to the hospital right away. Why would Natasha’s doctor do this?

Model Answer: When patients develop signs and symptoms of heart failure (HF), they often need to be hospitalized. Hospitalization is typical when a patient is first diagnosed with HF. Most patients are admitted due to fluid overload resulting in symptoms such as dyspnea, orthopnea, weight gain, or edema. The primary goal for HF-related hospitalization is to relieve symptoms, particularly congestion. Determining the etiology of the HF and EF will help determine what therapies are initiated. Another key goal while in the hospital is to identify and address precipitating factors for the decompensation such as poor adherence to medications or diet and fluid recommendations, poor social support or financial resources, lack of self-care education, or inadequate medical regimen prior to admission, as well as medical conditions such as atrial fibrillation, worsening renal function, hypertension, or ischemia.

5. Describe at least five nonpharmacological measures for management of heart failure.

Model Answer: For older adults (as well as those younger than 65), aggressive use of the nonpharmacological measures is imperative. General measures include: 1. Decreasing more or new cardiac injury by risk factor reduction 2. Limiting alcohol use to twToEgSlaTssBeA s/N daKySfoErLmLeE nRan.dCoOnM e glass/day for women 3. Maintaining fluid balance by restricted salt intake (2 g/day) 4. Improving physical conditioning 5. Careful management of comorbid conditions 6. Patient education regarding self-care 7. Smoking cessation when appropriate 8. Influenza vaccination every fall 9. Pneumococcal immunizations 10. Care of patients with heart failure across settings and by interprofessional teams 11. Careful monitoring of fluid status

CHAPTER 15: Chronic Lung Disease Multiple Choice 1. What is the cause of most cases of chronic obstructive pulmonary disease (COPD)?

A. Mesothelioma B. Pollution C. Pneumonia D. Smoking Answer: D Rationale: About 80% to 90% of COPD cases are the result of smoking. Ninety percent of patients with COPD die from causes attributable to smoking.

2. What are the most distinguishing consequences of COPD? A. Limitation and obstruction of airflow B. Increased levels of neutrophils and macrophages C. Tissue damage and inflammation D. Cough and bronchitis Answer: A Rationale: Airflow limitation and obstruction of airflow are the hallmark consequences of COPD. Increased levels of neutroTpE hiS lsTaB ndAm acSroEpL haLgEesR, . anCdOtM issue damage and inflammation NK result from constant irritation of the airways but are not distinguishing consequences. Cough but not always bronchitis occurs with COPD. 3. Alice’s spirometry reveals FEV1/FVC equal to or less than 70% and her FEV1 is 40%. What stage of COPD is she in?

A. Stage I B. Stage II C. Stage III D. Stage IV Answer: C Rationale: Patients with a spirometry that is FEV1/FVC equal to or less than 70%, and FEV1 >80% predicted are in Stage I COPD. FEV1/FVC equal to or less than 70%, and 50% ≥ FEV1 ≤ 80% predicted are in Stage II COPD. FEV1/FVC equal to or less than 70%, and 30% ≥ FEVI ≤ 50% predicted are in Stage III COPD. FEV1/FVC equal to or less than 70%, and 30% < FEVI predicted are in Stage IV COPD. 4. Which symptom is typically overlooked in diagnosing COPD? A. Mental changes B. Decreased appetite C. Increased appetite D. Sleep disturbances

Answer: D Rationale: Up to 60% of patients with COPD experience sleep disturbances, yet this symptom is often underassessed by providers or underreported by patients. Sleep quality is often fragmented, with episodes of dyspnea or coughing interrupting nighttime sleeping. Additionally, COPD patients may also experience sleep apnea, referred to as “overlay syndrome” when sleep apnea is diagnosed with COPD. The coexistence of sleep apnea with COPD is reported to be up to 60% in patients with COPD. 5. Which statement describes palliative care and COPD? A. COPD has easily recognized disease trajectory which indicates advanced illness and the need to request a palliative care consult..

B. Most healthcare professionals are able to effectively communicate the need for palliative care for patients with COPD. C. Fear of patient’s reaction to COPD diagnosis contributes to healthcare professionals’ lack of incorporation of palliative care.

D. Many health professionals can completely address the physical, emotional, and social needs of COPD patients without the need for palliative.

Answer: C Rationale: Fear of patients’ reactions to diagnosis and treatment may hinder discussions with patients and their families and contributes to a lack of specialized care, including palliative and end-of-life care. The underdiagnosis, undertreatment, and unpredictability of the trajectory of COPD contributes to confusion and uncertainty regarding the diagnosis and prognosis among Rm .uCnOicMation skills needed to discuss the interdisciplinary providers. ManyTpEroSvTidBeA rsNlaKcS kE thL eL coEm trajectory of COPD illness and the needs that patients experience at different stages of the COPD. Many providers have an inadequate understanding of the nature of palliative care and often perceive palliative care as synonymous with end-of-life care.

6. Which treatment modality is a pulmonologist likely to prescribe for all his or her patients with COPD? A. Regular exercise B. Smoking cessation C. Bronchodilators D. Vaccines Answer: B Rationale: Current treatment modalities for all patients with COPD include smoking cessation, prevention of infection, maximizing pulmonary function, and education. After the age of 65, smoking continues to be a major risk factor for death as well as a decreased quality of life.

7. Alastair is 57 and has just been diagnosed with COPD. He is feeling quite depressed because he stopped smoking 10 years ago and thought that would be long enough to make his lungs healthy again. What could his pulmonologist recommend for Alastair’s depression?

A. Exercise training B. Increased protein and calorie intake C. An anticholinergic agent D. Varenicline prescription

Answer: A Rationale: Exercise is central to the treatment of COPD and helps to improve both the physical symptoms of dyspnea and the psychological symptoms of depression. A combination of constant load or continuous exercise and interval exercise training provides the most beneficial outcomes compared to either treatment alone. Increased protein and calorie intake counteracts the malnutrition a patient with COPD may develop. An anticholinergic agent dilates airways.

Varenicline is a medication to help stop smoking.

8. When would a corticosteroid be prescribed for a patient with COPD? A. After the initial diagnosis B. At end-of-life care C. When bronchodilators are ineffective D. When progression becomes moderate to severe Answer: D Rationale: As the severity of COPD increases, and patients are diagnosed with moderate to severe forms of the disease, the GOLD Guidelines recommend as the next step the addition of an inhaled corticosteroid to long-acting bronchodilator therapy for all patients diagnosed with moderate-stage COPD, having an FEV1 of less than 50%, with frequent exacerbations of COPD. Inhaled corticosteroids have been shown to decrease the number and severity of exacerbation.

9. Which patient with COPD would be considered to have a life expectancy of less than six months?

A. FEV1 greater than 30% afTteErSuT seBoA fN aK brSoE ncLhL odEilRat.oC r OM B. PO2 greater than or equal to 55 mmHg on supplemental oxygen C. Progressive weight loss of greater than 10% of body weight D. Resting tachycardia greater than 80 beats per minute Answer: D Rationale: Progressive weight loss of greater than 10% of body weight is an indicator of low chance of survival longer than six months. FEV1 less than 30% after use of a bronchodilator, PO2 less than or equal to 55 mmHg on supplemental oxygen, and resting tachycardia greater than 80 beats per minute are also indicators of low chance of survival longer than six months.

10. If a patient is in chronic respiratory failure, which treatment is the only one that increases survival?

A. Morphine B. Steroids C. Oxygen therapy D. Pulmonary rehabilitation Answer: C Rationale: Oxygen is the only therapy associated with increased survival in patients who have chronic respiratory failure and must be administered for a minimum of 15 hours or more.

Morphine and steroids may assist with dyspnea. Pulmonary rehabilitation can be effective but not as effective as oxygen therapy.

Short Answer 1. How is COPD diagnosed?

Model Answer: The diagnosis of COPD is often considered when a patient reports a chronic cough, sputum production, or progressive dyspnea. A comprehensive history should be obtained including the duration and type of cough, whether dyspnea occurs at rest or with exercise, and the amount of sputum production. The baseline functional status of the client should be established and monitored over the course of the disease. Information regarding smoking history, recent exposure to toxic substances, or exposure to occupational fumes is necessary in establishing a diagnosis. Pulmonary function tests (PFTs) are needed to objectively confirm the diagnosis. Additional diagnostic tests may be necessary, and include a chest x-ray, arterial blood gases, and bronchodilator reversibility testing. If a client is diagnosed with COPD before the age of 45, and has a family history, alpha-1 antitrypsin testing may be performed. The revised GOLD guidelines recommend additional assessments to stratify patients. Symptom assessment is conducted using the COPD Assessment Tool (CAT) assessment or the Modified British Medical Research Council (mMRC) Questionnaire.

2. Jackson has been living with COPD for several years. Every fall, his pulmonologist warns him to guard against getting a cold or flu. What effect would getting a cold or flu have on Jackson?

Model Answer: Recurrent respiratory infections, commonly viral and bacterial in origin, can cause a transient worsening of COPD symptoms and are the most common cause of acute exacerbations. COPD patients are likely to experience one to two acute exacerbations per year. Haemophilus and Streptococcus pneumonia infections are the most common bacterial infections. The rhinovirus is responsible for approximately 25% of acute exacerbations.

Frequent infections are likely to worsen pulmonary function.

3. How would palliative care help a patient with COPD? Model Answer: The goal of PC for patients with COPD is to promote quality of life. The principles that underlie the provision of PC include effective communication among providers, clients, and their families, as well as maintaining independence and promoting psychosocial, spiritual, and emotional health. Patient education is an important component of communication and may help patients adjust to their illness and manage the disease.

Palliative care professionals educate clients about the causes of COPD as well as the progressive nature of the disease. Effective communication may assist clients with smoking cessation. Discussions about advanced directives and end-of-life care should be carried out throughout the early and late stages of the disease to promote quality of life. End-of-life care is especially important due to aggressive life-prolonging treatments that some patients receive in the last months of life because other alternative preferences, such as supportive comfort care, had not been discussed.

4. Maisie is 64 years old and recently diagnosed with COPD. She was a moderate smoker who has led a primarily sedentary life. She was able to finally quit smoking after receiving her diagnosis but is not happy about it. Now her pulmonologist wants her to start exercising and do breathing retraining. Maisie is very resistant to these. Exercising and breathing retraining sound like a lot of work, and she thinks that quitting smoking should be enough on her part to manage the COPD. How could a palliative care nurse encourage Maisie’s compliance with exercise and breathing retraining?

Model Answer: The nurse could explain that pulmonary rehabilitation can help give Maisie better quality of life and slow the progression of COPD. Pulmonary rehabilitation is focused on exercise and muscle reconditioning. Rehabilitation can take place in a community setting as well as in the client’s home. By increasing physical activity, muscle atrophy may be reduced and the efficiency of oxygen uptake will be improved. This will make Maisie stronger, and better able to fight off infections. The nurse could explain that breathing retraining for clients with COPD includes the techniques of pursed-lip breathing and diaphragmatic/abdominal breathing. Due to the pathophysiology of COPD, air becomes trapped in the terminal airways and adequate ventilation decreases. Pursed-lip breathing facilitates the expulsion of air from the lungs by the client controlling and lengthening the expiratory phase of respiration. This can contribute to Maisie’s pulmonary endurance.

Diaphragmatic/abdominal breathing serves a similar purpose as pursed-lip breathing. Maisie would use the diaphragmatic and abdominal muscles to control both inspiration and expiration. Both techniques would assist her in reducing panic and anxiety associated with dyspneic episodes.

5. What complementary therapies can nurses recommend for patients with COPD? Model Answer: Rest is necessary in order to decrease the intensity of dyspnea; it can also decrease the work of breathing. Promoting rest and sleep can also decrease anxiety.

Assessment of the patient’s sleep habits can be a helpful starting point to the promotion of restful sleep. Assisting the patient into a position of comfort can promote sleep, which generally means elevation of the head of the bed, which also facilitates diaphragmatic expansion. Guided imagery can be used to promote sleep and assist the patient through a stressful experience. Massage can promote sleep and reduce anxiety. Music therapy can also be added to the therapeutic plan for the promotion of rest and sleep and may help to reduce the need for pain medications. Several herbs that are used in the treatment of respiratory ailments. For example, Chaparral, cinnamon, horehound, and pansy have been used in the treatment of bronchitis,. However, caution must be taken as chaparral can cause severe liver damage and cinnamon can precipitate shortness of breath. Anise and astragalus have been used in the treatment of COPD. For general respiratory care and cough, lobelia and wild cherry have been used. The benefits of herbal interventions should be weighed against the harmful side effects that could exacerbate COPD or the complications of cor pulmonale and respiratory failure.

CHAPTER 16: Neurological Disorders Multiple Choice 1. Which person is most likely to have a stroke?

A. A 50-year-old Caucasian man who lives in Oregon B. A 65-year-old Caucasian woman who lives in Florida C. A 70-year-old Alaskan Native woman who lives in Idaho D. A 80-year-old African American man who lives in Georgia Answer: D Rationale: The prevalence of stroke is higher in older adults, African Americans, American Indians/Alaska Natives, persons with lower levels of education, and persons living in the southeastern United States. Racial and ethnic disparities in stroke care continue to be a major challenge for healthcare providers, with the burden of stroke remaining consistently higher among ethnic minority groups. Seventeen percent of all strokes occur in people who are older than 85 years. The incidence of stroke is higher in men than in women between the ages of 45 and 84 years. However, this changes after the age of 85 years, with women having a higher incidence of strokes than men.

2. Reginald had a stroke in which blood flow through an artery in his brain was blocked. What type of stroke does this describe?

A. Ischemic B. Atherosclerotic C. Hemorrhagic D. Thrombolytic Answer: A Rationale: An ischemic stroke results in a disruption of blood to a portion of the brain due to an occlusion of the cerebral artery by blood clots (emboli), or plaque and fatty deposits (thrombi).

3. Which statement describes Parkinsonʼs disease?

A. Average age of onset is 50 years.

B. Symptoms can mimic other conditions.

C. Genetics play a role in its development.

D. Symptoms result from acetylcholine depletion.

Answer: B Rationale: Parkinsonʼs disease symptoms mimic other conditions and there is no biomarker for Parkinsonʼs disease. The average age of onset is 60 years. Most cases of Parkinson’s disease occur without obvious genetic cause. Degenerative process results in depletion of dopamine.

4. Dahlia’s movements have become extremely slow, she has fallen a few times in the past several weeks, and her neck and head appear to have a slight shaking motion. Which condition is she most likely to be diagnosed with?

A. Parkinsonʼs disease B. Alzheimerʼs disease C. Multiple sclerosis D. Hemorrhagic stroke Answer: A Rationale: The four primary motor symptoms of Parkinsonʼs disease are bradykinesia, rigidity, postural instability or balance problems, and resting tremor. Dahlia’s symptoms of slow movement and instability issues leading to falling demonstrate that Parkinsonʼs disease can present similar to other diseases but the shaking motion is specific to Parkinsonʼs disease.

5. Which condition is characterized by muscle atrophy due to degeneration of upper and lower motor neurons?

A. Stroke B. Amyotrophic lateral sclerosis C. Multiple sclerosis D. Coma Answer: B Rationale: Amyotrophic lateral sclerosis (ALS) or Lou Gehrig disease is a rare but rapidly progressive neurodegenerative diT seEasSeTthBaA tN afK feS ctE sL boLtE hR up.pC erOaMnd lower motor neurons leading to progressive muscle atrophy of the voluntary muscles in the arms, legs, and trunk.

6. Which statement characterizes coma?

A. Most patients in a coma from a stroke survive.

B. Prognosis depends mostly on the age of the patient in the coma.

C. Patients who emerge from a coma can regain most of their function.

D. Most coma patients die in acute care.

Answer: D Rationale: The majority of coma patients will die in the acute care setting, except for those whose coma is persistent. Most comatose stroke patients do not survive. The most critical factors involved in determining prognosis is etiology of the coma, the clinical depth of coma, and the length of time the person remains comatose. People who do emerge from a coma may have problems with complex thinking, emotional stability, and physical difficulties.

7. George has dementia and lives in an assisted care facility. He shares a room with another patient who likes to have the TV on. George’s nightstand has photos of his family and roses his wife brings every few days. On his wall are several paintings he did in his younger years, and his bed has an afghan his wife crocheted and flannel sheets. The palliative care nurse has noticed that George is becoming agitated lately. What modification to his room might be calming to him?

A. Removing the photos from the nightstand B. Turning off the TV C. Discouraging his wife from bringing roses D. Taking the paintings off the wall Answer: B Rationale: The patient with dementia may become overstimulated easily. Turning off the TV will most likely decrease George’s agitation because it eliminates a possibly loud sensory stimulation. It is important that George’s room be as pleasant and as stress free as possible. He needs some items that are familiar in the immediate area, such as photos of his family, the roses from his wife, and his paintings.

8. Oral hygiene and honey-thick liquids most effectively address which condition?

A. Dysphagia B. Dyspnea C. Aphasia D. Paratonia Answer: A Rationale: Dysphagia is difficulty swallowing, which can be a complication in a patient with a neurological disorder. Oral hygiene, especially for patients who produce excessive saliva, and honey-thick liquids can help give these patients nutrition. Dyspnea is difficulty breathing.

Aphasia is leads to impaired difficulty in reading and writing. Paratonia is the involuntary resistance of an arm or a leg to movement of the limb by another person.

9. What factor is involved in pain management and palliative care?

A. Opiates are the first line of pharmacologic treatment for neuropathic pain.

B. Spasticity is a common problem that can become disabling.

C. Extremity pain in multiple sclerosis is dull and aching.

D. Range-of-motion exercises have little effect in poststroke patients.

Answer: B Rationale: Spasticity is a common problem that can become disabling, affecting ADLs and, ultimately, quality of life. Opiates play a relatively small role in the management of neuropathic pain.. Extremity pain in people with MS is a result of demyelinating lesions and is described as persistent and burning. Range-of-motion exercises, proper positioning, and techniques to manage edema should be initiated immediately poststroke in the affected limb.

10. What is the role of a palliative care professional for the family of a patient with brain death?

A. Ensure the patient receives opioids for pain relief B. Communicate physician’s treatment decisions to the family C. Determine when withdrawal of treatment should occur D. Support the family and give them time to process information they have been given Answer: D Rationale: The palliative care professional needs to give the family time to process and cope with information they have been given. The patient does not need opioids for pain relief because the patient who is brain dead does not feel pain. The palliative care professional communicates the family’s treatment decisions to the physician, not the other way around. The family determines when the withdrawal of treatment should occur.

Short Answer 1. A patient has just been diagnosed with Alzheimerʼs disease. How could the nurse explain to the patient’s son, who is not a healthcare professional, why his father will experience progressive memory loss and psychiatric disturbances, and will eventually lose basic body functions?

Model Answer: Within the brain, a certain type of protein twists around other neuroproteins inside nerve cells, forming tangles. The tangles disrupt the neuron’s functioning and then cause it to die. Scarring and these tangles occur in parts of the brain that control information TE ToBrA processing, acquisition of new mS em ieN s,KaS ndErLetLriE evRa. l oCfOoM ld memories. They also occur in another part of the brain involved in thinking and decision making. As a result, people with Alzheimerʼs disease experience progressive memory loss, loss of executive function, language difficulties, and psychiatric and behavioral disturbances; the disease then eventually affects the area of the brain that enable the person to carry out basic bodily functions such as walking or swallowing.

2. Describe the four ways multiple sclerosis can present.

Model Answer: There are four main patterns to the presentation of multiple sclerosis (MS).

Relapsing-remitting is the most common form of MS and is characterized by flare-ups that appear for several days to weeks followed by remissions during which not all symptoms resolve completely. Primary-progressive MS is a less common form, in which the disease manifestations gradually worsen over time without periods of remission. The secondaryprogressive MS form starts out as a relapsing-remitting course but later progresses to primary-progressive MS. Progressive-relapsing MS is the least common form that is progressive from the beginning with episodes of acute increased worsening of existing symptoms or new ones.

3. Bailey’s mother, Eliza, is recovering from a stroke, and it is a long, difficult process. Bailey is doing the best she can for caregiving, but is frustrated by how hard it is to communicate with Eliza. How can a palliative care nurse help?

Model Answer: Difficulty communicating is severely reducing the quality of life for both Eliza and Bailey. The palliative care nurse can develop a plan with the interprofessional team for providing meaningful communication and socialization for Eliza and Bailey. The nurse can explain to Bailey that supporting any of Eliza’s attempts to communicate helps Eliza feel connected and accepted. As a result, Eliza may begin using many more nonverbal cues to communicate needs. The nurse can help Bailey and Eliza develop a nonverbal system of communication for Eliza’s needs such as pain relief, hunger, or the need to eliminate or change positions. Other nonverbal communication through touch, massage, and eye contact can be helpful. Gestures are a three-dimensional language of communication; waving hello, pointing, beckoning with outstretched hands, and hugging used by Bailey may be effective communication tools. Bailey is conveying to Eliza that she is not alone and that she is respected.

4. What are benefits of exercise in patients with neurological disorders?

Model Answer: Research on exercise for people with Alzheimerʼs disease and related disorders has shown maintenance of motor skills, decreased falls, reduced rate of cognitive decline, and improved mood. Strengthening and balance exercises in patients with Parkinsonʼs disease increase physical function, strength, balance, gait speed, and healthrelated quality of life. Rhythmic auditory stimulation, in which rhythms of sounds function as a cue to stabilize and enhance the organization of movement, may be beneficial for improving gait parameters in stroke patients, including gait velocity, cadence, stride length, and gait symmetry. For patients with ALS, exercise can help to maintain the flexibility of muscles, but it will not strengT thEenST mB usAcN leK sS thE atLhL avEeRb. eeCnOwMeakened by ALS. For people with MS, exercise may decrease symptoms, but it must be done judiciously as overheating or overstressing the body can actually exacerbate symptoms. Occupational therapy may help patients to maintain independence for longer periods of time as the chronic neurological diseases progress.

5. How can a nurse help families with chronic neurological disorders?

Model Answer: The illness trajectory for patients with chronic neurological disorders is often long and unpredictable. The prognostic uncertainty is associated with a host of patient, family, caregiving, and reimbursement challenges. Patients with chronic neurological disorders have heavy physical and emotional care needs. Care in a hospice or long-term care facility may reduce the caregiving required of the family, but may lead to feelings of loss of control as well as feelings of isolation. Deciding on the preferred setting for end-of-life care is complex, with many factors to consider; family members may disagree with each other or with the patient. The nurse can serve as a nonjudgmental listener, can help to explore options, and can facilitate working through the process of decision making with family members.

In the case of illnesses that are associated with dementia, the nurse can facilitate early discussions, and assignment of trusted family members to decision-making roles when capacity is compromised is essential. With these illnesses, there is a lot of anticipatory grieving that occurs, and the nurse can support family members in accepting their feelings.

Acknowledging conflicting feelings, particularly both the dread and the desire for the death

to occur, as common and natural can be helpful. Early discussions about the typical course of the illness that are honest but sensitive are needed.

CHAPTER 17: End-Stage Renal Disease Multiple Choice 1. Chronic kidney disease is defined by which estimated glomerular filtration rate (eGFR)?

A. Less than 60 mL/min/1.73 m2 for 3 months or longer B. More than 60 mL/min/1.73 m2 for 3 months or longer C. Less than 60 mL/min/1.73 m2 for 6 months or longer D. More than 60 mL/min/1.73 m2 for 6 months or longer Answer: A Rationale: Chronic kidney disease can be defined as kidney damage or eGFR less than 60 mL/min/1.73 m2 for 3 months or longer.

2. Which condition is a patient with chronic kidney disease most likely to die from?

A. Hypertension B. Diabetes mellitus C. Myocardial infarction D. Dyspnea Answer: C Rationale: Cardiovascular disease is the leading cause of death in people with end-stage renal disease. Stable atherosclerotic heT arE t dSiT seB asAeN , aKcS utE eL mL yoEcRar.dC iaO l iMnfarction, congestive heart failure, stroke, peripheral vascular disease, atrial fibrillation, and sudden cardiac arrest increase the risk of premature death. Other comorbid conditions that can impact the health and wellbeing of patients with end-stage renal disease include diabetes mellitus, hypertension, osteoarthritis, and cognitive impairment.

3. How does the trajectory of end-stage renal disease present?

A. Death usually occurs within three years of starting dialysis.

B. Early mortality is highest in the first two weeks of dialysis.

C. Age is the most important predictor in older patients.

D. It presents as stable periods with intervals of steady decline.

Answer: D Rationale: Evidence supports that the disease trajectory in some adults with ESRD include stable periods followed by intervals of steady decline. Death usually occurs within five years of starting dialysis. Early mortality is the highest in the first four weeks of dialysis. In older adults, functional decline may be a more important predictor of the disease trajectory than age itself.

4. Which patient is exhibiting early signs or symptoms of end-stage renal disease?

A. Karen, who has nausea and vomiting B. Bill, who has leg cramps and joint pain C. Jan, who has chest pain and palpitations D. Darla, who has mood swings and depression

Answer: B Rationale: Early signs and symptoms of end-stage renal disease include leg cramps, joint pain, gout, arthritis, muscular pains, muscle weakness, hyperparathyroidism, anemia, hypertension, pitting edema, gains in weight with fluid retention, weakness, and fatigue. Nausea, vomiting, chest pain, palpitations, mood swings, and depression are all late signs and symptoms or uremic indicators.

5. What effect do comorbidities have on patients living with end-stage renal disease?

A. Patient’s age has no role in the type of complications.

B. Cognitive impairment rarely occurs.

C. Kidney replacement therapy is contraindicated.

D. Survival rate tends to become lower.

Answer: D Rationale: Survival rate tends to become lower because there is increased disease management burden. Although age is not a sole predictor for potential poor health outcomes, it plays a substantial role in the type of complications and health-related outcomes for people with ESRD. Both children and older adults with ESRD present special challenges because of the unique comorbid conditions and ESRD-related complications that are superimposed upon the normal anatomic and physiologic changes associated with those age groups. Cognitive impairment occurs more often in older adults; the majority of patients with end-stage renal disease are older adults. Kidney replacement therapy focuses primarily on filtering the blood and does so no matter what conditions the patient has.

6. Joyce is on Medicare and has recently started dialysis for her end-stage renal disease. Why is a dietician now on her healthcare team?

A. To provide nutritional advice, especially about phosphorous B. Health providers do not have knowledge to manage the calcium levels C. The Medicare Benefit does not focus on a patient-centered plan of care D. To monitor the patient’s bone density Answer: A Rationale: Constant, high levels of phosphorus and parathyroid hormone, and low levels of serum calcium, cause calcium to be leeched from the bone, thereby causing the unique form of bone thinning and weakening seen in end-stage renal failure. Foods high in phosphorus include dairy products, meats, legumes, nuts, whole-grain breads and cereals, and many soft drinks.

Collaboration with a dietitian can help establish a person-centered plan of care that considers the stage of chronic kidney disease and nutritional needs and honors patient preferences and wishes.

Prior to dialysis there is a Medicare benefit called Medical Nutritional Therapy, where a dietitian can educate and consult with patients who are not on dialysis. Once on dialysis, Medicare mandates that a dietitian be a member of the healthcare team.

7. What is a consideration for anemia in a patient with chronic kidney disease?

A. It is a rare occurrence and requires little intervention.

B. Treatment should occur only after dialysis has begun.

C. Target hemoglobin range is 10 to 11.5 g/dL. D. Iron deficiency anemia is a chronic complication with chronic kidney disease Answer: C Rationale: Recent guidelines from the Kidney Disease Improving Global Outcomes initiative recommend a target hemoglobin range of 10 to 11.5 g/dL, which is well below the normal adult range. The reason for this is evidence of increased thromboembolic events when the effort is made to normalize the hemoglobin with an erythropoiesis-stimulating agent. Normocytic, normochromic anemia is one of the most common complications of chronic kidney disease, with increasing prevalence in advanced chronic kidney disease. Treatment of anemia with an ESA should begin once the person is diagnosed and other causes of anemia are ruled out.

8. Arianna is 8 years old and has renal failure. Which procedure for dialysis is she most likely to receive?

A. Arteriovenous fistula B. Peritoneal catheter C. Arteriovenous graft D. Venous catheter Answer: B Rationale: In children, blood vessTeE lsSaT reBoA ftN enKtS ooEsLmLaE llR , n.eC ceOssMitating the use of the peritoneal dialysis. Individuals undergoing peritoneal dialysis will have a catheter placed through the abdominal wall into the peritoneal space and dialysis fluid is infused into the peritoneal space and drained out through the catheter after an exchange of electrolytes and systemic toxins.

9. What responsibility do healthcare professionals have when talking about kidney replacement therapy with a patient?

A. Emphasizing that dialysis is usually the best treatment option B. Discussing the complications of long term dialysis C. Explain that withholding dialysis is unethical D. Discussing the benefits and risks of kidney replacement Answer: D Rationale: For patients with multiple comorbidities, advanced age, and limited functional ability, conservative/supportive management may be as efficacious as kidney replacement therapy.

Dialysis may not be the best option for the patent. The family needs to be involved in the treatment decision. However, the discussion should be with the patient first, or the patient and family together. Informing the patient that withholding dialysis is a valid and ethical decision option

10. Which end-of-life symptom is managed with controlling blood levels of phosphorus, calcium, and parathyroid hormone?

A. Dyspnea B. Pruritus C. Anorexia D. Pain Answer: B Rationale: Pruritus is itching. Prevention includes adequate dialysis and achieving target phosphorus, calcium, and parathyroid hormone levels through a well-controlled diet and medications.

Short Answer 1. Malcolm has insulin-dependent diabetes mellitus. He has not always paid close attention to managing his condition. He is now in his fifties, has had several toes amputated, and his eyesight is becoming impaired. When Malcolm’s daughter takes him to his latest appointment with his physician, the physician asks Malcolm about his urinary output. Why would the physician want to know this?

Model Answer: The primary cause for end-stage renal disease is diabetes mellitus. In diabetic kidney disease, renal lesions include changes in the afferent and efferent arteries, tubular fibrosis, and thickening of the basement membrane with impingement on the filtration surfaces of the glomTerEuS luT s.BTAhN esK eS chEaL ngLeEs R pr.oC grOesMs as hyperglycemia persists and the resultant proteinuria contributes to hyperfiltration and high GFR and ultimately GFR decline. This is an indicator of chronic kidney disease.

2. Why should nurses encourage patients with chronic diseases, especially diabetes mellitus, hypertension, and cardiovascular disease, to be screened for kidney disease?

Model Answer: Not many people are aware they have kidney disease until it is advanced.

The absence of symptoms in early stages of chronic kidney disease limits self-awareness of kidney disease. Therefore, healthcare professionals, especially nurses, play a key role in educating patients about risk factors for kidney disease and the importance of being screened when at risk. This is important because early identification and treatment of comorbid conditions by a nephrology team can help delay end-stage renal disease and, when dialysis is required, help the patient arrive at that point in reasonably good health. Early referral to nephrology supports preservation of kidney function, reduced mortality, and delaying the onset of debilitating complications.

3. Ralph has been recently diagnosed with chronic kidney disease. His nephrologist says that he will give him a referral to a cardiac care center. Why would the nephrologist do this? What evaluations will Ralph undergo at the cardiac care center?

Model Answer: Cardiovascular disease is the leading cause of death among individuals with chronic kidney disease and end-stage renal disease undergoing dialysis. Living with

cardiovascular disease can substantially impact mortality, morbidity, and quality of life; thus, it is crucial that person-centered interventions are focused on prevention and the most appropriate treatment for the individual. KDIGO Clinical Practice Guidelines recommend the evaluation of risk factors for treatment includes screening for left ventricular hypertrophy and coronary artery disease; treating hypertension and hyperlipidemia using goals for patients who have preexisting coronary artery disease; low-sodium and low-fat diets; fluid restrictions; maintaining a calcium/phosphorus product below 55, which is obtained by multiplying the serum calcium number by the serum phosphorus number; as well as counseling for smoking cessation, exercise, and aggressive treatment of diabetes mellitus.

4. What factors are involved in a patient choosing a dialysis modality?

Model Answer: Indications for choosing one dialysis modality (hemodialysis vs. peritoneal dialysis) over another include lifestyle choice by the patient, healthcare provider preferences, distance to the nearest dialysis center (urban vs. rural), and concurrent illnesses and associated symptoms. In rural areas peritoneal dialysis or home hemodialysis with the NxStage® machine may be the best option because the closest dialysis center may be miles away, thus making it challenging for a person to get to the center three times a week.

5. How should pain management be addressed at the end of life for a patient with end-stage renal disease?

Model Answer: Pain is very common and distressing and requires a comprehensive assessment and individualizedTpElS anToBfAcaNrK eS foE rL peLoE plR e. wC itO hM end-stage renal disease. The first step in pain management is conducting a comprehensive pain assessment. Asking if the person has ever had pain management before, and what has worked and what has not worked, is also very important. There are a few important points to be made in the case of pain palliation in end-stage renal disease. For hospice patients, analgesics should be used on a regular schedule using the World Health Organization (WHO) analgesic ladder in guiding medications including opioids to be used. Even so, there are some drugs that should not be used, as well as some drugs for which dosing should be monitored, because their metabolites can accumulate in renal failure and cause unwanted side effects. Opioids are generally metabolized in the liver, but some accumulate. Nonpharmacological interventions like cognitive behavioral therapy, relaxation therapies, and mindfulness as adjunctive therapies may be useful.

CHAPTER 18: End-Stage Liver Disease Multiple Choice 1. Cirrhosis of the liver means that it is in what condition?

A. Enlarged B. Fibrotic C. Hemorrhaging D. Inflamed Answer: B Rationale: Cirrhosis is a diffuse pattern of liver injury and repair, which leads to fibrosis, changes in liver blood flow, and loss of liver cells.

2. Which virus is one of the major causes of liver cirrhosis, hepatocellular carcinoma, and death?

A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D Answer: C Rationale: Worldwide, hepatitis C virus (HCV) is one of the major causes of liver cirrhosis, hepatocellular carcinoma, and death.

3. Carl is in the early stages of liver disease. What symptom he is most likely experiencing?

A. Confusion B. Jaundice C. Pruritus D. Fatigue Answer: D Rationale: Fatigue is the most common symptom experienced by patients in the early stage of liver disease. Confusion, jaundice, and pruritus occur at a later stage of liver disease.

4. Which statement describes predicting mortality for a patient with liver disease?

A. The Child-Pugh-Turcotte scoring system is more accurate than the MELD scoring system.

B. The Child-Pugh-Turcotte scoring system measures ascites and the MELD scoring system measures serum factors.

C. Other health factors come into play besides the Child-Pugh-Turcotte and the MELD scoring systems.

D. The Child-Pugh-Turcotte and the MELD scoring systems should always be used together.

Answer: C

Rationale: Other health factors play a role in assessing mortality, and a person with an MELD of 25 may have a lower mortality than someone with an MELD of 18 who has an infection or hemorrhage. Because it is usually the complications of cirrhosis that determine morbidity and mortality, it is often hard to predict prognosis in an individual patient. There are two scoring systems in current use that describe mortality: the Child-Pugh-Turcotte Score and the MELD. Both measure ascites, encephalopathy, and serum factors.

5. What is a consideration for hepatocellular carcinoma?

A. It is one of the fastest-growing cancers in the world.

B. It is unrelated to cirrhosis of the liver.

C. Symptoms manifest early in the disease.

D. Cancer rarely recurs after a liver transplant.

Answer: A Rationale: Hepatocellular carcinoma (HCC) is one of the fastest-growing cancers in the world.

Patients who are known to have cirrhosis should be screened for liver cancer every 6 months.

Liver cancer most often grows silently, and patients become symptomatic late in the course of the disease. There are strict criteria for the size and number of HCCs, established to minimize the probability of recurrence of cancer post-transplant.

6. Which complication occurs when intestinal lymphatic vessels are unable to carry fluid back into the vascular system?

A. Peritonitis B. Ascites C. Encephalopathy D. Gastropathy Answer: B Rationale: Ascites occurs when fluid leaking into the peritoneal cavity from engorged intestinal veins overwhelms the ability of the lymph vessels to carry the fluid back into the vascular system. Peritonitis occurs because there is increased bacterial translocation. Gut bacteria or bacterial products are the most likely causes of encephalopathy. Gastropathy is stomach disease.

7. Which condition is most effectively treated by a liver transplant?

A. Cirrhotic cardiomyopathy B. Hepatic encephalopathy C. Portopulmonary syndrome D. Hepatopulmonary syndrome Answer: D Rationale: As cirrhosis becomes further decompensated, other organs also develop dysfunction.

About 10% to 15% of patients with cirrhosis will develop hepatopulmonary syndrome, with shunting in the lungs and hypoxia, or portopulmonary syndrome, with right ventricular and pulmonary artery hypertension. The former is cured by liver transplant; the latter is not cured and is associated with increased perioperative mortality. Cirrhotic cardiomyopathy occurs as decompensation progresses; the work of the heart increases until it is no longer able to meet

demands, leading to high-output cardiac failure. Cirrhotic myopathy occurs too late to be ameliorated by a liver transplant. Hepatic encephalopathy is treated by addressing levels of ammonia in the blood.

8. Patsy is receiving palliative care for cirrhosis of the liver. Which nutritional concern is essential for Patsy?

A. She will find it easier to digest vegetable protein than animal protein.

B. She is at a higher risk for hyperglycemia.

C. She will need a higher protein intake than the average patient.

D. She will need a higher carbohydrate than usual.

Answer: C Rationale: Studies have shown that patients with cirrhosis require more ingested protein than a normal patient. Animal protein is more easily digested and absorbed than vegetable protein; 40% to 50% of vegetable protein can be inaccessible to pancreatic enzymes due to binding to cellulose. Because of the alterations in liver blood flow, there is less first-pass clearance of nutrients from the small intestine, leading to a discrepancy between nutrient absorption and secretion of insulin, glucagon, and other digestive hormones. This can lead to the potential for hypoglycemia and to a shift in metabolism from glycogen to muscle protein.

9. Which statement describes pain management for patients with cirrhosis of the liver?

A. Health professionals may be reluctant to prescribe pain medication.

B. Patients are usually pain free.

C. Chronic use of NSAIDs isTtE heSoTpBtiA mN alKcS hoEiL ceLfE orRp.aC inO .M D. Opioids are ineffective in relieving hepatic pain.

Answer: A Rationale: Healthcare professionals are often reluctant to prescribe pain medication because of former addiction issues or concern for altered drug metabolism or triggering encephalopathy.

Research shows that patients with end-stage liver disease experience moderate to severe pain.

The chronic use of NSAIDs, such as ibuprofen or naproxen, is contraindicated because they decrease platelet function, may cause gastric ulcers, and lead to a higher risk of interstitial nephritis in patients with cirrhosis. Opioids can be prescribed starting with a lower dose.

10. What issue is a patient who is an addict likely to struggle the most with during the end of life?

A. Anxiety B. Forgiveness of self and family C. Body image D. Mental illness Answer: B Rationale: Patients with end-stage liver disease may seek forgiveness from family members from whom they have been estranged due to addiction or mental illness. As a result of estrangement, these patients may have little support at the same time they may be struggling with selfforgiveness. Self-forgiveness may be the hardest.

Short Answer 1. What is fatty liver disease?

Model Answer: Nonalcoholic fatty liver disease (NAFLD) is an increase in stored fat in liver cells and is associated with a chronic inflammatory reaction. Nonalcoholic steatohepatitis (NASH) is a more severe form of NAFLD, with increased inflammation and fibrosis, and is now a major cause of liver cirrhosis. Both NAFLD and NASH are called fatty liver disease. The term “fatty liver disease” is used when more than 5% to 10% of the liver’s weight is made up of fat. Fatty liver disease is prevalent in individuals who are overweight or have diabetes, or metabolic syndrome.

2. Geraldine is stunned when she receives a diagnosis of liver cancer. She had been feeling fatigued but otherwise fine. She barely hears the oncologist give her treatment options.

Finally, Geraldine interrupts the physician to say that she would prefer to treat her disease naturally, without poisonous chemicals being put into her body. What is the most appropriate response to this?

Model Answer: One of the greatest challenges in treating people with liver cancer is that they may feel good and find it hard to believe that there is anything wrong. This is true even in patients referred for palliative care. They may opt for naturopathic remedies that seem less toxic (e.g., cannabis/CBD oil), but have not been shown to be effective in halting the progression of cancer. Patients may decide to undergo liver-directed therapies when subsequent imaging shows thT atEnS atT urBoA paNthKiS cE reL mL edEieRs.hC avOeMnot halted the disease. But the cancer is often more difficult to treat.

3. What are the steps involved for a patient to become a liver transplant candidate?

Model Answer: A patient with decompensated cirrhosis and a MELD of 14–15, a significant complication of the liver disease, or the development of HCC within the Milan criteria can be referred for liver transplantation. A preliminary investigation into the health of other organ systems, acceptable psychosocial health, and adequate caregiver support is performed first; then the information is sent to a transplant center. Further workup is done at the center, the patient is discussed at a multidisciplinary conference, and a determination of the patient’s suitability for transplant is made. If all concerns of the transplant program personnel are satisfied, the patient is placed on a liver transplant waiting list corresponding to his or her blood type. The position on the list is determined by the MELD score.

4. What factors are involved in a recommending palliative care for a patient with end-stage liver disease?

Model Answer: Given that the disease progression from end-stage liver disease is slow and involves intermittent acute exacerbations, predicting survival is difficult. Death from endstage liver disease is relatively sudden and unpredictable until the last week of life. This uncertainty and challenges in prognostication is one of several barriers for early referral of individuals with end-stage liver disease to palliative care or hospice. Individuals with end-

stage liver disease often receive palliative care late in the disease trajectory. Individuals with end-stage liver disease tend to live in a state of poor and declining health, but often have a limited understanding of their disease severity and prognosis and, therefore, may not realize how close they are to death. This makes end-of-life care conversations and referral to palliative care challenging for healthcare professionals. At the same time, healthcare professionals may lack training and experience in initiating end-of-life conversations, and may overestimate life expectancy, focusing on medical interventions. Professionals may be concerned that palliative care referrals are alarming to patients and families. They may also be concerned about taking away patients’ hope for a potential liver transplant and therefore postpone difficult end-of-life conversations. Patients and families may perceive palliative care as similar to hospice and that professionals are “giving up” on them, rather than understanding that palliative care and hospice improve the quality of life until its end. It is important to realize that palliative care can be introduced at any time in the illness trajectory to improve the quality of life of patients and families, with discussions of the goals of care, and the management of physical, emotional, and spiritual needs. Palliative care interventions are beneficial to patients with end-stage liver disease, even those who are referred for a liver transplant evaluation and awaiting a transplant.

5. Valerie is a nurse in an inner city hospital. Her supervisor, Manuel, has noticed that Valerie delays seeing to the needs of Harper, a patient with end-stage liver disease. There is no notation in Harper’s chart about the cause of the disease. Twice, Manuel has heard Valerie talking to other nurses about how she doesn’t understand why their time is being taken up with junkies and that these people just cost the healthcare system money. How should Manuel approach Valerie?

Model Answer: Manuel should talk with Valerie about how she must be honest with herself and be aware of her own assumptions and biases about this population and their families.

Hearing that an individual has end-stage liver disease may lead a nurse to make assumptions about the cause of the disease (“he or she is an alcoholic and/or drug user”) and/or the individual’s previous or current lifestyle. Valerie needs to reflect on and explore such assumptions. It is important for her to acknowledge them so they do not interfere with the respect each individual and his or her family deserve. Valerie needs to keep in mind that there are many causes for end-stage liver disease. Patients should not be judged by their past but instead be supported as they move forward with a terminal illness potentially causing physical and psychological pain and suffering.

CHAPTER 19: Palliative Care and HIV/AIDS Multiple Choice 1. What is the trajectory of HIV/AIDS? A. Similar to that of cancer B. Rapid decline to death C. One of acute disease D. One of chronic disease Answer: D Rationale: In the past decade the trajectory of HIV/AIDS has changed significantly, shifting to a disease less like cancer and more like chronic disease such as diabetes or heart disease.

2. What is the primary goal of palliative care in patients with HIV/AIDS? A. Prevent or alleviate suffering at any point of the illness B. Minimize use of pain medications C. Offer physical support to patients and family D. Comfort care at end of life Answer: A Rationale: The goal of palliative care is to minimize and prevent suffering for patients who are dealing with serious illness, incluT diEnS gT HB IVA/N AK IDSSEiL nL anEyRs. taC geOoMf the disease. Palliative care offers physical, emotional, social, and spiritual support to promote, maximize and maintain good quality of life of patients and their families. Despite the advent of effective pharmacological therapy and its availability, patients with HIV/AIDS still continue to experience a high burden of pain and other chronic symptoms through the disease trajectory, which presents many palliative care challenges.

3. Which statement describes HIV’s life cycle?

A. An enzyme converts its DNA to RNA. B. It uses cells with CD4 markers as host cells.

C. It uses cells with CD8 markers as host cells.

D. Replication occurs in body fluids.

Answer: B Rationale: HIV survives by reproducing itself in a host cell. It has an affinity for any cell that has the CD4 molecule on its surface, such as T lymphocytes and macrophages. An enzyme called reverse transcriptase converts HIV’s two strands of viral RNA to DNA. 4. When is AIDS diagnosed?

A. With the detection of HIV infection B. CD4 count drops below 200 cells/mm3 C. CD4 count drops below 50 cells/mm3 D. With suppression of opportunistic infections

Answer: B Rationale: When the CD4 count drops below 200 cells/mm3, HIV infection now meets one of the Centers for Disease Control and Prevention’s definitions of AIDS (CDC, 2013). With AIDS, patients often experience several opportunistic infections or cancers.

5. What is the relationship between opportunistic infections and HIV infection?

A. Most opportunistic infections are considered curable.

B. Opportunistic infections are usually the cause of death.

C. Usually only one opportunistic infection occurs at a time.

D. Symptoms associated with opportunistic infections do not contribute to suffering Answer: C Rationale: Opportunistic infections are the greatest cause of morbidity and mortality in individuals with HIV disease. Most of these opportunistic infections are incurable and can at best be palliated to control the acute stage of infection and prevent recurrence through long-term suppressive therapy. In addition, patients with HIV/AIDS often experience concurrent or consecutive opportunistic infections and various malignancies that are severe and cause a great number of symptoms and related suffering.

6. Which statement describes palliative care for patients with advanced AIDS? A. Dieticians are unnecessary on the interprofessional team.

B. Pain relief is the single most important factor.

C. Antiretroviral therapy is unnecessary at this stage.

D. Balance between aggressiT veEaSnT dBsuApNpK orS tiE veLeLffEoR rts.iC sO thM e goal.

Answer: D Rationale: Healthcare providers and patients must determine the balance between aggressive and supportive efforts, particularly when increasing debility, wasting, and deteriorating cognitive function in the face of advanced disease. The interprofessional palliative care team involves physicians, advanced practice nurses, staff nurses, social workers, dietitians, physiotherapists, and clergy. Therapeutic interventions and decisions for patients with advanced AIDS should include patient’s expectations, preferences, and goals, as well as the benefits and burdens of antiretroviral therapy, pain management, and advance care planning as part of the clinical discussions and planning for the future.

7. Which part of the HIV/AIDS patient’s health history could enhance the progression of disease?

A. Substance abuse B. Childhood vaccinations C. Travel to Europe D. Nonvegetarian diet Answer: A Rationale: Health history includes lifestyle habits, such as the past and present use of recreational drugs, including alcohol, which may accelerate the progression of disease. Childhood vaccinations can help prevent disease. Travel to countries in Asia, Africa, and South America

increases the risk of opportunistic infections. A nonvegetarian diet does not necessarily contribute to disease progression.

8. Antiretroviral therapy is typically given to which HIV/AIDS patients?

A. All who are free from opportunistic infections B. Those who have two or more opportunistic infections C. Those with a CD4 cell count below 350 cells/mm3 D. All regardless of CD4 cell count Answer: D Rationale: Historically, the assessment of the CD4 cell count was used to determine the initiation of ART, with ART primarily reserved for CD4 counts below 350 cells/mm3. Currently, HIV therapy is recommended for all HIV patients regardless of CD4 cell count.

9. Which statement is true regarding healthcare professional’s care of patients with HIV/AIDS? A. History of the patient’s complementary therapies use is irrelevant.

B. Most patients overstate what they are feeling and experiencing.

C. Benefits and drawbacks of diagnostic testing and treatments must be weighed.

D. Waiting until the patient is experiencing a symptom and then treating it is most effective.

Answer: C Rationale: Detailed assessment of current medications, chemotherapy, and radiation therapy or complementary therapies such as biofeedback, herbal therapies, or yoga should also be ascertained to determine the effecTtsEaSnT dB siA deNeKffSeE ctL sL ofEtrRe. atC mO enMt, and to prevent drug interactions. Patient’s self-report of symptoms should be taken seriously by the practitioner and acknowledged as a real experience of the patient. In the case of extremely advanced disease, the need for daily blood draws or more invasive and uncomfortable practitioners must reevaluate the benefits versus burden of diagnostic testing and treatments, particularly procedures. An important rule in symptom management is to anticipate the symptom and attempt to prevent it.

10. What has been determined to be satisfying for patients with HIV/AIDS? A. Patient’s ability to control physical, social, and spiritual aspects of his or her illness B. Reliance on healthcare professionals to determine what is best for the patient C. Focus on patient’s physical functioning and comfort as the main indicators D. Patient’s ability to ignore uncertainty associated with his or her illness Answer: A Rationale: Quality of life is based on the patient’s perceptions of his or her ability to control the physical, emotional, social, cognitive, and spiritual aspects of the illness. By establishing a partnership with their healthcare professionals in planning and implementing their healthcare, patients can maintain a sense of control during the illness experience. Physical functioning and comfort are only two aspects of the many dimensions of a patient. It is impossible to ignore uncertainty associated with illness since this uncertainty is a major part of the illness and end of life.

Short Answer 1. What advances have been made in the diagnosis and treatment of HIV? Model Answer: Since the identification of the first case of HIV in 1981, there has been significant scientific advancements made in the diagnosis and treatment of the disease; specifically, the virus has been identified; screening for HIV infection has been implemented; biological and behavioral cofactors have been identified related to infection and disease progression; prophylactic treatments are available to prevent opportunistic infections; HIVRNA quantitative assays have been developed to measure VL; combination ARTs are available to treat the infection; and vaccines are being tested. Pre-exposure prophylaxis (PreEP) has become an important part of HIV prevention when approved by the U.S. Food and Drug Administration (FDA) in 2012. Daily regimen with tenofovir disoproxil fumarate (TDF) is recommended for sexually active adults at a substantial risk of HIV acquisition; men who have sex with men (MSM), heterosexually active men and women, adult injection drug users, and heterosexually active women and men whose partners are known to have HIV. 2. Tamara has HIV and is undergoing a very thorough assessment. Why does the assessment need to be so rigorous?

Model Answer: Throughout the course of their illness, individuals with HIV disease require primary care services to identify early signs of opportunistic infections and to minimize AhNisKiSncEluLdLeE related symptoms and compliT caEtiS onTsB .T s aRc.oC mOpM lete health history, physical examination, and laboratory data including determination of immunological and viral status.

3. Describe considerations of antiretroviral therapy in palliative care.

Model Answer: Clinicians must consider possible drug interactions with the administration of drugs in the treatment of HIV/AIDS and relief of symptoms. Patients and healthcare professionals should discuss the continuation of antiretroviral therapy (ART) in hospice or palliative settings. Such decisions are often contingent on the feelings of patients regarding the therapy. Patients who enter hospice may have a greater acceptance of their mortality and may wish to stop antiretrovirals because of the side effects. However, patients may wish to continue ART because of its symptom relief and the prevention of future symptoms related to opportunistic infections. Facilitating discussion of benefits and burdens of ART is an important aspect of palliative care and the decision to discontinue ART for hospice patients with AIDS should be a part of comprehensive palliative care. It is important for clinicians to discuss with patients and families their goals of care to make important decisions regarding the appropriateness of curative, palliative, or both types of interventions.

4. Colby is realizing that it might be time to think about his end of life. A major concern of his is the pain that might be involved. How should Colby’s healthcare provider approach pain management for him?

Model Answer: Following a complete assessment, including a history and physical examination, an individualized pain management plan should be developed to treat the underlying cause of Colby’s pain. The principles of pain management in the palliative care of patients with AIDS are the same as for patients with cancer and include regularity of dosing, individualization of dosing, and the use of combinations of medications. The three-step guidelines for pain management as outlined by WHO should be used. This approach advocates for the selection of analgesics based on the severity of pain. For mild-to-moderate pain, anti-inflammatory drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen are recommended. However, the use of NSAIDs in patients with AIDS requires awareness of the toxicity and adverse reactions because they are highly proteinbound, and the free fraction available is increased in AIDS patients who are cachectic or wasted. For moderate-to-severe pain that is persistent, opioids of increasing potency are recommended, beginning with opioids such as codeine, hydrocodone, or oxycodone, each available with or without aspirin or acetaminophen, and advancing to more potent opioids such as morphine, hydromorphone (Dilaudid), methadone (Dolophine), or fentanyl either orally, intravenously or transdermally. In conjunction with NSAIDs and opioids, adjuvant therapies are also recommended. In addition to pharmacological management of pain and other symptoms, Colby’s physician may consider the value of nonpharmacological interventions such as bed rest, simple exercise, heat or cold packs to affected sites, massage, transcutaneous electrical stimulation (TENS), and acupuncture. Psychological interventions to reduce pain perception and interpretation include hypnosis, relaxation, imagery, biofeedback, distraction, art therapy, and patient education.

5. What role can a nurse play inTthEeSsT piB riA tuN alKnS eeEdL sL ofEaRp.aC tieOnM t with HIV/AIDS? Model Answer: Nurses must assess patients’ spiritual values, needs, and religious perspectives, important to understand patients’ perspectives regarding their illness and their perception and meaning of life. Patients living with and dying from HIV disease have the spiritual needs of meaning, value, hope, purpose, love, acceptance, reconciliation, ritual, and affirmation of a relationship with a higher being. The nurse should encourage open communication between the patient and the family to work toward reconciliation and the completion of unfinished business. Spiritual healing may also come from life review. Nurses can offer patients an opportunity to reminisce about their lives, reflect on their accomplishments and misgivings, and forgive themselves and others for their imperfections.

For all patients with a chronic life-threatening illness, hope often shifts from hope that a cure will soon be found to hope for a peaceful death with dignity, including the alleviation of pain and suffering, determining one’s own choices, being in the company of family and significant others, and knowing that their end of life wishes will be honored. Often, the greatest spiritual comfort offered by caregivers or family for patients comes from active listening and meaningful presence. Simple gestures like sitting and holding the patient’s hands may have a great impact on the patient’s well-being and them not feeling abandoned.

Indeed, such spiritual care conveys that even in the shadow of death, there can be discovery, insight, the completion of relationships, the experience of love of self and others, and the transcendence of emotional and spiritual pain. Often, patients with AIDS, by their example, teach nurses, family, and others how to transcend suffering and how to die with grace and dignity.

CHAPTER 20: Pain: Assessment and Treatment Using a Multimodal Approach Multiple Choice 1. What is a major patient-related barrier to pain relief?

A. Incomplete assessment of pain being experienced B. Inadequate knowledge of pain management C. Fear of tolerance and addiction to pain medication D. Lack of visible presentation of pain in the body Answer: C Rationale: Patient-related barriers include reluctance to report pain, reluctance to follow treatment recommendations, fears of tolerance and addiction, concern about treatment-related side effects, fears regarding disease progression, and belief that pain is an inevitable part of disease and must be accepted. Incomplete assessment of pain being experienced and inadequate knowledge of pain management are clinician-related barriers. Lack of visible presentation of pain in the body is a healthcare setting–related barrier.

2. What is the correlation of pain between oncologic and non-oncologic patients?

A. Oncologic and non-oncologic patients both experience pain related to their diagnosis.

B. Oncologic patients feel more severe pain than patients with congestive heart failure. veKreSpEaLinLtE haRn.pCatOieMnts with liver cancer.

C. Non-oncologic patients feTelEm SoTreBsAeN D. Non-oncologic and oncologic patients have the same underlying pain mechanisms.

Answer: A Rationale: The pain experience for patients with noncancer diagnoses has not been well defined in the literature, but what is known highlights the frequency of suffering within this population.

As in cancer, these patients may experience pain related to their underlying diagnosis, as an outcome of treatment modalities or as a consequence of living longer with a chronic illness.

Oncologic and non-oncologic patients may have the same levels of pain. However, the pain mechanisms may be different.

3. What is the term for the type of pain that occurs in deep musculoskeletal tissues?

A. Acute B. Nociceptive C. Chronic D. Neuropathic Answer: B Rationale: Nociceptive pain occurs as a result of activating pain-sensitive structures, or nociceptors, in the cutaneous and deep musculoskeletal tissues, and the viscera. Acute pain is characterized by a well-defined pattern of onset. Chronic pain is defined as pain that persists for more than 3 months. Neuropathic pain results from injury to the peripheral or central nervous systems.

4. Wallace is being assessed for pain. What is the purpose of the nurse asking him to describe the quality of his pain?

A. To determine an inferred pain mechanism that influences the choice of medication B. To evaluate disease process, value system, goals of care, and nearness to death C. To reinforce techniques found to be useful in the past to relieve pain D. To identify vulnerabilities and anxieties that indicate a need for pain education Answer: A Rationale: In quality of pain, patient word descriptors help the clinician to arrive at an inferred pain mechanism. This, in turn, influences the choice of pharmacotherapy. The severity of pain helps evaluate the disease process, value system, goals of care, and nearness to death.

Exacerbating and relieving factors reinforce techniques that the patient has found useful in the past to relieve pain. The impact of the pain on the patient’s psychological state identifies vulnerabilities and anxieties that indicate a need for education about pain.

5. What category of medications is the primary pain treatment for palliative care patients?

A. Anticonvulsants B. Corticosteroids C. NSAIDs D. Opioids Answer: D Rationale: Opioid analgesics are the mainstay of pain treatment for palliative care patients. These drugs are used for moderate-to-seTvE erS eT paBinAN inKSS teEpL s 2LE anRd.3CoO fM the World Health Organization (WHO) analgesic ladder. They are frequently combined with acetaminophen or an NSAID. 6. Patients who are taking opioids may notice that, over time, a stronger dose is needed for pain relief. Which phenomenon does this describe?

A. Dependence B. Addiction C. Tolerance D. Diversion Answer: C Rationale: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time. The need for opioid escalation in a patient with cancer is usually associated with progressive disease rather than tolerance per se. Dependence is a state of adaptation that is manifested by a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Diversion is the shifting of legally obtainable drugs into illegal channels or the acquisition of a controlled substance by an illegal method.

7. Which opioid is generally the first choice for severe pain?

A. Fentanyl B. Morphine C. Oxycodone D. Codeine Answer: B Rationale: Morphine is the prototype of the pure opioid agonist. The World Health Organization (WHO) placed morphine on the essential drug list and requested that it be made available throughout the world for cancer pain relief (WHO, 2011). Morphine is available in tablet, elixir, suppository, and parenteral forms. Patients with severe pain are initially titrated with immediaterelease morphine, or with parenteral opioids if in a hospital setting, and are converted to a controlled-release preparation once stabilized.

8. Ruby has ovarian cancer and the pain has become excruciating. She has been receiving the strongest dose of morphine that is safe for her, and she is still suffering. Which type of nerve block would be the most effective for her?

A. Diagnostic B. Prognostic C. Therapeutic D. Prophylactic Answer: C Rationale: A therapeutic nerve blT ocEkSisTdBoA nN eK toSpE roLvL idE eR te. mCpO orM ary pain relief in a pain crisis or to treat painful conditions that respond to these blocks (e.g., a celiac block for the relief of pain due to pancreatic cancer). A diagnostic nerve block is done to determine the specific pain pathway and to aid in the differential diagnosis. A prognostic nerve block is one that is done to predict the efficacy of a permanent ablating procedure. A preemptive/prophylactic nerve block is done proactively to prevent the development of a chronic pain syndrome.

9. Which type of rehabilitative treatment is designed to place minimal stress on joints, tendons, and muscles for alleviation of pain?

A. Positioning B. Range of motion techniques C. Therapeutic exercise D. Hydrotherapy Answer: A Rationale: When properly done, positioning places minimal stress on the joint capsule, tendons, and muscle structure. Range-of-motion techniques are designed to promote comfort and maintain or restore the integrity of muscles, ligaments, joints, bones, and nerves used in movement.

Therapeutic exercise can enable that individual to achieve better function and decreased pain. A therapeutic exercise plan may include stretching, passive mobilization, and active exercise.

Hydrotherapy spondylitis involves immersing the painful body part in a tank of warm water. In this environment, patients with movement-related pain may be better able to undergo

individually planned therapeutic exercise because the warm water provides both buoyancy and decreased joint stress.

10. Which type of integrative treatment has been shown to provide pain relief by causing endorphin release and stress-induced analgesia?

A. Hypnosis B. Music therapy C. Massage therapy D. Acupuncture Answer: D Rationale: The proposed mechanisms of action for pain relief by acupuncture is considered by Western medicine to include endorphin release, mediation of pain-producing neurotransmitters, and stress-induced analgesia. Hypnosis, music therapy, and massage therapy can also provide pain relief but not necessarily through endorphin release and stress-induced analgesia.

Short Answer 1. What challenges healthcare professionals face when assessing pain in the advanced palliative care patient?

Model Answer: There are eight main challenges in assessing pain in the advanced palliative care patient: Multiple concurrent medical pTrE obSleTmBsANKSELLER.COM Multiple symptoms and symptom clusters Hepatic and renal failure and susceptibility to drug accumulation and adverse side effects Prevalence of delirium when close to death Requires more time than patients who are less ill Patients become easily fatigued and may be short of breath May be in “too much pain” or bothered by other symptoms to answer questions Possible tendency of family members to answer questions on patient’s behalf 2. Dylan is 38 years old and was a golf coach until he developed stomach cancer. The pain has been excruciating, and he has been prescribed an analgesic that has worked to a certain extent. He would like to try another method of pain relief. What other types of pain relief methods could his palliative care specialist recommend?

Model Answer: Although pharmacotherapy is the foundation of pain management, pharmacotherapy alone will not be an effective approach to pain control in the palliative care patient. A multimodal approach is usually required, including attention to the suffering and spiritual or existential component to the patient’s pain. Other treatments include interventional therapies, neurostimulation therapies, rehabilitative therapies, psychological therapies, and integrative treatments.

3. How do opioids produce their analgesic effects?

Model Answer: Opioids produce their effects through binding to receptors in the brain and spinal cord to prevent the release of neurotransmitters involved in pain transmission. Opioids can also have a peripheral site of action in the presence of inflammation. In addition, opioid receptors are present in immunocompetent cells that migrate to inflamed tissue. The opioids can be divided into agonists, agonist–antagonists, and antagonist classes based on their interactions with the receptor types. Pure opioid agonists (e.g., morphine, hydromorphone, oxycodone, fentanyl, and methadone) bind primarily to the mu receptors.

4. Explain how cognitive behavioral therapy and patient coping skills training can help a patient in severe pain.

Model Answer: Cognitive behavioral therapy (CBT) involves the use of four core modules: (1) psychoeducation and goal setting; (2) relaxation training; (3) coping with fears; and (4) activity planning and pacing. It works best in a series of structured sessions that are flexible and modifiable, according to the developing needs of the individual, no matter what the format.

There should be clear and explicit goal setting and treatment goals. These goals are to be developed collaboratively by the therapist and patient. Together, they look at the range of problems present and prioritize them. They review this list on a regular basis, and reprioritized goals as personal, social, and medical changes develop. Based on this list, appropriate, systematic intervT enEtiSoT nsBtA oN adKdS reEssLtL heEsR e. prCoO blM ems are determined. The purpose of the interventions is to resolve specifically defined current problems and not long-term personality and social relations disturbances. Ideally, work with CBT occurs early in the treatment phase of an illness. As disease progresses, an individual may experience cognitive impairment from a variety of causes that make it impossible to employ these techniques.

When this occurs, it may be necessary to focus more on the family and caregivers with the goals to maximize their coping skills and increase their sense of control. Pain coping skills training (PCST) may be the next addition to multimodal pain management, helping to combine pharmacological pain treatments with psychological pain interventions. A PCST program will teach such things as progressive muscle relaxation, brief relaxation, activity/rest cycling, pleasant activity scheduling, negative thoughts identification, coping with negative thoughts, distraction techniques, problem solving, and strategies to maintain these skills.

5. Adam is 8 years old and was born with sickle cell disease. He has had severe exacerbations throughout his life, and is currently hospitalized. How should Adam’s pain care management be approached?

Model Answer: Many of the principles of pain assessment and management reviewed in this chapter can be applied to children. However, children should not be viewed as mini-adults.

The nurse caring for Adam needs to be mindful of: Adam and his family is the unit of care. Successful interventions can happen only when Adam’s parents are included in the assessment and pain management plans.

It is helpful to initiate discussions with Adam about pain and to learn his words for pain.

Pain assessment is dependent on Adam’s age and cognitive developmental stage.

Using developmentally appropriate tools to evaluate Adam’s pain.

Adam’s self-report of pain is considered the most reliable and valid indicator for an estimate of pain location and intensity.

Observed pain behaviors in Adam may include vocalizations, facial expressions, body movements, autonomic responses, or changes in daily activities, usual behaviors, appetite, or sleep.

The goal of Adam’s pain management is to prevent as much pain as possible and to treat procedural pain aggressively.

It is important to consider Adam’s age, developmental level, verbal capabilities, past experiences, cultural factors, type of pain, and context when developing a pain management plan.

Addressing family concerns regarding the risk of addiction.

The pharmacological management principles—by the ladder, by the clock, by the appropriate route, and by the child—are similar to those used with adults with the exception that the starting doses are determined by chronological age and body weight. Adam should be frequently assessed and doses are titrated to effect.

The oral route is the desired route whenever possible. Avoid the rectal route and IM injections. Consider transdermal, IV, and topical routes when the oral route is not possible.

CHAPTER 21: Dyspnea Multiple Choice 1. Which statement describes dyspnea?

A. It is a clearly defined disorder.

B. It is occasionally accompanied by anxiety.

C. It is a symptom of underlying disorders.

D. It is usually fairly straightforward to treat.

Answer: C Rationale: Dyspnea is a symptom of underlying disorders, like those that fall under the COPD umbrella. Anxiety often accompanies dyspnea. Dyspnea may also be refractory to treatment, causing both patients and providers to feel powerless over the symptom.

2.

Which mechanism plays a role in the sensations associated with dyspnea?

A. There is decreased awareness of the activity of muscles of respiration.

B. Stretch receptors in the chest wall cause feeling of tightness.

C. Chemoreceptors become less active and decrease respiration.

D. The respiratory center in the medulla fails to activate muscles that expand the chest wall.

Answer: B Rationale: Though the neurophysT ioEloSgT yB isAnNoK tw deRrs.toCoO d,Mthree mechanisms remain SeEllLuLnE dominant and interrelated in the creation of the dyspneic sensation: (a) a conscious awareness of the neuromotor command to the respiratory muscles; (b) stimulation of the receptors in the airways, lungs, and chest wall, which detect changes in lung volume, stretch, and pressure and are responsible for the feeling of tightness; and (c) stimulation of the chemoreceptors; for example, the sensation of blood-gas abnormalities that indirectly trigger ventilation, thereby causing air hunger or unsatisfied inspiration.

3. How can dyspnea present?

A. Chronic dyspnea is associated with bronchoconstriction.

B. Dyspnea is associated with exercise in cardiopulmonary conditions.

C. Dyspnea is rarely associated with psychological symptoms.

D. Dyspnea is rarely associated with lying in the supine position.

Answer: B Rationale: Exercise or overexertion commonly precipitates dyspnea in most chronic cardiopulmonary conditions, as does a change in position. Dyspnea that comes on suddenly may reflect bronchoconstriction, pulmonary embolism, cardiac ischemia, or abrupt airway occlusion.

Chronic dyspnea occurs gradually and is likely to be manifested in slowly progressive disorders such as COPD, interstitial lung disease, or a slow-growing tumor. Psychological symptoms are equally as important since anxiety has been found to correlate with the intensity of dyspnea in patients with cancer and lung disease.

4. Maggie is being evaluated for dyspnea. Which sign would she most likely have?

A. Jugular venous distention B. Absence of nasal flaring C. Pink nail beds D. Tracheal alignment Answer: A Rationale: A focused physical examination of the head, neck, and chest will yield specific information about the patient’s condition and assist with the identification of treatment options.

Inspection should include the color of skin, nails, lips, nutritional state, sternal/spinal deformities, chest shape and movement, breathing rate and rhythm (full minute), capillary refill, the presence/absence of nasal flaring, tracheal deviation, jugular venous distention, costal retractions, accessory muscle use, and clubbing.

5. What is a correlation between aging and dyspnea?

A. Chemoreceptors are apt to trigger faster, causing slower breathing rate.

B. Comorbidities play a small role in changing breathing rate and depth.

C. Allergens are less likely to stimulate an episode.

D. Respiratory muscles decline in strength.

Answer: D Rationale: Three major factors contribute to the effects of aging on the pulmonary system: an increase in chest wall stiffness, a decline in respiratory muscle strength, and a decrease in lung elasticity. Neurologically, age redTuE ceSsTcB heAmNoK reSceEpLtoLr E fuRn. ctC ioO niMng, causing an inadequate ventilatory response to hypercapnia and acute hypoxia. Comorbidities are likely to increase the risk of dyspnea due to the toll they take on the patient’s metabolism. Aging increases susceptibility to both infections and allergens due to a diminished immune system.

6. Which nonpharmacological method modifies the perception of dyspnea by stimulating the trigeminal nerve?

A. Fan directed toward the face B. Hands plunged into cold water C. Diaphragmatic breathing D. Vibration on the feet Answer: A Rationale: When stimulated, temperature and mechanical receptors of the trigeminal nerve in the cheek and nasopharynx alter feedback to the brain and modify the perception of dyspnea. The use of a fan set on low speed and directed toward the face will stimulate this response.

7. What is a benefit of using cognitive behavioral and complementary therapies for the management of dyspnea?

A. Every treatment has been found to be useful in a wide range of patients.

B. Patients become empowered to take an active role in their treatment plan.

C. Patients have had the most success with minimal use.

D. Healthcare professionals remain in control of the treatment plan.

Answer: B Rationale: Education of the patient and family on dyspnea management techniques and the basic rationale for each empowers them to take an active role in the treatment plan. Not every treatment will be useful for every patient; a patient’s preference for a particular therapy needs to be taken into account. Patients who have the most success with cognitive behavioral and complementary therapies need to use them consistently. Healthcare professionals relinquish some control of the treatment plan and put it in the patient’s hands.

8. Which method is curative and being considered for treatment of dyspnea in end-of-life care?

A. Breathing retraining B. Percutaneous catheter to drain ascites C. Noninvasive positive pressure ventilation D. Energy conservation Answer: C Rationale: Noninvasive positive pressure ventilation (NIV), often referred to as bilevel positive airway pressure (BiPAP), represents a controversial alternative method to treat dyspnea. While it is widely accepted as a curative intervention, only one study has been conducted on NIV as a comfort measure at the EOL. Breathing retraining, percutaneous catheter to drain ascites, and energy conservation are not curative but palliative.

9. Theresa is at end-of-life care and her healthcare team recommends she receive opioids for her dyspnea. Her family is skeptical that opioids are the best option for her. What information about the effects of opioids wT ouElS dT beBuAsN efK ulStE oL TL heEreRs. aC anOdMher family?

A. Perception of breathlessness and oxygen need will be altered.

B. High blood carbon dioxide and low oxygen levels increase ventilation.

C. Metabolic rate and oxygen consumption will increase substantially.

D. Vasoconstriction and increased peripheral resistance improve oxygen supply.

Answer: A Rationale: Opioids reduce dyspnea through a number of mechanisms: decreasing the ventilatory response to hypercapnia and hypoxia, reducing metabolic rate and oxygen consumption, and altering the perception of breathlessness. Furthermore, the cardiovascular effects of vasodilatation and decreased peripheral resistance help to improve oxygen supply and reduce lung congestion.

10. Which category of medication can be of value in treating dyspnea because of its antiinflammatory actions?

A. Bronchodilators B. Anxiolytics C. Diuretics D. Corticosteroids Answer: D Rationale: Corticosteroids, while controversial in the treatment of dyspnea, may be of value because they reduce inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing the increase in capillary permeability. Euphoria in the form of an

overall feeling of well-being and an increase in appetite exhibit as secondary responses.

Bronchodilators cause smooth muscle dilation of the airways, thus removing any impedance to airflow and deflating an overinflated lung. Anxiolytics may help relieve dyspnea when morphine is not completely effective; anxiety is often one of the dimensions of dyspnea. Dyspnea may be associated with fluid volume excess, which can be treated with diuretics, such as furosemide, to mobilize edema, normalize blood volume, reduce vascular congestion, and reduce the workload of the heart Short Answer 1. Arthur is 68 years old and has come into the emergency room because of shortness of breath.

He cannot think of any reason he should have this. What factors need to be identified in his health assessment?

Model Answer: Dyspnea is a personal experience that accounts for a high proportion of disability, impaired quality of life, and suffering. Each patient’s experience with the symptom is as unique to the person as is the individual’s journey with a life-limiting condition. Thus, a thorough interprofessional assessment of Arthur should include a careful, comprehensive history to obtain a complete understanding of his experience with dyspnea.

Specific information about dyspnea, including its timing, precipitating factors, associated symptoms, alleviating factors, and quality of the symptom, should be assessed. The influences of Arthur’s culture, race, age, and gender should also be taken into account. orEm agAinNgKdSyE spLnL eaEiR n. peCdO iaM tric patients?

2. What are the considerations fT SaTnB Model Answer: Collaborative agreement on symptom severity by parents and healthcare professionals improves satisfaction with care as well as parental quality-of-life, even if symptom control is not successful. Because respiratory function is immature in younger patients, deterioration can occur rapidly when disease is present. Special attention should be given to the possibility of congenital anomalies (cardiac or respiratory) in this circumstance.

Another difference in pediatrics is a higher respiratory load detection threshold, meaning children and adolescents require a greater change in stimulus intensity before reporting a change in sensation. This finding may be responsible for the effectiveness of pictorial scales (nonlinear) in pediatrics since children and adolescents are less able to distinguish between numerous gradations of sensation, as presented in a numerical instrument (linear). Similar to adults is the fact that lung function improvement does not necessarily correlate with an improved dyspnea rating. Therefore, it may be important for health professionals to pursue additional diagnostic testing despite a decrease in reported dyspnea. Observation, physical assessment, and a medical history are the tools to evaluate respiratory distress as the pediatric patient is not always able to communicate how he or she feels, especially if very young. Once a baseline measurement has been obtained, integration of dyspnea management with opioids may be introduced along with other interventions for the child’s specific condition, as indicated.

3. Explain how positioning can alleviate dyspnea.

Model Answer: Patients should be assisted to find a position of comfort. The leaningforward position has been reported to improve overall inspiratory muscle strength, increase diaphragmatic excursion, and decrease abdominal paradoxical breathing as well as reduce dyspnea in patients with COPD. While reducing participation of the chest wall and neck muscles overall, sitting and leaning forward with arms supported on a table facilitates a more focused effort on respiration rather than on the maintenance of body posture and/or arm movement. Optimal comfort as well as ventilation and perfusion may be accomplished by placing the patient’s good lung in a dependent position where gravity may assist in perfusing the healthiest area of lung tissue. In some patients, terminal dyspnea may be relieved only by an upright position where vital capacity is increased because of the lowered diaphragm. The clinician should accept the patient’s position of choice, even if it belies traditional thinking.

4. Jermaine’s physician is prescribing supplemental oxygen for him. How will the oxygen alleviate his dyspnea? What are the considerations for its use?

Model Answer: Supplemental oxygen depresses the hypoxic drive, thereby reducing ventilation and subsequently relieving dyspnea. This physiological response occurs at rest and during exertion in patients with a variety of lung diseases. Oxygen should be titrated to Jermaine’s comfort level using the least restrictive device possible (e.g., nasal cannula does not interfere with eating and communication). Humidification is recommended for comfort and to prevent the drying of mucous membranes at or above 4 L/minute. Continuous oxygen KO SPEDLL might be beneficial to JermainTeEiS f hTeBhAasNC anEdRs. evCerOeMhypoxemia. However, he may prefer to use oxygen intermittently although assurance of the immediate availability of oxygen may be of greater importance.

5. If a patient in end-of-life care is already taking morphine, why would a healthcare professional also prescribe an anxiolytic?

Model Answer: An anxiolytic may help relieve dyspnea when morphine is not completely effective; anxiety is often one of the dimensions of dyspnea. Anxiolytics should be considered in combination with opioids and nonpharmacological anxiety-reduction measures as a way to break the anxiety–shortness of breath cycle. Low-dose benzodiazepines and phenothiazines are the categories of anxiolytics most commonly used in the management of dyspnea. These drugs have hypnotic, sedative, anxiolytic, anticonvulsant, and musclerelaxant actions, therefore achieving control of dyspnea via multiple mechanisms of action.

CHAPTER 22: Anxiety, Depression, and Delirium Multiple Choice 1. What is the relationship between anxiety and depression, and severe illness?

A. In primary care, anxiety and depression primarily occur separately from other illnesses.

B. In palliative care, anxiety and depression arise from loss of independence from illness.

C. Anxiety and depression rarely signal other more serious illnesses.

D. Anxiety and depression are best treated separately from other illnesses.

Answer: B Rationale: In palliative care, anxiety and depression commonly arise from fear of death, loss of independence and fear of being a burden to others, hopelessness, and loneliness, in addition to concern about symptom burden and disease progression.

2. Which statement describes anxiety in patients with a serious illness?

A. Anxiety is a normal response.

B. Anxiety is a mental disorder.

C. Anxiety has little effect on caregivers.

D. Anxiety related to treatments is mild.

Answer: A Rationale: Anxiety is defined as fTeeElS inT gsBoAf NdK istSreEsL s, LwEoR rry.,CaO ndMtension from a known or unknown stimulus. Anxiety is a normal response to an illness.

3. Donna has been diagnosed with end-stage renal failure and has learned she is not a good candidate for a kidney transplant. Her husband and her children have been trying to talk with her about palliative care, but she either changes the subject or walks out of the room. How is her anxiety manifesting?

A. Physical symptom B. Affective symptom C. Behavioral response D. Cognitive response Answer: C Rationale: Anxiety has four types of manifestations: physical symptoms, affective symptoms, behavioral responses, and cognitive responses. Changing the subject or walking out of the room is avoidance, which is a behavioral response.

4. Who is most likely to first identify that a patient has anxiety?

A. Attending physician B. Patient C. Family member D. Nurse Answer: D

Rationale: Nurses may be the first to identify anxiety for many patients. A collaborative interdisciplinary team approach is helpful in the treatment of anxiety for patients experiencing serious life-limiting illness.

5. Calvin is 82 years old and has been experiencing severity anxiety while being treated for stomach cancer. Which category of medication should be prescribed for Calvin?

A. Selective serotonin reuptake inhibitors B. Benzodiazepines C. Tricyclics D. Beta-adrenergic agents Answer: B Rationale: Benzodiazepines are recommended for older patients. Due to its shorter half-life, lorazepam is the recommended benzodiazepine of choice with older populations. It has a double result in both relief of nausea and reduction of panic attacks. In a younger, healthier population, selective serotonin reuptake inhibitors (SSRIs) are the first drug of choice for the treatment of anxiety disorders. Generally, tricyclics and beta-adrenergic agents are not well tolerated in older populations, though a trial may be warranted if other medications do not offer relief.

6. Which action of the interprofessional team provides support to the patient and family without causing further anxiety?

A. Assessment of the home for safety B. Provision of medications C. Investigation of group dynTaEmSicTsBANKSELLER.COM D. Delineation of clear roles Answer: D Rationale: Treatment of anxiety for a patient with a life-threatening illness requires a collaborative approach by an interprofessional team. The nurse has a role in assuring team communication within the plan of care. Specifically, the team needs to review the patient history and medications and then determine symptom management together. Since treatment usually requires psychological support and medication management, clear delineation of roles should be clarified for the patient and his or her family. This provides consistent direction and support to the patient and family without provoking further anxiety.

7. What is the relationship between depression and serious illness?

A. Depression needs treatment for closure and end-of-life issues during the illness.

B. Depression is a normal coping mechanism in the process of accepting the illness.

C. Treatment of depression should be a lower priority than that of the illness.

D. Depression is an uncommon occurrence in patients with illness.

Answer: A Rationale: It is now understood that leaving depression untreated can interfere with a patient’s ability to bring closure to his or her end-of-life issues and concerns. When dealing with serious illness, it is common for patients to experience psychological distress in response to their serious or life-threatening diagnosis. For many years, grief and depression were considered to be normal

coping mechanisms in the process of accepting a terminal illness, so the treatment of depression was not prioritized. The thought was that treatment would interfere with the natural dying process and the emotional work of dying.

8. Holly is 9 years old and has been living with rheumatoid arthritis since she was 3. She has become quite depressed. How would this most likely manifest in Holly?

A. Agitation B. Confusion C. Anger D. Hopelessness Answer: C Rationale: Signs of depression in children manifest as somatic complaints, periods of anger, and other behavior as well as sadness or melancholy. For teenagers and young adults, depression may be manifested by low self-esteem, guilt, and hopelessness. Patients of all ages may express recurrent thoughts of worthlessness, excessive or inappropriate guilt, and a sense of being a burden.

9. What should be the first intervention for a seriously ill child with depression?

A. Medications B. Psychotherapy C. Movement therapy D. Herbal remedies Answer: B Rationale: The treatment of children is more complex due to the safety of medications.

Therefore, nonpharmacological therapies are encouraged as first-line interventions. However, if the therapy is unsuccessful, medications are appropriate. Psychotherapy is the mainstay of nonpharmacological interventions.

10. How should delirium be considered in the terminally patient?

A. Alterations in thought processes are unusual in the last weeks of life.

B. Confusion and agitation are a normal part of the dying process.

C. Symptoms include sadness, helplessness, and hopelessness.

D. Symptoms should be thought of as an emergency.

Answer: D Rationale: Delirium should be considered an emergent situation, particularly in older populations. Delirium is associated with higher mortality rates when it occurs in older patients, as well as longer hospital admissions, increased costs of care, greater likelihood of being placed outside the home post hospitalization, and decreased functional ability. Alterations in thought processes are very common during the last weeks of life. Historically, this confusion and agitation was thought to be a normal part of the dying process and one of the expected stages of dying. Currently, delirium is recognized as a distressing symptom that warrants treatment.

Delirium-related behaviors include thrashing, agitation, muscle twitching, tossing or turning, moaning, and talking to the air; it also includes lethargy and listlessness in its quiet forms.

Short Answer 1. What are the causes of anxiety in patients who are seriously ill?

Model Answer: Anxiety in patients with a life-limiting illness is common and may have a multitude of causes, including adjustment disorder, panic disorder, generalized anxiety disorder, phobia, or agitated depression. The etiology of anxiety includes medical conditions such as poorly managed pain, endocrine disorders including hypo- and hyperglycemia, hypoand hyperthyroidism, Cushing’s disease, and carcinoid syndrome. Cardiovascular conditions include myocardial infarctions, angina, congestive heart failure, mitral valve prolapse, and hypovolemia; respiratory conditions include asthma, chronic obstructive pulmonary disease (COPD), pneumonia, pulmonary edema, dyspnea, and hypoxia. Neoplasms and neurological conditions such as akathisia, encephalopathy, seizure disorder, and postconcussion disorders can also contribute to or exacerbate anxiety disorders.

Stimulant substances may contribute to anxiety. The most common substance is caffeine.

The stimulant ephedrine, stimulant-type drugs such as methylphenidate, and withdrawal from medications such as benzodiazepines, alcohol, and barbiturates may cause anxiety.

Psychological distress, including worries about family relationships, family strife, and financial issues, can contribute to feelings of anxiety in seriously ill patients. These worries may be exacerbated by concerns about being or becoming a burden to family members during the course of their illness. Lastly, previous history of or a family history of anxiety may be a contributory factor resulting in more pronounced anxiety in older patients as they lose physical functioning.

2. Corinne is aware that she has a great deal of anxiety while she is undergoing chemotherapy for pancreatic cancer. Prior to her illness, she had been very active and owned her own business. She has been talking with her nurse about how she can’t seem to snap out of it; the anxiety just won’t let go. The nurse suggests a pharmacological agent, but Corinne is against it. She does not want any more chemicals coming into her body. What stress management options can the nurse recommend?

Model Answer: Stress management can include exercise programs, breathing exercises, relaxation techniques, massage, touch, distraction, music therapy, and visualization. Guided imagery and hypnosis may offer the patient more control in everyday life and in stressful situations. Massage therapy can be an effective method to help Corinne relax. Distraction can be used to manage anxiety, and it may occur in many forms, including watching television; listening to the radio; reading digital devices, books, or newspapers; participating in arts and crafts; and performing hobbies. It is important to assess how Corinne spends her time and what activities are distracting and helpful for her. Music therapy has been shown to be effective in anxiety, as it can reduce pain, promote physical comfort, and induce relaxation.

3. What are the four categories of depression etiology? Give examples of each.

Model Answer: The etiology of depression is multifactorial and falls into the following overlapping four categories: physical, psychological, social, and biological. Depression may be caused by deficiencies in serotonin, norepinephrine, and prolactin, as well as abnormal cortisol and dopamine levels. However, there may be factors to produce that and certain

medical conditions that cause depression. Physical factors encompass medical conditions, specific diseases, medication effects, and sensory deprivation from loss of vision or hearing.

Medications that may cause side effects that mimic depressive symptoms include chemotherapeutic agents, opioids, and glucocorticoids. Psychological issues that may precipitate depression cover a wide spectrum, including unresolved conflicts, memory loss, loss of independence, change in living situations, and possible financial consequences incurred from a life-limiting illness. When people have a serious illness, the loss of their social network may cause depression. Patients may not have the energy to participate in hobbies or activities or may want to be private about visible aspects of their condition.

Biological factors of depression include family history of depression or other mental illness, prior episodes of depression, neurotransmission deficiencies, and central nervous effects of cytokines.

4. Richard has liver cancer and is a good candidate for a liver transplant. At first, he was happy with the news; then his family noticed him becoming more withdrawn and lethargic. He has become forgetful and confused. His family was attributing this to his cancer, but when they explained their concerns to his palliative care nurse, she suspected he might have delirium.

How should the nurse assess Richard?

Model Answer: Assessment should first include a history and review of current medical conditions, including disease; disease side effects such as a tumor; and side effects of treatment, such as chemotherapy or radiation. Second, it is essential to review medications used to treat symptoms, like corticosteroids, antibiotics, opioids, anticholinergics, CiOthMdrawal from medications like antiemetics, and anticonvulsaT ntEs,SaT ndBA thN eK poSsE siL biL litEyRo. fw benzodiazepines or alcohol. Third, physiological causes must be assessed, including discomfort related to uncontrolled pain, urinary retention, or fecal impaction, as well as metabolic fluctuations in glucose, sodium, potassium, or calcium; organ failure including the kidneys, liver, lungs, heart, brain, thyroid, or adrenal glands; infections of CNS, urinary tract, respiratory tract, generalized and sepsis. Finally, attention should include a review of and finally nutritional deficiencies from thiamine or folate/vitamin B12. This is followed by a review of the patient’s behavior and sleep cycles from the chart, followed by a review of the complete medication regimen.

A mental status exam provides a baseline for monitoring the course of cognition and is a source of documentation for reference and repeat evaluations. The key aspects of mental status assessment include general state and appearance, orientation, state of consciousness, short- and long-term memory, language, visuospatial functions, cognitive/executive functions (calculations, abstraction, spelling), insight and judgment, thought control, and mood and affect.

Physical exam is important to rule out possible reversible and treatable causes of delirium.

5. How can a patient’s family help prevent, manage, and treat delirium?

Model Answer: Education of the family is a cornerstone in the prevention, management, and treatment of delirium. Education includes the importance of skin care; the use of glasses, hearing aids, and assistive devices when appropriate; and the importance of a well-balanced diet and hydration, if these interventions are not a burden or source of distress to the patient.

Families of seriously ill patients need to understand predisposing risk factors that can lead to

delirium, including pressure sores, poor nutrition, incontinence, sleep disturbances, and decreased functional ability. Other preventive measures include the use of cognitive assistive devices such as glasses and hearing aids; avoiding restraints for confusion; judicious use of urinary catheters; removal of unnecessary tubes (rectal tubes or g-tubes); judicious use or removal of lines (intravenous access, subcutaneous access, etc.); prevention of skin ulcers; and maximal psychosocial support and education to family caregivers. Additionally, an assessment of the home environment can be quite revealing, particularly whether the patient has the necessities such as food, finances, and medications.

When a patient becomes delirious at the end of life, ongoing support of the family is important. Delirium may be irreversible due to the various medical conditions the patient is experiencing as well as the dying process itself. When making decisions about the treatment, discussions about realistic options should occur within the context of life expectancy and the burden versus the benefit of any treatment intervention. Families often welcome a clear discussion about all current issues, particularly when a patient is thought to be close to death so they can prepare for the anticipated event.

CHAPTER 23: Posttraumatic Stress Disorder and End-of-Life Care Multiple Choice 1. Which statement describes posttraumatic stress disorder (PTSD)?

A. Feelings from the traumatic event always decrease over time.

B. Witnessing a traumatic event can create symptoms.

C. Most feel remorse and agitation after the traumatic event.

D. Direct exposure to the traumatic event creates the symptoms.

Answer: B Rationale: The likelihood of being exposed to a traumatic event, such as a natural disaster, child sexual or physical abuse, serious accident, sexual or physical assault, terrorist attack, or combat, increases across a life span. Feeling from the traumatic event may or may not decrease over time.

After experiencing a traumatic event, most people experience stress-related reactions such as fear, sadness, guilt, anger, or sleep problems. The exposure itself does not always need to be the direct experience of a traumatic event. According to DSM-5 criteria, an individual can also develop PTSD by witnessing a traumatic event in person, learning that the traumatic events occurred to a close family member or friend, or experiencing repeated or extreme exposure to aversive details of the traumatic event.

2. What qualifies symptoms to be indicative of posttraumatic stress disorder?

A. Duration of symptoms thrT eeEm onBthAsNoK r lo ngLeL r ER.COM ST SE B. Minimum of two or more reexperiencing symptoms C. Duration of symptoms two months or longer D. Minimum of two cognitive alteration symptoms Answer: C Rationale: Following the exposure, the individual must experience one or more symptoms in specific symptom clusters. The duration of the symptoms must be for a month or longer, cause clinically significant impairment, and cannot be due to substances or another medical condition.

The symptom clusters are: (a) reexperiencing (e.g., recurrent distressing memories or dreams); (b) avoidance (e.g., evasion of memories or cues related to traumatic event); (c) negative alterations in cognitions or mood (e.g., inability to remember details related to traumatic event, increased negative beliefs, persistent negative mood state); and (d) changes in arousal and reactivity (e.g., irritability, hypervigilance, poor sleep). The reexperiencing and avoidance symptom clusters require a minimum of one symptom in each cluster, while the other symptom clusters require two or more symptoms to be present to meet diagnostic criteria.

3. Ever since Travis got back from his tour of duty, he jumps at every little sound and has bouts of insomnia. Which DSM-5 category are these symptoms?

A. Reexperiencing B. Avoidance C. Negative alterations in cognitions or moods D. Changes in arousal and reactivity

Answer: D Rationale: According to the DSM-5, a posttraumatic stress disorder diagnosis means following the exposure, the individual must experience one or more symptoms in each of the following symptom clusters: (a) reexperiencing (e.g., recurrent distressing memories or dreams); (b) avoidance (e.g., evasion of memories or cues related to traumatic event); (c) negative alterations in cognitions or mood (e.g., inability to remember details related to traumatic event, increased negative beliefs, persistent negative mood state); and (d) changes in arousal and reactivity (e.g., irritability, hypervigilance, poor sleep).

4. What is the correlation between PTSD symptoms and life-threatening illnesses?

A. PTSD occurs at a lower rate in those with a life-threatening illness than the general population.

B. PTSD occurs at a higher rate in those with a life-threatening illness than the general population.

C. PTSD occurs at the same rate in those with a life-threatening illness as the general population.

D. PTSD rates are unable to be calculated in those with a life-threatening illness compared to the general population.

Answer: B Rationale: Compared to 8% in the general population, PTSD symptoms occurs at a significantly higher rate among individuals receiving care in a medical setting for potentially life-threatening illnesses. The prevalence of PTSD among patients treated in an ICU, regardless of diagnosis, LeLthEoRd.oC was found to be as high as 64% dTepEeS nT diB ngAoNnKtS heEm f aOsM sessment.

5. What challenge can PTSD manifest in family members of a patient with a serious illness?

A. Unlikely to develop symptoms themselves B. Acceptance of the symptoms C. Anger, guilt, and health problems D. Increased support in palliative care Answer: C Rationale: PTSD can negatively impact interpersonal relationships. The National Center for PTSD’s website documents that family members themselves may have a number of reactions to their family member having PTSD, including sympathy, negative feelings, avoidance, depression, anger, guilt, or health problems. As a result, individuals with severe PTSD in palliative care settings may have very limited social support networks and existing family relations may be strained. Family members of critically ill individuals are also susceptible to developing PTSD. 6. Randy is 58 years old and in palliative care. He experienced childhood sexual abuse, which he has received counseling for at certain times in his life. Now that he is in end of life care, and he has been resistant to most of the treatments that can provide comfort. Specifically, these are treatments that involve being touched such as having IVs put in, or even a visit from the massage therapist on staff. The nurses and Randy are on good terms, but the nurses

are concerned as to why Randy does not elaborate on why he is refusing these treatments.

Which reason is most likely why Randy is silent about his choices?

A. He thinks the abuse is irrelevant to what is currently happening B. He finds the nurses untrustworthy to talk to about the abuse C. He has difficulty recalling many parts of the abuse D. He wants to avoid talking about the abuse Answer: A Rationale: Randy is experiencing later-adulthood trauma reengagement. As people engage with their trauma memories as they age in later life, the developmental task of meaning-making and coherence may facilitate a reworking of their trauma, which may result in more adaptive functioning. On the other hand, patients may not offer information pertaining to traumatic events or their current understanding of these events freely, possibly because they may not consider the information relevant to their current circumstances, may not want to discuss the event, may not remember many aspects of the event (in the case of childhood trauma or dementia), or do not trust the provider. A thorough assessment should focus on the age of onset, duration, severity, and course of symptoms.

7. If a patient is reluctant to share information about a traumatic event that could be indicative of PTSD, which approach is the most effective first step?

A. Clinical interview B. Trauma exposure measure C. Comprehensive chart review D. Self-report measure Answer: C Rationale: There are numerous approaches to the assessment of PTSD or associated symptoms that includes chart review, screening measures, interviews, self-report measures, and trauma exposure measures. A comprehensive chart review can be an invaluable tool in assessing a patient for PTSD. The patient’s medical illness may inhibit him or her from being able to share his or her mental health history with you. Also, given that avoidance is a core symptom of PTSD, the patient may not readily share this information, even when asked if he or she has a mental health history.

8. Which method provides the most comprehensive assessment of PTSD? A. Clinical interview B. Trauma exposure measure C. Comprehensive chart review D. Self-report measure Answer: A Rationale: A clinical interview is considered to be the most comprehensive assessment of PTSD. 9. Juan has been dealing with PTSD most of his life. He is without family support. Which treatment would be most effective for the nurse to recommend for assisting Juan in having quality of life?

A. Nutritional counseling to alleviate insomnia B. Music therapy to increase relaxation C. Pharmacological approach to relieve depression D. Cognitive behavioral therapy to work through anxiety Answer: D Rationale: Cognitive behavioral therapies are the most effective treatment for PTSD. Cognitive behavioral therapies involve a multifaceted approach including psycho-education, anxiety management, exposure, and cognitive restructuring. Nutritional counseling, music therapy, and pharmacological management may assist Juan with certain aspects of his PTSD, but cognitive behavioral therapy will most directly address Juan’s PTSD. 10. Education and training on the symptoms of PTSD are given to the patient, family, and interprofessional treatment team members during which stage of treating PTSD symptoms at the end of life?

A. Stage I B. Stage II C. Stage III D. Stage IV Answer: B Rationale: In a staged model for treating PTSD at the end of life, Stage I involves providing immediate comfort and social supports. Stage II involves providing psycho-education and enhanced coping skills. Stage III T inEvS olT veBsAtrNeaKtiSnE gL spLeE ciR fic.tCraOuM ma issues. There is no Stage IV. Short Answer 1. What complicating behaviors could palliative nurses encounter in a patient with PTSD who is at the end of life?

Model Answer: The very nature of the symptoms, including hyperarousal and avoidance, may complicate end-of-life care. The simple distress associated with being confronted with a life-threatening illness may exacerbate PTSD symptoms and provoke similar responses to the original trauma. Normal life review is an important part of the dying process in order to resolve unfinished business, but it may also result in symptoms such as intense anxiety, anger, guilt, or sadness due to traumatic memories. As a result, individuals with PTSD may avoid traumatic memories and may be unable to come to terms with unresolved life events.

Avoidance symptoms may also interfere with processes, such as communication with medical providers, which are paramount to successful end-of-life care. PTSD symptoms can impede the ability for the healthcare practitioner to engage in direct, problem-focused communication regarding the patient’s care. Refusal of care or excessive questioning of providers’ actions or distrust of authority may result. It has been documented that people with PTSD diagnoses tend to have poor medical adherence. In addition, individuals with PTSD may experience decreased social support or a lack of caregivers as a result of social isolation and avoidance.

2. Alicia is being evaluated for PTSD by a palliative care nurse. What are the five factors the nurse will need to take into consideration to accurately assess Alicia’s symptoms?

Model Answer: Accurately assessing symptoms, providing appropriate treatment, monitoring symptom change, communicating, and evaluating the effectiveness of an intervention are all crucial. When determining the most appropriate measure to utilize in assessing PTSD at the end of life, there are several factors that are important to consider.

First, due to the varied nature of life-threatening or life-limiting illnesses, the amount of time required to administer the measure is a critical factor. There are numerous measures that vary in the amount of time required to administer, ranging from 5 to 120 minutes. Second, not all measures are written at the same comprehension level; therefore, the reading level of the patient and English language fluency are important considerations. Third, the clinician needs to evaluate for a single event or multiple traumatic events. Another important consideration when assessing patients for PTSD is whether the assessment focuses on determining the specific diagnosis of PTSD or if the objective is to identify PTSD symptoms. Finally, the level of training and competency of the clinician administering and interpreting the results will impact the validity of the findings.

3. What are the components of a comprehensive chart review in a patient suspected of having PTSD? Model Answer: A comprehensive chart review can be conducted by evaluating the following: history of a preexisting mental health diagnosis, use of prescribed psychotropic medication (past/present), andTaEnS yTdB ocAuN mK enStaEtL ioL nE peRr. taC inO inM g to the patient’s mental health.

Once the patient’s chart has been reviewed, a brief note including the findings from the chart review and a discussion of the clinical implications for end-of-life care should be documented. After reviewing the mental health history in the medical record, the next phase of assessment is to talk with the patient to discuss his or her symptoms and background to fill in missing data from the chart review. Any of the remaining approaches (screening, interview, self-report, and trauma exposure measure) can be utilized after the chart review has been conducted.

4. Carrie works at a community hospital in a small town. Several times a year, patients are admitted with serious illnesses whom they have difficulty treating because these patients have PTSD. Carrie would like to do more for these patients, but the hospital has limited resources and only one mental health professional on staff. What can Carrie do?

Model Answer: Carrie can work toward an interprofessional team approach.

Interprofessional treatment providers can directly implement portions of the stage-based model to manage PTSD symptoms. For example, in Stages I and II, practitioners outside of mental health should be able to assist in the identification of PTSD symptoms and implement effective environmental interventions. In order to facilitate this, both active and passive approaches to staff education need to be implemented in palliative care settings. An active approach to staff education is to require general training on PTSD symptoms by palliative care staff. Free, online educational resources are accessible to the general public.

Interprofessional treatment practitioners with some expertise in the management of PTSD

can educate staff during interprofessional treatment team meetings and even through their charting notes. For example, when a chart review reveals a potential or confirmed diagnosis of PTSD, the provider can alert others to possible symptoms of PTSD and their impact on patient care.

5. How can pharmacological approaches to treatment of PTSD be used in palliative care?

Model Answer: Pharmacological approaches to the treatment of PTSD are important to consider in conjunction with psychosocial approaches, particularly when life expectancy is limited. Patient preference regardless of life expectancy may also dictate the use of pharmacological approaches. Therefore, interprofessional practitioners should know that there are two major classes of medications that have been shown to be effective for alleviating symptoms of PTSD. The first major class of drugs is selective serotonin reuptake inhibitors (SSRIs), which have been found to alleviate the avoidance and numbing symptoms associated with PTSD. The second class of medications are tricyclic antidepressants (TCAs), which have been shown to alleviate intrusive symptoms, anxiety, and depressed affect.

In conjunction with SSRIs or TCAs, practitioners may also choose to prescribe other medications such as benzodiazepines. Benzodiazepines can be prescribed in combination with SSRIs in order to alleviate anxiety, panic, and hyperarousal symptoms. It is important to note that benzodiazepines are not recommended for long-term treatment of PTSD because they have not been found to treat the core symptoms of PTSD and have additive properties, although they can be effective for end-of-life care.

CHAPTER 24: Gastrointestinal Symptoms Multiple Choice 1. Which gastrointestinal conditions do patients find more debilitating than pain?

A. Anorexia and cachexia B. Diarrhea and constipation C. Dysphagia and malnutrition D. Nausea and vomiting Answer: D Rationale: Nausea and vomiting (N&V) are unpleasant gastrointestinal symptoms that often are described by patients as more severe and disabling than pain.

2. What is cachexia?

A. Loss of appetite as well as the reduction of oral intake B. Loss of skeletal muscle mass due to protein and energy imbalance C. Unpleasant sensation in the stomach D. Inability to swallow Answer: B Rationale: Cachexia is a syndrome where protein and energy balance are affected, leading to a loss of skeletal muscle mass. Anorexia is loss of appetite as well as the reduction of oral intake.

TESTB ANKSELLER.COM Nausea is a non-observable subjective symptom involving an unpleasant sensation experienced in the back of the throat and the epigastrium that precedes but may or may not result in vomiting.

Dysphagia is inability to swallow.

3. What is the nurse doing if he is describing to an anorexic patient side effects of a medication designed to stimulate appetite as well as increased quality of life from better nutrition?

A. Allowing the patient to consider balance between curative treatment, palliation, and symptom support B. Explaining to the patient why curative treatment and symptom support are more important than palliation C. Focusing on the patient’s goals and preferences while providing support D. Assessing the patient’s physical and emotional needs and support Answer: A Rationale: Support of patients with anorexia should primarily be directed at treating underlying causes when appropriate. Being considerate of the impact of treatment on the symptom of anorexia should be addressed. Likely there is a balance of the need to offer curative treatment, palliation, and symptom support, each of which needs to be discussed with any patient and their family.

4. What is an example of a chemoreceptor trigger zone–mediated stimulus of the vomiting center?

A. Medication

B. Anxiety C. Gastritis D. Meningitis Answer: A Rationale: Chemoreceptor trigger zone–mediated stimuli include certain medications and metabolic conditions.

5. Kelsie has AIDS and has asked her nurse for a way to manage her nausea and vomiting without taking more medication. The nurse suggests that she focus her mind on images of a relaxing place. Which nonpharmacological method is the nurse recommending?

A. Biofeedback B. Desensitization C. Imagery D. Distraction Answer: C Rationale: Imagery involves mentally taking oneself away by focusing the mind on images of a relaxing place. Biofeedback is control of specific physiological responses by receiving information about changes in response to induced state of relaxation. Desensitization is a threestep process involving relaxation and visualization to decrease sensitization to aversive situations. Distraction is learning to divert attention from a threatening situation to relaxing sensations.

6. What is a typical cause of systemic dysphagia?

A. Neoplasm B. Inflammatory factor C. Multiple sclerosis D. Dementia Answer: B Rationale: Causes of dysphagia are systemic dysphagia as a result of inflammatory and infectious factors; neoplasm (includes brain tumors, head and neck cancer, and esophageal tumors); progressive neuromuscular diseases such as ALS, Parkinson’s disease, and MS; connective tissue disorders like scleroderma; dementia; and general deconditioning that may include multisystem disease and failure; and the side effects of medications and/or polypharmacy.

7. What is the most emergent issue with dysphagia?

A. Heartburn from esophageal reflux B. Malnutrition and loss of body weight C. Food feeling stuck in the esophagus D. Aspiration of food and liquids Answer: D Rationale: Because foods and liquids are entering the lungs, aspiration is the most emergent issue and needs to be treated immediately.

8. How is constipation involved in palliative care?

A. It rarely occurs.

B. It is usually treated.

C. It is defined by the patient.

D. It rarely causes morbidity.

Answer: C Rationale: There is a wide variation of the “normal” frequency for passage of stool, anywhere from three times daily to three times weekly, and therefore, assigning a precise definition is difficult, although fundamentally it is defined by the patient. Similar to the concept of pain, constipation is a subjective complaint and often undertreated. It is a common complaint in all populations and typically refers to persistent, difficult, infrequent, or the sensation of incomplete passage of stool. Constipation is a common cause of morbidity in the palliative care setting and the numbers increase if the patient is treated with opioids.

9. What is considered a functional obstruction of the bowel?

A. Dysmotility B. Adhesion C. Inflammation D. Neoplasm Answer: A Rationale: Functional obstructionT, EaS lsoTB knAoNwKnSaE sL ileLuEs Ran.dCpOsM eudo-obstruction, can occur when dysmotility prevents intestinal contents from being propelled through the lumen and there is no existing mechanical blockage. Mechanical bowel obstruction may be caused by extrinsic processes such as adhesions and neoplasms; intrinsic abnormalities of the bowel wall like congenital, inflammatory, neoplastic, or traumatic; or intraluminal abnormalities.

10. A patient has been prescribed a diuretic. Which condition does this patient have?

A. Xerostomia B. Ascites C. Diarrhea D. Constipation Answer: B Rationale: The use of diuretics to decrease sodium reabsorption and urinary retention, along with increasing urinary excretion, is the primary intervention for ascites.

Short Answer 1. How is the Malnutrition Universal Screening Tool (MUST) used for a patient at risk for malnutrition?

Model Answer: The MUST screening tool is a five-step approach that includes management guidelines for developing a care plan. It is used in hospitals, community, and other care

settings where patients are acutely ill and there has been or is likely to be no nutritional intake for greater than 5 days. Step 1 involves measurement of a patient’s height and weight to get a BMI score. If these measurements are not possible to obtain, an alternate approach can estimate height by using forearm length and estimate weight by mid–upper arm circumference. Step 2 calculates the percentage of unplanned weight loss and creates a score using tables provided. Step 3 establishes the impact of acute disease and the potential effect on a patient’s nutrition. Step 4 then takes the cumulative score from the scores of steps 1, 2, and 3 to obtain the overall risk of malnutrition for the patient. Using the results of the MUST scoring, patients are categorized into low (0), medium (1), or high risk (≥2) for malnutrition.

Management guidelines are suggested after the assessment of that patient’s nutritional status.

Importantly, the guidelines suggest routine reassessment of patients identified at risk as they move through care settings so that ongoing support can be addressed.

2. Harold has been struggling with nausea and vomiting from chemotherapy for lung cancer. He knew before he started treatment that he was likely to experience nausea and vomiting but had no idea it would be this bad. What are the seven steps his healthcare professional should use to determine which medication would be best for him?

Model Answer: The seven steps in choosing the appropriate antiemetic include (a) identify the cause of the nausea and vomiting, (b) identify the pathway triggering the vomiting reflex, (c) identify the neurotransmitter receptor involved in the pathway, (d) choose the most potent antagonist to the receptor identified, (e) choose a route of administration that ensures optimal action, (f) titrate the dosage, and (g) if symptoms persist, review the cause.

3. Roberta has just entered hospice for a rare form of sarcoma. She is having some difficulty swallowing food. Her family is very concerned that she maintains adequate nutrition so that she can have a high quality of life for as long as possible. Roberta would like that too but is feeling more fatigued every day. How should the management of Roberta’s dysphagia proceed?

Model Answer: If the patient has a very short prognosis (days), it may be determined by the patient, family, and caregivers that hydration and/or feeding are not warranted. If the patient has a longer prognosis, medically assisted feeding and hydration may be attempted. The following factors can help determine the appropriateness of interventions: 1.

2.

3.

4.

5.

Anticipated decline of Roberta Roberta’s opinion Opinions of Roberta’s significant other and family Opinions of formal caregivers Feasibility/advantages/disadvantages of alternative feeding routes

Transnasal intubation, percutaneous endoscopic gastronomy or jejunostomy, esophagogastroduodenoscopy (EGD), or surgical gastrostomy or jejunostomy may be considered if Roberta’s prognosis determines that these interventions will provide optimal palliation. Any surgical intervention must be undertaken with significant input from Roberta and her family and is determined by the overall goals of care.

4. What are treatment strategies for a patient with constipation?

Model Answer: Prevention of constipation is an essential strategy in providing palliative care. A mix of dietary alterations in addition to pharmacological agents may be required.

Bulk-forming agents and stool-softening agents assist with normal peristaltic function. All patients beginning opioid therapy should be started on a laxative. Generally, a combination of a stool softener and laxative offers the most relief from constipation.

5. How can nurses improve symptom management and quality of life for patients with a bowel obstruction?

Model Answer: Nurses could improve symptom management and quality of life for patients that are experiencing malignant bowel obstruction by frequent assessments and being aware that patients with intra-abdominal tumors are at the highest risk for bowel obstruction.

Physical assessment that reveals dehydration, dry mucosa, tachycardia, and hypotension are all signs of possible bowel obstruction. Examination of the abdomen may reveal distention, pain, and varied bowel sounds. Bowel obstruction from a malignant source is a pivotal point in the patient’s illness and nurses should have an active role in helping the patient through the decisions that need to be made about aggressive treatment or a more palliative approach to the bowel obstruction.

CHAPTER 25: Fatigue Multiple Choice 1. How can fatigue be characterized in patients needing palliative care?

A. It is due to exertion from muscular force.

B. It is a natural part of the aging process.

C. It comes from emotional effort related to work.

D. It comes from the interplay of many different factors.

Answer: D Rationale: Chronic, unrelenting fatigue is a common symptom in patients with chronic disease at the end of life, with a complex array of complaints including variations in the level of irritability, nighttime sleeplessness, and daytime sleepiness. The clinical definition of fatigue at this stage of life includes lacking physical or mental energy. Fatigue affects how patients interact with others, their self-perception, ability to function, and sense of hopefulness. Its impact compounds the suffering associated with life-threatening illness.

2. How does fatigue associated with illness typically manifest in comparison to healthy exertion?

A. Comes on after a longer period of time B. Relieved relatively quickly by rest C. Daily feeling of tiredness D. Feels less severe Answer: C Rationale: The concept of fatigue also encompasses emotional, cognitive, and behavioral dimensions. Psychosocial etiologic factors of fatigue across an ethnically diverse population include social adversity, social support, physical inactivity, anxiety, and depression (Bhui et al., 2011). In healthy individuals, overexertion may produce ordinary fatigue, which is relieved relatively quickly by rest; fatigue may also be interpreted as satisfaction given the accomplishment of hard work. However, fatigue associated with illness is perceived as more severe and comes on after a shorter period of time and with less exertion than ordinary fatigue. It is often described as a general feeling of tiredness or “sapped” energy that occurs on a daily basis and is present intermittently throughout the day or during the evening after a day of normal activities.

3. What is the term for fatigue that occurs without any exertion or activity?

A. Chronic B. Acute C. Physiologic D. Central Answer: A Rationale: Chronic fatigue has no known physiologic purpose and can occur without any relationship to exertion or activity. Chronic fatigue is commonly associated with severe

deconditioning or limited mobility as seen in patients with anemia and diminished aerobic capacity, including those with heart failure, chronic lung conditions, and neurological disorders.

Acute or physiologic fatigue is a protective state that is identifiably linked to a single cause, in usually healthy individuals. Acute fatigue has a rapid onset and short direction, is viewed as normal in the usually healthy person, and can be alleviated by restorative techniques such as rest, diet, exercise, and stress management. In central fatigue, the motor pathways in the central nervous system (CNS) fail to sustain recruitment and/or frequency of motor units or the generation of descending volleys in the motor cortex due to neurotransmitter modulation.

4. Which type of fatigue occurs from depletion of body stores from stress and pathology of having a disease?

A. Primary B. Secondary C. Acute D. Physiologic Answer: B Rationale: When a person is experiencing the stress and pathology of chronic disease or cancer, the body reserves can become depleted and ultimately unable to counterbalance the physiologic insults. Primary fatigue comes from having the disease itself. Acute or physiologic fatigue is a protective state that is identifiably linked to a single cause, in usually healthy individuals. Acute fatigue has a rapid onset and short direction, is viewed as normal in the usually healthy person, and can be alleviated by restorative techniques such as rest, diet, exercise, and stress management.

5. Which patient is most likely to experience the most fatigue?

A. A child with cancer in the last month of life B. An adult experiencing the second round of chemotherapy C. An adult who was just diagnosed with HIV infection D. A child who is living with sickle cell disease Answer: A Rationale: For children with advanced cancer, fatigue is the most common symptom reported in the last month of life. An adult experiencing the second round of chemotherapy, an adult who was just diagnosed with HIV infection, and a child who is living with sickle cell disease will all experience fatigue, but the most severe fatigue comes toward end of life from a serious disease.

6. Ronald is 69 years old and is being treated for a nonaggressive form of leukemia. He has been experiencing fatigue quite a bit lately. What considerations around Ronald’s fatigue apply?

A. Fatigue is a normal part of the aging process.

B. Underlying cause will determine treatment.

C. Quality of life will remain the same.

D. Methods to cope with it are unreliable.

Answer: B

Rationale: Many elders and their families erroneously consider fatigue to be an inevitable aspect of aging, and therefore not a symptom to be treated. In fact, older adults may not even report symptoms of weakness and fatigue to their primary care provider. Even for the older adult in palliative care, many causes of fatigue can be successfully treated by examining for and treating the underlying cause. The goal for the healthcare provider related to the symptom fatigue is to improve the patient’s quality of life by treating the symptom and teaching the older adult coping mechanisms and lifestyle changes.

7. If the nurse asks a patient where he or she feels fatigue in his or her body, which dimension of the Fatigue Assessment is being used?

A. Behavioral B. Temporal C. Affective D. Sensory Answer: D Rationale: The sensory dimension of the Fatigue Assessment focuses on how the fatigue feels in the body. For example, is the fatigue localized (e.g., tired eyes, arms, legs) or generalized (e.g., whole body tiredness, weariness, weakness, lethargy), and what is the intensity or severity of fatigue (using 0–10 scale)? Additional assessment questions include what exacerbates the fatigue (e.g., pain, nausea, vomiting, environmental heat, or noise). What helps the patient feel better or alleviates the symptoms (e.g., rest, food, listening to music etc.)?

8. What is the goal of fatigue maTnEagSeTmBeA ntNfK orSaEpL atL ieEnR t i. nC paOlM liative care?

A. Return to pre-illness feeling of well-being B. Have enough energy to combat disease C. Achieve best quality of life possible D. Ease gently into last stages of end of life Answer: C Rationale: The goal of the management of fatigue is to achieve the best quality of life that is possible given the patient’s specific circumstances. Having the energy to do what is important to the person so that they may finalize specific tasks or interact in special relationships is a valuable outcome for treatment.

9. Which dietary consideration will help alleviate fatigue?

A. Avoiding high-sugar foods B. Decreasing fluid intake C. Decreasing protein intake D. Eating large meals Answer: A Rationale: Nutritional status is also an important consideration; eating low-fat foods, several small meals in a day, and avoiding high-sugar foods results in less energy used for digestion.

Given that nutrition and hydration are important in preventing fatigue, increasing fluids may be

of benefit, unless contraindicated by other medical problems. Protein intake and supplements can also be encouraged if the patient is having trouble with regular food.

10. Which medication would be used to treat fatigue in a patient who has anemia from chemotherapy?

A. Erythropoietin B. Methylphenidate C. Prednisone D. Trazodone Answer: A Rationale: If the patient has had chemotherapy, the fatigue may be a result of anemia or vitamin deficiency. Treatment with recombinant erythropoietin has been shown in randomized studies to increase hemoglobin level, which improves the patient with cancer-related fatigue energy levels and quality of life. Methylphenidate is a psychostimulant. Prednisone is a corticosteroid.

Corticosteroids can improve appetite and elevate mood, resulting in an improved sense of wellbeing, although the duration of effect may be limited. Trazodon reduces depressive symptoms associated with fatigue.

Short Answer 1. Joanna has been exhausted daily for almost a year, which she has found very frustrating. She was finally diagnosed with fibromyalgia. What approach should her healthcare professional take?

Model Answer: Patients with chronic conditions, such as fibromyalgia, may manifest progressive symptoms of psychogenic fatigue, physiologic fatigue, pain, depression, sleep disorders, and loss of adaptability. Given the unknown etiology of fibromyalgia, there are limited treatment options for this disease, with relief primarily achieved by the palliation of symptoms. There have been positive results from treatment with complementary and alternative medicines. Exercise is also recommended in levels that help sufferers to feel better without initially aiming at training or conditioning.

2. What are at least five risk factors for cancer-related fatigue?

Model Answer: Multiple risk factors, rather than a single risk factor, appear to put patients with cancer at risk for cancer-related fatigue. These risk factors include poor nutrition, sleep disorders, stress, cancer comorbidities (i.e., cardiac, pulmonary, renal, liver, neurologic, thyroid, and endocrine, and associated medications), hypoxia, pain, infection, deconditioning, and ongoing therapy.

3. How can a nurse empower a patient to cope with fatigue to promote quality of life?

Model Answer: Energy-conserving strategies may be used to manage and alter the fatigue.

These include avoiding unnecessary or excessive use of energy by pacing oneself and taking extra rest periods; energy restoration to avoid further deconditioning and deterioration in

physical functioning through keeping muscles strong through exercising; continuing to be self-reliant by asking for help only when necessary, while taking into account the possibility of escalating fatigue at the end of life; encouraging patients to rejuvenate their energy through relaxation strategies such as reading, watching television, or taking relaxing baths.

4. Maureen is 57 and has had lupus since she was in her 30s. Recently, several exacerbations of lupus have left her exhausted. What advice can her healthcare provider give her to manage her fatigue?

Model Answer: Although patients may believe that more rest and sleep will increase energy, sleep is not restorative of energy in chronic conditions associated with fatigue. Maureen should sleep no longer than 8 hours, which establishes a more solid, less fragmented sleep pattern. Waking up and going to sleep at the same time each day strengthens the circadian cycles, the disruption of which can contribute to depression.

Maureen will need to save her energy and plan for activities that are very important to her. She should schedule activities she enjoys the most for the time of the day that she has the most energy. Breaks should be scheduled during activities to help restore energy levels, and taking short therapeutic naps (15–20 minutes) between the hours of 3 p.m. and 5 p.m. tends to be more restoring than getting into a longer, deeper sleep. Energy conservation techniques should be reinforced, such as doing activities sitting down, using a power scooter for grocery shopping, storing frequently used items at the chest level to avoid bending and stretching, putting a terry robe on after the shower instead of using energy to dry off, or wearing slip-on shoes. Having devices such as a raised toilet seat, a reaching device, or a walker can also help conserve energy. Maureen shT ouEldSaTlB soAbNeKenScEoL urL agEeR d. toCaOskMfor help with specific chores.

Spending time with family and friends is also very important in promoting a sense of well-being, which may lessen the perception of fatigue. Prioritizing who she would like to visit with can be helpful, as well as planning such visits at a time of day when Maureen has the most energy to avoid excessive fatigue.

5. What causes family fatigue? How can palliative care nurses assist the caregivers?

Model Answer: Severe family fatigue is commonly experienced in four situations: inadequate relief of patient’s pain and suffering; inadequate resources to cope with home care; unrealistic expectations of family caregivers of themselves or professional healthcare supports; and emotional distress that persists even when there is adequate relief of patient suffering. Palliative care nurses recognize the patient and family as the unit of care, and therefore, assessment and interventions to relieve caregiver burden are essential. Validating the needs and concerns of family caregivers is important. Helping family caregivers to set priorities with regard to competing demands, optimizing stress and coping strategies, encouraging relaxation and rest, while assisting caregivers with respite care are important interventions in preventing or alleviating caregiver fatigue.

CHAPTER 26: Minimizing Skin Alterations Multiple Choice 1. Which statement describes a nonhealable wound?

A. Patient has too much blood supply for the area to mend.

B. The area can mend, but the patient is unable to tolerate treatment.

C. The area can mend, but treatment is unavailable to the patient.

D. Patient has too little protein for the area to mend.

Answer: D Rationale: In this population, wound healing is not often the goal; nonetheless, realistically classifying a wound as healable, maintenance, or nonhealable (heal ability) is important. A healable wound has adequate blood supply and the cause can be corrected. A maintenance wound is healable, but either patient factors (unable to tolerate compression bandaging for venous leg edema) or system factors (protective footwear or pressure-relieving devices not covered for patients in the home) are not available. A nonhealable wound is a pressure injury with a patient in a negative protein balance or has inadequate blood supply to facilitate healing.

2. Focus on which aspect of wound care should be in the patient’s palliative care plan?

A. Color of injury B. Bacterial colonization C. Amount of itching D. Duration of injury Answer: B Rationale: Many wounds are treated as maintenance, with important aspects of patient-centered care being the important focus of the patient care plan, including wound odor, excessive exudate, superficial critical bacterial colonization (responds to topical antimicrobials) and deep/surrounding infection (requires systemic therapy), bleeding, and wound-associated pain.

3. Harriet is hospitalized for end-stage heart failure. Which condition is she most likely to develop if her skin assessment is neglected?

A. Treatment injury B. Basal cell carcinoma C. Pressure injury D. Integument tear Answer: C Rationale: Skin changes do occur at life’s end and can be part of the dying process. Studies show that the patients confined to bed present with pressure injuries more often than skin injuries from treatment, skin tumors, and tears in the integument.

4. A Braden scale score of 15 to 18 means the patient is at what level of risk for developing a pressure injury?

A. Mild

B. Moderate C. High D. Severe Answer: A Rationale: According to the Braden scale, a score of 15 to 18 means the patient is at mild risk for developing a pressure injury. A score of moderate risk is 13 to 14. A score of high risk is 10 to 12. A score of severe risk is less than 9.

5. Which guideline is recommended for preventing pressure injury in a patient in end-of-life care?

A. Providing medication after repositioning B. Adhering to a strict repositioning schedule C. Predetermining the most comfortable position D. Providing medication before repositioning Answer: D Rationale: For palliative care patients, following a rigid set time interval for a repositioning schedule may cause the patients undue pain. Caregivers should negotiate a flexible time interval, premedicating prior to repositioning, determine which positions provide the most comfort, and focus on the support surface used, coupled with the preference, needs, and tolerance of the patient.

6. Roger is in hospice for end-ofT-lE ifS eT caBreAaNnK d ShE asLdLevEeR lo.pC edOaMn infected pressure injury. Which treatment method is recommended for the injury?

A. Mechanical debriding B. Using a cytotoxic cleanser C. Using a normal saline cleanser D. Covering with a film dressing Answer: B Rationale: Cytotoxic agents, instead of normal saline cleansers, are typically not recommended for cleaning of pressure ulcers that are healable. For PC patients, the use of these solutions may be warranted, because the goal is no longer healing. The benefits of odor control from these solutions may make them an appropriate choice for persons who are at the end of their lives.

Mechanical debriding would likely cause too much discomfort to the patient. Film dressings are not recommended for infected wounds.

7. Where on the patient’s body are most skin tears likely to occur?

A. Legs and feet B. Back and buttocks C. Arms and hands D. Neck and head Answer: C

Rationale: Eighty percent of skin tears occur on the extensor surface of the upper extremities (arms and hands) over areas of sun damage that also predisposes these regions to senile purpura.

8. Which method demonstrates appropriate peristomal care?

A. Using alcohol-based products for infection control B. Protecting the skin by avoiding the use of a skin barrier C. Using adhesive removers to avoid skin stripping D. Changing the pouch–skin barriers very frequently Answer: C Rationale: Peristomal skin must be protected from mechanical trauma that can occur from inappropriate cleaning. To avoid skin stripping, use adhesive removers to remove skin barriers and pouching systems. Alcohol-based products should never be used, especially if the peristomal skin is denuded. If solvents are used, the skin should be cleaned, and the solvent removed before applying the ostomy pouch. A variety of skin barriers can be used to protect the peristomal skin from effluent. Avoid too frequent or unnecessary changing of the pouch–skin barrier.

9. Which option is most effective for the management of odorous fistulas in elderly patients?

A. Pouching system B. Trough system C. Drainage tube with suction D. Drainage tube without suction Answer: A Rationale: A pouching system may be the primary choice for management for older adults with odorous fistulas. Using a clear pouch will enable the caregiver or nurse to easily see the type and amount of effluent. Pouching is superior to dressings because it provides better protection for the skin. High-output enterocutaneous fistulas can be managed using a Jackson–Pratt (JP) drain connected to low-wall suction (60 mmHg of pressure) covered with saline-soaked gauze and a large surgical plastic drape. When using this technique, be careful in placing the catheter tube so it does not inadvertently cause injury to the tissue. The trough procedure is used for fistulas that are deep within wounds. It is made up of several layers of transparent dressing with an ostomy pouch on the bottom of the wound.

10. Tanis is undergoing radiation therapy. Which approach by the nurse is appropriate to use on Tanis’s treatment area?

A. Shaving and rubbing the skin B. Using a lotion to moisturize the skin C. Sprinkling talcum powder on the skin D. Using a gel with aloe vera on the skin Answer: D Rationale: While undergoing radiation therapy, products with vitamin A and E or aloe vera gels may be used for treating erythema, although topical steroids should also be considered with the presence of a topical contact irritant dermatitis. Avoid activities that could cause mechanical skin damage such as vigorous rubbing, heat, or shaving of the skin in the treatment area. Use of any

topical products, such as lotions, creams, or deodorants, is generally discouraged. Talcum, cornstarch, and baby powder use is controversial as they often contain heavy metals; however, if they are applied, an even layer can be obtained with a cotton ball dabbed on the affected area rather than sprinkling the powder from a container. Sprinkling often leads to local clumping.

Short Answer 1. Deepak is a new nurse who has been assigned to assess the skin integrity of each of the patients in the hospice unit of the hospital he works in. What elements does he need to check with each patient?

Model Answer: Actual physical examination of the skin is needed to identify patients at risk for skin injury and to initiate prevention protocols. There is, however, no consensus in the literature as to what constitutes a minimum skin assessment. Baranoski and Ayello have suggested five elements to include in a basic skin assessment: skin temperature, color, moisture, turgor, and whether the skin is intact or has areas of injury including open areas.

2. What are patient risk factors for pressure injuries according to the Skin Changes at Life’s End (SCALE) Panel Statements?

Model Answer: Risk factors, symptoms, and signs associated with SCALE have not been fully elucidated, but may include:

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Weakness and progressive limitation of mobility Suboptimal nutrition, including loss of appetite, weight loss, cachexia and wasting, low serum albumin/prealbumin level, and low hemoglobin, as well as dehydration Diminished tissue perfusion, impaired skin oxygenation, decreased local skin temperature, mottled discoloration, and skin necrosis Loss of skin integrity from any of a number of factors, including equipment or devices, incontinence, chemical irritants, chronic exposure to body fluids, skin tears, pressure, shear, friction, and infections Impaired immune function 3. What is an effective skin tear treatment protocol?

Model Answer: An effective skin tears treatment protocol is as follows: Gently clean the skin tear with normal saline.

Let the area air dry or pat dry carefully.

Approximate the skin tear flap.

Apply petroleum-based ointment, steri-strips, or a moist nonadherent wound dressing.

Calcium alginate dressings facilitated closing in 7 to 10 days.

Use caution if using film dressings as skin damage can occur when removing this dressing.

Consider using silicone dressings with low tack to avoid tearing the skin.

Consider putting an arrow on the dressing to indicate the direction of the skin tear to minimize any further skin injury during dressing removal.

Always assess the size of the skin tear; consider doing a wound tracing.

Document assessment and treatment findings.

4. Now that Marlene is reaching the end stages of Alzheimerʼs disease, one of her family’s concerns about her comfort and care is whether or not the skin around her stoma is healthy and properly taken care of. They do not want her suffering unduly from an infection. What would the nurse look for in terms of peristomal skin complications?

Model Answer: Peristomal skin complications are described according to three criteria: discoloration, erosion, and hyperplasia, or raised lesions that can be measured with size and severity for a maximum score of 5 points for each. Normal peristomal skin should be intact without discoloration and no difference between the peristomal skin and adjacent skin surfaces. Peristomal skin damage has erythema, maceration, denudation, skin rash, ulceration, or blister formation. In darkly pigmented patients, the damaged skin may appear lighter or darker than the surrounding skin.

5. What palliative care considerations need to be given for patients whose tumors have invaded the skin?

Model Answer: Frequent irrigation of the wound with large amounts of fluid may be important to reduce the bacterial burden on the wound surface. Wound exudate needs to be managed with absorbent dressings, and debridement may be necessary because of necrotic tissue. Bleeding commonly occurs. Calcium alginate dressings and topical thrombin have a hemostatic effect and are a goToE dS chToB icA eN foKr S bE leL edLinEgRw.oCuO ndMs. Silver nitrate sticks can be used to control small amounts of blood. Pain also results from the tumor growing on the skin and from treatment procedures. Ice packs or topical anesthetic aerosol spray (Hurricane) may alleviate wound pain. Topical extemporaneously compounded opioids or preparations containing amide local anesthetics pyridoxine have also been used to relieve wound pain.

Odor may be one of the most distressing problems for the patients and their caregivers. There are commercially available wound gel deodorizers; however, some patients may experience burning with the application of these products. The use of Metrogel (1% topical antibiotic wound-deodorizing gel) to control even the most noxious odors has been reported. Topical application of yogurt or buttermilk has been used to combat the extensive odors from tumor necrosis. Antimicrobial cadexomer iodine or silver dressings are also excellent at reducing odor with the added plus of also controlling the bacterial burden in the surface compartment wound.

Clinicians should be aware of their nonverbal and verbal communication to patients during dressing changes. Patients and/or family members may have difficulty coping with wound odor or appearance and will look to the clinician to see their reaction. Seeing the extensive death of their own body, coupled with overpowering smells and weeping feces, may be extremely overwhelming to patients. The clinician’s resolve to problem solve and provide the patient with the physical comfort from appropriate wound management is vital in helping these patients overcome their (sometimes self-imposed) isolation and hiding.

CHAPTER 27: Peri-Death Nursing Care Multiple Choice 1. Which factor is part of pain management during the dying process?

A. Patients will always request pain medication for suffering.

B. Patients may be suffering more from pain than they are saying.

C. Families determine survival potential risks and benefits for the patient.

D. Inadequate pain management for the patient has been resolved by opioids.

Answer: B Rationale: There may be gaps between a patient’s preferred level of comfort and how a patient describes suffering. The patient may seek pain relief or may view pain as a way to atone for sins and refuse to be medicated. Healthcare providers must help alleviate that suffering, but examine survival potential, risks, and benefits of therapy. Pain management has improved; the prevalence of inadequate pain management at the end of life (EOL) remains a key issue. Identifying the appropriate dose and frequency, especially of opioids, can be challenging and may require creativity.

2. Jocelyn is 46 years old and dying from metastatic breast cancer. She feels that she battled it for as long as she could but now is just tired and wants a peaceful end of life. Jocelyn has decided to refuse nutrition and asks the palliative care nurse what will happen in her body from this decision. What can T thE eS nuTrB seAtN elK l hSeE r?LLER.COM A. Ketone levels will increase causing endorphins to increase, providing analgesia.

B. Electrolytes will likely become imbalanced, decreasing analgesia.

C. Decreased fluid intake stimulates mucus production, causing coughing.

D. Decreased fluid intake stimulates tumor growth, causing more pain.

Answer: A Rationale: With calorie deprivation comes an increased production of ketones, which results in an elevation of naturally occurring opioid peptides or endorphins that provide analgesia. An electrolyte imbalance, if present, will also result in increased analgesia. Decreased fluid intake will result in fewer pulmonary fluids, which ease respiration, lessen coughing, and reduce the drowning sensations. If a tumor is present, dehydration may make it smaller in size by reducing the edematous layer around the tumor, resulting in less pressure and pain.

3. If a patient at the end of life alternates between being agitated and drowsy, and moans and grimaces, what could the patient be experiencing?

A. Dyspnea B. Nausea C. Pain D. Delirium Answer: D Rationale: Individuals at the end of life can manifest symptoms of end-stage multiorgan failure and other irreversible factors that result in a disturbance of fluctuating consciousness, cognition,

and perception known as delirium, but it is often underdiagnosed in the terminally ill. Delirium can be classified into three subtypes: hyperactive (restless and agitated), hypoactive (drowsy and inactive), and a combination of these two. These are typical symptoms that are indicative that the patient is close to death. Moaning and grimacing can accompany agitation and restlessness and may be misinterpreted by the nurse as pain.

4. Which action is a responsibility of a palliative care nurse?

A. Avoiding talking with the patient about death B. Determining food and activity choices for the patient C. Helping the patient work through any unfinished business D. Telling the family to be realistic about a miracle cure for the patient Answer: C Rationale: Two very important goals of PC nursing are to help patients live until they die and to encourage hope. First, the nurse can help patients live until they die by encouraging socialization, listening, being honest, and helping them finish any unfinished business. The nurse can also help families find meaning in the situation. Dialogues about death with healthcare professionals, families, and friends can benefit all involved. By offering patients choices regarding routines, food, and activities, nurses promote continued independence and the ability to help maintain control over their lives. There may be hope for the miracle of a complete cure; it is not acceptable for the nurse to take this hope away or to tell the patient and family to be realistic.

5. What is a consideration for thT eE paSllTiaBtiA veNcKaS reEnLuL rsE eR ta. kiC ngOM care of a terminally ill child?

A. The priority is the child, and family’s needs come second.

B. The parent’s wishes always supersede the child’s wishes.

C. Someone needs to be with the child until the end of life.

D. Discussing end of life will cause depression in the child.

Answer: C Rationale: Palliative care for the child encompasses a holistic approach to physical, psychological, and spiritual care. Offering time for discussion related to death and the dying process helps the child recognize that he or she will not be alone in the process and will be loved and remembered. Consideration for both the dying child and his or her family supporting optimal functioning until the time of death is a vital role for the nurse. The child needs to make as many decisions about his or her end-of-life care as possible to feel some sense of control. Children are often very perceptive and may know far more than adults assume. End-of-life communication will not typically send a dying child into a deep depression.

6.

Which sign indicates death?

A. Eyes are slightly closed.

B. Pupils are fixed.

C. Body color turns pink.

D. Jaw is closed.

Answer: B

Rationale: Signs of death include cessation of a heartbeat and respiration, release of bowel and bladder, eyelids slightly open and not blinking, the eyes glaze, and pupils are fixed and dilated.

There is a drop in body temperature, and as the blood settles, the body color turns to a waxen pallor, the jaw is relaxed and slightly open, and there is no response from the patient.

7. Which statement describes embalming?

A. It is commonly done for health reasons.

B. It is a legal requirement.

C. It is necessary for viewing of the body.

D. Five methods are used to preserve the body.

Answer: A Rationale: Embalming is the process by which the corpse is preserved and prepared for viewing; it is common for health reasons and protects mourners from being in the presence of a decaying body, but is not legally required, even if it is to be viewed. There are four embalming methods that all involve the injection of chemicals to preserve the body.

8. What role does the palliative care nurse play in the family’s customs, values, practices, and traditions regarding the patient’s death?

A. Inform families of the rites that are performed in the United States B. Allow only rituals that are permitted by hospital policy C. Participate as much as possible in the rituals D. Understand the need for the rituals Answer: D Rationale: Throughout the dying process, and particularly at the very end of life, the nurse must be aware of cultural and religious values, practices, and traditions of the patient and the family.

Customs and rituals have tremendous significance in the healing process following death, and the grief response is often structured by these rituals. The nurse’s role is to help the family carry out the rites and practices that provide solace and support. The nurse should be open minded and understanding of the physical, psychosocial, and spiritual needs of the dying patient and his or her family and offer them respect and privacy.

9. While each Native American tribe has its own unique traditions regarding death of a member, which action do they all have in common?

A. Embalming is done after the body undergoes a cleansing ceremony.

B. The deceased is buried without any jewelry on the body.

C. Spirit of the deceased remains where the person dies.

D. The deceased needs to die alone in preparation for the next world.

Answer: C Rationale: Native Americans have different traditions in each tribe. There is a belief that the spirit of the deceased remains where the person has died; therefore, family may not want the person to die at home. At the same time, it is considered inappropriate for the person to die alone. If the person dies at home, the house must be abandoned or a ceremony is held to cleanse it. Families gather together at the time of death and material possessions are dispersed. When a person dies, a cleansing ceremony is performed or else the spirit of the deceased may try to take

over someone else’s spirit. Those who work with the dead also must have a ceremonial cleansing to protect themselves from the dead person’s spirit. No embalming is done; the deceased are buried in sacred ground with their shoes on the wrong feet, rings on their index fingers, and with many gifts surrounding them; or the body is cremated.

10. Bereaved family members are talking about the deceased and voicing their feelings. Which therapeutic part of the funeral process does this describe?

A. Therapy of direct expression B. Therapy of language C. Therapy of sharing D. Therapy of activity Answer: B Rationale: Seven specific therapeutic values have been assigned to the funeral process as delineated by Raether. First, the “therapy of direct expression” denotes that the funeral furnishes the setting and opportunity for the bereaved to express their grief physically. Funerals offer “therapy of language” by providing the bereaved an opportunity to talk about what has happened, voice their feelings, and begin to feel relief in the telling. The “therapy of sharing” is the coming together of the family and significant others to provide emotional and physical support to each other. Immersion in the many aspects of the funeral process also encompasses the “therapy of activity.” The funeral also provides the “therapy of ceremony” that is both glorifying and ennobling. Given that accepting the reality of the death is difficult for many people, the “therapy of viewing” establishes a final and amended view of the deceased. This revised image replaces those comTpE osSedTB duAriNnK gS thE eL ilL lnE esRs . orCaOt M the time of death and may bring comfort to the mourner. Finally, the “therapy of suffering” addresses the guilt that mourners may be experiencing and provides the occasion to verbalize what had been left unsaid previously.

Short Answer 1. Edmond has begun the stages of dying. His family has gathered to be with him during his last days. Edmond’s breathing pattern has started to change, upsetting some of his family members. What should the palliative care nurse tell Edmond and his family about his breathing?

Model Answer: Families should be warned that dyspnea and loud respirations are a possibility during the peri-death period. Patients may fear they will suffocate while they are dying, and families fear they will have to watch their loved one struggle to breathe. Nurses should educate the patient and family regarding what they can expect and give assurances that medications will be used to effectively palliate these symptoms. Nursing interventions include positioning Edmond on his side, semi-prone or in brief Trendelenburg, to prevent the accumulation of secretions in the back of his throat and upper airways. Edmond can be given a low-dose opiate, such as morphine 5 mg PO every 4 hours, to alleviate the sensation of breathlessness. Oxygen is typically only effective if the dyspnea is secondary to hypoxia, although it may provide a placebo effect. A fan blowing a gentle breeze toward Edmond’s face can also be very effective. Suctioning is usually not recommended as it may incidentally increase secretion production. Emotion-focused interventions such as relaxation techniques,

prayer and meditation, and distraction may alleviate the anxiety Edmond and his family associate with dyspnea.

2. What is most helpful for the palliative care nurse to tell an end-of-life patient’s family when the patient exhibits delirium?

Model Answer: The family is in need of education and support regarding the cause and the irreversible nature of the behavior. Maintaining a calm environment, spiritual comfort, and emotional support are vital at this time. The family can be advised to continue to talk to the patient and calm the patient with their words. Light massage of the arms, back, or forehead can be very soothing. Soft music and low lights can also be effective. It may be suggested that the number of people in the room be decreased if there is a lot of activity. Refraining from asking the patient many questions can diminish agitation.

Eventually the patient’s level of consciousness will decrease and he or she may even become unable to be aroused. This is typically a very upsetting time for family because the patient may seem unresponsive and withdrawn, but it is a normal aspect of the dying process.

At this time, the patient is starting to “let go” in preparation for death and is detaching from relationships and the physical environment. A patient may ask to be with only one person toward the end or seem distracted from the family. Reassure the family that this is not a personal rejection, only another aspect of the dying process. A dying person may talk about seeing people who have already died or talk about taking a trip with a long-deceased relative.

Patients may describe feeling separate from their body. This is a normal experience and is not considered a hallucination.

Even if the patient is unresponsive, encourage family members to talk with him or her.

Assume that the patient hears everything; this is the time for loved ones to say “Good-bye,” “I’m sorry,” “I love you,” or “Thank you.” The patient may have difficulty letting go and the nurse may need to encourage the family to give the patient permission to die. Encourage the family to show affection to the patient, touch the patient, and let the patient know he or she will be missed.

3. What post-death care does the nurse perform when a patient dies?

Model Answer: Post-death nursing care involves preparing the body for the morgue or funeral home and helping the family through decisions regarding autopsy and burial. Care of the body by the nurse should include closing the eyes, inserting dentures and closing the mouth, and elevating the head of the bed so that the blood does not drain into the face and discolor it. Any IV or catheter can be removed at this time, and the physical environment should be straightened. Removal of tubes and equipment is dependent on institutional protocol. Follow the agency protocol regarding jewelry; if there is a wedding ring, secure it on the finger with tape. The body should be bathed in plain water and dried; a bed protector should be placed under the body. If there are dressings on wounds, they should be replaced with clean ones. The hair should be combed, the extremities straightened, and the right great toe tied with an identification tag. When the family has given permission for the body to be moved, the nurse should follow the institutional protocol regarding shrouding the body. If a person has died at home and it is an expected death, the undertaker is called and they remove the body as it is. In a hospital or nursing home setting, the body is wrapped in a shroud or

body bag. The shroud should be secured with safety pins or ties and a second identification tag should be attached to the shroud or body bag. The body is then taken to the morgue.

4. Amjad is Muslim and has just died in a hospital. What should the palliative care nurse be aware of regarding rituals for Amjad’s body?

Model Answer: Following the death, non-Muslims should wear gloves when touching the body. If there is no family available to carry out postmortem care, the nurse should wear gloves in administering care of the body. However, the body is not washed and hair and nails are not cut; the eyes are closed. The normal Muslim procedure is that the body is straightened immediately after death. This is done by flexing the elbows, shoulders, knees, and hips first, before straightening them. This is thought to ensure that the body does not stiffen, thus facilitating its washing and shrouding. Turn the head toward the right shoulder. This is so the body can be buried with the face toward Mecca.

The body is then covered with a sheet that cloaks the whole body until a Muslim is available to perform the ritual bath. The ritual bath includes washing the body three times, first with lotus water, then with camphor water, and lastly with plain water. This bathing is done from head to toe and front to back. All body orifices are closed and packed with cotton (to prevent body-fluid leakage that is considered unclean). Prayers from the Qur’an are read (especially verses of hope and acceptance) and the body is wrapped in a special cotton shroud. This shroud is made from three pieces of white unsewn cloth, 9 yards long, which are wrapped above, below, and around the midsection. Muslims are buried in a brick- or cementlined grave with the head facing east toward Mecca.

5. What role can the palliative care nurse play in helping bereaved family members form new identities?

Model Answer: Another important aspect of the post-death experience for the bereaved is the formation of a new identity within their community. The role of widow, of no longer having a child, or of one who has lost a parent brings with it a change in how the bereaved interact and correspond to society at large. Social groups may shrink, volunteer opportunities may be lost, and favorite activities may be forfeited due to the loss of the deceased. Nurses need to be aware of the difficulties inherent in these role shifts and offer alternatives and community-support referrals during this transitional stage.

CHAPTER 1 Palliative Care Nursing Multiple Choice 1. The majority of hospice care is provided in which setting?

A. Hospitals B. Private residences C. Jails D. PC clinics Answer: B Rationale: While hospice occurs in many different settings such as acute care hospital units, PC clinics or ambulatory settings, private practices, and prisons, most hospice care is provided in private residences such as nursing homes, homes, and residential facilities.

2. Which entity is the first professional organization for excellence in the practice of hospice nursing?

A. National Board for Certification of Hospice and Palliative Nurses (NBCHPN) B. Hospice and Palliative Nurses Foundation (HPNF) C. Advancing Expert Care (AEC) D. Hospice and Palliative Care Nurses Association (HPNA) Answer: D Rationale: Incorporated in 1987, the Hospice Nurses Association (HNA) became the first professional nursing organization dedicated to promoting excellence in the practice of hospice nursing. NBCHN is the National Board for Certification of Hospice and Palliative Nurses. HPNF is the Hospice and Palliative Nurses Foundation. In 2014, the HPNA came together with the Hospice and Palliative Nurses Foundation (HPNF) and the Hospice and Palliative Credentialing Center (HPCC) to form a partnership with a synergized mission. The three distinct organizations form Advancing Expert Care (AEC).

3. In 1995, SUPPORT investigators came to which conclusion?

A. Patients with end-of-life care felt they had adequate communication with their healthcare providers.

B. Patients with end of life care were requesting less-aggressive medical treatments.

C. Dying patients require an individual and collective commitment from healthcare providers.

D. Dying patients were reporting moderate levels of pain and needed little increase in medication.

Answer: C Rationale: The “Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment” (SUPPORT; SUPPORT Study Investigators, 1995) investigators believed that improving the end-of-life care for patients required an individual and collective commitment of healthcare providers and that the caregiving processes needed to be reshaped. SUPPORT findings indicated a lack of communication between patients and their providers, particularly

related to EOL preferences, aggressiveness of medical treatments, and a high level of reported pain by seriously ill and dying patients.

4. Which type of disease is a leading cause of death today?

A. Infectious B. Autoimmune C. Chronic D. Acute Answer: C Rationale: People today are living much longer than those of previous eras. The leading causes of death have changed from primarily infectious diseases to chronic illnesses. In 2014, the 10 leading causes of death were heart disease, cancer, chronic lower respiratory diseases, unintentional injuries, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide. These 10 causes of death accounted for 74% of the 2.6 million deaths in 2014.

5.

What is the purpose of the eight domains of palliative care?

A. To reflect national guidelines for quality palliative care B. To correlate palliative care with hospice parameters C. To determine nursing school palliative care learning objectives D. To educate physicians on the benefits of a palliative care

Answer: A Rationale: The domains of quality palliative care are designed to complement the process of improving PC quality. The qualifications of caregivers are determined by the organizations that grant professional credentials and programmatic accreditation. As a specialty organization, the Hospice and Palliative Care Nurses Association has identified the scope and standards of hospice and palliative care nursing and the competencies at all levels of nursing practice, specifically nursing assistants, licensed vocational nurses, professional registered nurses, and advanced practice nurses.

6. In addition to the nurse, which professionals are core members of the palliative care team?

A. Dietician and physical therapist B. Physician and pharmacist C. Physician and nursing assistant D. Physician and social worker Answer: D Rationale: At the very minimum, the interprofessional team includes the physician, nurse, social worker, and clergy. While physical therapists, dieticians, and nursing assistants can play significant roles in the patient’s care, they are not considered part of the minimal team.

7. What is the last step in the advanced practice nurse’s standards for development and implementation of a plan of care?

A. Planning B. Consultation C. Diagnosis D. Evaluation Answer: D Rationale: A specific notation of standards applies only to the advanced practice nurse, especially when creating a plan of care for the patient. The steps involved are assessment, diagnosis, outcome identification, planning, implementation, coordination of care, health teaching and health promotion, consultation, prescriptive authority and treatment, and evaluation.

8. Which situation shows a nurse demonstrating competency in collaboration when providing palliative care?

A. Checking current research on effective pain management when determining the care plan for an end-of-life patient B. Consulting with a dietician when determining the meal plan for a patient with end-stage renal failure C. Providing a list of caregiver support groups to a patient's family members D. Reflecting on actions taken in a care situation and how they may be improved Answer: B Rationale: Interprofessional collaborative practice involves different types of health professionals working together with patients, families, and communities to deliver best practices and best patient outcomes. Practicing evidence-based nursing, being knowledgeable regarding resources to assist patients and families, and evaluating care are nursing competencies but does not reflect interprofessional collaboration.

9. What is the core principle of palliative care?

A. Patient’s family involvement is approved by the healthcare provider.

B. Patient’s care depends primarily on the disease involved.

C. Patient and healthcare provider are the unit of care.

D. Patient and family are the unit of care.

Answer: D Rationale: A core principle of palliative care across the entire disease spectrum and in all settings is that the patient and family constitute the unit of care. The patient and family, rather than the disease, are the primary focus of care. Family-centered care forms the foundation of palliative care philosophy; it addresses the meaning of disease, suffering, life, and death within the context of each family unit.

10. Physical, psychological, spiritual, and social dimensions are part of which conceptual model?

A. Whole-person suffering B. Calkin model of advanced nursing practice C. Systems approach D. Clinical ethics

Answer: A Rationale: Dame Cicely Saunder is the founder of St. Christopher’s Hospice in London. She developed a conceptual model of “whole-person” suffering that has four dimensions: physical, psychological, spiritual, and social. Suffering affects each domain of the bio–psycho–social– spiritual aspects of care. This forms the basis for the description of palliative care nursing practice.

Short Answer 1. What is the difference between palliative care and hospice care?

Model Answer: While there are similarities between palliative care and hospice care, palliative care involves identifying and preventing serious, chronic, or life-threatening illness, and is used along with measures to reverse the illness or prolong life. The focus is pain and symptom relief for the patient, comfort measures, and management of physical, psychological, or spiritual issues that the patient may experience during the illness trajectory.

Palliative care was built on the foundation of Hospice care which is holistic, comprehensive care of the patient and family with serious, life-threatening, and progressive illness. The difference is that patients may be enrolled in Hospice, as a Medicare benefit, only during that last six months before death. Palliative and Hospice care exist on the same continuum of care with palliative care offered earlier in the illness experience. If a patient decides not to enroll in Hospice, Palliative care can also continue through the death of the patient and into the bereavement period of families.

2. Describe three factors that drew national attention to palliative care as it was first emerging as a care specialty.

Model Answer: Billings and Block (1997) identified forces that increased national attention on palliative care. These included growing interest in death and dying; development of hospice programs; increasing integration of pain and symptom management into conventional care; concern about the high cost of dying; increased national focus on pain management; greater attention in medicine to caring rather than curing; national debates on physician-assisted suicide and euthanasia. All of these forces led to increased demand for expert, comprehensive palliative and hospice care.

3. What are at least four standards of nursing practice?

Model Answer: The standards of nursing practice, which are the foundations of palliative care and hospice nursing, include providing age-appropriate and culturally, ethnically, and spiritually sensitive care and support; maintaining a safe environment; educating patients and families to identify appropriate settings and treatment options; assuring continuity of care and transitioning to the next appropriate setting; coordinating care across settings and among caregivers; managing information and protecting confidentiality; communicating promptly and effectively.

4. Discuss ways in which relief of suffering and quality of life can be enhanced for patients receiving palliative care and hospice.

Model Answer: Relief of suffering and quality of life for individuals who are undergoing palliative care or hospice and their families are enhanced by providing effective pain and symptom management; addressing psychosocial and spiritual needs; incorporating cultural values and attitudes in the plan of care; creating a healing environment for a peaceful death; supporting those who are experiencing loss, grief, and bereavement; promoting ethical and legal decision making; advocating for personal wishes and preferences; using therapeutic communication skills in all interactions; facilitating collaborative practice; ensuring access to care and community resources through influencing and developing health and social policy; contributing to improved quality and cost-effective services; creating opportunities and implementing initiatives for palliative education for patients, families, colleagues, and community; and participating in the generation, testing, and evaluation of PC knowledge and practice.

5. Why is certification in hospice and palliative care valuable and important?

Model Answer: Certification in hospice and palliative care means achieving tested and proven competency, increasing knowledge, committing to this specialty, being dedicated to professional development, committing to improved patient outcome, having compensation incentives, gaining recognition, and being an asset to an employer because certification is a recognized quality marker by patients, physicians, providers, quality organizations, insurers, and the federal government.

CHAPTER 2: Palliative Care: Responsive to the Need for Healthcare Reform in the United States Multiple Choice 1. Which statement describes palliative care for a patient recently diagnosed with pancreatic cancer?

A. Patients with a rapidly progressing cancer benefit little from palliative care.

B. Palliative care is offered in the last 6 months of life.

C. Palliative care focuses primarily on disease management D. Palliative care can be provided along with curative treatments.

Answer: D Rationale: Palliative care can be provided in the context of curative treatments, concurrently with symptom alleviation of the disease or its treatment, as well as offering psychological and spiritual support during the illness experience. Palliative care begins at the time of the patient’s diagnosis and continues until the patient’s death, and into the bereavement period for families.

2. The rising cost of healthcare has caused which of the following effects?

A. Palliative care is becoming a structured system of care within mainstream healthcare.

B. The number of patient consultations to palliative care is decreasing.

C. Palliative care is increasing medical expenses. beErSoT f tBreAaN tmKeS ntEoLpL tioEnRs .oC ffeOrM ed.

D. The need to limit the numT Answer: A Rationale: Palliative care is moving into the mainstream of healthcare as a highly structured and organized system of care. Because of the increase in the number of people age 65 and older, more patients are seeking palliative care. Palliative care promotes quality health outcomes, providing added value while lowering health care costs. Palliative care which is comfort and supportive care can be offered along with curative therapies.

3. A patient has just received a diagnosis of rheumatoid arthritis. If the patient receives a palliative care consultation, which outcome is most likely?

A. Care will be shifted from home to hospital.

B. Comprehensive, coordinated care will occur C. Quality of life for family will be unchanged.

D. Laboratory and pharmaceutical costs will increase.

Answer: B Rationale: Palliative care results in fewer hospital days, fewer emergency department or physician office visits, and fewer days in a skilled nursing facility. As more patients wish to remain at home during an illness and to die at home, palliative care allows the shift of care from hospital to home, while providing comprehensive coordinated care across settings. Palliative care increases the quality of life for patients and their families, and reduces the total costs of ICU admissions, lowers the cost per day, lowers the direct costs per admission, and also reduces laboratory costs.

4. Which patient is most likely to have access to quality hospice or palliative care?

A. Jason, who receives outpatient services in rural Tennessee B. Carmine, who has been admitted to a small community hospital in Arizona C. Nancy, who has been admitted to an academic medical center in Massachusetts D. Adele, who receives outpatient services at the VA hospital in Georgia Answer: C Rationale: There is state-to-state and region-to-region variability in accessibility and availability of palliative care. Issues may be due to a shortage of trained professionals in PC, particularly in public and community provider hospitals, which serve Americans who are without healthcare insurance or those who live in geographically isolated areas. PC has grown rapidly in the U.S. healthcare system, with 90% of large hospitals with 300 or more beds now having a PC team.

The number of palliative care programs is highest in the New England (88% of hospitals), Pacific (77% of hospitals), and mid-Atlantic (77% of hospitals) areas and lowest in the west south central (43%) and east south central (42%) states. In contrast, only 26% of for-profit hospitals, 37% of community hospitals, and 54% of public hospitals offer PC. Most veterans receive hospice care (71%), while 52% received palliative care.

5. In which way does voluntary certification in palliative care support healthcare reform?

A. Increases the number of palliative care programs supervised by physicians B. Links palliative care with hospice care in the minds of patients C. Insures that palliative care programs meet the criteria for quality palliative care D. Maintains current reimbursement standards for palliative care Answer: C Rationale: The current voluntary certification in PC, as recommended by the Joint Commission, as well as the expectation for hospitals to achieve Magnet status, supports the mandate for healthcare reform in America and the provision of PC for patients and families. Certification insures that a palliative care program meets the criteria for quality palliative care as identified in the National Quality Forum Consensus Guidelines for Quality Palliative Care.

6. The family of a patient with Alzheimerʼs disease requests an appointment with a palliative care specialist. Which of the four “As” of Maryland’s Blueprint for Success does this demonstrate?

A. Awareness B. Acknowledgment C. Action D. Access Answer: D Rationale: Access is the right, privilege, or ability to make use of resources and information related to palliative and hospice care.

7. Which statement describes palliative care on a global level?

A. Most countries are starting to consider palliative care to be a human right.

B. Palliative care has been well integrated into the healthcare systems of most countries.

C. Funding for palliative care is highly reimbursed in most countries.

D. Palliative care occurs primarily in the home across most countries.

Answer: A Rationale: In many countries, access to PC is being considered a human right, as it ensures the relief of pain and suffering from cruel, inhumane, and degrading treatment. The integration of palliative care into global health care settings is moving forward in many countries but not all countries. The reimbursement of palliative care remains a challenge.

8. Which action by the nurse most empowers the patient?

A. Consulting with the attending physician B. Explaining risks and benefits of treatments C. Discussing the prognosis with family members D. Choosing a plan of care based on research evidence Answer: B Rationale: Explaining risks and benefits of treatments most empowers the patient because the patient is informed of and can make decisions about his or her healthcare accordingly.

9. What role in the nursing profession develops new palliative care knowledge?

A. Nurse researchers B. Nurse educators C. Doctors of Nursing Practice D. Clinical Nurse Leaders Answer: A Rationale: Nurse researchers have the skill to conduct nursing studies and add to the development of knowledge related to palliative care. Doctors of Nursing Practice translate knowledge into practice. Nurse educators and Clinical Nurse Leaders educate nurses and promote the advancement of quality palliative care.

10. Which action by nurses will best integrate palliative care into mainstream healthcare?

A. Establish networks of palliative care providers B. Increase public knowledge of palliative care C. Ensure the funding of palliative care D. Participate in social and political activism for palliative care Answer: B Rationale: Modification of public perceptions of palliative care is central to improving knowledge of, and access to, services, empowering individuals and involving communities in end-of-life care. Nurses, as educators, must focus on achieving a comprehensive knowledge of the public regarding palliative care.

Short Answer 1. Describe the 3-year palliative care/hospice demonstration project implemented by the Centers for Medicare & Medicaid Services under the requirements of the Affordable Care Act of 2010.

Model Answer: This project is designed to allow patients to receive aggressive treatment and palliative/hospice care concurrently. It requires an evaluation of the current hospice eligibility criteria, with the expectation that the current prognosis of 6 months or less to live for patients with advanced illness will be relaxed. Additional project outcomes measured are the cost saving of palliative home healthcare programs and an evaluation of patients’ and families’ quality of life. The project hypothesizes that, compared to usual care, there will be improved survival rates when palliative care is performed along with life-sustaining treatments.

2. What are four positive health outcomes of palliative care?

Model Answer: Studies conclude that palliative care reduces the overuse of marginally effective, ineffective, and unnecessary treatments, and results in fewer hospital readmissions, allowing greater continuity of care and the development of safe transition plans upon initial discharge. Other positive health outcomes of palliative care include better management of pain and other symptoms; emotional, spiritual, and social support of patients and families; better quality of life for patients and families; increased patient/family satisfaction; efficient TiElyS/pTaBtiA ELmLeE handling of time-intensive fam enNt/K teS am etR in. gsC; O beMtter coordination of care; increased specialty-level assistance to attending physicians; support for discharge planning staff; and nurse and physician satisfaction.

3. What roles do healthcare professionals have in promoting healthcare reform, especially in palliative care?

Model Answer: According to Maryland’s Action Plan, healthcare professionals play major roles in the education of patients, families, and communities regarding palliative and hospice care, including advanced care planning. They should develop and implement educational programs (formal and informal) related to palliative and hospice care, and communicate these programs to patients through conversations, healthcare publications, and media/marketing. In addition, healthcare professionals must be educated to ensure adequate staffing of PC programs, particularly given the increase in the number of programs. Medical, nursing, and social work schools are not only integrating PC into their curriculum, but are also creating graduate programs with a focus on PC. In addition, several interprofessional fellowship programs in PC are offered across the country, which reinforce the importance of interprofessional collaboration and teamwork. Healthcare professionals should also actively participate in palliative education and palliative care initiatives by attending national conferences, increase certification and credentialing rates, and make referrals to palliative care services and hospice care. Lastly, healthcare professionals should incorporate the National Quality Forum Preferred Practices of Palliative Care as a standard of care within the institution.

4. What are the most optimal and efficient methods for implementing palliative care on an international level?

Model Answer: To direct the international future of PC, a meeting of clinicians, health economists, researchers, policy makers, and advocates was convened with the identification of seven recommendations. These include sharing definitions of PC; recognizing the strengths and weaknesses of different payment systems; identifying country-specific and international research priorities; determining appropriate economic evaluation methods; evaluating PC costs; supporting interprofessional PC education and training programs; and developing national standards to regulate and determine PC planning and development.

5. What responsibilities do advanced practice nurses have in implementing a palliative care program?

Model Answer: Advanced practice nurses make the case to hospital administration to implement a palliative program and develop the business plan that includes interprofessional resources, feasibility and accessibility, cost control, revenue generation, integration and leveraging of existing services, and decisions regarding the structure and model of the programs. They design the operational plan for the implementation of PC programs, such as space needs, staffing roles and requirements, basic policies and procedures, and projections of patient volumes and program capacity, as well as consideration of financial and strategic planning issues. The hospital’s financial viability, including the value of the program regarding the length of stay at the hospital, daily census, hospital billing revenues, estimated cost savings, and potential coT ntE riS buTtiBoA nsNbKySpE hiL laL nE thR ro.pC y,OaM re outlined. Given their advanced clinical knowledge and expertise related to healthcare systems, advanced practice nurses provide the perspective as to how PC can meet the expectations of quality care within the context of cost effectiveness and reform.

CHAPTER 3: Interprofessional Collaboration Multiple Choice 1. Which patient would benefit most from an interprofessional palliative care team?

A. Janice, who has Crohnʼs disease, is an active member of her synagogue, and lives near her two adult children B. Troy, who has a torn meniscus, is running back for his high school football team, and lives with his parents and three sisters C. Carl, who has hypertension controlled by medication, works long hours as a custodian, and lives by himself D. Ann, who has lupus, has retired from being a research assistant, and is recently widowed and lives by herself Answer: D Rationale: While all patients can benefit from an interprofessional palliative care team, some patients have more resources than others. Of the four patients listed, Ann would benefit the most.

She has a chronic disease that requires pain management and occasional hospitalization. Since she is retired, she may not have supportive friends from work, and since she is recently widowed, she has undergone a great loss.

2. Which example demonstrates interprofessional team care?

A. A patient addicted to alcoT hoElSwThB oA atN teK mSpE tsLsuLici de., C thO enMreceives a visit from a social ER worker after going home from the hospital B. A mother on the obstetrical unit whose premature infant is in the NICU receives a visit from the hospital clergy C. An overweight patient, with heart disease who undergoes bypass surgery, receives a referral for a dietician upon discharge to help him lose weight D. An indigent patient with cancer who undergoes chemotherapy and is then referred to a radiologist.

Answer: B Rationale: Quality, comprehensive, whole-person care depends on the integration of curative and palliative care. The mother of a premature infant in the NICU who then receives a visit from the hospital clergy is an example of interprofessional team care. Her spiritual needs are being addressed at the same time that her baby is receiving medical care. All the other examples involve healthcare and healthcare professionals brought in later when they should have been brought in concurrently with the medical care.

3. Which process demonstrates interprofessional practice?

A. Curative methods are used first, then palliative methods.

B. Communication is primarily through the patient’s chart.

C. Integrated plan of care is formulated by many professionals.

D. Family needs are addressed after the plan of care is enacted.

Answer: C Rationale: An interprofessional team approach integrates separate disciplines into a single consultation, discussing the patient history, assessment, diagnosis, intervention, and short- and long-term care management. The goals of care are established by the team, together with the patient and the family, who are involved in making healthcare decisions.

4. Which interprofessional team member usually assesses patient and family physical, emotional, and spiritual needs?

A. Registered nurse B. Chaplain C. Palliative care physician D. Social worker Answer: A Rationale: A registered nurse conducts a comprehensive assessment of patients’ and families’ physical, emotional, and spiritual needs and intervenes through therapeutic presence and communication, use of nursing interventions, and administration of medical treatments to improve the quality of life.

5. Which of the following is an example of good interprofessional communication?

A. Confirming a registered nurse was aware that a patient was being given two prescriptions B. Ensuring physicians communicate with one another and the palliative care nurse about what to prescribe for a patient TuBnA C. Asking the pharmacist to T coEmSm icN atK eS wE itL hL thE eR re.gC istOeM red nurse about what prescriptions a patient should receive D. Having the palliative care nurse inform physicians which prescriptions would be best for a patient Answer: B Rationale: Certain levels of decision making may be made by individual members of the interprofessional team, whereas other levels will require input from the entire team as a whole.

Poor, fragmented decision making results from the failure to include appropriate team members in the decision-making process. Physicians should communicate with one another and the palliative care nurse about what to prescribe for a patient. The registered nurse is not responsible for writing prescriptions. Asking the pharmacist to communicate with the registered nurse about what prescriptions a patient should receive is inappropriate, as is having the palliative care nurse inform physicians what prescriptions they should write.

6. If the interprofessional team leader asks other team members for their expert opinions but develops the plan of care on his or her own and expects the other team members to follow it, what will the result most likely be?

A. Fragmented decision making B. Lack of input C. Lack of innovated problem solving D. Miscommunication of information

Answer: C Rationale: The interprofessional team leader is displaying lack of respect for the knowledge and skills of other team members. This may stifle the creativity and innovative solutions if team members consistently think they are not being listened to. There is no lack of input because the team leader has asked for expert opinions.

7. Which healthcare professional is demonstrating interprofessional competence?

A. A physician who makes sure the nurse sees to the family’s needs while he or she focuses on curative methods B. An advanced care nurse who wants a clergy member on every patient’s team C. A physician who uses the same team model at a new hospital that was used at a previous hospital for continuity D. A registered nurse who asks patients and families regarding their needs and preferences and involves support of the community Answer: D Rationale: Interprofessional competence means following the principles of interprofessional healthcare, which are patient centered and community/population focused rather than profession centered. A registered nurse who wants to restructure her work schedule to do community outreach is community/population focused rather than profession centered. A physician who makes sure the nurse sees to the family’s needs while he or she focuses on curative methods is not looking at the patient holistically, which is a basic tenet of the interprofessional care. An advanced care nurse who wants a clergy member on every patient’s team is not being patient EL centered if the patient does not wT anEt S aT clB erAgN yK mS em beLr.EARp.hCyO siM cian who uses the same team model at a new hospital that was used at a previous hospital for continuity is not being sensitive to the fact that different practice settings may require different team models.

8. What is the key to healthcare reform for providing compassionate, cost-effective, evidencebased healthcare that is individualized for each patient?

A. Interprofessional education B. New laws concerning medical treatments C. Surveys requesting input from patients D. Interprofessional marketing Answer: A Rationale: Interprofessional education is key to developing a workforce of the future that will provide comprehensive, compassionate, cost-effective, continuous, evidence-based healthcare for varying patient populations, families, and communities. Interprofessional marketing can bring awareness about the interprofessional team approach but does not necessarily lead to healthcare reform.

9. Which statement describes the use of an interprofessional team care?

A. It is effective only in large hospitals with many team members.

B. Patients become confused with so many different team members.

C. Team members develop their own discipline specific plan of care.

D. Team members can share leadership for the patient’s best interest.

Answer: D Rationale: Sharing or rotating group leadership is of value in equalizing power and responsibility and acknowledging and appreciating the expertise of all members of the interprofessional group.

This provides new insights; the best thinking of colleagues is valued since there is a sense of shared responsibility in insuring the best patient and family healthcare outcomes.

10. Which statement regarding an interprofessional team is incorrect?

A. Leadership of the team is shared depending on the patient issue.

B. Health professional competencies are unique to their discipline, as well as shared.

C. The plan of care is developed by the champion of the team.

D. Collaboration, coordinated decision making, and conflict avoidance are essential.

Answer: B Rationale: The Center for Advancement of Interprofessional Education (IPE) emphasizes the unique and shared competencies of health professionals, as well as the importance of having a champion of interprofessional collaboration, who may assume a leadership role, but engages all team members. The champion of interprofessional collaboration may be the leader of the interprofessional team, or another healthcare professional may assume that role. Leadership may also change, depending on the patient’s case. An interprofessional team approach integrates separate disciplines into a single consultation, discussing the patient history, assessment, diagnosis, intervention, and short- and long-term care management. A dynamic and outcomeoriented interprofessional team requires collaboration, leadership, coordinated decision making, and conflict resolution.

Short Answer 1. What are the driving forces behind an interprofessional approach to palliative care?

Model Answer: Palliative care requires a comprehensive and holistic approach that cannot be addressed by just one healthcare professional. There is a need to reduce morbidity and mortality rates, improve care coordination, provide patient-centered care, reduce healthcare costs, and enhance group accountability for the quality of healthcare. Healthcare professionals need to work together as a team. This will involve redesigning healthcare education, retraining health professionals already in the workforce, and reforming the overall healthcare system. Research suggests that interprofessional learning is essential for patientcentered, cost-effective, efficient, safer, timelier, and more equitable healthcare. For patients and family members, interprofessional practice can decrease total patient complications, decrease the length of hospital stay, reduce outpatient visits, and reduce mortality rates, including suicide rates.

2. Kacie is 32, married, and the mother of two small children. She was admitted to the hospital with weakness and pain that seemed to come out of the blue. After extensive tests, she has been diagnosed with multiple sclerosis. What would be the advantages of an interprofessional model of care for her?

Model Answer: Based on an interprofessional model of care, leadership, communication, and decision-making means leadership is shared and based on patient and family needs and

goals. Many different healthcare professionals will be brought together to formulate her plan of care. Team members will directly interact with Kacie and her family, share information, provide consultation, and work interdependently together to provide comprehensive, continuous care. The team will likely consist of her physician, palliative care nurse, as well as a physical therapist, an occupational therapist, and pharmacist.

3. What roles does the interprofessional team nurse have in the therapeutic relationship with the patient and other team members?

Model Answer: As a coordinator of care and a core member of the interprofessional team, the nurse has the responsibility of developing therapeutic relationships with the patient and family and among all pertinent members of the team. The goal is to ensure effective and supportive communication and quality patient outcomes. The nurse continually reassesses the goals of the patient and family, and their treatment preferences, and offers support. Often, the physician has had a long-term relationship with the patient and family, and as the needs for traditional medical model of curative care lessen, the physician may feel a sense of loss. The collaborative relationship with the physician may also be a source of support for the physician both personally and professionally. The nurse is also a primary conduit for information, critical assessments, and evaluation of the patient and family goals within the interprofessional team. A critical aspect of palliative care involves the identification and subsequent resolution of often differing goals of the patient, family, or the healthcare team.

The nurse is instrumental in coordinating and implementing a comprehensive family-focused plan of care.

4. An advanced care nurse in a 300-bed hospital located in a mid-sized city has taken note of high dissatisfaction rates from patients regarding their hospital stays. The nurse knows that budget cuts have had much to do with this, and is concerned that this may be a continuing trend. While researching other hospitals that are similar in size that are facing the same issues, the nurse reads about interprofessional team healthcare. The nurse is concerned about how well it could be implemented, given the diverse personalities of the hospital healthcare professionals. What steps could the nurse take as an experiment for interprofessional collaboration?

Model Answer: The nurse could try an interprofessional case study modeled after the one used by a group of eight interprofessional colleagues in the College of Nursing and Health Sciences. This was a reflective process by the group leader that led to the identification of eight steps of the group collaborative process. These include the discussion of the leadership of the group going forward, depending on clinical issue to be addressed; the group process promoting commitment and accountability, such as establishing the best day and time to meet or the use of technology in conducting meetings, as well as strategies for communication through email; shared group responsibility in reviewing the health sciences literature regarding the care of the specific patient population, with each member contributing their findings during a group discussion from their disciplinary perspective; outlining the components of the comprehensive health history and physical examination from an interprofessional perspective and developing case-specific details; reviewing the case findings with identification and prioritization of clinical diagnoses; developing holistic interventions, including discipline-specific and complementary interventions from an

interprofessional perspective to address diagnoses/clinical problems; and involving all team members in the evaluation of health outcomes. This method involved all members contributing equally from their area of expertise instead of using traditional hospital hierarchy.

5. What is necessary to keep the momentum going for healthcare reform through the implementation of interprofessional healthcare teams?

Model Answer: Transformative change in education and clinical practice is needed. It will involve interprofessional networking of colleagues within, across, and beyond the university environment and those within healthcare systems and agencies. Further research on the structure, processes, and outcomes related to interprofessional collaboration is needed as it relates to patients and their families, healthcare providers, and institutional outcomes.

CHAPTER 4: Ethical Aspects of Palliative Care Multiple Choice 1. If a nurse is wondering if removing a terminal patient’s feeding tube was the right action to do, what is the nurse engaged in?

A. Ethics consultation B. Ethical inquiry C. Value clarification D. Moral uncertainty Answer: B Rationale: Ethical inquiry seeks to interpret acts, and to answer such questions as “What is the right thing to do?” includes an evaluation of the moral agent and his or her character, the motive for the act itself, and the effect of the action on others.

2. Which situation is an example of an ethic of caring?

A. A nurse who avoids telling terminal patients to prepare for the end of life so they will remain calm.

B. A nurse who spends an extra few minutes with each patient to find out how he or she is feeling.

C. A nurse who recommends that patients receive palliative care only in the hospital for the best outcome.

D. A nurse who urges patients to request opioids for pain relief since they provide the most analgesia.

Answer: B Rationale: Caring, within the context of an ethics of care, refers to care for, emotional commitment to, and willingness to act on behalf of persons with whom one has a significant relationship. An example of this is a nurse who spends an extra few minutes with each patient to find out how he or she is feeling because the nurse is forming a relationship with these patients.

3. The custodial parent of a terminally ill child in a hospital has requested that the noncustodial parent be prevented from visiting the child. The concern is that the child will become upset.

However, the child has been asking to see the noncustodial parent. The healthcare professionals are trying to decide how to handle the situation. Which concept is involved?

A. Moral analysis B. Value clarification C. Ethics of doing D. Ethics of being Answer: C Rationale: Ethical theories that focus primarily on actions and decisions are considered ethics of doing. Moral analysis is employed to discern all the parameters involved in a decision. Ethical theories that focus on an individual’s character attributes and virtues are considered ethics of

being. Values clarification is a process of self-reflection that helps individuals identify, consider, and articulate the belief, purposes, and attitudes they prize and that drive their actions.

4.

Which situation describes a nurse breaking the fundamental principle of respect for persons?

A. Allowing family to stay in the room with the patient after hospital visiting hours are over B. Questioning whether a patient’s DNR order has been properly documented C. Forgetting to note a dietary allergy in the patient’s chart, which causes an anaphylactic event D. Administering pain medications last to patients on the floor who are on government assistance

Answer: D Rationale: The most fundamental ethical principle within nursing practice is the principle of respect for persons. The first provision in the Code of Ethics for Nurses calls for nurses to “respect the dignity and rights of all human beings regardless of the factors contributing to the person’s health status. The worth of a person is not affected by illness, ability, socioeconomic status, functional status, or proximity to death.” Administering pain medications last to patients on the floor who are on government assistance shows lack of respect for these persons.

5. Melanie has just been diagnosed with early-onset Alzheimerʼs disease. She is terrified about her future and is unsure what do to about her healthcare. Which surrogate decision-making option is the most optimal for Melanie?

A. Writing an advance directive that outlines her wishes EbSeT B. Depending on a family mT em r’B sA suN bK stiStuEteLdLjuEdRg. mC enOt M C. Relying on healthcare professionals to make decisions in her best interest D. Trusting that she will make her own best decisions when she is lucid Answer: A Rationale: There are three standards for surrogate decision making: written advance directives (e.g., living wills), substituted judgment, and best interest. These three standards are ordered so that advance directives have priority over the other two, and substituted judgment has priority over the best-interest standard. The best of all situations is a thoughtfully drafted advance directive applied by a surrogate decision maker who knows the patient’s values and wishes.

6. Jeremy has been living with an aggressive form of leukemia for some time and is currently undergoing chemotherapy. Recently, a nurse making a home healthcare visit said that Jeremy might consider experimental treatments. The survival rate with the experimental treatments is lower than that for chemotherapy, but the side effects are milder. What issue does this present?

A. Duty-based ethics B. Principle of double effect C. Nonmaleficence D. Morality Answer: B Rationale: Any discussion that includes attempts to distinguish between harming and benefiting patients often includes the principle of double effect. The traditional formulation of this principle

stipulates that four conditions be met before an act with both good and bad consequences may be morally justified: The action itself must be good or at least morally indifferent; the individual must sincerely intend only the good effect and not the evil; the evil effect cannot be the means to the good effect; there must be a proportionately valid reason for permitting the evil effect; that is, there must be a favorable balance between the good and the evil effects of the action. Nurses may appeal to this principle in morally difficult situations where it is not possible to benefit a patient by an action without at the same time causing harm.

7. If a nurse is confronted with an ethical dilemma, which approach would be most useful in resolving it?

A. Organize a committee, identify authority figures who can make decisions, notify legal entities B. Consider past actions, present relevant information to patient, have patient make choices C. Gather relevant facts, identify parties involved, identify choices and consequences D. Identify conflicts of ethical principles, give information to authority figures, step away from the situation Answer: C Rationale: Steps that can help resolve an ethical dilemma include reviewing the situation; gathering all relevant facts; identifying the parties or stakeholders involved; identifying relevant legal data; identifying specific conflicts of ethical principles or values; identifying possible choices, their purpose, and their probable consequences to the welfare of the patient; identifying and making use of interprofessional and institutional resources; identifying practical constraints .aCkO to decision making; taking actionTifEySoT uBarAeNthKeSdE ecLisLioEnRm erMor supporting the authorized decision maker; reviewing and evaluating the situation after action is taken.

8. Which consideration demonstrates the primary moral concern for nurses?

A. Whether parents are choosing the correct course of chemotherapy for their child B. Whether parents understand if a medication’s benefit outweighs side effects for their child C. Whether family members understand the end of life is near for their loved one D. Whether family members are initiating life-sustaining treatments too late Answer: B Rationale: Optional or nonburdensome treatments include all medications, treatments, and operations that offer a reasonable hope of benefit and can be obtained and used without excessive expense, pain, or other inconvenience from the patient’s perspective. Extraordinary (or burdensome) treatments are those that are very costly, unusual, difficult or dangerous, or do not offer a reasonable hope of benefit to the patient. What should be of moral concern for nurses is not what the intervention is, but whether the benefits of its continued use outweigh its associated burdens, as determined by the patient or surrogate decision maker.

9. Which concern plays a central role in the debate surrounding assistance in dying?

A. If prescriptions for lethal amounts of medication is the same as withholding food and water B. That increasing numbers of terminal patients will end their lives rather than receive palliative care

C. Negative attitudes that have been directed toward those who choose to end their lives D. A possible cultural shift leading to vulnerable patients perishing too soon Answer: D Rationale: While some individuals benefit from access to lethal prescriptions to control the timing of their death, others are harmed by lack of access, leading to concerns about unintended negative consequences of legalizing and sanctioning this practice. The concern is that allowing healthcare providers to support patients who choose to end their life through legally and professionally sanctioned access to lethal prescription will accelerate a cultural shift that will lead some of the most vulnerable members of society to die too soon.

10. Which statement accurately describes pediatric medical considerations?

A. Minors need to be included in decisions about their care B. Parents have the final say about their infant’s care C. Parents can always choose what type of care their children receive D. Minors cannot override parents’ decisions about what care they receive Answer: A Rationale: Minors have rights to be included in end-of-life decision making, depending on their decision-making capacity and maturity.

Short Answer

.oCrO 1. Describe a situation in whichTaEnS urT seBiA sN exKpS erE ieL nL ciE ngRm alMuncertainty, and a situation in which the nurse is experiencing an ethical dilemma. Explain how these situations are similar, and how they are different.

Model Answer: Moral uncertainty occurs when nurses are uncertain if a moral problem exists, are unsure about its nature, and are unclear which values conflict and which principles might facilitate clarification. An ethical dilemma occurs less frequently and is understood as a situation in which two or more clear ethical principles apply that support mutually inconsistent courses of action. Each alternative course of action can be justified by an ethical rule or principle, but one can choose or satisfy only one course of action at the expense of not satisfying the other. A situation involving moral uncertainly could be a patient who is alcoholic and continues to drink even though the alcohol interferes with potentially lifesaving medication. The moral uncertainty could be in how to address the patient’s drinking and discussing the ramifications, especially if the nurse has values against drinking excessively. A situation involving an ethical dilemma is a nurse who is with a patient who has just been sexually assaulted by a man. The attending physician is male, and the patient is terrified to be touched by him. The patient needs care but refuses to be seen by the physician.

Both situations require the nurse to do self-inquiry, to come up with the best course of action, and to ensure the client’s care and safety. The first situation, however, requires the nurse to examine his or her own morals. The second situation requires the nurse to discern the most ethical solution.

2. Myron is 23 years old and is addicted to heroin. He has been in and out of treatment for his addiction since he was 15 and cannot seem to stay clean. He has lucid moments but is high more often than not. He has just been brought to the emergency room by his parents when they discovered him passed out in his room. As he is being treated for the overdose, the physician notes an orange tint to his skin, mucous membranes, and sclera of his eyes. A liver panel is ordered, and he is tested for hepatitis infection. The physician would like to do further liver testing. What are the steps needed to determine whether Myron is decisionally capable for his own healthcare?

Model Answer: A decisionally capable person is able to understand a proposed intervention (or its termination), deliberate regarding major risks and benefits, make a decision in light of that deliberation, and communicate the choice to others (whether verbally or nonverbally). If Myron is decisionally capable, he should understand the condition for which the intervention is recommended (hepatitis infection and/or cirrhosis of the liver), the nature of the recommended intervention (further liver testing), and the risks and benefits of the recommended intervention and of alternative interventions, including no intervention or treatment. The physician should determine that Myron acknowledges that treatment is recommended, he understands how the proposed treatment or lack of treatment can affect his quality of life, and his decision is not substantially based on a delusional belief.

3. What factors are involved in ensuring that justice is done within cost containment measures for healthcare?

Model Answer: This is a com TpEleSxTisBsA ueN. K InStE heLcLuE rrR en.t C erO aM of cost containment and social injustice, those who are already marginalized and disadvantaged by poverty, chronic or terminal illness, old age, cultural and racial status, or gender may not think they are entitled to life-sustaining procedures. Additionally, in certain political and societal realms, these people may be seen as a drain on resources and entitled to only minimal care. This is a conflict with the basic tenet of nursing, which is respect for all persons, and nurses may feel a great deal of ethical and moral conflict. However, many who advocate for U.S. healthcare reform agree that cost must be considered in the allocation of healthcare resources. There are increasing numbers of people with chronic critical illnesses in the United States. Fairly weighing such costs and associated burdens against benefits requires interprofessional understanding and cooperative effort among all affected parties within society. Caregivers face challenges in reaching ethical decisions that are fair to individual patients while using available resources responsibly and treating comparable cases alike.

4. Jackie is 14 years old and was hit by a car while riding her bicycle. She has been in a persistent vegetative state for over a year. Her parents are trying to come to terms with letting her go and have started talking about letting her die with dignity. Jackie’s nurses and physicians are recommending withdrawing artificial nutrition and hydration. What are ethical considerations of this?

Model Answer: Often the most difficult decisions about withholding treatments are those that involve caring and nurturing interventions, such as providing food and fluids.

“Artificial” or technologically provided nutrition and hydration (ANH) is not the same as oral provision of food and water. Food and water are continued to be offered orally as long as

patients desire them. However, a moral and legal consensus is that ANH is a medical treatment that may be refused or withdrawn on the same grounds as any other medical intervention—whether it is a benefit or a burden. Jackie’s parents and healthcare providers may have ethical difficulties if they are unclear whether continued provision of nutrition is more beneficial or harmful to Jackie. On one hand, continuing to provide ANH is unlikely to achieve the clinical outcome for which it is most often used, namely, to enhance comfort, prolong life, and improve the quality of life. On the other hand, Jackie is still alive, and the basic tenet of humanity and medicine is “do no harm.” Additionally, nurses should know whether their state’s legislative policy restricts or limits parental rights to decide about the administration of ANH, as that will play a role in the decision as well.

5. What resources are available for nurses to assist them in ethical decision making and to help prevent burnout?

Model Answer: Nurses may experience conflict between their own moral values and the values of the profession, and they have the right to remain true to their own conscientious moral and religious beliefs. Although prohibited from compromising legitimate patient choices or imposing their values on others, nurses who are ethically opposed to certain patient interventions will find support for their position in the Code of Ethics for Nurses.

They have the right to withdraw from providing interventions that run counter to their core beliefs, assuming that arrangements can be made for the patient’s safe transfer to the care of another. Conflict inevitably arises between nurses’ roles as caregivers and patient advocates, institutional employees, and clinicians expected to implement physicians’ orders. The nurse LoErR ethicist helps nurses identify T anEdSbT etB teA rN mK anSaE geLm al.dC isO trM ess in the workplace. Ethics consultation help staff identify and understand the specific ethical issues the case raises; improve communication between the patient, family, and healthcare team; provide emotional support to the health team members involved in a difficult case; offer ethically justifiable recommendations for how to resolve an ethical question or dilemma; and improve patient care by preventing patient care decisions that run counter to ethical guidelines and standards.

Multidisciplinary and nursing ethics committees should be available to nurses for case consultation regarding ethical conflicts. Activities such as “Schwartz rounds” and nurse resilience programs proactively address factors that can lead to moral distress and burnout.

Interprofessional ethics rounds also present an opportunity for individuals working in different patient care disciplines to discuss regularly troubling cases that may not require an immediate decision. Such meetings allow for analysis, exploration, and sharing of different points of view. Thus, when ethical problems do occur, a foundation exists to provide guidance about the most effective way to respond.

CHAPTER 5: Legal Aspect of Palliative Care and Advance Care Planning Multiple Choice 1. Which legality makes sure that Cho completely understands all the aspects of the hysterectomy her physician recommends before agreeing to the surgery?

A. Life-sustaining treatment order B. Advance directive C. Informed consent D. Durable power of attorney for healthcare Answer: C Rationale: The fundamental goals of informed consent are patient autonomy and selfdetermination, empowering them to exercise these rights rationally and intelligently. Informed consent means all the benefits and risks of medical procedures have been explained to the patient before the patient makes a decision whether to receive the treatment or not.

2. Which statement describes informed consent regarding children?

A. Children have little sense of autonomy, so parents make healthcare decisions for them.

B. Children younger than adolescents can understand treatment options and the potential end of their lives.

C. School-age children are uT suEaS llyTaBllAoN wK edStE oL haLvE eR th.eCfiO naMl say on whether they will receive treatments.

D. Adolescent children have full autonomy and can make their own healthcare decisions.

Answer: B Rationale: A study by Hinds et al. found that children as young as 10 years dying from brain tumors could understand the potential treatment options and recognize that their death could be the consequence of their decision.

3. Delphina is 67 years old, with a history of strokes, and is on Medicare. She does not want to receive painful or invasive procedures that prolong her life but decrease her quality of life and concerned that her children would override her wishes should she have a medical emergency. According to the Patient Self-Determination Act (PSDA), what is her hospital required to provide her that will help her?

A. An in-person meeting about individual rights concerning advance directives B. Verbal information about rights under state law to have an advance directive C. Written documents about hospital policies regarding advance directives D. Online sites to research how to write an advance directive Answer: C Rationale: The PSDA requires that facilities participating in the Medicare and Medicaid program provide written information to individuals about hospital policies regarding advance directives and about their right to participate in medical decision making and formulate advance directives.

Information about rights under state law to have an advance directive and policies regarding advance directive need to be given in writing, not verbally or as a verbal consultation.

4. Which document causes concern for healthcare providers because it may not allow for advances in medical treatment?

A. Durable power of attorney B. Do-not-resuscitate directive C. Living will D. Medical directive Answer: D Rationale: Healthcare providers voice concern with the accuracy of medical directives because they do not allow for advances in medical treatment or for the patient to change his or her mind about one of the interventions or situations without changing or destroying the directive.

5. In which case do laws allow physicians to prescribe large doses of opioids?

A. Chronic pain B. Intractable pain C. Patient request for the end of life D. Family request for patientʼs end of life Answer: B Rationale: Several states have enacted intractable pain statutes to encourage those who treat patients who are terminally ill anT dE haSvT eB inA trN acKtaSbE leLpL aiE nRto.m CaOnMage the pain without the threat of legal liability if the treatment results in the patient’s death. Chronic pain, patient request for the end of life, and family request for patientʼs end of life are not legally supported reasons for prescription of large doses of opioids.

6. A patient has been left unconscious from a car accident and had never formulated an advance directive. Which entity has the primary legal right to make decisions on the patient’s behalf?

A. Court system B. Healthcare institution C. Family member D. Family lawyer Answer: C Rationale: In 1982, the President’s Commission concluded that family decision making had gained and should be accorded legal acceptance. Motivated by concern over the formal legal status of family decision making in the 1980s, state legislatures recognized and began to regulate it by statute. Since the patient does not have an advance directive, the family lawyer has not been given authority to act on his or her behalf. The healthcare institution and the court system would step in only if no one else is able to act on the patient’s behalf.

7. Which question may be the most beneficial in initiating a discussion with the patient about the end-of-life preparation?

A. “Do you have an advance directive for your future medical care?”

B. “Is it okay to talk with you about your health and future medical care?”

C. “Can we talk about procedures for your future medical care?”

D. “Are you okay with talking about legal aspects of your future medical care?

Answer: B Rationale: The provider asking for permission to discuss the patient’s current condition and possible future medical care displays caring and sensitivity, and is inviting the patient into a discussion about this difficult topic. Asking about an advance directive, procedures, and legal aspects of future medical care may feel abrupt and insensitive to the patient. These types of questions are more utilitarian in approach and can be off-putting.

8. Which is an accurate statement about advance directives?

A. People may think they cause treatment to be withheld unnecessarily.

B. Most patients have them and have given them to their physicians.

C. Emergency admission is the best time to receive information about them.

D. Physicians adhere to them even in conflict with family preferences.

Answer: A Rationale: People may be concerned that once an advance directive is completed and it contains a statement to withhold treatment, providers will devote less attention to their care and may withhold more treatment than was desired. The public has not embraced the use of advance directives, and most Americans do not have one even though surveys demonstrate strong support for them. teE nS anTaBdA vaNnK ceSdEiL reL ctE ivR e. wC itO hM a DNR order and presented it to 9. A patient had previously writT her family and physician. The patient slips into a coma from diabetic complications and her family members are unable to accept the DNR order, forbidding the physician from using it.

What is the most appropriate first step for the physician?

A. Try to resolve the issue with the family members B. Refer the issue to the courts and have it resolved there C. Bring the issue to an ethics committee for discussion D. Think carefully and critically through the ethical issues Answer: D Rationale: Physicians need to think carefully and critically through the ethical issues themselves before they try to resolve disagreements with the patient or family. It is important that this reflection be done first before other actions so that the physician is clear about all the factors involved in the situation.

10. Which resource would best help nurses in enhancing their knowledge of professional moral obligations?

A. American Nurses Association Center for Ethics and Human Rights B. Supreme Court of the United States C. Black’s Law Dictionary D. Joint Commission on Accreditation of Healthcare Organizations Answer: A

Rationale: Ethics rounds, grand rounds, ethics colloquia, courses in basic nursing education, continuing education offerings, and conferences all provide forums for nurses, students, faculty, and clinicians to enhance their ethical and legal awareness. The American Nurses Association Center for Ethics and Human Rights is one rich resource for nurses who seek consultation and ethics information.

Short Answer 1. What are the purposes of natural death acts?

Model Answer: Natural death acts sprang from the belief that medical technology had made possible the artificial prolongation of patients’ lives beyond their natural limits. Another underlying assumption of the acts was that adults in the United States have the right to control decisions about how they live their lives as well as how they die. Natural death acts allow patients to refuse excessive medical care at the end of life. In addition, some natural death acts specifically state that “physicians and nurses should not withhold or unreasonably diminish pain medication for patients in a terminal condition where the primary intent of providing such medication is to alleviate pain and maintain or increase the patient’s comfort.” Most states also include in their natural death act a provision that a person’s right to control his or her healthcare may be exercised by an authorized representative who validly holds the person’s durable power of attorney for healthcare.

2. A young and active couple has not discussed how to handle medical issues, thinking it would be something to worry about T inElaStT erByA eaNrsK. S OE neLoLfEthRe. mCeOxM periences a traumatic and significant brain injury, and the physicians tell the patient’s partner that recovery is unlikely and asks about the patient’s preferred treatment. What factors will the partner need to consider? Why is it likely the partner will have trouble making decisions about the treatment?

Model Answer: In this situation, there is no clear and convincing evidence of what the patient would have wanted, so the partner is being called on to make decisions. The factors that should be taken into account when deciding what is in the patient’s best interest are the level of cognitive functioning, quality of life, treatment options, current level of pain and suffering, likelihood of pain and suffering if treatment is continued versus withdrawn, and benefits and burdens from treatment. Although these factors seem objective, the partner is likely to find the factors difficult to consider, and intense emotions may make it difficult to deliberate carefully. Shapiro (2015) notes that even the most diligent and responsible surrogates experienced a lack of clarity and were unsure about how to weigh the risks and benefits to the patients. It was difficult for the surrogates to extrapolate from incomplete information and to appreciate the uncertainty of a prognosis. Shapiro states that “many surrogates know the right outcome, it is the process that haunts and paralyzes them.”

3. A 74-year-old patient with cancer has been transported to the hospital to be stabilized in the ICU. The patient has an advance directive refusing life-sustaining treatments. The patient’s children arrive to find they cannot talk with him because of his intubation. The physician explains that life-sustaining treatments may be used for the patient, but they are painful and invasive, and it may be time to prepare for the patient’s end of life. The family becomes

upset and comes into conflict over further treatment decisions. What could have been done to help prevent or resolve the emotional anguish of this situation?

Model Answer: Decision about end-of-life care needs to be made in a family context.

Discussion with patients about end-of-life care helps a patient and their family prepare for death. The patient should have made his physician aware of his advance directive, and thoughtful discussions among the patient, his physician, and his children about his choices would have been helpful. The attending physician now has an ethical dilemma about whether to follow the advance directive or to follow the wishes of the patient’s children. Even if the patient had discussed his advance directive with his children, it is still possible they would not be prepared for his end of life and would want life-sustaining treatments performed.

Conflicts among the physician, the patient’s wishes, and his family about his end-of-life care may need to be resolved by the development of consensus about goals for care through listening, thoughtful discussion, multidisciplinary rounds, and ethics consultation.

4. Describe physician orders for life-sustaining treatment (POLST).

Model Answer: Physician orders for life-sustaining treatment (POLST) are not an advance directive. They are a set of medical orders for a patient with a serious, life-threatening condition. The physician discusses predictable future events for a patient with a lifethreatening condition (such as cardiac arrest with severe heart failure) and determines in conjunction with the patient or surrogate how the patient should be treated if/when the events arise. A document is created that specifies the treatment the physician has prescribed. The document is usually brightly T coEloSreTdBsA oN thKatSiE t iLs L eaEsR y. toCidOeMntify, and it accompanies the patient across healthcare settings, ensuring continuity of care. It is designed to provide quick, clear guidance to healthcare providers about the care that the patient desires and the primary healthcare provider has prescribed. The categories for choices on POLST forms vary from state to state. Physicians, after consultation with their patients or surrogates, prescribe either “attempt resuscitation” or DNAR at the start of the document. Other categories on the documents used in most states provide places for the physician to prescribe or to withhold a range of medical interventions from comfort measures only to full treatment, the use of antibiotics, and the administration of artificially administered nutrition.

5. Explain how the nurse is an advocate for a patient’s end-of-life preferences.

Model Answer: As the ANA has stated in its position statement, it is the responsibility of nurses to facilitate informed decision making for patients at the end of life. This responsibility begins when the nurse has a patient consider what would be important to him or her at the end of life, continues with the nurse educating the person about end-of-life care options, and is completed when the nurse advocates for and delivers the type of care the patient desires at the end of her or his life. However, this process of communication about EOL care is not solely the responsibility of the patient and the nurse; it is an interprofessional process that includes at least the physician and family in addition to the patient and nurse. On admission to a healthcare institution, the nurse should ask the patient and family if the patient has an advance directive and, if a directive exists, whether they can produce a copy of the directive. The nurse or another healthcare provider needs to inquire if the patient still wants

the directive to take effect. The nurse may use the directive to help families to understand and follow the choices laid out in the directive for a family member who has become gravely ill and is incapacitated. Often, however, no advance directive exists. When the patient is gravely ill, it is often the nurse who first notices that death is approaching. Clear communication to the family and physician is essential at this time because the family frequently has not considered death as an alternative. If death appears imminent and there has been no decision about end-of-life expectations, nurses may introduce the discussion of withholding or withdrawing life-sustaining interventions, such as CPR, intubation, and ventilation. Most patients and families want to discuss end-of-life care with their nurse, but they need to hear the same message from the patient’s physician. The nurse must be in communication with the physician about the patient’s prognosis and the patient and family’s preferences about end-of-life care. In situations in which death is not imminent, the nurse can assist a surrogate or family member to understand her or his role in the multidisciplinary team and to help make the decision about the patient’s end-of-life care. The nurse must educate the person about what the role of the surrogate entails as well as how important it is.

CHAPTER 6: Culture and Spirituality as Domains of Quality Palliative Care Multiple Choice 1. When a patient has a terminal illness, which aspect informs the nurse the most about how the patient will approach death?

A. Level of education B. Cultural background C. Views of family members D. Type of support system Answer: B Rationale: Cultural background relates to the degree of fatalism or activism in accepting or controlling death, and maintaining hope, as well as to the views of the patient and family about death. Level of education, views of family members, and type of support may play roles in how the patient approaches death, but the core factor is the patient’s cultural background.

2. Qiu is a Chinese American and the patriarch of his family. Qiu is now 84 years old and in end-stage renal failure. What can the nurse expect when approaching him about the end-oflife care?

A. Request for hospice services prEoS gnToB siA s NKSELLER.COM B. Reluctance to discuss the T C. Belief in fighting to the end D. A sense of fatalism Answer: B Rationale: Generally, members of Chinese culture are reluctant to discuss prognosis and diagnosis as they believe discussing end-of-life issues is like wishing death upon the patient, or may lead to hopelessness, especially as terminal illness is not socially accepted. There is also the belief a person’s final days should be characterized by calm and that the patient should not be involved in decision making.

3. If a nurse refrains from casually touching and making direct eye contact with a patient because these actions are considered disrespectful, which principle is being observed?

A. Cultural diversity B. Cultural awareness C. Cultural sensitivity D. Cultural knowledge Answer: C Rationale: Cultural sensitivity requires the recognition of individual attitudes and beliefs and a refinement of communication skills related to active listening, use of silence and touch, conversational distance, language patterns, and the effective use of translators.

4. Which action demonstrates cultural awareness on the part of the nurse?

A. Consider the role of family members in making decisions regarding patient care.

B. Asking a family member to translate medical treatment procedures to the patient C. Being honest with the patient about his or her chances of survival D. Avoiding asking about the patient’s spiritual beliefs because these are private Answer: A Rationale: Consideration should be given to the issue of family involvement in decision making.

Disagreement and conflict between family and healthcare professionals may occur when the family insists on making decisions for patients who have decisional capacity. As healthcare professionals, it is important to identify the key members of the family and involve them in the discussions as desired by the patient.

5. What is the purpose of the nurse asking patients about their degree of ethnic identity, family structure, and beliefs about health and illness?

A. Assess cultural diversity B. Create cultural competencies C. Determine cultural sensitivity D. Conduct cultural assessments Answer: D Rationale: In conducting cultural assessments, there are many areas to be addressed, including asking patients about their Degree of ethnic identity, family structure, and beliefs about health and illness.

6. Jaime explains to her physician that she feels calm in the face of her end of life because she believes she will be transitioning to another plane of existence in the universe. What is Jaime describing?

A. Her religiosity B. Her spirituality C. Her culture D. Her reverence Answer: B Rationale: Throughout a person’s lifetime, and particularly as people age, religion and spirituality assist them to confront their finitude and vulnerability; to uncover meaning, value, and dignity in illness and death; to establish connection with others and a higher life force; and to find hope, love, and forgiveness in the midst of fear and despair. As such, spirituality engenders serenity and transcendence, thereby buffering stress. Religiosity is one means of expressing spirituality. Religiosity refers to beliefs and practices of different faiths and an acceptance of their traditions, such as Catholicism, Eastern perspectives, Islam, Judaism, and Protestantism.

7. What relationship do spirituality and religiosity have with end-of-life care?

A. Patients may use them to assert an indirect form of control B. They are a small part of the patient’s plan of care C. Patients should never substitute them for medical treatment D. They have a slight effect on the despair and isolation patients may feel

Answer: A Rationale: Religiosity or spirituality also facilitates coping with chronic pain, disability, and serious illness by providing an indirect form of control that helps to interrupt the cycle of anxiety and depression. For some individuals, prayer provides a form of control by believing that through prayer they can influence their medical outcome; in contrast, others deliberately turn over to God their health situation. It is essential that the patient’s spirituality and/or religiosity be integrated into the patient’s plan of care because they can be a source of comfort and anxiety relief.

8. How can nurses best help alleviate a patient’s suffering?

A. Assure the patient that family members are unaffected B. Tell the patient that physical pain is the predominate form C. Disclose to the patient personally painful events in a show of empathy D. listen to the feelings and experiences of a patient’s losses and how they found meaning.

Answer: D Rationale: Genuinely listening to the patient navigate through losses to find meaning can help alleviate a patient’s suffering. This builds trust; the patient will not feel alone, can express thoughts of despair, and search for hope.

9. What is the nurse engaged in by asking the patient questions about their faith, their religious community, and whether faith is helping them cope?

A. Spiritual assessment B. Spiritual caregiving C. Spiritual distress D. Spiritual intervention Answer: A Rationale: The nurse is engaged in spiritual assessment to determine what spiritual or religious needs the patient may have.

10. How can hospice and palliative care nurses prevent or alleviate burnout?

A. Research spiritual aspects of other cultures B. Align patientʼs spiritual needs with their own C. Take care of their own spiritual needs D. Keep their spiritual side separate from their work Answer: C Rationale: In caring for people with life-threatening and progressive illness, nurses must remain in tune with their own spiritual needs, healing themselves as well as others.

Short Answer 1. What are the seven themes representing core principles relevant to Native American healthcare identified by Lowe and Struthers (2001)?

Model Answer: The themes include caring, which embodies characteristics of health, relationships, holism, and knowledge, and is characterized as a “partnership in healing”; traditions, which refers to valuing and connection with heritage; respect, which includes characteristics of honor, identity, and strength and refers to the components of presence and compassion; connection, which honors all people, the past, present, and future, harmony with nature, and explores differences and similarities; holism, which includes balance and culture; trust, which is characterized through relationship, presence, and respect; and spirituality, which includes unity, honor, balance, and healing and includes components of touching, learning, and utilizing traditions to recognize oneness and unity.

2. Olivia is a recent graduate of nursing school. In her first week of work at the hospital, Bharat is admitted. Bharat is from India and is now living in the United States with her adult son.

She has had a persistent productive cough, and her respiration has become labored. Olivia comes in one day to discover that Bharat died during the evening. She is horrified to see someone from Bharat’s family tending to her body, and to hear that Bharat will be cremated.

Olivia is confused and thinks that someone should explain how things are done in America.

Which principles of culturally sensitive care would Olivia benefit from?

Model Answer: The first principle is to be knowledgeable about cultural values and attitudes. Healthcare professionals should attend to a patient’s needs in a sensitive, understanding, and nonjudgmental way, and respond with flexibility as much as possible.

Olivia should understand that cultures different from hers have different rituals surrounding death. For Asian Indians, after death, family members should be the only ones to touch the body, and ideally a family meTmEbS erToBf A thNeKsaSmEeLsL exEsRh. ouCldOM clean the body. After the body is cleansed, a cloth is tied under the chin and over the top of the head, and the body is wrapped in red cloth. Embalming and organ donation are prohibited, and there is a preference for cremation. The tenth principle is for health professionals to conduct a self-assessment of their own beliefs about illness and death. For Olivia, this would include how her beliefs influence her attitudes; how culture and religion influence her personal attitudes toward death; what kind of death does she prefer for herself; what efforts does she believe should be made to keep a seriously ill person alive; how their bodies should be disposed of; as well as what rituals they have participated in to honor the dead.

3. Malachi grew up without spiritual or religious instruction and identifies as an agnostic. He is a nurse in a small community hospital. The community has a strong religious presence, with churches of several denominations, a synagogue, and a mosque with a small congregation.

Malachi has been the nurse for several patients as they faced end of life. Each has requested that he pray for him or her, and once a family clasped hands in a prayer circle around their loved one’s hospital bed and asked Malachi to join them. These situations have made Malachi acutely uncomfortable and unsure of what to say. He wants to be respectful but is at a loss for words. What recommendations could be made to Malachi?

Model Answer: Since the spiritual needs of the patient are important, Malachi could talk with his supervisor about the best approaches. He could do a self-evaluation about what he is comfortable doing and saying. Patients at end-of-life care just need to feel their caregivers are present and genuine, and sometimes a touch on the shoulder and a smile are enough. His kindness will show through. He may not need to say anything and just respectfully listen to

the patient and the patient’s family. He could also say something like, “You are in my thoughts and I am here for you.” What he should not do is offer his personal beliefs of agnosticism.

4. How can healthcare professionals help patients discover hope during a serious illness and end-of-life care?

Model Answer: Despite the stage of illness and a situation of poor prognosis, healthcare professionals can provide hope and a positive outlook by discussing goals of care, offering symptom control, providing supportive resources, and promising the patient that they will not abandon her or him. At times, the most important way to provide hope is by listening attentively and being physically present, which convey a sense of value and affirmation of worth. Hope is then gained that the patient will not be abandoned and isolated. Health professionals can help dying patients co-create meaning day by day while emphasizing the importance of bearing witness to the struggles, joys, and hope of the dying person.

5. Describe ways health professionals can be spiritual caregivers for their patients.

Model Answer: During hospitalizations, health professionals may ask if the person would like to speak with the clergy or chaplain or have the opportunity to attend a hospital worship service. Patients may also be asked if they would like someone to pray with or for them or have spiritual reading materials. If a person is not religious or does not want a health professional to address religious issues, spiritual conversations around hope, love, courage, and forgiveness can occur in T thE eS prToB viA deNr–KpSaE tieLnL t rEeR la. tioCnO shMip. Humor also has an effect on the spiritual aspect of healing, as many patients find humor “spiritually uplifting.” Health professionals can also encourage patients to socialize with friends, family, and children, as well as encouraging them to help others, even if only by active listening. Adults can also pass on their legacy to others by recording personal histories, telling stories, and reminiscing about the past. If the person is isolated, the health practitioner can suggest his or her watching spiritual or religious television programs or provide an opportunity to enjoy his or her favorite sacred or secular music, or other forms of art. Healthcare professionals may encourage opportunities for patients to experience nature in whatever ways they can, such as a walk or wheelchair ride in the garden or courtyard, or as they sit outside feeling the air and warmth of the sun. Spiritual uplifting in the present moment can also occur as the practitioner attempts to create meaning and a source of pleasure in the present moment.

CHAPTER 7: Intimacy and Sexual Health Multiple Choice 1. Which statement describes sexual health?

A. Ability of sexual structures to orgasm B. Optimally functioning sexual organs C. Ability to communicate sexual needs and desires D. Physical, emotional, and social aspects of being sexual Answer: D Rationale: One definition of sexual health is the integration of somatic, intellectual, and social aspects of being sexual. The ability of sexual structures to orgasm and optimally functioning sexual organs are only part of sexual health—the somatic aspect. The ability to communicate sexual needs and desires is also only part of sexual health—the intellectual aspect.

2. A patient has been treated for breast cancer and is seeing her physician for a follow-up examination. She has been wondering if it is okay to resume sexual relations with her husband, but instead avoids eye contact with her physician and answers in monosyllables.

What issue is most likely preventing the patient from talking with her physician about sex?

A. She is embarrassed.

B. She would like more privacy.

C. She thinks her physician iT sE toS oTbB usAyN . KSELLER.COM D. She is unsure if her physician is knowledgeable.

Answer: A Rationale: Sexuality assessment is frequently overlooked by palliative care providers when healthcare needs are being assessed. Healthcare professionals may avoid discussion of sexuality because of embarrassment, assuming that the sex life is over due to the disease, lack of knowledge, and lack of time. Patient-reported barriers can include embarrassment, privacy, and environmental factors. The patient’s behavior indicates that she is embarrassed.

3. Which statement most describes conversations between healthcare professionals and their patients about the patients’ sexual issues?

A. Healthcare professionals usually initiate the dialogue.

B. Healthcare professionals may be too embarrassed to discuss these issues.

C. Healthcare professionals are eager to offer their knowledge.

D. Healthcare professionals are willing to set aside time for these issues.

Answer: B Rationale: Healthcare professionals’ barriers to discussing sexuality include embarrassment, misinformed beliefs and assumptions, lack of knowledge, inadequate communication skills, and time constraints. Sexual health is not routinely assessed due to the belief that the patient will bring up the topic if it is a concern; the perception that people are “too sick” to be sexual; lack of their own comfort with the topic; preconceived ideas, attitudes, and values regarding sexuality;

perceived lack of time for this conversation; and the feeling that there are “more important” issues to be addressed.

4. When should the initial assessment of the patient’s sexual needs be made?

A. After healing is complete B. Before the diagnosis C. At the time of diagnosis D. During the course of treatment Answer: C Rationale: The most effective communication addresses the needs of the patient at each stage of his or her illness. The initial assessment should begin when the diagnosis is made and continue throughout the disease process. Communication with cancer patients is delicate in that the disease is both life threatening and potentially treatable or curable, which creates much uncertainty and stress on the patient.

5. Women most likely to report sexual issues are those diagnosed with which type of cancer?

A. Colorectal B. Breast C. Gynecological D. Lung Answer: B Rationale: Hughes et al. (2017) stTuE diS edTsBeA xuNaK l hSeE alLthLoEfRw.oC mO enMdiagnosed with breast cancer versus non-breast-cancer patients, noting that issues of sexual dysfunction are primarily documented in colorectal or gynecological cancer. However, their study found that regardless of demographic variables, women diagnosed with breast cancer were statistically more likely to report sexual problems. Women living with breast cancer typically experience body image issues, permanent menopause resulting from cancer treatments, and aromatase inhibitors that negatively affect sexual expression. Other types of cancer can result in sexual issues, but breast cancer causes the most reporting of sexual issues.

6. What change in sexual health is usually focused on for men?

A. Prostate function B. Sperm production C. Testosterone levels D. Erectile function Answer: D Rationale: Alterations in sexual health for men primarily focus on erectile function. Cancer treatments can interfere with erection by damaging a man’s pelvic nerves, pelvic blood vessels, or hormone balance. Prostate, bladder, and colon cancer are often treated with radiation to the pelvis. The higher the total dose of radiation and the wider the section of the pelvis irradiated, the greater the chance of an erection problem later. Erectile dysfunction (ED) is a common complication of diabetes (secondary to autonomic neuropathy, vascular insufficiency, or psychological factors) in at least half of men over age 50. ED can also occur as a result of cardiovascular disease, hypertension, hypercholesterolemia, smoking, and the abuse of drugs including alcohol. Prostate

function, sperm production, and testosterone levels can also be of concern, but the primary concern is erectile function.

7. A patient is being prepped for laser surgery for cervical cancer. Her respirations increase, and she begins sweating. As the treatment begins, she starts trembling and crying, then yells for the physician to stop while pulling herself away from the physician. What is the patient most likely experiencing?

A. Posttraumatic stress symptoms B. Fear about the prognosis C. Sexual health anxiety D. Pain from the procedure Answer: A Rationale: Posttraumatic stress symptoms (PTSS) can be exemplified by re-experiencing the trauma, avoidance of trauma-related stimuli, and negative alterations of cognition, mood, arousal, and reactivity following exposure to a stressor. It is possible that the patient could be experiencing fear about the prognosis, sexual health anxiety, and pain from the procedure, but her extreme reactions point to PTSS. 8. What characterizes sexuality in those with severe illness?

A. Sexual health concerns vary widely B. Positional modifications are too cumbersome C. Masturbation is used only minimally for sexual gratification oE enSgTagBeAiN nK paSrtEnL erL edEsRe. xuCaO l aMctivity D. Patients feel encouraged tT Answer: A Rationale: Sexual health concerns in those with severe illness vary widely. Some patients are comfortable talking with their healthcare professionals about issues, some are not. There are psychological, physical, and emotional aspects of sexuality that can be traumatized by severe illness, and it is difficult to determine what these will be at the onset of disease.

9. A patient is being treated for testicular cancer and would like to discuss sexual issues with his healthcare professional. Which question should his healthcare professional ask first?

A. Can you describe your issues with erectile dysfunction?

B. What are your concerns about being able to father children?

C. How has your illness affected your emotional intimacy with your partner?

D. What are your worries about your attractiveness to your partner?

Answer: C Rationale: While patients indicate that emotional connections take precedence over physical concerns, healthcare professionals may focus more on whether a patient is capable of having sex and on the impact of illness on menopause, erectile, or fertility status. This perspective offers a medicalized approach to sexuality, which may be different than the patient’s goals. Asking the patient’s concerns for emotional intimacy with his or her partner is a good way to initiate dialog and what is likely foremost in his or her mind.

10. Which method is most effective for healthcare professionals to decrease patient anxiety about sexual issues?

A. Prescribe mindfulness techniques to the patient B. Initiate a conversation with the patient C. Recommend the patient exercise regularly D. Give the patient positive statistics for recovery Answer: B Rationale: Often, medically ineffective and wasteful processes are carried out when the patientʼs need is healthcare provider presence and a sense of being cared about. Patients are vulnerable, and often feel a loss of control in what is happening to their bodies.

Short Answer 1. Describe the Sexual Health Model for palliative care.

Model Answer: The Sexual Health Model identifies 10 broad components posited to be essential aspects of healthy human sexuality. These include talking about sex comfortably, especially sexual values, preferences, attractions, history, and behaviors; cultural influences on sexuality and sense of sexual self; basic knowledge, understanding, and acceptance of sexual anatomy and functioning; sexual healthcare; overcoming challenges to sexual health; body image as an important aspect of sexual health; realistic appreciation of the important role of masturbation and fantasy; positive sexuality including a developmental approach to BaAcN sexual health over the life spaTnE ; iS ntTim yK anSdErL elL atE ioR ns.hC ipOs;Mand spirituality and values, including the assumption of congruence between one’s ethical, spiritual, and moral beliefs and one’s sexual behaviors and values.

2. A patient has been diagnosed with ovarian cancer. Fortunately, it was caught early and her prognosis is good. What factors make her at risk for decreased sexual functioning?

Model Answer: Risk factors for poorer sexual functioning after being diagnosed with gynecological cancer are age, treatment, time since treatment, poor self-esteem/body image, physical symptoms, poor performance status, depression, and anxiety. Ovarian cancer is usually treated with a hysterectomy, oophorectomy, and chemotherapy, which can all affect sexual functioning, through a decrease in estrogen production (resulting in vaginal atrophy, loss of vaginal lubrication, and hot flashes) and loss of sexual interest resulting from changes in body, fatigue, and nausea.

3. A patient has had several axillary lymph nodes removed and is experiencing pain down her arm and up her neck. What recommendations can she be given regarding engaging in sexual activity?

Model Answer: The American Cancer Society has recommendations for patients regarding overcoming nongenital pain. The patient can plan sexual activity for the time of day she feels the least pain. If using pain medicine, she should take it an hour before planned sexual activity, so it will be in full effect during sex. She and her partner can find a position for

touching or intercourse that puts as little pressure as possible on the sore areas, support the sore area, and limit its movement with pillows. If a certain motion is painful, she can choose a position that does not require it or ask her partner to take over the hip movements during intercourse. The patient and her partner should talk about what brings the most pleasure. The patient should be encouraged to focus on her feelings of pleasure and excitement; with this focus, the pain may fade into the background.

4. How do adolescents develop emotionally and intellectually, and how does palliative care affect their sexual development?

Model Answer: Adolescents in palliative care share the same developmental tasks as other adolescents. Cognitive thinking is required to link consequences to behavior; however, in early adolescence, thinking is predominately concrete and long-term consequences are not considered. Abstract thinking begins in middle adolescence; at this point, consequences of behavior begin to be considered. However, under times of stress, the middle adolescent often reverts to concrete thinking. Late adolescence is a time when abstract thinking begins to mature and the consequences of behavior are considered. Here, adolescents are striving for autonomy and peer support. Issues of romance, sexuality, and reproduction are normal developmental tasks and should be given attention by healthcare providers. A life-threatening illness may also compromise the development of body image and self-esteem.

5. A patient is in a hospice facility for congestive heart failure. His partner visits every day with expressions and displays of love and intimacy. The patient and his partner would like to be sexually intimate again since T thEeyST arB eA unNsK urSeEhL ow mR uc.hCtO imMe they have left together. What LE are the barriers to this?

Model Answer: Barriers to sexual expression in the hospice facility include lack of privacy, staff interruptions, and bed size. Additionally, the partner may be concerned about hurting the patient, or that he is too fatigued. The sense of bereavement that the partner knows will happen when the patient dies could be on his mind now, causing him anxiety. Even though sexuality is an integral aspect of palliative care, they may feel a decreased loss of control over this aspect of their relationship. They may be reluctant to discuss possibilities for sexual intimacy with the hospice care workers due to embarrassment.

CHAPTER 8: Family Caregivers Multiple Choice 1. Della, her best friend of 40 years, her sister, and her prayer group would be defined by which category of family?

A. Structural B. Functional C. Symbolic representation D. Group interaction Answer: D Rationale: A category of definitions of family is based on interactions within the family group. It looks at the role of family members, the power dynamics within the family, and how family members relate to one another. This broad category would allow for work-groups or societies to be defined as family, as well as a group of friends who view themselves as a family.

2. Health professionals often make assumptions regarding who will be the family caregiver.

Which statement is most likely assumed?

A. Nancy, who is 49 years old and the eldest of three children, will take care of her mother with Alzheimerʼs disease B. Brad, who is 31 years old, will take care of his children after his wife dies C. Logan, who is 24 years olT dEanSdTm ,w BaArrNieKdS EiLllLtaEkRe .caCreOoMf his niece and nephew when their mother is incarcerated D. Emma, who is 18 years old and not married, will take care of her father with leukemia Answer: A Rationale: Due to cultural and societal expectations, healthcare professionals might tend to assume that Nancy will take care of her mother. Myths about the family may influence the health professionals’ assumptions, beliefs, and expectations related to families and their interactions within the healthcare system. One belief is that children, especially female children, have an obligation to care for chronically ill or impaired family members, especially elders. This expectation is shared by family, medical providers, and cultural norms, irrespective of the burden this places on the individual, and without recognition of their additional family and work responsibilities.

3. Rosalind, who is 78 years old, has been diagnosed with transcient ischemic attacks (TIAs).

The healthcare professionals recommend Rosalind have full-time care of some type. Her niece, Denise, and her husband decide to have Rosalind move in with them. What is Denise likely to experience with this new living situation?

A. Increased reliance on her religious community for support B. Better time management skills C. Need to mask feelings of burden and anxiety D. Increased family time together Answer: C

Rationale: Denise will likely feel the need to mask feelings of burden and anxiety. Caregivers are reluctant to identify themselves as individuals who need support. This reflects the concept of “legitimacy of needs” or “caregiver ambivalence” as they do not want to “bother” professionals or shift attention away from the patient.

4. The qualities of trust, honesty, and sharing are part of what dimension of strength in families?

A. Coping B. Spiritual well-being C. Commitment D. Positive communication Answer: B Rationale: Spiritual well-being is demonstrated by hope, faith, compassion, shared ethical values, and oneness with humankind.

5. What is the purpose of studying models and theories of responses to caregiving?

A. Guide caregiver assessment and interventions B. Create remedial plans for overhauling caregiver culture C. Initiate discussion on caregiver reform D. Determine healthcare responsibilities of caregivers Answer: A Rationale: Theoretical frameworkTsEreSlaTteBdAtN oK faS mEilL yL caEreRg.ivCinOgMcan guide questions for family assessment and the development of family caregiver interventions to alleviate stress.

6. Which approach do caregivers typically receive from healthcare professionals?

A. Support for the caregiver’s emotional and physical needs equal to the patient’s B. Standardized approach of seeing the patient and caregiver as a unit C. Standardized approach of seeing the patient’s needs as more important than the caregiver’s D. Support for the caregiver’s knowledge once the patient has been stabilized Answer: C Rationale: Caregivers typically receive a standardized (“one size fits all”) approach that focuses on the patient’s needs, while the caregiver’s needs are considered secondarily, if at all.

7. Rebekah’s sister had a stroke during the delivery of her second child. The stroke has left her incapacitated. Rebekah is understandably very worried about her sister’s prognosis and has questioned the physicians about all possible treatments. She has also been spending time every evening after work online researching treatments, including alternative therapies.

Rebekah has not spoken much about this with her sister’s husband, or the rest of their family.

What type of communication pattern is Rebekah displaying?

A. Manager B. Carrier C. Partner D. Lone

Answer: D Rationale: With the lone communication pattern, there is great focus on hope of the efficacy of treatments and the lone caregiver attempts to seek treatments for the patient’s condition.

8. What is the primary reason caregivers may suffer from depression, anxiety, and guilt?

A. Lack of support and services B. Failure to access support and services C. Unwillingness to take on the role of caregiver D. Insufficient knowledge about medical conditions Answer: B Rationale: Often caregivers are unaware of resources available to them or simply lack the energy to seek them out. Repeatedly, family caregivers report that information given to care for their loved one is insufficient. Caregivers want to feel a sense of readiness and confidence in their role as a caregiver. When a caregiver is not prepared, they risk suffering from depression, anxiety, guilt, and grief.

9. Why is negotiating expectations usually the most difficult category of interventions for caregivers?

A. Caregivers are unable to recognize key tasks and responsibilities.

B. There are few resources currently available for caregivers.

C. Caregivers often take on more than one person can actually accomplish.

D. There is little recognition that sometimes tough conversations are necessary.

Answer: C Rationale: Caregivers often take on more than one person can actually accomplish. Sometimes they may not be aware of all the factors involved in adding on care for another person in addition to their usual responsibilities.

10. Who should address the needs and concerns of caregivers?

A. All members of the palliative or hospice care team B. The patient’s physician C. Clergy on the palliative or hospice care team D. The patient’s family Answer: A Rationale: The needs and concerns of family caregivers should be addressed by all members of the interprofessional palliative or hospice care team. The patient and the family caregiver should be considered a unit.

Short Answer 1. Describe the typical caregiver in the United States.

Model Answer: The majority of caregivers care for one other adult. Upward of 75% of all caregivers are female and may spend as much as 50% more time providing care than males.

Female caregivers are more likely than male caregivers to provide personal care. Higher-hour

caregivers are, on average, 51.8 years of age. Lower-hour caregivers are on average 48 years of age. Family caregivers increasingly provide care for aging adults, most of whom have one or more chronic conditions and who wish to remain in their own homes and communities.

Other family caregivers belong to the “sandwich generation,” which describes the caregivers sandwiched between caring for elder parents or grandparents and spouse and/or children.

These caregivers are pulled in both directions and often have jobs as well as these dual responsibilities. They are typically middle-aged women who are overwhelmed with responsibility, act out of duty, and neglect themselves because there are competing demands for their time.

2. Carlotta and Roberto have two young children and are in their mid-30s. Carlotta has a brother, Miguel, with Down syndrome and several severe health challenges. When Carlotta’s parents died three years ago, Carlotta and Robert brought Miguel to live with them. Between Roberto working two jobs and Carlotta taking care of the home, children, and Miguel, they wonder sometimes how they are making it through life. How can healthcare professionals support Carlotta and Roberto?

Model Answer: Sometimes the simplest actions and words have the most meaning.

Healthcare professionals can support Carlotta and Roberto by acknowledging the good care they are giving to their children and Miguel, that they understand the stress they may be under, and that healthcare professionals can direct them toward other resources that can help them. Given the strengths of the family, the caregiving experience may also have benefits and possible gains, yet these outcomes have received little attention. Health professionals should not miss the opportuniTtyEtS oT idBenAtN ifyKS thE eL reL wEarRd. sC anOdMsatisfaction that come from the role of caregiving. Studies indicate that family caregivers describe feelings of satisfaction for a job well done, particularly when the patient appreciates and acknowledges their care and support, and when caregivers feel a sense of giving back for the care and nurturing they received themselves. The positive aspects associated with the caregiving experience may act as a buffer against overwhelming burden and traumatic grief. Caregivers who have a positive approach to life are better able to cope with caregiving demands and are motivated to maintain their caregiving role.

3. What are the benefits of performing a caregiver assessment?

Model Answer: Caregiver assessment can be used for determining the eligibility for services and identifying unrecognized or subtle problems that have great impact on successful caregiving. The assessment process also allows for the development of a strong, trusting, and therapeutic relationship between the clinician and the caregivers. The best assessments include all family caregivers as well as the care recipient. Both the patient and the family should be assessed by the same provider in the caregivers’ home or another place where they both feel safe to discuss all aspects of the situation. The first advantage of performing a caregiver assessment is the identification of actual or potential problems such as interpersonal, relational, situational, or financial problems within the caregiving role. The second advantage is the clarification of roles and responsibilities for family members, as well as a clear estimate of the resources available versus those that will be needed to provide the required care. The assessment can also reveal stresses that can be intervened with before they

reach overwhelming and incapacitating anxiety and depression leading to despair. The structured and systematic nature of a good caregiver assessment assures that important aspects will not be missed and that a comprehensive approach is implemented.

4. George and Monica are expecting their fourth child. It is a difficult delivery, and when Sydney is born, the physician notes that Sydney has some issues. Further testing reveals that Sydney has cerebral palsy. George and Monica are overwhelmed with the news and have no idea of how to care for her. How can a family assessment assist them in their new caregiving capacity?

Model Answer: A careful family assessment with George and Monica will identify family strengths and weaknesses that will have an impact on them as caregivers and Sydney. Their relationships should be identified, clustered, and organized in a way that they reflect the priorities and function of George, Monica, and Sydney. Generally, strategies can be successful by addressing four general areas: setting realistic goals, having difficult discussions, finding help, and negotiating expectations.

5. Martha cared for her partner, Janet, through the 10-year-long trajectory of her dementia.

When Janet finally died, Martha managed to make it through her funeral, then collapsed, and was hospitalized with pneumonia. What could have the interprofessional team done to help prevent this?

Model Answer: Beyond words of encouragement and support, which validates the NeKmSbEerLsLoE importance of Martha’s caregT ivEeS r rToB leA ,m f tRh. eC inO teM rprofessional team should have offered their expert advice, advocated for Martha’s well-being, and assisted her in accessing valuable community resources. At the end of Janet’s life, both the palliative care team and the hospice should have provided a lifeline to Martha, as her health was at risk and she became a second-order patient.

CHAPTER 9: Communicating With Seriously Ill and Dying Patients, Their Families, and Their Healthcare Practitioners Multiple Choice 1. Which statement describes communication about the end of life between healthcare professionals and patients?

A. Most patients report physicians discussing it with them.

B. Physicians are more willing than nurses to initiate the discussion.

C. Nurses are more comfortable initiating the discussion than physicians.

D. Families prefer to discuss it after the patient is in hospice.

Answer: C Rationale: Surveys show that nurses tend to be more comfortable initiating discussion about the end of life with patients than physicians are.

2. Which factor is most important when the healthcare professional needs to impart bad news?

A. Absolute honesty B. Preparation ahead of time C. Keeping the recipient from feeling anxiety D. Maintaining the therapeutic relationship Answer: B Rationale: Conveying bad news requires thought and preparation. When preparing for the discussion, the healthcare professional should locate a private place for the discussion, ask the patient to have a family member or friend present, have all information available to explain to the patient, and practice what she or he is planning to say.

3. Joe’s son, Casey, was helping Joe clean out the gutters on the house when Casey fell off the ladder, landing in the driveway and hitting his head. In the emergency room, Casey’s pupils are unresponsive to light and his breathing is irregular and shallow. Despite their best efforts to stabilize him, it soon becomes apparent to the attending physicians that Casey is dying.

Which sentence is the most compassionate way to initiate this conversation with Joe? A. “Joe, due to blunt force trauma, Casey’s reflexes are nonexistent, he’s hypoventilating, and recovery is unlikely.”

B. “Joe, I am sorry, but I have some difficult news for you in that Casey’s recovery is unlikely.”

C. “Joe, I need to talk to you about Casey; is there someone you want to call to have here with you?”

D. “Joe, Casey should have been more careful on that ladder because now he’s seriously injured.”

Answer: B Rationale: “Joe, I am sorry, but I have some difficult news for you in that Casey’s recovery is unlikely” is the most compassionate way to initiate the conversation with Joe. Before actually stating the problem, it is recommended to foreshadow the news in simple language.

4. What is the nurse doing if he or she is identifying and responding to the patient’s and family’s concerns about the patient’s treatments?

A. Opening the relationship B. Structuring the care agreement C. Exploring dying expectations D. Clarifying the problem Answer: D Rationale: There are several components to the phase of clarifying the problem. They include facilitating the patient’s expression of emotions, identifying what the patient and family believe are problems, and identifying and responding to the patient’s and family’s concerns about care.

5. Jai responds to the news that her ovarian cancer is terminal with disbelief, saying, “That can’t be true! I’m only 22. I’m sure that I’ll beat this if I get another round of chemo.” What is the nurse’s most appropriate response?

A. “Well, you might think you can beat this but the chances aren’t good.”

B. “You really need to face reality here. You have to think about what you want to do.”

C. “I know this is difficult to hear when it seemed like the treatments were working.”

D. “It’s difficult to hear but you should live whatever time you have left to the fullest.”

Answer: C Rationale: Denial is a natural response that may be helping Jai deal with her illness and should be respected. The nurse should not argue with Jai, but instead should acknowledge the difficulty in accepting the truth, and suggesTt E aS poTsB sibAlN eK reS asEoL nL foEr R th.e CdO iffMiculty, without giving any sense of blame. The best approach is to acknowledge that the news is difficult and understanding why Jai would want to deny it.

6. What is the nurse doing if he or she is initiating a discussion of the patient’s treatment goals?

A. Opening the relationship B. Structuring the care agreement C. Exploring dying expectations D. Clarifying the problem Answer: B Rationale: Structuring and formulating the care agreement means the healthcare team will initiate a discussion of the patient’s treatment goals.

7. Alden was diagnosed with tumors in his lungs and brain. Alden’s palliative care nurse, Shenae, asks him what is most important to him in the time he has left. Alden says he would like to live long enough to see his grandson born. What is Shenae helping Alden do?

A. Explore what dying well means to him B. Deny that the end of life is near C. Form their therapeutic relationship D. Take action toward the end of life Answer: A

Rationale: Nurses should be able to assist a patient to define what she or he believes constitutes dying well or represents a good and timely death. Shenae is helping Alden identify which issue would be most important for him to address so that he might die well.

8. Which statement describes appropriate communication from the nurse to the parents of a dying child?

A. “We need to make some decisions today, so we can get to work planning.”

B. “Stopping treatment now is the right thing to do.”

C. “Let me know when you are ready to talk about some options.”

D. “At least you know your child will be at peace soon.”

Answer: C Rationale: Multiple studies of family members of both dying adults and children have indicated that at least as important as the information provided is the sensitivity with which the information is conveyed. Experienced nurses can assist the parents to understand the issues, express their feelings, and delineate their roles so that the parents can be actively involved in the decision-making process for their children. “Let me know when you are ready to talk about some options” is inviting the parents to start a conversation about their child’s end-of-life care, while allowing the space and time to start coming to terms with it.

9. Terrell and his wife, Lisa, are trying to decide whether it is time to remove Terrell’s mother from life support. He and Lisa decide to talk with the nurse since the physician seems to be busy. They converse with the nurse for a few minutes; then the nurse’s eyes drift to the clock OeMhave lots of options for end-ofon the wall. Finally, she smileTsEaS ndTsBaA ysN, K “DSoEnL ’tLwEoR rr. y.CW life care,” which wraps up the conversation, and she leaves to check on other patients. Which concern are Terrell and Lisa most likely having about Terrell’s mother right now?

A. The hospital has inadequate hospice facilities.

B. They will be unable to have enough time to say goodbye.

C. She will be given too little medication for her pain.

D. She will be abandoned by the healthcare team.

Answer: D Rationale: The nurse is responsible for ensuring that palliative care and end-of-life planning are carried out. It is imperative that the nurse demonstrate, by words and deeds, that the healthcare providers will not abandon the patient after end-of-life choices are made and that, instead, nurses and other healthcare workers will provide the care the patient needs or will teach and assist family members or friends to provide the care and support the patient requires while dying. The nurse did not make time to talk with Terrell and his wife, nor did she suggest another time to sit down and talk with them. Her words most likely came off as rushed and uncaring, even though that may not have been her intent. As a result, Terrell and Lisa are most likely to think Terrell’s mother will be abandoned by the healthcare team.

10. What do bereaved families need most from healthcare professionals when their family member has died?

A. Spiritual counseling B. To be listened to

C. Professional distance D. To be prayed for Answer: B Rationale: Although students and recent graduates often are worried about what they ought to say to the family at this time, bereaved families usually are more in need of someone to listen to them. Thus, one of the major roles of the nurse at this time is active, compassionate listening.

Short Answer 1. Explain how the mnemonic NURSE can be used as an empathetic approach to helping patients sort through feelings after receiving the news that they are dying.

Model Answer: An empathetic approach to helping patients sort through their feelings means the nurse should reflect, name, and legitimize the person’s feelings. The mnemonic NURSE is helpful to uncover and respond to the patient’s or family’s emotions. The mnemonic followed by sample statements for the nurse to use is as follows: Name the emotion: You seem (insert appropriate emotion—e.g., worried).

Understand the emotion: I can see that this is difficult for you.

Respect: I can see that you are trying to .

Support the participants: I (or we) will help you to .

Explore possibilities: Tell me what options you can envision.

2. Angela is 39 years old and has cystic fibrosis. She received a partial lung transplant seven years ago, which worked for quite some time. She is now hospitalized because that lung is failing, and she is finding it more and more difficult to breathe. Angela’s air passageways need quite a bit of suctioning, and each time seems a little bit worse than the last. Angela just feels frail and tired, and has not had much energy or appetite since before she was hospitalized. Her nurse, Javier, comes in to check on her. He asks how she is doing. Angela smiles weakly, and says, “Not too good. Life seems to be slipping by.” Javier responds with, “Well, at least it’s a beautiful day today. You can just look out the window and see the trees in bloom. How uplifting is that!” Angela pauses for a moment, then says, “Well, I’ve already seen a lot of life, but I’m getting so tired. I’m wondering if all this is worth it.” Javier says, “Sure it is! We just need to find the right combination of meds for you and you’ll be sailing out of here. I think you’re just having a down day.” What methods is Javier using to block communication with Angela about the end of life?

Model Answer: Wilkinson identified three groups of nurses who used different methods to block patient communication. These were ignorers, informers, and mixed responders. Javier is mixed responding, which is a combination of ignoring and informing. He has ignored Angela’s cues to talk about the end of life by trying to change the subject and using social chitchat to avoid an emotionally laden conversation. He has been an informer by offering inappropriate advice and/or stating his opinion without being asked to avoid talking with Angela about the end of life.

3. What roles do nurses have in the goal-setting phase of the therapeutic relationship?

Model Answer: Nurses in the goal-setting phase of the therapeutic relationship support patients and families following the physician’s discussion of death and dying and end-of-life goals. The skills they use include taking stock, asking open-ended questions, checking patient understanding, endorsing asking questions, clarifying, and restating. The nurse’s process tasks are tailoring information to the patient’s level of understanding, asking if a discussion of the dying process would be helpful, describing the natural dying process, avoiding jargon and euphemisms, and addressing cultural and religious needs. During this phase, it is essential that the nurse determine not only what treatment the patient believes he or she wants but also what the patient believes will happen if he or she receives the treatment.

4. Toni is 63 years old and Apache. She has lived with lupus most of her life, and in the past few years, she could feel her health unraveling. She is hospitalized and has started to come to terms with the fact that her end of life is near. What responsibilities does the nurse have about Toni’s end of life and Apache customs?

Model Answer: The nurse will need to ask Toni and her family about any Apache end-oflife customs or rituals that provide meaning to them. Because a range of responses occurs within cultural and religious groups, it is essential that the nurse not assume that specific rituals will be of significance to Toni and her family simply because they are Apache. The nurse might want to inquire, “What is your faith or belief? Is there a religious or ethnic community that is a source of support for you? Would you like me to notify the community or arrange for something for yToEuS ?”TOBnAceNtKhS esE eL cuLsE toRm.sCoO r rMituals have been identified, they should be integrated into Toni’s plan of care.

5. Carmichael is a nurse who disagrees with the physician about a patient’s end-of-life care.

What steps can he take to have effective communication with the physician?

Model Answer: To establish effective communication with the physician, crucial elements for Carmichael include assessing the patient by learning the details of the situation and identifying any questions that Carmichael or the patient have prior to contacting the physician; focusing on the patient’s and family’s desires and concerns while identifying their readiness for additional information; identifying medications or interventions that Carmichael and/or the patient believe might be effective, recommending them to the physician, and providing a rationale for their use; and respectfully questioning interventions chosen by the physician with which Carmichael, the patient, or family does not agree.

CHAPTER 10: Health Promotion and Rehabilitation in Palliative Care Multiple Choice 1. Which statement describes the concept of health promotion in palliative care?

A. Primary focus is pain relief.

B. Patients need to rest as much as possible.

C. Incurable disease precludes physical therapy.

D. Communities can provide support.

Answer: D Rationale: Health-promoting palliative care (HPPC) addresses not only the ways in which clinicians support the seriously ill and dying, but also how communities can be more effectively engaged in the care and support of their dying members.

2. Chelsea is developing muscular contractures from lying in bed during her late stage of cancer. Her mother recently read that physical therapy may be able to help alleviate the contractures and give her some relief. Chelsea’s attending physician and nurse are resistant to the physical therapy, saying it will most likely cause her more pain than she is already in.

Which core area of HPPC needs to be addressed?

A. Encouragement of interpersonal reorientation B. Encouragement of reorientation of palliative care services C. Providing education and iT nfEoS rmTaBtiA onNfKoS rw EeLllL-bEeRin.gCOM D. Combatting death-denying policies and attitudes Answer: B Rationale: Encouragement of reorientation of palliative care services needs to be addressed. This involves reorientation from a conventional to a health-promoting approach to Chelsea’s care.

3. Which outcome occurs with viewing palliative and end-of-life care as a whole-person experience?

A. There is an increased focus among physical, psychological, social, and spiritual aspects.

B. Focus is directed more toward the individual than the community.

C. Community perspectives toward illness and death reflect the dominant culture..

D. Death and dying are viewed primarily within a medical framework.

Answer: C Rationale: Viewing palliative and end-of-life care as a whole-person experience means respecting all the domains of human existence—physical, psychological, social, and spiritual.

Therefore, the whole-person experience involves community participation, not just focus on the individual, and community perspectives toward death and dying change.

4. Which activity could a nurse do as a first step toward promoting health in palliative care?

A. Lead support groups for patients and caregivers B. Incorporate research into the caregiving approach C. Support professional development of staff

D. Conduct death education workshops in the community Answer: A Rationale: The micro-individual level of promoting health promotion in palliative care involves the most direct, individualized contact with patients, their caregivers, and their families. It gives nurses a way to begin promoting health in palliative care. Leading a support group for patients and caregivers is an example of this.

5. Louise is 56 years old and has rheumatoid arthritis since she was 32. She has the extremity changes that are typical for the disease, and the exacerbations and treatment have left her with a great deal of weakness. What would be a goal of palliative rehabilitation for her?

A. Increase muscle mass so that she can do the hikes she loved to do in her 40s B. Increase her overall strength so that she can keep the disease from flaring up C. Increase her stamina so that she can travel across the country to visit her daughter D. Increase joint mobility so that she can continue to do activities of daily living Answer: D Rationale: Palliative rehabilitation focuses on maintaining a person’s independence and increasing their quality of life by supporting and enabling them to live as normal a life as possible despite their stage of illness or age. Increasing joint mobility so that she can continue to do activities of daily living is an example of palliative rehabilitation for Louise.

6. At which point should the patient participate in palliative rehabilitation?

A. Before being diagnosed wTitE hS aT dB iseAaN seKSELLER.COM B. Throughout the trajectory of a disease C. Only when feeling weak and unstable D. Only when other treatment options stop working Answer: B Rationale: Palliative rehabilitation is appropriate to start from the time of diagnosis through to the terminal phase of illness. Typically, a patient will not participate in palliative rehabilitation before being diagnosed with a disease. The patient can participate in palliative rehabilitation even if he or she is not feeling weak and unstable, and palliative rehabilitation can occur concurrently with other treatments.

7. Which type of rehabilitation could involve adjusting body positions to prevent further contractures and the use of muscle relaxants to decrease pain and spasm?

A. Preventive B. Restorative C. Supportive D. Palliative Answer: D Rationale: Palliative rehabilitation targets symptoms such as pain, dyspnea, edema, and contractures through positioning, breathing assistance, relaxation, and assistive devices. Ongoing support of families and caregivers continues.

8. Cassidy is 13 years old and living with terminal cancer and has been hospitalized. It has become apparent that medical treatments are no longer working. Her parents, her oncologist, and her nurses have avoided talking with her about end of life, but she has a hunch that may be happening. Cassidy has decided to make memory bracelets out of cording and beads for all the nurses and her friends. What is the best approach for her healthcare team to help her with this goal?

A. Encourage her to commit to following through on making all of them B. Avoid involving her parents since this is a very personal project C. Have her decide how many she can do in a given space of time D. Have her parents buy them instead so she can conserve her energy Answer: C Rationale: In order for Cassidy’s goal to be achievable, she should set short-term goals due to fluctuating functional performance levels and the uncertainty of time. Short-term goals should relate to the completion of activities that are meaningful to Cassidy and enable her to live as normal a life as possible during this period. Her goal to make all the bracelets may not be realistic over time, so encouraging her to commit to following through on making all of them may place undue stress on her. Her parents should be aware of this project so they can support her, and also guide her should the goal become unrealistic.

9. Which condition are nurses most likely to perform rehabilitation intervention for?

A. Reflux disease B. Breathlessness C. Decubitus ulcer D. Indigestion Answer: B Rationale: The most common nursing rehabilitation interventions in palliative care nursing are related to managing a patient’s symptoms of pain, fatigue, and breathlessness. Reflux disease, decubitus ulcers, and indigestion will possibly need rehabilitation intervention, but they are not among the most common conditions.

10. What should be the overall focus when establishing goals for a patient receiving rehabilitative palliative care?

A. Enhance acceptance of the diagnosis B. Eliminate the need for family caregiving C. Maximize the use of palliative care resources D. Enable the patient to live as normal a life as possible Answer: D Rationale: Palliative care patients have progressive illness and require increasing care from caregivers. Acceptance of their diagnosis can occur at anytime during the illness experience and not specifically at the rehabilitative phase. The overall goal for rehabilitative palliative care is to promote the quality of life until death, assisting patients to live as normally as possible.

Short Answer 1. Using information from the Ottawa Charter, what are three strategies healthcare professionals can use to develop personal skills in health-promoting palliative care?

Model Answer: Participation of palliative care organizations in the development of personal skills to deal with issues of illness, dying, death, grief, and loss can involve strategies such as holding conferences that teach healthcare professionals these skills, developing online resources about how to develop these skills, and providing written materials about these skills. It would also be highly valuable for healthcare professionals to evaluate these skills in each through activities such as role playing and giving feedback after observing each other with end-of-life patients. Another responsibility is to gently educate end-of-life patients in these skills and guide them as they navigate through their issues surrounding their end of life.

2. Marjorie and Tariq are two advanced practice nurses who have noted that the caregivers and families of end-of-life patients have been, for the most part, unhappy with how their loved ones have received end-of-life care. They have done their best, but it seems like their hands are tied when it comes to certain hospital policies. Both Marjorie and Tariq have a great deal of experience in end-of-life care and have attended conferences on the topic. Lately, they have been talking about the whole-person approach and were wondering what they could do to change the climate and, ultimately, policies of end-of-life care at the hospital. What steps could they take to do this?

Model Answer: ImplementinTgEhS eaTltB h-ApN roKmSoE tinLgLpEaR lli. atCivOeMcare (HPPC) into the hospital will not happen overnight. Marjorie and Tariq are likely to encounter some resistance from physicians and administration. The first step would be to develop a cohesive description of the whole-person approach with fellow nurses and discuss it with them. As they garner support, they could perhaps form a core group that create an action plan, using existing, effective quality improvement approaches. They need buy-in from the executive management, and a main feature of the action plan would be showing how the whole-person approach increases patient satisfaction and decreases costs. It is important to build within the organization a critical mass of health professionals with knowledge and vision. With a realistic plan for service development that includes a sustainable approach, HPPC could become a realistic goal.

3. Carol is single and living with emphysema. She was diagnosed with it two years ago when she noticed shortness of breath climbing the flight of stairs to her bedroom. She is continuing to work full-time as an office manager but has noticed that she feels tired quite a bit these days. What supportive rehabilitation recommendations would be useful for her?

Model Answer: Supportive rehabilitation recommendations can include modifying her work schedule so that she is no longer working full-time. If possible, she should move her bedroom downstairs so that she does not have to use the stairs. She may need a cane or walker to help her with locomotion. A walk-in shower or tub can also be recommended.

Tasks such as cleaning the house and doing the laundry could be subdivided into smaller sections of shorter duration, so she can conserve her strength in between, or she could look into having someone come in to help her.

4. Corey has been a nurse for six months and still feels like he is “learning the ropes” at the large teaching hospital he works in. Recently, he transferred to the oncology unit, and has discovered that he has an aptitude for working with patients who have cancer. His supervisor, Shawna, has been working with him to enhance his skills, and has just assigned him to talk with a patient about pain management for her bone cancer. Shawna can see how nervous Corey is about this. What recommendations can Shawna give Corey?

Model Answer: Nurses are essential for delivering pain education and evaluating its effectiveness for patients. Corey’s pain education to the patient should address her misconceptions and fears about pain treatments, explain the WHO pain control ladder, and identify pain management goals. Corey should then discuss the patient’s pain with the treating physician and help develop strategies to meet these goals. Corey should give the patient written information to complement the verbal information he gives her; it should contain information on pain management, pain treatments, guidelines for discussing pain with the physician, free space to write down any questions or goals, and a pain scale to document changes in pain intensity with activities of daily living. Since nurses do not always feel confident with administering pain medications for patients with palliative pain needs, Shawna should accompany him as he does this until he feels comfortable.

5. What factors are involved in providing psychosocial support for patients and their families?

Model Answer: Through communication and rapport building with the family, the palliative rehabilitation nurse is able to provide information, give emotional support, and coordinate care for the family’s loved onT e,EtS huTsBenAhNaK ncSinEgLaLpEatRie.nC t’sOrMehabilitation process. Nursing interventions developed for caregivers were found to reduce caregiver burden, improve coping abilities, increase confidence as caregivers, reduce anxiety, and improve marital and family relationships. Nurses can reduce caregiver burden and improve coping abilities by providing education on the nature of the disease and treatment options for the patient; identifying caregivers’ physical, emotional, and supportive needs; and problem solving and evaluating any negative reactions to caregiving. Improving caregiving skills was seen to be an effective way to increase caregivers’ confidence in caring for their loved ones.

Additionally, nurses have been found to play a role in maintaining marital satisfaction, providing family support, and improving couples’ communication in patients with cancer.

Interventions are focused on educating the patient and his or her spouse on symptoms, symptom management, caregiver-related skills, communication techniques, and intimacy expectations.

CHAPTER 11: Loss, Grief, and Bereavement Multiple Choice 1. Which situation is a nurse most likely to encounter when providing end-of-life care?

A. Personal grief experiences have little impact on relating to the patient.

B. Cultural norms of the patient apply only after death.

C. Communication with the patient may be difficult.

D. Focus should be on comfort instead of activities the patient can do.

Answer: C Rationale: Communication may be impaired or even unintelligible in the dying patient. In such circumstances, the nurse needs to inform the patient that the nurse is attempting to understand.

2. There are many theories and studies about grief. What do they all have in common in real life?

A. Stages of grief are sequential.

B. Stages of grief are nonlinear.

C. Resolution of the grief comes at some point.

D. Grief stops when attachment to the deceased stops.

Answer: B Rationale: The commonly recognTizEedST stB agAesNoKfSgE riL efL(dEeRn. iaC l, O anMger, bargaining, sadness, acceptance), no matter how they are named or discussed in the various theories and studies, occur in a nonlinear fashion.

3. Ellie has just retired from working as a nurse her entire professional life. Between work, raising a family, and volunteering on her church board, she had little time to do needlework, which is her passion. She had been having trouble seeing for a few months and so made an appointment with her ophthalmologist two weeks after her retirement party. She is devastated to learn she has macular degeneration, making needlework impossible. What is Ellie most likely experiencing from this news?

A. Loss B. Suffering C. Grief D. Bereavement Answer: A Rationale: Loss is being deprived of something or someone. It can be actual, potential, physical, or symbolic. Loss is related to health, function, roles, relationships, and life itself. Suffering is the bearing of pain or distress. Suffering impacts a patient’s body, mind, and spirit. Grief is deep or intense sorrow or distress, particularly arising from bereavement concerning someone with whom a close bond was formed. Bereavement is the state or act of being deprived of a loved one.

4. Which correlation tends to occur regarding relationships and loss?

A. Intimate relationships inspire the most suffering from loss.

B. The longer the relationship, the more the loss and suffering.

C. The significance of the relationship determines loss and grieving.

D. Therapeutic relationships are unlikely to result in loss and grieving.

Answer: C Rationale: The significance of the relationship impacts how the individual will interpret the loss and the accompanying suffering.

5. Which situation is a nurse likely to encounter in performing end-of-life care?

A. The patient’s physician usually knows the patient’s wishes.

B. The nurse needs to advocate for the patient’s wishes.

C. The patient’s care is well coordinated among providers.

D. The nurse needs to keep the patient’s goals from changing.

Answer: B Rationale: The nurse needs to keep abreast of the patient’s treatment wishes (which may change during the dying process) and coordinate care between facilities and providers.

6. Craig is 42 years old and living with acute myeloid leukemia. He is the owner of a gym, and has been fit and athletic his entire life, up until now. He is currently hospitalized while receiving his latest round of chemotherapy, feeling weaker than he has ever felt in his life, and has come to realize that hTe E isSpTroBbA abNlyKS ouEt L ofLtE reR at. mCeO ntMoptions. He had turned the gym management over to his business partner but seldom calls her. The coaches from his gym try to stop in and see him, but he says no. A year ago he had set up a social media page and posted on it regularly. Now he never looks at it. What issue in the living–dying interval is Craig most likely struggling with?

A. Planning remaining time B. Arranging his affairs C. Attending to future care needs D. Confronting loss of identity and self Answer: D Rationale: The living–dying interval occurs from the time death is acknowledged as imminent to the point of the actual death. Craig is struggling with confronting loss of identity and self because he has stepped away from his gym and being an athlete. He has not yet reached the point where he is planning his remaining time. He has already started arranging his affairs by turning his gym over to his business partner, and he has not started thinking about attending to his future care needs yet.

7. Which action by the nurse demonstrates acknowledgment of the importance of significant others at the end of life for the patient?

A. Incorporating significant others into the patient’s care as desired by the significant others B. Focusing primarily on the patient’s needs and secondarily on the significant others’ needs C. Stepping away from significant others in their loss and grief to protect their privacy

D. Recognizing the need to work with both the patient and the significant others Answer: D Rationale: There is interdependence between the patient, the significant others, and the nurse in relation to providing optimal care for the patient with a terminal illness. The nurse can maximize the positive aspects of this interdependence by recognizing and affirming the patient’s significant others, incorporating them into the patient’s care as desired by the patient, and assisting the significant others in their loss, suffering, and grief related to the patient’s dying and death.

8. Which statement describes influences on grief in significant others?

A. Some factors may cause depression instead.

B. Physiological factors are the most predominant.

C. They are best addressed after the patient has died.

D. Addressing them is out of nursing scope of practice.

Answer: A Rationale: Some of the same factors that influence grief may cause depression instead. A way to distinguish between grief and depression is to note if the individual in question is able to experience pleasure. Grieving individuals generally can experience pleasure; depressed individuals often have difficulty experiencing pleasure and may lose morale and hope.

9. Which approach is most appropriate for nurses when helping family members of a terminally ill patient with their grief?

A. Recognizing that a parentT ’sEgS riT efBwAilNl K beSdEeL epLeE r tRh. anCaOsMibling’s when a child dies B. Understanding that the child may have the fear for their own well-being when a sibling dies C. Being aware that depression and grief present quite differently in an elderly person D. Having insight that the level of grief for loss of a parent is the same as that for the loss of a child Answer: B Rationale: Grief is a deep and complex issue. If a child loses a sibling, other issues, such as guilt, ambivalence, denial, increased vulnerability, and fear for his own well-being, may arise. When a child dies, siblings can feel grief as deeply as the parent. In the elderly, often depression and grief present quite similarly. If a person loses a parent and loses a child, the loss of the child tends to inspire a deeper level of grief.

10. Josiah is sitting with his brother, Jeremiah, who is in hospice. Jeremiah was born with muscular dystrophy and is now reaching the end of life. Josiah’s grief is palpable, all the more so because the anniversary of his parents’ deaths in a car accident is approaching.

Which action by the nurse would be the most helpful to Josiah right now?

A. Giving him lists of chronic illness organizations he could volunteer for in his brother’s memory B. Checking to see that Josiah has plenty of reading material while by his brother’s bedside C. Staying in the room with Josiah without talking unless he initiates it D. Asking Josiah to speak about what he is feeling about his brother

Answer: C Rationale: Staying in the room with Josiah without talking unless he initiates it is being authentically present for Josiah. Nurses are accustomed to action-oriented, “doing for” interventions. However, when caring for the patient with a terminal illness, the nurse’s role may be less action oriented and more presence oriented. Giving Josiah lists of chronic illness organizations he could volunteer for in his brother’s memory, checking to see that Josiah has plenty of reading material while by his brother’s bedside, and asking Josiah to speak about what he is feeling about his brother are all action-oriented approaches.

Short Answer 1. Describe the differences among mourning, grief, and bereavement.

Model Answer: Mourning, grief, and bereavement often are used interchangeably.

Mourning involves social and cultural factors such as customs and rituals influenced by the community in which the person lives, heritage, and religious beliefs and values. Grief involves the physical, mental, emotional, and spiritual dimensions of a person as he or she responds to loss or the perception of loss. Grief is a part of mourning. Bereavement is also a part of mourning and is the state of having suffered a loss.

2. What recommendations will help nurses who become close to certain terminally ill patients?

Model Answer: Nurses are encouraged to maintain their composure when caring for patients. However, nurses canTbEeSpT roBfeAsN sioKnSaE l aLnL dE stR ill.eCnO gaMge emotionally with the patient and the patient’s family. What they should not do is bring their own emotional needs into the therapeutic relationship. Authentic self-disclosure of feelings by nurses may role model to others a healthy process of acknowledging and resolving the suffering of loss. Nurses need to do honest self-reflection as to why they are disclosing these feelings and to make sure they are not doing so as to get their own emotional needs met. If nurses release emotional stress through crying, they need to be able to direct this into a meaningful and positive experience for the patient and the patient’s family. Peer support groups can be helpful for nurses to work through their grief. When a team is involved, it is helpful to provide an opportunity for staff members to have open communication and to sustain and care for one another. Other recommendations include regular exercise, good nutrition, diversional activities, focus on caring rather than curing, emphasizing the positive dimensions of nurses’ roles, and recalling positive experiences with families.

3. Beatrice is in hospice for end-stage renal failure. She never married nor had children but has several nieces and a nephew who love her very much. They are traveling to be with her, but it will take several days for everyone to arrive. Beatrice is frightened about death, worried that she won’t have enough time to tell her nieces and nephew what she wants to tell them, and what to do about her condo, her pet cats, and her estranged sister. What can the nurse do to ensure that Beatrice has some closure in her personal affairs?

Model Answer: The nurse can conduct an assessment with Beatrice about her end-of-life issues. The questions the nurse can ask include:

How do you view your illness?

What is the meaning of your illness to you?

What fears or concerns do you have regarding your illness?

In what ways are you experiencing loss and suffering?

Are there any unresolved issues or business matters that need to be resolved?

Do you have any specific fears about dying and death in general? About your own dying and death?

What concerns do you have for others now and after your death?

What helps you maintain a sense of hope during difficult times?

The nurse can then help Beatrice with methods and resources for closure with her personal affairs.

4. Lia and Cade are 9-year-old twins. Their 72-year-old grandfather has lived with them and their parents for as long as they remember, and they are all very close. The grandfather dies suddenly from a heart attack. What are the best recommendations to give the parents for the twins about grieving for their grandfather?

Model Answer: Lia and Cade need gentle confirmation and reassurance. Their parents should give Lia and Cade clear and realistic information about what happened to their grandfather. If they want to be there, Lia and Cade should be included in the funeral ceremonies. Even though Lia and Cade’s parents are grieving themselves, they should give the children permission to express their feelings and provide opportunities to do so. As much SE as possible, Lia and Cade’s paTrE enStsTsBhA ouNldKm aiL ntL aiE nR a. stC ruOcM tured schedule and continue individual and family activities. Lia and Cade’s school needs to be notified about what is occurring.

5. How can patient spiritual care be incorporated into nursing practice?

Model Answer: Medical science has limitations, and often patients feel dehumanized during some medical procedures. In addition to addressing comfort needs, patients need assurance that their humanity will be respected and valued. The nursing profession has reawakened to the importance of integrating spiritual care within total patient care. Patients have indicated that their spiritual needs are best met through nurses’ listening to, talking with, supporting their religious practices, and being with them. Even in the midst of suffering through the loss of physical well-being, patients may sense spiritual well-being. Buckwalter (2003) refers to “moments of ministry” or “ministry of the moment” as those times when nurses or others assist patients in a “holy moment of connection,” especially for someone who may be experiencing profound memory loss. If a nurse feels inadequate or uncomfortable assisting dying patients in this area in any way, a pastoral care referral may be indicated. In addition, the patient may desire to have clergy closely involved even if the nurse is comfortable meeting the patient’s spiritual needs.

CHAPTER 12: Holistic Integrative Therapies in Palliative Care Multiple Choice 1. Which statement describes holistic care?

A. It is folk medicine.

B. It less effective than traditional medicine.

C. It can increase a person’s sense of control over illness D. It provides only temporary relief.

Answer: C Rationale: Holism focuses on unity, mutuality, meaning, and the interrelationship of all beings, events, and things. It can help patients participate in their own care. Some aspects of holistic care have been handed down through the ages, but some of them are based on science. Traditional medicine has many benefits, but it is not effective for every disease or condition a patient can have. There are many instances in which holistic care is more effective, such as in helping patients relax. Some benefits of holistic care are temporary, just like some benefits of traditional medicine. However, holistic care can also provide long-term or even life-time relief of symptoms.

2. Who is most likely to use complementary integrative health approaches (CIHAs)?

A. Lindsay, who is 24 and is trying to lose weight B. Martin, who is 19 and phyTsE icS alT lyBfA it NKSELLER.COM C. Gisele, who is 54 and has chronic pain D. Alberto, who is 42 and gets the occasional cold Answer: C Rationale: Many people use CIHAs for many different reasons. The most common reasons for using CIHA are to prevent illness or for overall wellness (77%), to reduce pain or treat painful conditions (73%), to treat a specific health condition (59%), or to supplement conventional medicine (53%). There is also great interest among the chronically ill, those with life-threatening conditions, and those at the end of their lives.

3. Carmen and her physician recently had the difficult conversation about preparing for her end of life. She is distraught and filled with anxiety, which is compounded by chronic pain. The nurse suggests that a complementary integrative healing modality might be helpful for Carmen. Which statement is ethical for the nurse to make to Carmen about trying this approach?

A. “The modality will eliminate your pain.”

B. “The modality may be calming and allow you to rest.”

C. “The modality can increase your chances of extending your life.”

D. “The modality works better than your other medical treatments.”

Answer: B Rationale: “The modality may be calming and allow you to rest” is an ethical statement. CIHA has documented calming influences and some physiological effects. “The modality will eliminate

your pain,” “The modality can increase your chances of extending your life,” and “The modality works better than your other medical treatments” are all unethical statements because they are not true. Some modalities may alter the perception of pain, but they do not eliminate pain. No treatment, whether allopathic or holistic, can guarantee to extend life. Claiming a holistic modality works better than other treatments the patient is receiving undermines the treatment approach. In the healthcare setting, holistic modalities are used to complement, not replace, medical treatments.

4. Which holistic modality has as its primary aim protecting the body from the effects of stress?

A. Relaxation techniques B. Guided imagery C. Music thanatology D. Life review Answer: A Rationale: Relaxation techniques are the basis of many holistic modalities. Relaxation has three aims: (a) as a prevention to protect body organs from unnecessary stress and wear; (b) as a treatment to alleviate stress in numerous conditions, for example, hypertension, tension headache, insomnia, asthma, immune deficiency, panic, and pain; and (c) as a coping skill to calm the mind and to help thinking to become clearer and more effective.

5. Which holistic modality can influence the patient’s mind and body by directly affecting the limbic system?

A. Meditation B. Imagery C. Reiki D. Aromatherapy Answer: D Rationale: Aromatherapy involves the distillation of oils from plants. The advantage of these oils comes from their influence on the limbic system, which coordinates mind and body activity. This system is very sensitive to odors and encodes them into associations and memories, which when awakened alter basic physical functions such as heart rate, blood pressure, breathing, and hormone level.

6. A nurse is helping a patient do a life review. Why would the patient choose this particular holistic modality?

A. To feel that he is vital again B. To feel his experiences have meaning C. To feel connected to the universe D. To more easily transition into his death Answer: B Rationale: Life review provides integration, a feeling that this life was individual and unique.

The client may verbalize sadness as well as achievement, but the objective is to allow a person to see the meaning in his or her life. Feeling vital and connected to the universe, and to more easily

transition into death, can be side benefits of a life review, but the main purpose is for the patient to feel his life had meaning.

7. Alan is receiving end-of-life care and spends most of his time in bed, with occasionally being able to sit in a recliner. He has noticed that the muscles in his back seem to always hurt, and sometimes he has difficulty raising his arms from shoulder tightness. Which holistic modality would have the most direct benefit for Alan?

A. Massage B. Reiki C. Therapeutic touch D. Compassionate touch Answer: A Rationale: Massage can be used for pain reduction, comfort, tension release, prevention of atrophy of muscles and stiffness of joints, and inducing sleep. Reiki and therapeutic touch work with the patient’s energy field, and compassionate touch involves stationary placement of hands on the patient’s body. These holistic modalities may have an effect on Alan’s issues, but massage will have the most direct benefit.

8. A nurse notices that a patient’s family has been bringing in small bags of herbs to one of the patients in hospice. The nurse checks the patient’s chart and sees that only prescription medications are listed in it. Which action should the nurse take?

A. Ignore the herbs because they are most likely ineffective at this stage in the patient’s illness B. Tell the patient to cease taking the herbs immediately and confiscate them C. Ask the patient to disclose what herbs they are because they may interfere with treatment D. Tell the patient that herbs are unregulated, so are illegal in healthcare settings Answer: C Rationale: The nurse should ask the patient to disclose what herbs he or she is taking because they may interfere with treatment. This can be done in a respectful manner. The nurse should not ignore the herbs because there could be deleterious effects or side effects on the patient. The nurse does not have the right to tell the patient to cease taking the herbs immediately and confiscate them. Even though there is little to no regulation of herbs, they are not illegal in healthcare settings.

9. How are holistic modalities meant to be used?

A. To cure common diseases B. To serve as a placebo C. To improve a sense of well-being D. To limit the number of medications prescribed Answer: D Rationale: Holistic modalities address physical, emotional, and spiritual needs of a person. In Western cultures, they are not primarily used to cure common diseases, serve as placebos, or limit the number of medications prescribed.

Complementary, holistic modalities are used most often to improve a sense of well-being by reducing symptoms, such as pain, stress, or anxiety and improving overall quality of life.

10. A nurse is advocating for holistic modalities to be part of palliative care. A physician who is heavily invested in traditional medicine is skeptical that holistic modalities can be of any benefit to patients. What information could the nurse give him that might change his mind?

A. Holistic therapies have been handed down through generations of practitioners.

B. Holistic therapies are aimed toward strengthening the body’s own defenses and healing abilities.

C. Family members and caregivers can be taught simple holistic techniques to use with their loved ones and themselves.

D. Interconnectedness of physical, mental, emotional, environmental, and spiritual aspects of the person is supported by holistic therapies.

Answer: B Rationale: The fact that holistic therapies are aimed toward strengthening the body’s own defenses and healing abilities may appeal to the physician’s traditional medicine mindset.

Short Answer 1. How can nurses help patients heal while dying?

Model Answer: Healing the dying involves regard for relationships and connectedness.

Transcendence implies a sensT eE ofScToB nnAeN ctK ioSnEbL etL wE eeRn.sC elO f aMnd a greater reality. Selftranscendence integrates self with past and future, giving meaning to the present. This caring relationship emphasizes quality rather than length of life. Healing the dying includes palliative care and focuses on all types of relationships. Opportunities and choices allow the dying person to live life to its fullest and, at some point, comfortably forgive, let go, release, and experience a peaceful death. The nurse is in a partnership with the dying client, sharing rather than denying the experience. The focus of nursing care is on providing sacred space and the setting for a calm and peaceful death. The nurse works with the client to foster hope and cultivate an appreciation of the seemingly irrelevant things in life. Learning to appreciate simple occurrences such as a sunset or the joys of life can cultivate a more positive view of life and one’s present experience. Enhancing avenues of support, whether professional, social (family and friends), or support groups, can often facilitate grieving and increase a sense of meaning in illness. Developing unrecognized inner strengths and resources is of great importance to the person who is dying or grieving.

2. Miles is an artist known for painting large, colorful canvases. He is now in the end stages of AIDS and is having difficulty with pain management. Which holistic modality might be the most useful for him?

Model Answer: Guided imagery might be the most useful for Miles because, as an artist, he is highly visual. Imagining is a powerful technique of focusing and directing the imagination.

All the senses are used—vision, sound, smell, taste, movement, position, and touch. Imagery influences attitudes, feelings, behaviors, and anxiety, which can either lead to a sense of hopelessness or promote a perception of well-being that assists in changing opinions about

disease, treatment, and healing potential. Imagery can affect people physically, emotionally, mentally, and biochemically, and the body and mind respond as if the event is actually occurring. Guided imagery has many applications in end-of-life and palliative care, including relaxation, stress reduction, pain relief, symptom management, grief work, and assisting clients to comprehend meaning in their illness experience.

3. An advanced practice nurse would like to start offering healing modalities in the form of touch to end-of-life patients. What benefits of touch should she include when she designs a proposal to present to hospital administration?

Model Answer: In the later stages of life, individuals are often deprived of tender and nurturing physical contact such as being touched in a way that is healing, nourishing, relaxing, and pleasurable. Touch is essential to one’s quality of existence. It provides comfort, warmth, and renewed vitality—a sense of security and assurance that we are not alone. The benefits of touch include increased circulation and mobility, a decrease in pain, increase in vitality, increase in physical functioning, the experience of being nurtured and cared for, a boost in self-esteem, increased motivation to receive and give attention to self and others, energy and emotional release, a sense memory triggering a relaxation response, relief from loneliness and isolation, decreased feelings of abandonment and deprivation, verbal interaction, and calming reassurance and support. It often induces much-needed sleep.

4. What steps can a person preparing for end of life take to die consciously?

.nCdOeM Model Answer: Individuals bTeE coSmTeBaAwNarKeSoE f tLhL eiE r oRw aths in phases, and this awareness can lead to consciousness in dying. Keegan and Drick and Olson identified some tasks for dying consciously. One is to live life fully until death comes and participate in care for as long as possible. Another one is to plan to say good-bye to family and friends, finish things you wanted to do, and make final decisions regarding the last will and testament, the estate, organ donation, and so forth. A third is to participate in emotional and spiritual tasks such as forgiving yourself and others, feeling that life mattered and the world is different because you were here, and knowing and accepting love as one changes. The last is to rehearse the dying process. Through an awareness of dying, learn to diminish the fear of death and to “let go of this life” when it is time to do so. Imagery, relaxation, meditation and prayer can help patients to transcend pain and grief by enabling them to be more peaceful, let go, open their heart, forgive themselves and others. Such holistic modalities also help people to find comfort and peace, and the achievement of closure.

5. James has been working as a nurse in pediatric oncology for almost three years. He is joyful for the patients who are able to overcome cancer and leave the hospitals. However, lately it seems that many more patients than usual have died or are approaching end of life. James has been finding himself having sharp words with other nurses, calling in sick when he was not sick, and feeling a sense of dullness inside when a new patient is admitted to the floor. How can James take care of himself to alleviate the stress from “death overload?”

Model Answer: James can address five areas of self-care. Spiritual self-care involves him asking himself if spirituality is important in his life. What is his relationship with God or a

higher power? Why is he here and what is his purpose? What is his relationship to the universe? Emotional self-care involves him asking if he can identify his emotions. How does he deal with them? Is he usually in control? Can he discuss his emotions? Is he open to others, and does he respect the feelings of others or does he jump to conclusions? When do his emotions get out of control? Physical self-care involves him asking himself what areas of his lifestyle are unhealthy. What can he do to improve his lifestyle? Mental self-care involves him asking himself if he is knowledgeable and strives to continually increase his knowledge.

Is he satisfied with the status quo or is he open to new ideas? What is he doing to stimulate his mind? Relationships self-care involve him asking himself if he is open and honest with himself and others? Does he have satisfying relationships with others? Is he willing to accept the thoughts and feelings of others even though they are different from his own or is he judgmental? Must he have all the control or can he share it? Does he have a balance among work, home, and leisure?

CHAPTER 13: Cancer Multiple Choice 1. Which factor is involved in current cancer care?

A. Palliative care for cancer occurs mostly in hospice.

B. Care is shifting to the interprofessional model of support.

C. The number of cancer cases continues to decrease.

D. Cancer is most frequently diagnosed in later stages.

Answer: B Rationale: Cancer care has evolved in the past 20 years not only as a result of changes in treatment efficacy but also due to the interprofessional model of support currently offered.

Healthcare consumers prefer honest and more complete information pertaining to diagnosis, prognosis, symptom burden, and survival benefits related to treatment. The increasing number of healthcare professionals certified in PC offers more options for the supportive care of cancer than just hospice. Worldwide cancer cases are expected to continue to increase, and cancer is being diagnosed in earlier stages.

2. What are effects of having a palliative care consult?

A. Increased medical costs for facilities because of additional healthcare professionals B. Increased patient and family spiritual and bereavement referrals to other locations C. Increased support for patiT enEtsS, T faB mAilN ieK sS anEdLthLeEoRn. coCloOgM y team D. Reduced need for evidenced-based research into pain management treatments Answer: C Rationale: Palliative care (PC) teams support the clinicians and work closely with a patient population living with a life-threatening disease by providing emotional and educational support.

Evidence suggests that PC teams assisting in cancer care improve patient care and reduce costs to the family and healthcare system. Where multiple clinicians representing different specialties are involved, PC teams provide the hub of communication and specialized spiritual and bereavement support of patients, families, and clinicians that cancer care requires. Having PC providers on the interprofessional team does not reduce the need for evidence-based research into pain management teams.

3. Which type of cancer is most prevalent in children?

A. Leukemia B. Neuroblastoma C. Bone D. Colorectal Answer: A Rationale: Leukemias (mainly acute lymphocytic leukemia) account for approximately 31% of all childhood cancers; brain and nervous system cancers make up about 25% of childhood cancers; while neuroblastoma is the most commonly occurring (6% of all childhood cancer

types) solid tumor outside of the central nervous system. Bone cancer does occur in children but is not as common as leukemia. Colorectal cancer is much more common in adults.

4. Katherine has Stage III breast cancer. Which treatment regimen is she most likely undergoing?

A. Surgery, radiation, and hormonal therapy B. Surgery, chemotherapy, and radiation C. Hormonal therapy and chemotherapy D. Radiation and hormonal therapy Answer: B Rationale: Treatment for Stage III breast cancer (locally advanced tumors) involves a combination of surgery, chemotherapy, and radiation for local control of the tumor and to decrease the risk of distant recurrence. Hormonal therapy is considered the standard of care for treatment of hormone receptor positive breast cancer.

5. Why is colorectal cancer difficult to detect in older adults?

A. They are usually asymptomatic.

B. Few diagnostic methods exist.

C. Symptoms may be attributed to the aging process.

D. Symptoms are diffuse and mimic other diseases.

Answer: C Rationale: Diagnosis of colorectaT lE caS ncTeB rA (CNRKCS) E inLtL heEoRld.eC rO adMult is especially challenging because many of the common symptoms associated with CRC such as constipation, change in bowel patterns, and fatigue may be inaccurately attributed to the aging process. Diagnosis is made through screening to detect polyps and cancer.

6. Which type of comorbidity is a risk factor for any type of cancer?

A. Obesity B. Genetics C. Smoking D. Frailty Answer: D Rationale: Frailty at any age adds a risk factor to cancer morbidity. Anticancer therapies often decrease the patient’s functional level, leading to catabolic syndrome, muscle wasting, and increased risk of infection. Obesity, genetics, and smoking are risk factors for various types of cancer, but frailty is the only risk factor for all types.

7. When should palliative care begin for a patient with cancer?

A. At the time of diagnosis B. At the initiation of chemotherapy C. During discussion of prognosis D. During end of life

Answer: A Rationale: Palliative care is best initiated at the time of a cancer diagnosis, especially for patients with a life-limiting cancer. Many individuals experience symptoms that interfere with quality of life at the time of diagnosis as well as other points in time along the disease trajectory.

8. Which statements represents barriers to pediatric palliative care?

A. Parents have a need to try every available therapy to increase the chance for survival.

B. Parents and physicians recognize the level of suffering C. Parents and physicians understand the difference between palliative care and hospice D. Physicians understand the limitations of cancer therapies Answer: A Rationale: Palliative care health professionals working in the field of pediatrics have reported the parental need to provide every available therapy to their child in order to feel confident they have given their child the best chance for survival. Parents and physicians may not recognize the degree of physical or emotional suffering of a child. They may associate palliative care with hospice care rather than understanding the palliative care can involve not only curative treatments but treatments that alleviate suffering. Many oncologists view death as a failure and therefore attempt cancer therapies that may not prevent death.

9. Which consideration is most important for cancer care of adults?

A. Age is the most useful determinant in prognosis.

B. Older adults with and without disease need the same amount of assistance.

C. All older adults are frail bT yEvS irtTuB eA ofNthKeSirEaL geL. ER.COM D. Functional abilities at any age determine the treatment plan.

Answer: D Rationale: Natural changes associated with age often lead to a greater susceptibility to chronic and acute disease, yet a comprehensive evaluation of the older adult’s comorbidities, cognition, functional status, nutritional status, social supports, psychological state, and personal resolve gives a more accurate definition of age in relation to cancer treatment tolerance. Age itself is not the most useful factor to determine prognosis and consider treatment options for older adults.

Chronological age can be used as a functional status indicator for older adults because it is assumed that adults living with cancer are more likely to need functional assistance than their same-age peers without cancer. The medical literature often refers to a frail individual as someone with poor physiological reserves and a high prevalence of repeated chronic illness requiring multiple hospital admissions.

10. Which action by the healthcare professional most often results in generating hope in the family of a patient with cancer?

A. Giving the patient information about latest medical treatments B. Building a trusting relationship with the patient C. Withholding the prognosis that the patient is terminal D. Making all the decisions about care for the patient

Answer: B Rationale: When physicians establish a compassionate, trusting relationship with the patient, family prognostic disclosure could support hope, even when the prognosis is poor. The palliative team assists caregivers to develop the physical, emotional, and mental reserves that are required to maintain hope, coupling that with the provision of timely, accurate, and honest information on the impending death. Nurses should respond to patient and family concerns with patience and assurance of non-abandonment and an increase in attention to aggressive symptom.

Short Answer 1. Sharon is a nonsmoker, very active physically, a vegetarian who eats only organically grown produce, and drinks ultra-filtered water. She is shocked when she is diagnosed with cancer.

How does cancer develop?

Model Answer: Malignant tumors are produced by a synergy between the accumulation of mutations and tissue changes that support the survival of mutant cells. Factors that cause or facilitate cancer development include chemical mutagens, radiation, free radicals, genomic instability, inherited cancer susceptibility, telomere shortening, and altered cellular environment. Modifiable risk factors such as smoking, diet, physical activity, and weight control can alter cellular environment and influence the proliferation of cancer cells.

Carcinogenesis works in a stepwise progression in which a normal cell undergoes malignant transformation. Steps include tumor initiation, promotion, malignant conversion, and, finally, tumor progression. Occasionally, family members will question the cause of cancer when a loved one is diagnosed; howeT veErS , fT urBthAeN rK inS veEsL tigLaE tioRn.uCsO uaMlly reveals an existential concern that a genetic explanation may not satisfy.

2. Caleb is 69 years old and has been having difficulty urinating lately. He is wondering if it is due to prostate cancer, so he makes an appointment with the nurse at his assisted living facility. What signs and symptoms will the nurse ask him about, and what type of further examinations will Caleb need?

Model Answer: Early and localized stages of prostate cancer generally do not present with symptoms. Hallmark symptoms that occur more frequently in locally advanced stage cancer are usually associated with urinary outlet obstruction: frequent urination, urinary hesitancy, inability to urinate, nocturia, and dysuria. Impotence, painful ejaculation, bloody urine or semen, pain, and stiffness in the lower back, hips, or upper thighs are additional symptoms suggestive of malignancy. Since many of the common symptoms may mimic other conditions, it is common for men to postpone medical consultation. Symptoms of malignant prostate disease usually do not subside, which distinguishes prostate cancer from benign disorders. Digital rectal examination and/or PSA blood test are the most commonly used screening methods for prostate cancer.

3. Explain the differences in disease management for small cell lung cancer (SCLC) and non– small cell lung cancer (NSCLC).

Model Answer: Because SCLC is considered a systemic disease, surgery is not a treatment option. Chemotherapy alone or with radiation is the usual treatment for SCLC with a high rate of early remission but frequent recurrences. NSCLC has more treatment options such as chemotherapy, radiation, surgery, immunotherapy, targeted therapy, and kinase inhibitors.

However, surgical resection remains the only potential curative treatment for patients with NSCLC presenting with surgically resectable disease. Surgery is recommended for all adults with good performance status. Newer surgical techniques, such as the VATS, have provided a minimally invasive approach with similar long-term survival rates. Current treatment options will include surgical resection, systemic therapy, radiation, or combinations of these modalities depending on stage.

4. Kari is 15 years old and recently diagnosed with a rare form of bone cancer. She is undergoing treatment, and her parents and oncologists are cautiously optimistic. Needless to say, her life has been turned upside down. What should healthcare professionals assess in terms of the effects uncertainty, disease, and treatment have on her?

Model Answer: Uncertainty while living with cancer has been identified as a significant aspect of pediatric cancer and a major concern of adolescent and young adult cancer survivors. Treatments can have serious implications through each phase of the patient’s life.

Chemotherapy and radiation therapy can harm developing organs, and surgery can alter normal physical functioning or cause disfigurement. Many survivors of childhood cancer have physical, mental, or emotional limitations resulting from successful anticancer treatment. A major concern is thoughts of suicide. Risk factors associated with a higher significance of suicidal sympT toE mS sT inB clAuN deKySoE unLgLerEaRg. eC atOdM iagnosis, a greater time lapse since diagnosis, and radiation treatments to the head. Add those risk factors to feelings of depression and hopelessness, chronic pain, physical dysfunction, and appearance alterations due to treatment and the data suggest that healthcare professionals should perform a thorough psychosocial assessment upon long-term follow-up of survivors. Survivors with 5 or more years from diagnosis had higher uncertainty related to knowing what to expect for disease recurrence and multiple meanings of communication from doctors.

5. If a patient and his or her family is asking for chemotherapy even though the patient is transitioning to end of life, how should healthcare professionals respond?

Model Answer: A discussion of patient preference for quality and quantity of life with or without chemotherapy is a good start to a palliative treatment discussion. Before chemotherapy is recommended, a definable benefit must be identified, and a straightforward discussion can be initiated by asking patients how much they want to know about their current condition and prognosis. The healthcare professionals should define the words “response” and “cure” because many patients will use these terms interchangeably. Printed resources should be provided that list benefits and adverse reactions to chemotherapy. The patient should be asked about his or her goals for treatment, views on undesirable side effects, and plans for the future. Extending survival time for an upcoming special event may be the benefit that could justify treatment in the patient’s mind. If the patient receives the chemotherapy, the plan should be revisited when the cancer is resistant to chemotherapy.

CHAPTER 14: End-Stage Heart Disease Multiple Choice 1. Which statement is accurate regarding heart failure?

A. It is a curable disease.

B. End of life is difficult to predict.

C. Disease progression usually occurs in a linear fashion.

D. There are usually one or two admissions to the hospital.

Answer: B Rationale: Heart failure is considered a progressive disease which has exacerbations and remissions but eventually the heart fails and it becomes a terminal disease. As such, it is difficult to predict when death will occur. In the final phase, patients and their families experience office visits, hospitalizations, and decreased quality of life despite optimal therapy.

2. Which statement describes end of life for patients with heart failure?

A. Referral rates for hospice and palliative care are high.

B. Referrals to hospice and palliative care tend to occur in the last four weeks of life.

C. Palliative care needs to be incorporated into general care.

D. Healthcare costs are likely to go up with increased use of palliative care.

Answer: C Rationale: Because of the low rate of hospice utilization and pattern of late referrals in end-stage heart disease, there is a need for the infusion of palliative care principles into general care. While a majority of hospice admissions for cardiovascular disease has surpassed admissions for cancer diagnosis, there is still a low referral rate for heart failure patients. Referrals to hospice and palliative care tend to occur in the last two weeks of life. Cardiovascular disease results in hospital admissions and readmissions. Palliative care, with its focus on symptom management and decisional support, has the potential to ameliorate some of the burden of heart failure.

3. What effect does depression have on heart failure?

A. Decreased incidence of clot formation can result from low cytokine levels.

B. Hypertension from increased afterload can result from high cortisol levels.

C. Decreased ventricular filling can result from low serotonin levels.

D. Increased incidence of diabetes mellitus can result from high cytokine levels.

Answer: B Rationale: Depression and anxiety are important as they relate to the pathophysiology of heart failure (HF). Depression may independently worsen HF and increase the risk of death. Cortisol levels are persistently high in patients with depression, which, over time, leads to hypertension caused by increased afterload and an increase in heart rate resulting from decreased ventricular filling time. Proinflammatory cytokines, which are activated in the stress response, reduce the available serotonin, which leads to not only depression but also increased platelet aggregation and ultimately coronary artery occlusion.

4. Which substance is used as a predictor of hospitalization and mortality for heart failure?

A. MR-proADM B. Soluble ST2 C. Galectin 3 D. C-reactive protein Answer: A Rationale: MR-proADM has natriuretic, vasodilatory, and hypotensive effects; is elevated in acute and chronic heart failure; and is used as a predictor of hospitalization and mortality. Two markers, soluble ST2 receptor and Galectin 3, are linked to myocardial remodeling and fibrosis that eventually leads to the myocardial dysfunction and heart failure and may be considered as prognostic markers of heart failure. C-reactive protein, tumor necrosis factor-α (TNF-α), and interleukins 1, 6, 18 are all inflammatory markers that appear to have direct adverse effects on the myocardium through myocyte apoptosis and necrosis.

5. Mary finally went to see her physician after not feeling well for some time. Her physician suspects Mary might be in Stage C of heart failure. Which symptom would have presented first in Mary?

A. Cough B. Abdominal bloating C. Peripheral edema D. Dyspnea Answer: D Rationale: Of Stages A through C, Stage C of heart failure is when patients notice the first signs and symptoms. Dyspnea is typically the first manifestation of heart failure in patients.

6. If the healthcare professional is asking the patient about how well he or she gets around, what activities he or she does, what type of status is being assessed?

A. Cardiac B. Self-care C. Symptom D. Functional Answer: D Rationale: Functional status assessments include asking the patient about ambulation, activity level, self-care ability, oral intake, and level of consciousness.

7. Which type of medication will all patients with heart failure be prescribed?

A. Angiotensin-converting enzyme inhibitor B. Diuretic C. Beta-blocker D. Aldosterone antagonist Answer: C

Rationale: All patients with HF, unless contraindicated, should be prescribed a beta-blocker and one of the following: an angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) or angiotensin receptor blockers with neprilysin inhibitor (ARNI).

8. Joseph has Stage C heart failure and is at his appointment with his cardiologist. When the physician asks Joseph how he has been feeling, Joseph says he has been okay for the most part, but the arthritis in his hip has acted up so he took a couple of aspirin for the pain. Why will the cardiologist tell Joseph to stop taking aspirin?

A. It can cause increased blood pressure.

B. It can cause cardiac depression.

C. It can increase the risk of clot formation.

D. It can stimulate the release of epinephrine.

Answer: A Rationale: Nonsteroidal anti-inflammatory drugs cause sodium retention and peripheral vasoconstriction, as well as decrease efficacy and increase toxicity of diuretics and ACEI. In addition, they increase the risk of bleeding when used with anticoagulants such as warfarin, a drug widely used in this population.

9. Which piece of equipment is designed to synchronize contractions of both sides of the heart?

A. Implantable cardioverter defibrillator B. Biventricular pacemaker C. Left ventricular assist device D. Transthoracic doppler Answer: B Rationale: A biventricular pacemaker provides electrical stimulation that is programmed precisely to synchronize and coordinate the right and left ventricular contraction.

10. Which statement most accurately indicates the relationship between disease management and palliative care in heart failure?

A. Disease management and palliative care are two terms for the same practices.

B. Palliative care is used after disease management runs out of options.

C. Disease management focuses on medical interventions and palliative care focuses on quality of life.

D. Palliative care and disease management occur at the same time to improve the quality of life of a patient and their family caregivers.

Answer: D Rationale: There is a common misperception that disease management and palliative care are synonymous types of care. Disease management can attempt to cure a disease or the lessen its progression. Disease management are treatments targeted at the disease while palliative care improves the physical or psychological symptoms associated with the disease. Disease management does not include all of the domains identified in quality care for people with lifelimiting conditions such as heart failure. For example, the psychological and psychiatric; social,

spiritual, religious, and existential; and cultural aspects of care and care of the patient and patient’s family at the end of life are part of palliative care.

Short Answer 1. Roman is 72 years old and has just been diagnosed with systolic heart failure due to left ventricular hypertrophy. When he asks his cardiologist what that means, the physician answers in medical jargon, leaving Roman quite confused and unsure what to ask next. How can the cardiologist explain heart failure so that Roman understands?

Model Answer: Your heart is made mainly of muscle and when the muscle contracts, it pumps blood out of the heart. Heart failure means that your heart is a slowly failing pump.

There are two sides of the heart, right and left. The right side of the heart pumps blood to the lungs, and the left side of the heart pumps blood out to the rest of the body. Roman, your heart is failing on the left side. The muscle simply is not strong enough to pump enough blood out to meet the needs of the rest of your body. The most common cause is hypertension, or high blood pressure. Because the blood pressure is so high in the artery leading away from your heart, the left side of your heart has had to work extra hard to pump, and it has enlarged but not in a good way. The strain on the muscle in the left side of your heart is now slowly giving out.

2. As part of the interprofessional team, the palliative care (PC) professional would need to perform an assessment on a patient with heart failure. What does this assessment encompass?

Model Answer: A hallmark of quality PC is the assessment of the physical, psychological, social, and spiritual/existential aspects of care. Particular areas for assessment involve a complete physical assessment as well as taking a psychological history and assessing for reaction to the current condition, indicators of distress, family structure and function, strengths and vulnerabilities, caregiving needs, access to community services and resources, and advanced care planning. It should also include a spiritual assessment. Using the acronym FICA, the clinician assesses for faith or belief systems, important influences in the person’s life, community support, and addressing the issues in the person’s healthcare.

3. Why would a patient with heart failure be prescribed digitalis?

Model Answer: Digitalis glycosides, positive inotropic agents, have been a part of the medical regime for patients with heart failure (HF) for over 200 years. These agents are still indicated for use in patients with systolic dysfunction (HFrEF) and ongoing symptoms of HF despite already being on optimum doses of ACEIs or ARBs and BBs. Patients with mild to moderate HF on digoxin experienced a decrease in the progression of HF and had decreased hospital admissions, but had no overall decrease in mortality. Digoxin is also indicated in patients with HF with atrial fibrillation and uncontrolled ventricular response. However, this drug must be used carefully, while monitoring for and preventing digoxin toxicity.

4. Natasha is 56 years old and has been happy leading a sedentary life. Lately, however, she has noticed she is little more short of breath than she used to be and her weight has started to

creep up. One evening her daughter comes to visit and notices how swollen Natasha’s ankles are. It seems excessive, so her daughter insists that Natasha make an appointment with her doctor. After examining Natasha, her doctor insists that she be admitted to the hospital right away. Why would Natasha’s doctor do this?

Model Answer: When patients develop signs and symptoms of heart failure (HF), they often need to be hospitalized. Hospitalization is typical when a patient is first diagnosed with HF. Most patients are admitted due to fluid overload resulting in symptoms such as dyspnea, orthopnea, weight gain, or edema. The primary goal for HF-related hospitalization is to relieve symptoms, particularly congestion. Determining the etiology of the HF and EF will help determine what therapies are initiated. Another key goal while in the hospital is to identify and address precipitating factors for the decompensation such as poor adherence to medications or diet and fluid recommendations, poor social support or financial resources, lack of self-care education, or inadequate medical regimen prior to admission, as well as medical conditions such as atrial fibrillation, worsening renal function, hypertension, or ischemia.

5. Describe at least five nonpharmacological measures for management of heart failure.

Model Answer: For older adults (as well as those younger than 65), aggressive use of the nonpharmacological measures is imperative. General measures include: 1. Decreasing more or new cardiac injury by risk factor reduction 2. Limiting alcohol use to twToEgSlaTssBeA s/N daKySfoErLmLeE nRan.dCoOnM e glass/day for women 3. Maintaining fluid balance by restricted salt intake (2 g/day) 4. Improving physical conditioning 5. Careful management of comorbid conditions 6. Patient education regarding self-care 7. Smoking cessation when appropriate 8. Influenza vaccination every fall 9. Pneumococcal immunizations 10. Care of patients with heart failure across settings and by interprofessional teams 11. Careful monitoring of fluid status

CHAPTER 15: Chronic Lung Disease Multiple Choice 1. What is the cause of most cases of chronic obstructive pulmonary disease (COPD)?

A. Mesothelioma B. Pollution C. Pneumonia D. Smoking Answer: D Rationale: About 80% to 90% of COPD cases are the result of smoking. Ninety percent of patients with COPD die from causes attributable to smoking.

2. What are the most distinguishing consequences of COPD? A. Limitation and obstruction of airflow B. Increased levels of neutrophils and macrophages C. Tissue damage and inflammation D. Cough and bronchitis Answer: A Rationale: Airflow limitation and obstruction of airflow are the hallmark consequences of COPD. Increased levels of neutroTpE hiS lsTaB ndAm acSroEpL haLgEesR, . anCdOtM issue damage and inflammation NK result from constant irritation of the airways but are not distinguishing consequences. Cough but not always bronchitis occurs with COPD. 3. Alice’s spirometry reveals FEV1/FVC equal to or less than 70% and her FEV1 is 40%. What stage of COPD is she in?

A. Stage I B. Stage II C. Stage III D. Stage IV Answer: C Rationale: Patients with a spirometry that is FEV1/FVC equal to or less than 70%, and FEV1 >80% predicted are in Stage I COPD. FEV1/FVC equal to or less than 70%, and 50% ≥ FEV1 ≤ 80% predicted are in Stage II COPD. FEV1/FVC equal to or less than 70%, and 30% ≥ FEVI ≤ 50% predicted are in Stage III COPD. FEV1/FVC equal to or less than 70%, and 30% < FEVI predicted are in Stage IV COPD. 4. Which symptom is typically overlooked in diagnosing COPD? A. Mental changes B. Decreased appetite C. Increased appetite D. Sleep disturbances

Answer: D Rationale: Up to 60% of patients with COPD experience sleep disturbances, yet this symptom is often underassessed by providers or underreported by patients. Sleep quality is often fragmented, with episodes of dyspnea or coughing interrupting nighttime sleeping. Additionally, COPD patients may also experience sleep apnea, referred to as “overlay syndrome” when sleep apnea is diagnosed with COPD. The coexistence of sleep apnea with COPD is reported to be up to 60% in patients with COPD. 5. Which statement describes palliative care and COPD? A. COPD has easily recognized disease trajectory which indicates advanced illness and the need to request a palliative care consult..

B. Most healthcare professionals are able to effectively communicate the need for palliative care for patients with COPD. C. Fear of patient’s reaction to COPD diagnosis contributes to healthcare professionals’ lack of incorporation of palliative care.

D. Many health professionals can completely address the physical, emotional, and social needs of COPD patients without the need for palliative.

Answer: C Rationale: Fear of patients’ reactions to diagnosis and treatment may hinder discussions with patients and their families and contributes to a lack of specialized care, including palliative and end-of-life care. The underdiagnosis, undertreatment, and unpredictability of the trajectory of COPD contributes to confusion and uncertainty regarding the diagnosis and prognosis among Rm .uCnOicMation skills needed to discuss the interdisciplinary providers. ManyTpEroSvTidBeA rsNlaKcS kE thLe LcoEm trajectory of COPD illness and the needs that patients experience at different stages of the COPD. Many providers have an inadequate understanding of the nature of palliative care and often perceive palliative care as synonymous with end-of-life care.

6. Which treatment modality is a pulmonologist likely to prescribe for all his or her patients with COPD? A. Regular exercise B. Smoking cessation C. Bronchodilators D. Vaccines Answer: B Rationale: Current treatment modalities for all patients with COPD include smoking cessation, prevention of infection, maximizing pulmonary function, and education. After the age of 65, smoking continues to be a major risk factor for death as well as a decreased quality of life.

7. Alastair is 57 and has just been diagnosed with COPD. He is feeling quite depressed because he stopped smoking 10 years ago and thought that would be long enough to make his lungs healthy again. What could his pulmonologist recommend for Alastair’s depression?

A. Exercise training B. Increased protein and calorie intake C. An anticholinergic agent D. Varenicline prescription

Answer: A Rationale: Exercise is central to the treatment of COPD and helps to improve both the physical symptoms of dyspnea and the psychological symptoms of depression. A combination of constant load or continuous exercise and interval exercise training provides the most beneficial outcomes compared to either treatment alone. Increased protein and calorie intake counteracts the malnutrition a patient with COPD may develop. An anticholinergic agent dilates airways.

Varenicline is a medication to help stop smoking.

8. When would a corticosteroid be prescribed for a patient with COPD? A. After the initial diagnosis B. At end-of-life care C. When bronchodilators are ineffective D. When progression becomes moderate to severe Answer: D Rationale: As the severity of COPD increases, and patients are diagnosed with moderate to severe forms of the disease, the GOLD Guidelines recommend as the next step the addition of an inhaled corticosteroid to long-acting bronchodilator therapy for all patients diagnosed with moderate-stage COPD, having an FEV1 of less than 50%, with frequent exacerbations of COPD. Inhaled corticosteroids have been shown to decrease the number and severity of exacerbation.

9. Which patient with COPD would be considered to have a life expectancy of less than six months?

A. FEV1 greater than 30% afTteErSuT seBoA fN aK brSoE ncLhL odEilRat.oC r OM B. PO2 greater than or equal to 55 mmHg on supplemental oxygen C. Progressive weight loss of greater than 10% of body weight D. Resting tachycardia greater than 80 beats per minute Answer: D Rationale: Progressive weight loss of greater than 10% of body weight is an indicator of low chance of survival longer than six months. FEV1 less than 30% after use of a bronchodilator, PO2 less than or equal to 55 mmHg on supplemental oxygen, and resting tachycardia greater than 80 beats per minute are also indicators of low chance of survival longer than six months.

10. If a patient is in chronic respiratory failure, which treatment is the only one that increases survival?

A. Morphine B. Steroids C. Oxygen therapy D. Pulmonary rehabilitation Answer: C Rationale: Oxygen is the only therapy associated with increased survival in patients who have chronic respiratory failure and must be administered for a minimum of 15 hours or more.

Morphine and steroids may assist with dyspnea. Pulmonary rehabilitation can be effective but not as effective as oxygen therapy.

Short Answer 1. How is COPD diagnosed?

Model Answer: The diagnosis of COPD is often considered when a patient reports a chronic cough, sputum production, or progressive dyspnea. A comprehensive history should be obtained including the duration and type of cough, whether dyspnea occurs at rest or with exercise, and the amount of sputum production. The baseline functional status of the client should be established and monitored over the course of the disease. Information regarding smoking history, recent exposure to toxic substances, or exposure to occupational fumes is necessary in establishing a diagnosis. Pulmonary function tests (PFTs) are needed to objectively confirm the diagnosis. Additional diagnostic tests may be necessary, and include a chest x-ray, arterial blood gases, and bronchodilator reversibility testing. If a client is diagnosed with COPD before the age of 45, and has a family history, alpha-1 antitrypsin testing may be performed. The revised GOLD guidelines recommend additional assessments to stratify patients. Symptom assessment is conducted using the COPD Assessment Tool (CAT) assessment or the Modified British Medical Research Council (mMRC) Questionnaire.

2. Jackson has been living with COPD for several years. Every fall, his pulmonologist warns him to guard against getting a cold or flu. What effect would getting a cold or flu have on Jackson?

Model Answer: Recurrent respiratory infections, commonly viral and bacterial in origin, can cause a transient worsening of COPD symptoms and are the most common cause of acute exacerbations. COPD patients are likely to experience one to two acute exacerbations per year. Haemophilus and Streptococcus pneumonia infections are the most common bacterial infections. The rhinovirus is responsible for approximately 25% of acute exacerbations.

Frequent infections are likely to worsen pulmonary function.

3. How would palliative care help a patient with COPD? Model Answer: The goal of PC for patients with COPD is to promote quality of life. The principles that underlie the provision of PC include effective communication among providers, clients, and their families, as well as maintaining independence and promoting psychosocial, spiritual, and emotional health. Patient education is an important component of communication and may help patients adjust to their illness and manage the disease.

Palliative care professionals educate clients about the causes of COPD as well as the progressive nature of the disease. Effective communication may assist clients with smoking cessation. Discussions about advanced directives and end-of-life care should be carried out throughout the early and late stages of the disease to promote quality of life. End-of-life care is especially important due to aggressive life-prolonging treatments that some patients receive in the last months of life because other alternative preferences, such as supportive comfort care, had not been discussed.

4. Maisie is 64 years old and recently diagnosed with COPD. She was a moderate smoker who has led a primarily sedentary life. She was able to finally quit smoking after receiving her diagnosis but is not happy about it. Now her pulmonologist wants her to start exercising and do breathing retraining. Maisie is very resistant to these. Exercising and breathing retraining sound like a lot of work, and she thinks that quitting smoking should be enough on her part to manage the COPD. How could a palliative care nurse encourage Maisie’s compliance with exercise and breathing retraining?

Model Answer: The nurse could explain that pulmonary rehabilitation can help give Maisie better quality of life and slow the progression of COPD. Pulmonary rehabilitation is focused on exercise and muscle reconditioning. Rehabilitation can take place in a community setting as well as in the client’s home. By increasing physical activity, muscle atrophy may be reduced and the efficiency of oxygen uptake will be improved. This will make Maisie stronger, and better able to fight off infections. The nurse could explain that breathing retraining for clients with COPD includes the techniques of pursed-lip breathing and diaphragmatic/abdominal breathing. Due to the pathophysiology of COPD, air becomes trapped in the terminal airways and adequate ventilation decreases. Pursed-lip breathing facilitates the expulsion of air from the lungs by the client controlling and lengthening the expiratory phase of respiration. This can contribute to Maisie’s pulmonary endurance.

Diaphragmatic/abdominal breathing serves a similar purpose as pursed-lip breathing. Maisie would use the diaphragmatic and abdominal muscles to control both inspiration and expiration. Both techniques would assist her in reducing panic and anxiety associated with dyspneic episodes.

5. What complementary therapies can nurses recommend for patients with COPD? Model Answer: Rest is necessary in order to decrease the intensity of dyspnea; it can also decrease the work of breathing. Promoting rest and sleep can also decrease anxiety.

Assessment of the patient’s sleep habits can be a helpful starting point to the promotion of restful sleep. Assisting the patient into a position of comfort can promote sleep, which generally means elevation of the head of the bed, which also facilitates diaphragmatic expansion. Guided imagery can be used to promote sleep and assist the patient through a stressful experience. Massage can promote sleep and reduce anxiety. Music therapy can also be added to the therapeutic plan for the promotion of rest and sleep and may help to reduce the need for pain medications. Several herbs that are used in the treatment of respiratory ailments. For example, Chaparral, cinnamon, horehound, and pansy have been used in the treatment of bronchitis,. However, caution must be taken as chaparral can cause severe liver damage and cinnamon can precipitate shortness of breath. Anise and astragalus have been used in the treatment of COPD. For general respiratory care and cough, lobelia and wild cherry have been used. The benefits of herbal interventions should be weighed against the harmful side effects that could exacerbate COPD or the complications of cor pulmonale and respiratory failure.

CHAPTER 16: Neurological Disorders Multiple Choice 1. Which person is most likely to have a stroke?

A. A 50-year-old Caucasian man who lives in Oregon B. A 65-year-old Caucasian woman who lives in Florida C. A 70-year-old Alaskan Native woman who lives in Idaho D. A 80-year-old African American man who lives in Georgia Answer: D Rationale: The prevalence of stroke is higher in older adults, African Americans, American Indians/Alaska Natives, persons with lower levels of education, and persons living in the southeastern United States. Racial and ethnic disparities in stroke care continue to be a major challenge for healthcare providers, with the burden of stroke remaining consistently higher among ethnic minority groups. Seventeen percent of all strokes occur in people who are older than 85 years. The incidence of stroke is higher in men than in women between the ages of 45 and 84 years. However, this changes after the age of 85 years, with women having a higher incidence of strokes than men.

2. Reginald had a stroke in which blood flow through an artery in his brain was blocked. What type of stroke does this describe?

A. Ischemic B. Atherosclerotic C. Hemorrhagic D. Thrombolytic Answer: A Rationale: An ischemic stroke results in a disruption of blood to a portion of the brain due to an occlusion of the cerebral artery by blood clots (emboli), or plaque and fatty deposits (thrombi).

3. Which statement describes Parkinsonʼs disease?

A. Average age of onset is 50 years.

B. Symptoms can mimic other conditions.

C. Genetics play a role in its development.

D. Symptoms result from acetylcholine depletion.

Answer: B Rationale: Parkinsonʼs disease symptoms mimic other conditions and there is no biomarker for Parkinsonʼs disease. The average age of onset is 60 years. Most cases of Parkinson’s disease occur without obvious genetic cause. Degenerative process results in depletion of dopamine.

4. Dahlia’s movements have become extremely slow, she has fallen a few times in the past several weeks, and her neck and head appear to have a slight shaking motion. Which condition is she most likely to be diagnosed with?

A. Parkinsonʼs disease B. Alzheimerʼs disease C. Multiple sclerosis D. Hemorrhagic stroke Answer: A Rationale: The four primary motor symptoms of Parkinsonʼs disease are bradykinesia, rigidity, postural instability or balance problems, and resting tremor. Dahlia’s symptoms of slow movement and instability issues leading to falling demonstrate that Parkinsonʼs disease can present similar to other diseases but the shaking motion is specific to Parkinsonʼs disease.

5. Which condition is characterized by muscle atrophy due to degeneration of upper and lower motor neurons?

A. Stroke B. Amyotrophic lateral sclerosis C. Multiple sclerosis D. Coma Answer: B Rationale: Amyotrophic lateral sclerosis (ALS) or Lou Gehrig disease is a rare but rapidly progressive neurodegenerative diT seEasSeTthBaA tN afK feS ctE sL boLtE hR up.pC erOaMnd lower motor neurons leading to progressive muscle atrophy of the voluntary muscles in the arms, legs, and trunk.

6. Which statement characterizes coma?

A. Most patients in a coma from a stroke survive.

B. Prognosis depends mostly on the age of the patient in the coma.

C. Patients who emerge from a coma can regain most of their function.

D. Most coma patients die in acute care.

Answer: D Rationale: The majority of coma patients will die in the acute care setting, except for those whose coma is persistent. Most comatose stroke patients do not survive. The most critical factors involved in determining prognosis is etiology of the coma, the clinical depth of coma, and the length of time the person remains comatose. People who do emerge from a coma may have problems with complex thinking, emotional stability, and physical difficulties.

7. George has dementia and lives in an assisted care facility. He shares a room with another patient who likes to have the TV on. George’s nightstand has photos of his family and roses his wife brings every few days. On his wall are several paintings he did in his younger years, and his bed has an afghan his wife crocheted and flannel sheets. The palliative care nurse has noticed that George is becoming agitated lately. What modification to his room might be calming to him?

A. Removing the photos from the nightstand B. Turning off the TV C. Discouraging his wife from bringing roses D. Taking the paintings off the wall Answer: B Rationale: The patient with dementia may become overstimulated easily. Turning off the TV will most likely decrease George’s agitation because it eliminates a possibly loud sensory stimulation. It is important that George’s room be as pleasant and as stress free as possible. He needs some items that are familiar in the immediate area, such as photos of his family, the roses from his wife, and his paintings.

8. Oral hygiene and honey-thick liquids most effectively address which condition?

A. Dysphagia B. Dyspnea C. Aphasia D. Paratonia Answer: A Rationale: Dysphagia is difficulty swallowing, which can be a complication in a patient with a neurological disorder. Oral hygiene, especially for patients who produce excessive saliva, and honey-thick liquids can help give these patients nutrition. Dyspnea is difficulty breathing.

Aphasia is leads to impaired difficulty in reading and writing. Paratonia is the involuntary resistance of an arm or a leg to movement of the limb by another person.

9. What factor is involved in pain management and palliative care?

A. Opiates are the first line of pharmacologic treatment for neuropathic pain.

B. Spasticity is a common problem that can become disabling.

C. Extremity pain in multiple sclerosis is dull and aching.

D. Range-of-motion exercises have little effect in poststroke patients.

Answer: B Rationale: Spasticity is a common problem that can become disabling, affecting ADLs and, ultimately, quality of life. Opiates play a relatively small role in the management of neuropathic pain.. Extremity pain in people with MS is a result of demyelinating lesions and is described as persistent and burning. Range-of-motion exercises, proper positioning, and techniques to manage edema should be initiated immediately poststroke in the affected limb.

10. What is the role of a palliative care professional for the family of a patient with brain death?

A. Ensure the patient receives opioids for pain relief B. Communicate physician’s treatment decisions to the family C. Determine when withdrawal of treatment should occur D. Support the family and give them time to process information they have been given Answer: D Rationale: The palliative care professional needs to give the family time to process and cope with information they have been given. The patient does not need opioids for pain relief because the patient who is brain dead does not feel pain. The palliative care professional communicates the family’s treatment decisions to the physician, not the other way around. The family determines when the withdrawal of treatment should occur.

Short Answer 1. A patient has just been diagnosed with Alzheimerʼs disease. How could the nurse explain to the patient’s son, who is not a healthcare professional, why his father will experience progressive memory loss and psychiatric disturbances, and will eventually lose basic body functions?

Model Answer: Within the brain, a certain type of protein twists around other neuroproteins inside nerve cells, forming tangles. The tangles disrupt the neuron’s functioning and then cause it to die. Scarring and these tangles occur in parts of the brain that control information TE ToBrA processing, acquisition of new mS em ieN s,KaS ndErLetLriE evRa. l oCfOoM ld memories. They also occur in another part of the brain involved in thinking and decision making. As a result, people with Alzheimerʼs disease experience progressive memory loss, loss of executive function, language difficulties, and psychiatric and behavioral disturbances; the disease then eventually affects the area of the brain that enable the person to carry out basic bodily functions such as walking or swallowing.

2. Describe the four ways multiple sclerosis can present.

Model Answer: There are four main patterns to the presentation of multiple sclerosis (MS).

Relapsing-remitting is the most common form of MS and is characterized by flare-ups that appear for several days to weeks followed by remissions during which not all symptoms resolve completely. Primary-progressive MS is a less common form, in which the disease manifestations gradually worsen over time without periods of remission. The secondaryprogressive MS form starts out as a relapsing-remitting course but later progresses to primary-progressive MS. Progressive-relapsing MS is the least common form that is progressive from the beginning with episodes of acute increased worsening of existing symptoms or new ones.

3. Bailey’s mother, Eliza, is recovering from a stroke, and it is a long, difficult process. Bailey is doing the best she can for caregiving, but is frustrated by how hard it is to communicate with Eliza. How can a palliative care nurse help?

Model Answer: Difficulty communicating is severely reducing the quality of life for both Eliza and Bailey. The palliative care nurse can develop a plan with the interprofessional team for providing meaningful communication and socialization for Eliza and Bailey. The nurse can explain to Bailey that supporting any of Eliza’s attempts to communicate helps Eliza feel connected and accepted. As a result, Eliza may begin using many more nonverbal cues to communicate needs. The nurse can help Bailey and Eliza develop a nonverbal system of communication for Eliza’s needs such as pain relief, hunger, or the need to eliminate or change positions. Other nonverbal communication through touch, massage, and eye contact can be helpful. Gestures are a three-dimensional language of communication; waving hello, pointing, beckoning with outstretched hands, and hugging used by Bailey may be effective communication tools. Bailey is conveying to Eliza that she is not alone and that she is respected.

4. What are benefits of exercise in patients with neurological disorders?

Model Answer: Research on exercise for people with Alzheimerʼs disease and related disorders has shown maintenance of motor skills, decreased falls, reduced rate of cognitive decline, and improved mood. Strengthening and balance exercises in patients with Parkinsonʼs disease increase physical function, strength, balance, gait speed, and healthrelated quality of life. Rhythmic auditory stimulation, in which rhythms of sounds function as a cue to stabilize and enhance the organization of movement, may be beneficial for improving gait parameters in stroke patients, including gait velocity, cadence, stride length, and gait symmetry. For patients with ALS, exercise can help to maintain the flexibility of muscles, but it will not strengT thEenST mB usAcN leK sS thE atLhL avEeRb. eeCnOwMeakened by ALS. For people with MS, exercise may decrease symptoms, but it must be done judiciously as overheating or overstressing the body can actually exacerbate symptoms. Occupational therapy may help patients to maintain independence for longer periods of time as the chronic neurological diseases progress.

5. How can a nurse help families with chronic neurological disorders?

Model Answer: The illness trajectory for patients with chronic neurological disorders is often long and unpredictable. The prognostic uncertainty is associated with a host of patient, family, caregiving, and reimbursement challenges. Patients with chronic neurological disorders have heavy physical and emotional care needs. Care in a hospice or long-term care facility may reduce the caregiving required of the family, but may lead to feelings of loss of control as well as feelings of isolation. Deciding on the preferred setting for end-of-life care is complex, with many factors to consider; family members may disagree with each other or with the patient. The nurse can serve as a nonjudgmental listener, can help to explore options, and can facilitate working through the process of decision making with family members.

In the case of illnesses that are associated with dementia, the nurse can facilitate early discussions, and assignment of trusted family members to decision-making roles when capacity is compromised is essential. With these illnesses, there is a lot of anticipatory grieving that occurs, and the nurse can support family members in accepting their feelings.

Acknowledging conflicting feelings, particularly both the dread and the desire for the death to occur, as common and natural can be helpful. Early discussions about the typical course of the illness that are honest but sensitive are needed.

CHAPTER 17: End-Stage Renal Disease Multiple Choice 1. Chronic kidney disease is defined by which estimated glomerular filtration rate (eGFR)?

A. Less than 60 mL/min/1.73 m2 for 3 months or longer B. More than 60 mL/min/1.73 m2 for 3 months or longer C. Less than 60 mL/min/1.73 m2 for 6 months or longer D. More than 60 mL/min/1.73 m2 for 6 months or longer Answer: A Rationale: Chronic kidney disease can be defined as kidney damage or eGFR less than 60 mL/min/1.73 m2 for 3 months or longer.

2. Which condition is a patient with chronic kidney disease most likely to die from?

A. Hypertension B. Diabetes mellitus C. Myocardial infarction D. Dyspnea Answer: C Rationale: Cardiovascular disease is the leading cause of death in people with end-stage renal disease. Stable atherosclerotic heT arE t dSiT seB asAeN , aKcS utE eL mL yoEcRar.dC iaO l iMnfarction, congestive heart failure, stroke, peripheral vascular disease, atrial fibrillation, and sudden cardiac arrest increase the risk of premature death. Other comorbid conditions that can impact the health and wellbeing of patients with end-stage renal disease include diabetes mellitus, hypertension, osteoarthritis, and cognitive impairment.

3. How does the trajectory of end-stage renal disease present?

A. Death usually occurs within three years of starting dialysis.

B. Early mortality is highest in the first two weeks of dialysis.

C. Age is the most important predictor in older patients.

D. It presents as stable periods with intervals of steady decline.

Answer: D Rationale: Evidence supports that the disease trajectory in some adults with ESRD include stable periods followed by intervals of steady decline. Death usually occurs within five years of starting dialysis. Early mortality is the highest in the first four weeks of dialysis. In older adults, functional decline may be a more important predictor of the disease trajectory than age itself.

4. Which patient is exhibiting early signs or symptoms of end-stage renal disease?

A. Karen, who has nausea and vomiting B. Bill, who has leg cramps and joint pain C. Jan, who has chest pain and palpitations D. Darla, who has mood swings and depression

Answer: B Rationale: Early signs and symptoms of end-stage renal disease include leg cramps, joint pain, gout, arthritis, muscular pains, muscle weakness, hyperparathyroidism, anemia, hypertension, pitting edema, gains in weight with fluid retention, weakness, and fatigue. Nausea, vomiting, chest pain, palpitations, mood swings, and depression are all late signs and symptoms or uremic indicators.

5. What effect do comorbidities have on patients living with end-stage renal disease?

A. Patient’s age has no role in the type of complications.

B. Cognitive impairment rarely occurs.

C. Kidney replacement therapy is contraindicated.

D. Survival rate tends to become lower.

Answer: D Rationale: Survival rate tends to become lower because there is increased disease management burden. Although age is not a sole predictor for potential poor health outcomes, it plays a substantial role in the type of complications and health-related outcomes for people with ESRD. Both children and older adults with ESRD present special challenges because of the unique comorbid conditions and ESRD-related complications that are superimposed upon the normal anatomic and physiologic changes associated with those age groups. Cognitive impairment occurs more often in older adults; the majority of patients with end-stage renal disease are older adults. Kidney replacement therapy focuses primarily on filtering the blood and does so no matter what conditions the patient has.

6. Joyce is on Medicare and has recently started dialysis for her end-stage renal disease. Why is a dietician now on her healthcare team?

A. To provide nutritional advice, especially about phosphorous B. Health providers do not have knowledge to manage the calcium levels C. The Medicare Benefit does not focus on a patient-centered plan of care D. To monitor the patient’s bone density Answer: A Rationale: Constant, high levels of phosphorus and parathyroid hormone, and low levels of serum calcium, cause calcium to be leeched from the bone, thereby causing the unique form of bone thinning and weakening seen in end-stage renal failure. Foods high in phosphorus include dairy products, meats, legumes, nuts, whole-grain breads and cereals, and many soft drinks.

Collaboration with a dietitian can help establish a person-centered plan of care that considers the stage of chronic kidney disease and nutritional needs and honors patient preferences and wishes.

Prior to dialysis there is a Medicare benefit called Medical Nutritional Therapy, where a dietitian can educate and consult with patients who are not on dialysis. Once on dialysis, Medicare mandates that a dietitian be a member of the healthcare team.

7. What is a consideration for anemia in a patient with chronic kidney disease?

A. It is a rare occurrence and requires little intervention.

B. Treatment should occur only after dialysis has begun.

C. Target hemoglobin range is 10 to 11.5 g/dL. D. Iron deficiency anemia is a chronic complication with chronic kidney disease Answer: C Rationale: Recent guidelines from the Kidney Disease Improving Global Outcomes initiative recommend a target hemoglobin range of 10 to 11.5 g/dL, which is well below the normal adult range. The reason for this is evidence of increased thromboembolic events when the effort is made to normalize the hemoglobin with an erythropoiesis-stimulating agent. Normocytic, normochromic anemia is one of the most common complications of chronic kidney disease, with increasing prevalence in advanced chronic kidney disease. Treatment of anemia with an ESA should begin once the person is diagnosed and other causes of anemia are ruled out.

8. Arianna is 8 years old and has renal failure. Which procedure for dialysis is she most likely to receive?

A. Arteriovenous fistula B. Peritoneal catheter C. Arteriovenous graft D. Venous catheter Answer: B Rationale: In children, blood vessTeE lsSarTeBoA ftN enKtS ooEsLmLaE llR , n.eC ceOssMitating the use of the peritoneal dialysis. Individuals undergoing peritoneal dialysis will have a catheter placed through the abdominal wall into the peritoneal space and dialysis fluid is infused into the peritoneal space and drained out through the catheter after an exchange of electrolytes and systemic toxins.

9. What responsibility do healthcare professionals have when talking about kidney replacement therapy with a patient?

A. Emphasizing that dialysis is usually the best treatment option B. Discussing the complications of long term dialysis C. Explain that withholding dialysis is unethical D. Discussing the benefits and risks of kidney replacement Answer: D Rationale: For patients with multiple comorbidities, advanced age, and limited functional ability, conservative/supportive management may be as efficacious as kidney replacement therapy.

Dialysis may not be the best option for the patent. The family needs to be involved in the treatment decision. However, the discussion should be with the patient first, or the patient and family together. Informing the patient that withholding dialysis is a valid and ethical decision option

10. Which end-of-life symptom is managed with controlling blood levels of phosphorus, calcium, and parathyroid hormone?

A. Dyspnea B. Pruritus C. Anorexia D. Pain Answer: B Rationale: Pruritus is itching. Prevention includes adequate dialysis and achieving target phosphorus, calcium, and parathyroid hormone levels through a well-controlled diet and medications.

Short Answer 1. Malcolm has insulin-dependent diabetes mellitus. He has not always paid close attention to managing his condition. He is now in his fifties, has had several toes amputated, and his eyesight is becoming impaired. When Malcolm’s daughter takes him to his latest appointment with his physician, the physician asks Malcolm about his urinary output. Why would the physician want to know this?

Model Answer: The primary cause for end-stage renal disease is diabetes mellitus. In diabetic kidney disease, renal lesions include changes in the afferent and efferent arteries, tubular fibrosis, and thickening of the basement membrane with impingement on the filtration surfaces of the glomTerEuS luT s.BTAhN esK eS chEaL ngLeEs R pr.oC grOesMs as hyperglycemia persists and the resultant proteinuria contributes to hyperfiltration and high GFR and ultimately GFR decline. This is an indicator of chronic kidney disease.

2. Why should nurses encourage patients with chronic diseases, especially diabetes mellitus, hypertension, and cardiovascular disease, to be screened for kidney disease?

Model Answer: Not many people are aware they have kidney disease until it is advanced.

The absence of symptoms in early stages of chronic kidney disease limits self-awareness of kidney disease. Therefore, healthcare professionals, especially nurses, play a key role in educating patients about risk factors for kidney disease and the importance of being screened when at risk. This is important because early identification and treatment of comorbid conditions by a nephrology team can help delay end-stage renal disease and, when dialysis is required, help the patient arrive at that point in reasonably good health. Early referral to nephrology supports preservation of kidney function, reduced mortality, and delaying the onset of debilitating complications.

3. Ralph has been recently diagnosed with chronic kidney disease. His nephrologist says that he will give him a referral to a cardiac care center. Why would the nephrologist do this? What evaluations will Ralph undergo at the cardiac care center?

Model Answer: Cardiovascular disease is the leading cause of death among individuals with chronic kidney disease and end-stage renal disease undergoing dialysis. Living with

cardiovascular disease can substantially impact mortality, morbidity, and quality of life; thus, it is crucial that person-centered interventions are focused on prevention and the most appropriate treatment for the individual. KDIGO Clinical Practice Guidelines recommend the evaluation of risk factors for treatment includes screening for left ventricular hypertrophy and coronary artery disease; treating hypertension and hyperlipidemia using goals for patients who have preexisting coronary artery disease; low-sodium and low-fat diets; fluid restrictions; maintaining a calcium/phosphorus product below 55, which is obtained by multiplying the serum calcium number by the serum phosphorus number; as well as counseling for smoking cessation, exercise, and aggressive treatment of diabetes mellitus.

4. What factors are involved in a patient choosing a dialysis modality?

Model Answer: Indications for choosing one dialysis modality (hemodialysis vs. peritoneal dialysis) over another include lifestyle choice by the patient, healthcare provider preferences, distance to the nearest dialysis center (urban vs. rural), and concurrent illnesses and associated symptoms. In rural areas peritoneal dialysis or home hemodialysis with the NxStage® machine may be the best option because the closest dialysis center may be miles away, thus making it challenging for a person to get to the center three times a week.

5. How should pain management be addressed at the end of life for a patient with end-stage renal disease?

Model Answer: Pain is very common and distressing and requires a comprehensive assessment and individualizedTpElS anToBfAcaNrK eS foE rL peLoE plR e. wC itO hM end-stage renal disease. The first step in pain management is conducting a comprehensive pain assessment. Asking if the person has ever had pain management before, and what has worked and what has not worked, is also very important. There are a few important points to be made in the case of pain palliation in end-stage renal disease. For hospice patients, analgesics should be used on a regular schedule using the World Health Organization (WHO) analgesic ladder in guiding medications including opioids to be used. Even so, there are some drugs that should not be used, as well as some drugs for which dosing should be monitored, because their metabolites can accumulate in renal failure and cause unwanted side effects. Opioids are generally metabolized in the liver, but some accumulate. Nonpharmacological interventions like cognitive behavioral therapy, relaxation therapies, and mindfulness as adjunctive therapies may be useful.

CHAPTER 18: End-Stage Liver Disease Multiple Choice 1. Cirrhosis of the liver means that it is in what condition?

A. Enlarged B. Fibrotic C. Hemorrhaging D. Inflamed Answer: B Rationale: Cirrhosis is a diffuse pattern of liver injury and repair, which leads to fibrosis, changes in liver blood flow, and loss of liver cells.

2. Which virus is one of the major causes of liver cirrhosis, hepatocellular carcinoma, and death?

A. Hepatitis A B. Hepatitis B C. Hepatitis C D. Hepatitis D Answer: C Rationale: Worldwide, hepatitis C virus (HCV) is one of the major causes of liver cirrhosis, hepatocellular carcinoma, and death.

3. Carl is in the early stages of liver disease. What symptom he is most likely experiencing?

A. Confusion B. Jaundice C. Pruritus D. Fatigue Answer: D Rationale: Fatigue is the most common symptom experienced by patients in the early stage of liver disease. Confusion, jaundice, and pruritus occur at a later stage of liver disease.

4. Which statement describes predicting mortality for a patient with liver disease?

A. The Child-Pugh-Turcotte scoring system is more accurate than the MELD scoring system.

B. The Child-Pugh-Turcotte scoring system measures ascites and the MELD scoring system measures serum factors.

C. Other health factors come into play besides the Child-Pugh-Turcotte and the MELD scoring systems.

D. The Child-Pugh-Turcotte and the MELD scoring systems should always be used together.

Answer: C

Rationale: Other health factors play a role in assessing mortality, and a person with an MELD of 25 may have a lower mortality than someone with an MELD of 18 who has an infection or hemorrhage. Because it is usually the complications of cirrhosis that determine morbidity and mortality, it is often hard to predict prognosis in an individual patient. There are two scoring systems in current use that describe mortality: the Child-Pugh-Turcotte Score and the MELD. Both measure ascites, encephalopathy, and serum factors.

5. What is a consideration for hepatocellular carcinoma?

A. It is one of the fastest-growing cancers in the world.

B. It is unrelated to cirrhosis of the liver.

C. Symptoms manifest early in the disease.

D. Cancer rarely recurs after a liver transplant.

Answer: A Rationale: Hepatocellular carcinoma (HCC) is one of the fastest-growing cancers in the world.

Patients who are known to have cirrhosis should be screened for liver cancer every 6 months.

Liver cancer most often grows silently, and patients become symptomatic late in the course of the disease. There are strict criteria for the size and number of HCCs, established to minimize the probability of recurrence of cancer post-transplant.

6. Which complication occurs when intestinal lymphatic vessels are unable to carry fluid back into the vascular system?

A. Peritonitis B. Ascites C. Encephalopathy D. Gastropathy Answer: B Rationale: Ascites occurs when fluid leaking into the peritoneal cavity from engorged intestinal veins overwhelms the ability of the lymph vessels to carry the fluid back into the vascular system. Peritonitis occurs because there is increased bacterial translocation. Gut bacteria or bacterial products are the most likely causes of encephalopathy. Gastropathy is stomach disease.

7. Which condition is most effectively treated by a liver transplant?

A. Cirrhotic cardiomyopathy B. Hepatic encephalopathy C. Portopulmonary syndrome D. Hepatopulmonary syndrome Answer: D Rationale: As cirrhosis becomes further decompensated, other organs also develop dysfunction.

About 10% to 15% of patients with cirrhosis will develop hepatopulmonary syndrome, with shunting in the lungs and hypoxia, or portopulmonary syndrome, with right ventricular and pulmonary artery hypertension. The former is cured by liver transplant; the latter is not cured and is associated with increased perioperative mortality. Cirrhotic cardiomyopathy occurs as decompensation progresses; the work of the heart increases until it is no longer able to meet

demands, leading to high-output cardiac failure. Cirrhotic myopathy occurs too late to be ameliorated by a liver transplant. Hepatic encephalopathy is treated by addressing levels of ammonia in the blood.

8. Patsy is receiving palliative care for cirrhosis of the liver. Which nutritional concern is essential for Patsy?

A. She will find it easier to digest vegetable protein than animal protein.

B. She is at a higher risk for hyperglycemia.

C. She will need a higher protein intake than the average patient.

D. She will need a higher carbohydrate than usual.

Answer: C Rationale: Studies have shown that patients with cirrhosis require more ingested protein than a normal patient. Animal protein is more easily digested and absorbed than vegetable protein; 40% to 50% of vegetable protein can be inaccessible to pancreatic enzymes due to binding to cellulose. Because of the alterations in liver blood flow, there is less first-pass clearance of nutrients from the small intestine, leading to a discrepancy between nutrient absorption and secretion of insulin, glucagon, and other digestive hormones. This can lead to the potential for hypoglycemia and to a shift in metabolism from glycogen to muscle protein.

9. Which statement describes pain management for patients with cirrhosis of the liver?

A. Health professionals may be reluctant to prescribe pain medication.

B. Patients are usually pain free.

C. Chronic use of NSAIDs isTtE heSoTpBtiA mN alKcS hoEiL ceLfE orRp.aC inO .M D. Opioids are ineffective in relieving hepatic pain.

Answer: A Rationale: Healthcare professionals are often reluctant to prescribe pain medication because of former addiction issues or concern for altered drug metabolism or triggering encephalopathy.

Research shows that patients with end-stage liver disease experience moderate to severe pain.

The chronic use of NSAIDs, such as ibuprofen or naproxen, is contraindicated because they decrease platelet function, may cause gastric ulcers, and lead to a higher risk of interstitial nephritis in patients with cirrhosis. Opioids can be prescribed starting with a lower dose.

10. What issue is a patient who is an addict likely to struggle the most with during the end of life?

A. Anxiety B. Forgiveness of self and family C. Body image D. Mental illness Answer: B Rationale: Patients with end-stage liver disease may seek forgiveness from family members from whom they have been estranged due to addiction or mental illness. As a result of estrangement, these patients may have little support at the same time they may be struggling with selfforgiveness. Self-forgiveness may be the hardest.

Short Answer 1. What is fatty liver disease?

Model Answer: Nonalcoholic fatty liver disease (NAFLD) is an increase in stored fat in liver cells and is associated with a chronic inflammatory reaction. Nonalcoholic steatohepatitis (NASH) is a more severe form of NAFLD, with increased inflammation and fibrosis, and is now a major cause of liver cirrhosis. Both NAFLD and NASH are called fatty liver disease. The term “fatty liver disease” is used when more than 5% to 10% of the liver’s weight is made up of fat. Fatty liver disease is prevalent in individuals who are overweight or have diabetes, or metabolic syndrome.

2. Geraldine is stunned when she receives a diagnosis of liver cancer. She had been feeling fatigued but otherwise fine. She barely hears the oncologist give her treatment options.

Finally, Geraldine interrupts the physician to say that she would prefer to treat her disease naturally, without poisonous chemicals being put into her body. What is the most appropriate response to this?

Model Answer: One of the greatest challenges in treating people with liver cancer is that they may feel good and find it hard to believe that there is anything wrong. This is true even in patients referred for palliative care. They may opt for naturopathic remedies that seem less toxic (e.g., cannabis/CBD oil), but have not been shown to be effective in halting the progression of cancer. Patients may decide to undergo liver-directed therapies when subsequent imaging shows thT atEnS atT urBoA paNthKiS cE reL mL edEieRs.hC avOeMnot halted the disease. But the cancer is often more difficult to treat.

3. What are the steps involved for a patient to become a liver transplant candidate?

Model Answer: A patient with decompensated cirrhosis and a MELD of 14–15, a significant complication of the liver disease, or the development of HCC within the Milan criteria can be referred for liver transplantation. A preliminary investigation into the health of other organ systems, acceptable psychosocial health, and adequate caregiver support is performed first; then the information is sent to a transplant center. Further workup is done at the center, the patient is discussed at a multidisciplinary conference, and a determination of the patient’s suitability for transplant is made. If all concerns of the transplant program personnel are satisfied, the patient is placed on a liver transplant waiting list corresponding to his or her blood type. The position on the list is determined by the MELD score.

4. What factors are involved in a recommending palliative care for a patient with end-stage liver disease?

Model Answer: Given that the disease progression from end-stage liver disease is slow and involves intermittent acute exacerbations, predicting survival is difficult. Death from endstage liver disease is relatively sudden and unpredictable until the last week of life. This uncertainty and challenges in prognostication is one of several barriers for early referral of individuals with end-stage liver disease to palliative care or hospice. Individuals with end-

stage liver disease often receive palliative care late in the disease trajectory. Individuals with end-stage liver disease tend to live in a state of poor and declining health, but often have a limited understanding of their disease severity and prognosis and, therefore, may not realize how close they are to death. This makes end-of-life care conversations and referral to palliative care challenging for healthcare professionals. At the same time, healthcare professionals may lack training and experience in initiating end-of-life conversations, and may overestimate life expectancy, focusing on medical interventions. Professionals may be concerned that palliative care referrals are alarming to patients and families. They may also be concerned about taking away patients’ hope for a potential liver transplant and therefore postpone difficult end-of-life conversations. Patients and families may perceive palliative care as similar to hospice and that professionals are “giving up” on them, rather than understanding that palliative care and hospice improve the quality of life until its end. It is important to realize that palliative care can be introduced at any time in the illness trajectory to improve the quality of life of patients and families, with discussions of the goals of care, and the management of physical, emotional, and spiritual needs. Palliative care interventions are beneficial to patients with end-stage liver disease, even those who are referred for a liver transplant evaluation and awaiting a transplant.

5. Valerie is a nurse in an inner city hospital. Her supervisor, Manuel, has noticed that Valerie delays seeing to the needs of Harper, a patient with end-stage liver disease. There is no notation in Harper’s chart about the cause of the disease. Twice, Manuel has heard Valerie talking to other nurses about how she doesn’t understand why their time is being taken up with junkies and that these people just cost the healthcare system money. How should Manuel approach Valerie?

Model Answer: Manuel should talk with Valerie about how she must be honest with herself and be aware of her own assumptions and biases about this population and their families.

Hearing that an individual has end-stage liver disease may lead a nurse to make assumptions about the cause of the disease (“he or she is an alcoholic and/or drug user”) and/or the individual’s previous or current lifestyle. Valerie needs to reflect on and explore such assumptions. It is important for her to acknowledge them so they do not interfere with the respect each individual and his or her family deserve. Valerie needs to keep in mind that there are many causes for end-stage liver disease. Patients should not be judged by their past but instead be supported as they move forward with a terminal illness potentially causing physical and psychological pain and suffering.

CHAPTER 19: Palliative Care and HIV/AIDS Multiple Choice 1. What is the trajectory of HIV/AIDS? A. Similar to that of cancer B. Rapid decline to death C. One of acute disease D. One of chronic disease Answer: D Rationale: In the past decade the trajectory of HIV/AIDS has changed significantly, shifting to a disease less like cancer and more like chronic disease such as diabetes or heart disease.

2. What is the primary goal of palliative care in patients with HIV/AIDS? A. Prevent or alleviate suffering at any point of the illness B. Minimize use of pain medications C. Offer physical support to patients and family D. Comfort care at end of life Answer: A Rationale: The goal of palliative care is to minimize and prevent suffering for patients who are dealing with serious illness, incluT diEnS gT HB IVA/N AK IDSSEiL nL anEyRs. taC geOoMf the disease. Palliative care offers physical, emotional, social, and spiritual support to promote, maximize and maintain good quality of life of patients and their families. Despite the advent of effective pharmacological therapy and its availability, patients with HIV/AIDS still continue to experience a high burden of pain and other chronic symptoms through the disease trajectory, which presents many palliative care challenges.

3. Which statement describes HIV’s life cycle?

A. An enzyme converts its DNA to RNA. B. It uses cells with CD4 markers as host cells.

C. It uses cells with CD8 markers as host cells.

D. Replication occurs in body fluids.

Answer: B Rationale: HIV survives by reproducing itself in a host cell. It has an affinity for any cell that has the CD4 molecule on its surface, such as T lymphocytes and macrophages. An enzyme called reverse transcriptase converts HIV’s two strands of viral RNA to DNA. 4. When is AIDS diagnosed?

A. With the detection of HIV infection B. CD4 count drops below 200 cells/mm3 C. CD4 count drops below 50 cells/mm3 D. With suppression of opportunistic infections

Answer: B Rationale: When the CD4 count drops below 200 cells/mm3, HIV infection now meets one of the Centers for Disease Control and Prevention’s definitions of AIDS (CDC, 2013). With AIDS, patients often experience several opportunistic infections or cancers.

5. What is the relationship between opportunistic infections and HIV infection?

A. Most opportunistic infections are considered curable.

B. Opportunistic infections are usually the cause of death.

C. Usually only one opportunistic infection occurs at a time.

D. Symptoms associated with opportunistic infections do not contribute to suffering Answer: C Rationale: Opportunistic infections are the greatest cause of morbidity and mortality in individuals with HIV disease. Most of these opportunistic infections are incurable and can at best be palliated to control the acute stage of infection and prevent recurrence through long-term suppressive therapy. In addition, patients with HIV/AIDS often experience concurrent or consecutive opportunistic infections and various malignancies that are severe and cause a great number of symptoms and related suffering.

6. Which statement describes palliative care for patients with advanced AIDS? A. Dieticians are unnecessary on the interprofessional team.

B. Pain relief is the single most important factor.

C. Antiretroviral therapy is unnecessary at this stage.

D. Balance between aggressiT veEaSnT dBsuApNpK orS tiE veLeLffEoR rts.iC sO thM e goal.

Answer: D Rationale: Healthcare providers and patients must determine the balance between aggressive and supportive efforts, particularly when increasing debility, wasting, and deteriorating cognitive function in the face of advanced disease. The interprofessional palliative care team involves physicians, advanced practice nurses, staff nurses, social workers, dietitians, physiotherapists, and clergy. Therapeutic interventions and decisions for patients with advanced AIDS should include patient’s expectations, preferences, and goals, as well as the benefits and burdens of antiretroviral therapy, pain management, and advance care planning as part of the clinical discussions and planning for the future.

7. Which part of the HIV/AIDS patient’s health history could enhance the progression of disease?

A. Substance abuse B. Childhood vaccinations C. Travel to Europe D. Nonvegetarian diet Answer: A Rationale: Health history includes lifestyle habits, such as the past and present use of recreational drugs, including alcohol, which may accelerate the progression of disease. Childhood vaccinations can help prevent disease. Travel to countries in Asia, Africa, and South America

increases the risk of opportunistic infections. A nonvegetarian diet does not necessarily contribute to disease progression.

8. Antiretroviral therapy is typically given to which HIV/AIDS patients?

A. All who are free from opportunistic infections B. Those who have two or more opportunistic infections C. Those with a CD4 cell count below 350 cells/mm3 D. All regardless of CD4 cell count Answer: D Rationale: Historically, the assessment of the CD4 cell count was used to determine the initiation of ART, with ART primarily reserved for CD4 counts below 350 cells/mm3. Currently, HIV therapy is recommended for all HIV patients regardless of CD4 cell count.

9. Which statement is true regarding healthcare professional’s care of patients with HIV/AIDS? A. History of the patient’s complementary therapies use is irrelevant.

B. Most patients overstate what they are feeling and experiencing.

C. Benefits and drawbacks of diagnostic testing and treatments must be weighed.

D. Waiting until the patient is experiencing a symptom and then treating it is most effective.

Answer: C Rationale: Detailed assessment of current medications, chemotherapy, and radiation therapy or complementary therapies such as biofeedback, herbal therapies, or yoga should also be ascertained to determine the effecTtsEaSnT dB siA deNeKffSeE ctL sL ofEtrRe. atC mO enMt, and to prevent drug interactions. Patient’s self-report of symptoms should be taken seriously by the practitioner and acknowledged as a real experience of the patient. In the case of extremely advanced disease, the need for daily blood draws or more invasive and uncomfortable practitioners must reevaluate the benefits versus burden of diagnostic testing and treatments, particularly procedures. An important rule in symptom management is to anticipate the symptom and attempt to prevent it.

10. What has been determined to be satisfying for patients with HIV/AIDS? A. Patient’s ability to control physical, social, and spiritual aspects of his or her illness B. Reliance on healthcare professionals to determine what is best for the patient C. Focus on patient’s physical functioning and comfort as the main indicators D. Patient’s ability to ignore uncertainty associated with his or her illness Answer: A Rationale: Quality of life is based on the patient’s perceptions of his or her ability to control the physical, emotional, social, cognitive, and spiritual aspects of the illness. By establishing a partnership with their healthcare professionals in planning and implementing their healthcare, patients can maintain a sense of control during the illness experience. Physical functioning and comfort are only two aspects of the many dimensions of a patient. It is impossible to ignore uncertainty associated with illness since this uncertainty is a major part of the illness and end of life.

Short Answer 1. What advances have been made in the diagnosis and treatment of HIV? Model Answer: Since the identification of the first case of HIV in 1981, there has been significant scientific advancements made in the diagnosis and treatment of the disease; specifically, the virus has been identified; screening for HIV infection has been implemented; biological and behavioral cofactors have been identified related to infection and disease progression; prophylactic treatments are available to prevent opportunistic infections; HIVRNA quantitative assays have been developed to measure VL; combination ARTs are available to treat the infection; and vaccines are being tested. Pre-exposure prophylaxis (PreEP) has become an important part of HIV prevention when approved by the U.S. Food and Drug Administration (FDA) in 2012. Daily regimen with tenofovir disoproxil fumarate (TDF) is recommended for sexually active adults at a substantial risk of HIV acquisition; men who have sex with men (MSM), heterosexually active men and women, adult injection drug users, and heterosexually active women and men whose partners are known to have HIV. 2. Tamara has HIV and is undergoing a very thorough assessment. Why does the assessment need to be so rigorous?

Model Answer: Throughout the course of their illness, individuals with HIV disease require primary care services to identify early signs of opportunistic infections and to minimize AhNisKiSncEluLdLeE related symptoms and compliT caEtiS onTsB .T s aRc.oC mOpM lete health history, physical examination, and laboratory data including determination of immunological and viral status.

3. Describe considerations of antiretroviral therapy in palliative care.

Model Answer: Clinicians must consider possible drug interactions with the administration of drugs in the treatment of HIV/AIDS and relief of symptoms. Patients and healthcare professionals should discuss the continuation of antiretroviral therapy (ART) in hospice or palliative settings. Such decisions are often contingent on the feelings of patients regarding the therapy. Patients who enter hospice may have a greater acceptance of their mortality and may wish to stop antiretrovirals because of the side effects. However, patients may wish to continue ART because of its symptom relief and the prevention of future symptoms related to opportunistic infections. Facilitating discussion of benefits and burdens of ART is an important aspect of palliative care and the decision to discontinue ART for hospice patients with AIDS should be a part of comprehensive palliative care. It is important for clinicians to discuss with patients and families their goals of care to make important decisions regarding the appropriateness of curative, palliative, or both types of interventions.

4. Colby is realizing that it might be time to think about his end of life. A major concern of his is the pain that might be involved. How should Colby’s healthcare provider approach pain management for him?

Model Answer: Following a complete assessment, including a history and physical examination, an individualized pain management plan should be developed to treat the underlying cause of Colby’s pain. The principles of pain management in the palliative care of patients with AIDS are the same as for patients with cancer and include regularity of dosing, individualization of dosing, and the use of combinations of medications. The three-step guidelines for pain management as outlined by WHO should be used. This approach advocates for the selection of analgesics based on the severity of pain. For mild-to-moderate pain, anti-inflammatory drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen are recommended. However, the use of NSAIDs in patients with AIDS requires awareness of the toxicity and adverse reactions because they are highly proteinbound, and the free fraction available is increased in AIDS patients who are cachectic or wasted. For moderate-to-severe pain that is persistent, opioids of increasing potency are recommended, beginning with opioids such as codeine, hydrocodone, or oxycodone, each available with or without aspirin or acetaminophen, and advancing to more potent opioids such as morphine, hydromorphone (Dilaudid), methadone (Dolophine), or fentanyl either orally, intravenously or transdermally. In conjunction with NSAIDs and opioids, adjuvant therapies are also recommended. In addition to pharmacological management of pain and other symptoms, Colby’s physician may consider the value of nonpharmacological interventions such as bed rest, simple exercise, heat or cold packs to affected sites, massage, transcutaneous electrical stimulation (TENS), and acupuncture. Psychological interventions to reduce pain perception and interpretation include hypnosis, relaxation, imagery, biofeedback, distraction, art therapy, and patient education.

5. What role can a nurse play inTthEeSsT piB riA tuN alKnS eeEdL sL ofEaRp.aC tieOnM t with HIV/AIDS? Model Answer: Nurses must assess patients’ spiritual values, needs, and religious perspectives, important to understand patients’ perspectives regarding their illness and their perception and meaning of life. Patients living with and dying from HIV disease have the spiritual needs of meaning, value, hope, purpose, love, acceptance, reconciliation, ritual, and affirmation of a relationship with a higher being. The nurse should encourage open communication between the patient and the family to work toward reconciliation and the completion of unfinished business. Spiritual healing may also come from life review. Nurses can offer patients an opportunity to reminisce about their lives, reflect on their accomplishments and misgivings, and forgive themselves and others for their imperfections.

For all patients with a chronic life-threatening illness, hope often shifts from hope that a cure will soon be found to hope for a peaceful death with dignity, including the alleviation of pain and suffering, determining one’s own choices, being in the company of family and significant others, and knowing that their end of life wishes will be honored. Often, the greatest spiritual comfort offered by caregivers or family for patients comes from active listening and meaningful presence. Simple gestures like sitting and holding the patient’s hands may have a great impact on the patient’s well-being and them not feeling abandoned.

Indeed, such spiritual care conveys that even in the shadow of death, there can be discovery, insight, the completion of relationships, the experience of love of self and others, and the transcendence of emotional and spiritual pain. Often, patients with AIDS, by their example, teach nurses, family, and others how to transcend suffering and how to die with grace and dignity.

CHAPTER 20: Pain: Assessment and Treatment Using a Multimodal Approach Multiple Choice 1. What is a major patient-related barrier to pain relief?

A. Incomplete assessment of pain being experienced B. Inadequate knowledge of pain management C. Fear of tolerance and addiction to pain medication D. Lack of visible presentation of pain in the body Answer: C Rationale: Patient-related barriers include reluctance to report pain, reluctance to follow treatment recommendations, fears of tolerance and addiction, concern about treatment-related side effects, fears regarding disease progression, and belief that pain is an inevitable part of disease and must be accepted. Incomplete assessment of pain being experienced and inadequate knowledge of pain management are clinician-related barriers. Lack of visible presentation of pain in the body is a healthcare setting–related barrier.

2. What is the correlation of pain between oncologic and non-oncologic patients?

A. Oncologic and non-oncologic patients both experience pain related to their diagnosis.

B. Oncologic patients feel more severe pain than patients with congestive heart failure. veKreSpEaLinLtE haRn.pCatOieMnts with liver cancer.

C. Non-oncologic patients feTelEm SoTreBsAeN D. Non-oncologic and oncologic patients have the same underlying pain mechanisms.

Answer: A Rationale: The pain experience for patients with noncancer diagnoses has not been well defined in the literature, but what is known highlights the frequency of suffering within this population.

As in cancer, these patients may experience pain related to their underlying diagnosis, as an outcome of treatment modalities or as a consequence of living longer with a chronic illness.

Oncologic and non-oncologic patients may have the same levels of pain. However, the pain mechanisms may be different.

3. What is the term for the type of pain that occurs in deep musculoskeletal tissues?

A. Acute B. Nociceptive C. Chronic D. Neuropathic Answer: B Rationale: Nociceptive pain occurs as a result of activating pain-sensitive structures, or nociceptors, in the cutaneous and deep musculoskeletal tissues, and the viscera. Acute pain is characterized by a well-defined pattern of onset. Chronic pain is defined as pain that persists for more than 3 months. Neuropathic pain results from injury to the peripheral or central nervous systems.

4. Wallace is being assessed for pain. What is the purpose of the nurse asking him to describe the quality of his pain?

A. To determine an inferred pain mechanism that influences the choice of medication B. To evaluate disease process, value system, goals of care, and nearness to death C. To reinforce techniques found to be useful in the past to relieve pain D. To identify vulnerabilities and anxieties that indicate a need for pain education Answer: A Rationale: In quality of pain, patient word descriptors help the clinician to arrive at an inferred pain mechanism. This, in turn, influences the choice of pharmacotherapy. The severity of pain helps evaluate the disease process, value system, goals of care, and nearness to death.

Exacerbating and relieving factors reinforce techniques that the patient has found useful in the past to relieve pain. The impact of the pain on the patient’s psychological state identifies vulnerabilities and anxieties that indicate a need for education about pain.

5. What category of medications is the primary pain treatment for palliative care patients?

A. Anticonvulsants B. Corticosteroids C. NSAIDs D. Opioids Answer: D Rationale: Opioid analgesics are the mainstay of pain treatment for palliative care patients. These drugs are used for moderate-to-seTvE erS eT paBinAN inKSS teEpL s 2LE anRd.3CoO fM the World Health Organization (WHO) analgesic ladder. They are frequently combined with acetaminophen or an NSAID. 6. Patients who are taking opioids may notice that, over time, a stronger dose is needed for pain relief. Which phenomenon does this describe?

A. Dependence B. Addiction C. Tolerance D. Diversion Answer: C Rationale: Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug’s effects over time. The need for opioid escalation in a patient with cancer is usually associated with progressive disease rather than tolerance per se. Dependence is a state of adaptation that is manifested by a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. Diversion is the shifting of legally obtainable drugs into illegal channels or the acquisition of a controlled substance by an illegal method.

7. Which opioid is generally the first choice for severe pain?

A. Fentanyl B. Morphine C. Oxycodone D. Codeine Answer: B Rationale: Morphine is the prototype of the pure opioid agonist. The World Health Organization (WHO) placed morphine on the essential drug list and requested that it be made available throughout the world for cancer pain relief (WHO, 2011). Morphine is available in tablet, elixir, suppository, and parenteral forms. Patients with severe pain are initially titrated with immediaterelease morphine, or with parenteral opioids if in a hospital setting, and are converted to a controlled-release preparation once stabilized.

8. Ruby has ovarian cancer and the pain has become excruciating. She has been receiving the strongest dose of morphine that is safe for her, and she is still suffering. Which type of nerve block would be the most effective for her?

A. Diagnostic B. Prognostic C. Therapeutic D. Prophylactic Answer: C Rationale: A therapeutic nerve blT ocEkSisTdBoA nN eK toSpE roLvL idE eR te. mCpO orM ary pain relief in a pain crisis or to treat painful conditions that respond to these blocks (e.g., a celiac block for the relief of pain due to pancreatic cancer). A diagnostic nerve block is done to determine the specific pain pathway and to aid in the differential diagnosis. A prognostic nerve block is one that is done to predict the efficacy of a permanent ablating procedure. A preemptive/prophylactic nerve block is done proactively to prevent the development of a chronic pain syndrome.

9. Which type of rehabilitative treatment is designed to place minimal stress on joints, tendons, and muscles for alleviation of pain?

A. Positioning B. Range of motion techniques C. Therapeutic exercise D. Hydrotherapy Answer: A Rationale: When properly done, positioning places minimal stress on the joint capsule, tendons, and muscle structure. Range-of-motion techniques are designed to promote comfort and maintain or restore the integrity of muscles, ligaments, joints, bones, and nerves used in movement.

Therapeutic exercise can enable that individual to achieve better function and decreased pain. A therapeutic exercise plan may include stretching, passive mobilization, and active exercise.

Hydrotherapy spondylitis involves immersing the painful body part in a tank of warm water. In this environment, patients with movement-related pain may be better able to undergo

individually planned therapeutic exercise because the warm water provides both buoyancy and decreased joint stress.

10. Which type of integrative treatment has been shown to provide pain relief by causing endorphin release and stress-induced analgesia?

A. Hypnosis B. Music therapy C. Massage therapy D. Acupuncture Answer: D Rationale: The proposed mechanisms of action for pain relief by acupuncture is considered by Western medicine to include endorphin release, mediation of pain-producing neurotransmitters, and stress-induced analgesia. Hypnosis, music therapy, and massage therapy can also provide pain relief but not necessarily through endorphin release and stress-induced analgesia.

Short Answer 1. What challenges healthcare professionals face when assessing pain in the advanced palliative care patient?

Model Answer: There are eight main challenges in assessing pain in the advanced palliative care patient: Multiple concurrent medical pTrE obSleTmBsANKSELLER.COM Multiple symptoms and symptom clusters Hepatic and renal failure and susceptibility to drug accumulation and adverse side effects Prevalence of delirium when close to death Requires more time than patients who are less ill Patients become easily fatigued and may be short of breath May be in “too much pain” or bothered by other symptoms to answer questions Possible tendency of family members to answer questions on patient’s behalf 2. Dylan is 38 years old and was a golf coach until he developed stomach cancer. The pain has been excruciating, and he has been prescribed an analgesic that has worked to a certain extent. He would like to try another method of pain relief. What other types of pain relief methods could his palliative care specialist recommend?

Model Answer: Although pharmacotherapy is the foundation of pain management, pharmacotherapy alone will not be an effective approach to pain control in the palliative care patient. A multimodal approach is usually required, including attention to the suffering and spiritual or existential component to the patient’s pain. Other treatments include interventional therapies, neurostimulation therapies, rehabilitative therapies, psychological therapies, and integrative treatments.

3. How do opioids produce their analgesic effects?

Model Answer: Opioids produce their effects through binding to receptors in the brain and spinal cord to prevent the release of neurotransmitters involved in pain transmission. Opioids can also have a peripheral site of action in the presence of inflammation. In addition, opioid receptors are present in immunocompetent cells that migrate to inflamed tissue. The opioids can be divided into agonists, agonist–antagonists, and antagonist classes based on their interactions with the receptor types. Pure opioid agonists (e.g., morphine, hydromorphone, oxycodone, fentanyl, and methadone) bind primarily to the mu receptors.

4. Explain how cognitive behavioral therapy and patient coping skills training can help a patient in severe pain.

Model Answer: Cognitive behavioral therapy (CBT) involves the use of four core modules: (1) psychoeducation and goal setting; (2) relaxation training; (3) coping with fears; and (4) activity planning and pacing. It works best in a series of structured sessions that are flexible and modifiable, according to the developing needs of the individual, no matter what the format.

There should be clear and explicit goal setting and treatment goals. These goals are to be developed collaboratively by the therapist and patient. Together, they look at the range of problems present and prioritize them. They review this list on a regular basis, and reprioritized goals as personal, social, and medical changes develop. Based on this list, appropriate, systematic intervT enEtiSoT nsBtA oN adKdS reEssLtL heEsR e. prCoO blM ems are determined. The purpose of the interventions is to resolve specifically defined current problems and not long-term personality and social relations disturbances. Ideally, work with CBT occurs early in the treatment phase of an illness. As disease progresses, an individual may experience cognitive impairment from a variety of causes that make it impossible to employ these techniques.

When this occurs, it may be necessary to focus more on the family and caregivers with the goals to maximize their coping skills and increase their sense of control. Pain coping skills training (PCST) may be the next addition to multimodal pain management, helping to combine pharmacological pain treatments with psychological pain interventions. A PCST program will teach such things as progressive muscle relaxation, brief relaxation, activity/rest cycling, pleasant activity scheduling, negative thoughts identification, coping with negative thoughts, distraction techniques, problem solving, and strategies to maintain these skills.

5. Adam is 8 years old and was born with sickle cell disease. He has had severe exacerbations throughout his life, and is currently hospitalized. How should Adam’s pain care management be approached?

Model Answer: Many of the principles of pain assessment and management reviewed in this chapter can be applied to children. However, children should not be viewed as mini-adults.

The nurse caring for Adam needs to be mindful of: Adam and his family is the unit of care. Successful interventions can happen only when Adam’s parents are included in the assessment and pain management plans.

It is helpful to initiate discussions with Adam about pain and to learn his words for pain.

Pain assessment is dependent on Adam’s age and cognitive developmental stage.

Using developmentally appropriate tools to evaluate Adam’s pain.

Adam’s self-report of pain is considered the most reliable and valid indicator for an estimate of pain location and intensity.

Observed pain behaviors in Adam may include vocalizations, facial expressions, body movements, autonomic responses, or changes in daily activities, usual behaviors, appetite, or sleep.

The goal of Adam’s pain management is to prevent as much pain as possible and to treat procedural pain aggressively.

It is important to consider Adam’s age, developmental level, verbal capabilities, past experiences, cultural factors, type of pain, and context when developing a pain management plan.

Addressing family concerns regarding the risk of addiction.

The pharmacological management principles—by the ladder, by the clock, by the appropriate route, and by the child—are similar to those used with adults with the exception that the starting doses are determined by chronological age and body weight. Adam should be frequently assessed and doses are titrated to effect.

The oral route is the desired route whenever possible. Avoid the rectal route and IM injections. Consider transdermal, IV, and topical routes when the oral route is not possible.

CHAPTER 21: Dyspnea Multiple Choice 1. Which statement describes dyspnea?

A. It is a clearly defined disorder.

B. It is occasionally accompanied by anxiety.

C. It is a symptom of underlying disorders.

D. It is usually fairly straightforward to treat.

Answer: C Rationale: Dyspnea is a symptom of underlying disorders, like those that fall under the COPD umbrella. Anxiety often accompanies dyspnea. Dyspnea may also be refractory to treatment, causing both patients and providers to feel powerless over the symptom.

2.

Which mechanism plays a role in the sensations associated with dyspnea?

A. There is decreased awareness of the activity of muscles of respiration.

B. Stretch receptors in the chest wall cause feeling of tightness.

C. Chemoreceptors become less active and decrease respiration.

D. The respiratory center in the medulla fails to activate muscles that expand the chest wall.

Answer: B Rationale: Though the neurophysT ioEloSgT yB isAnNoK tw deRrs.toCoO d,Mthree mechanisms remain SeEllLuLnE dominant and interrelated in the creation of the dyspneic sensation: (a) a conscious awareness of the neuromotor command to the respiratory muscles; (b) stimulation of the receptors in the airways, lungs, and chest wall, which detect changes in lung volume, stretch, and pressure and are responsible for the feeling of tightness; and (c) stimulation of the chemoreceptors; for example, the sensation of blood-gas abnormalities that indirectly trigger ventilation, thereby causing air hunger or unsatisfied inspiration.

3. How can dyspnea present?

A. Chronic dyspnea is associated with bronchoconstriction.

B. Dyspnea is associated with exercise in cardiopulmonary conditions.

C. Dyspnea is rarely associated with psychological symptoms.

D. Dyspnea is rarely associated with lying in the supine position.

Answer: B Rationale: Exercise or overexertion commonly precipitates dyspnea in most chronic cardiopulmonary conditions, as does a change in position. Dyspnea that comes on suddenly may reflect bronchoconstriction, pulmonary embolism, cardiac ischemia, or abrupt airway occlusion.

Chronic dyspnea occurs gradually and is likely to be manifested in slowly progressive disorders such as COPD, interstitial lung disease, or a slow-growing tumor. Psychological symptoms are equally as important since anxiety has been found to correlate with the intensity of dyspnea in patients with cancer and lung disease.

4. Maggie is being evaluated for dyspnea. Which sign would she most likely have?

A. Jugular venous distention B. Absence of nasal flaring C. Pink nail beds D. Tracheal alignment Answer: A Rationale: A focused physical examination of the head, neck, and chest will yield specific information about the patient’s condition and assist with the identification of treatment options.

Inspection should include the color of skin, nails, lips, nutritional state, sternal/spinal deformities, chest shape and movement, breathing rate and rhythm (full minute), capillary refill, the presence/absence of nasal flaring, tracheal deviation, jugular venous distention, costal retractions, accessory muscle use, and clubbing.

5. What is a correlation between aging and dyspnea?

A. Chemoreceptors are apt to trigger faster, causing slower breathing rate.

B. Comorbidities play a small role in changing breathing rate and depth.

C. Allergens are less likely to stimulate an episode.

D. Respiratory muscles decline in strength.

Answer: D Rationale: Three major factors contribute to the effects of aging on the pulmonary system: an increase in chest wall stiffness, a decline in respiratory muscle strength, and a decrease in lung elasticity. Neurologically, age redTuE ceSsTcB heAmNoK reSceEpLtoLr E fuRn. ctC ioO niMng, causing an inadequate ventilatory response to hypercapnia and acute hypoxia. Comorbidities are likely to increase the risk of dyspnea due to the toll they take on the patient’s metabolism. Aging increases susceptibility to both infections and allergens due to a diminished immune system.

6. Which nonpharmacological method modifies the perception of dyspnea by stimulating the trigeminal nerve?

A. Fan directed toward the face B. Hands plunged into cold water C. Diaphragmatic breathing D. Vibration on the feet Answer: A Rationale: When stimulated, temperature and mechanical receptors of the trigeminal nerve in the cheek and nasopharynx alter feedback to the brain and modify the perception of dyspnea. The use of a fan set on low speed and directed toward the face will stimulate this response.

7. What is a benefit of using cognitive behavioral and complementary therapies for the management of dyspnea?

A. Every treatment has been found to be useful in a wide range of patients.

B. Patients become empowered to take an active role in their treatment plan.

C. Patients have had the most success with minimal use.

D. Healthcare professionals remain in control of the treatment plan.

Answer: B Rationale: Education of the patient and family on dyspnea management techniques and the basic rationale for each empowers them to take an active role in the treatment plan. Not every treatment will be useful for every patient; a patient’s preference for a particular therapy needs to be taken into account. Patients who have the most success with cognitive behavioral and complementary therapies need to use them consistently. Healthcare professionals relinquish some control of the treatment plan and put it in the patient’s hands.

8. Which method is curative and being considered for treatment of dyspnea in end-of-life care?

A. Breathing retraining B. Percutaneous catheter to drain ascites C. Noninvasive positive pressure ventilation D. Energy conservation Answer: C Rationale: Noninvasive positive pressure ventilation (NIV), often referred to as bilevel positive airway pressure (BiPAP), represents a controversial alternative method to treat dyspnea. While it is widely accepted as a curative intervention, only one study has been conducted on NIV as a comfort measure at the EOL. Breathing retraining, percutaneous catheter to drain ascites, and energy conservation are not curative but palliative.

9. Theresa is at end-of-life care and her healthcare team recommends she receive opioids for her dyspnea. Her family is skeptical that opioids are the best option for her. What information about the effects of opioids wT ouElS dT beBuAsN efK ulStE oL TL heEreRs. aC anOdMher family?

A. Perception of breathlessness and oxygen need will be altered.

B. High blood carbon dioxide and low oxygen levels increase ventilation.

C. Metabolic rate and oxygen consumption will increase substantially.

D. Vasoconstriction and increased peripheral resistance improve oxygen supply.

Answer: A Rationale: Opioids reduce dyspnea through a number of mechanisms: decreasing the ventilatory response to hypercapnia and hypoxia, reducing metabolic rate and oxygen consumption, and altering the perception of breathlessness. Furthermore, the cardiovascular effects of vasodilatation and decreased peripheral resistance help to improve oxygen supply and reduce lung congestion.

10. Which category of medication can be of value in treating dyspnea because of its antiinflammatory actions?

A. Bronchodilators B. Anxiolytics C. Diuretics D. Corticosteroids Answer: D Rationale: Corticosteroids, while controversial in the treatment of dyspnea, may be of value because they reduce inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing the increase in capillary permeability. Euphoria in the form of an

overall feeling of well-being and an increase in appetite exhibit as secondary responses.

Bronchodilators cause smooth muscle dilation of the airways, thus removing any impedance to airflow and deflating an overinflated lung. Anxiolytics may help relieve dyspnea when morphine is not completely effective; anxiety is often one of the dimensions of dyspnea. Dyspnea may be associated with fluid volume excess, which can be treated with diuretics, such as furosemide, to mobilize edema, normalize blood volume, reduce vascular congestion, and reduce the workload of the heart Short Answer 1. Arthur is 68 years old and has come into the emergency room because of shortness of breath.

He cannot think of any reason he should have this. What factors need to be identified in his health assessment?

Model Answer: Dyspnea is a personal experience that accounts for a high proportion of disability, impaired quality of life, and suffering. Each patient’s experience with the symptom is as unique to the person as is the individual’s journey with a life-limiting condition. Thus, a thorough interprofessional assessment of Arthur should include a careful, comprehensive history to obtain a complete understanding of his experience with dyspnea.

Specific information about dyspnea, including its timing, precipitating factors, associated symptoms, alleviating factors, and quality of the symptom, should be assessed. The influences of Arthur’s culture, race, age, and gender should also be taken into account. orEmSaTnB agAinNgKdSyE spL nL eaEiR n. peCdO iaM tric patients?

2. What are the considerations fT Model Answer: Collaborative agreement on symptom severity by parents and healthcare professionals improves satisfaction with care as well as parental quality-of-life, even if symptom control is not successful. Because respiratory function is immature in younger patients, deterioration can occur rapidly when disease is present. Special attention should be given to the possibility of congenital anomalies (cardiac or respiratory) in this circumstance.

Another difference in pediatrics is a higher respiratory load detection threshold, meaning children and adolescents require a greater change in stimulus intensity before reporting a change in sensation. This finding may be responsible for the effectiveness of pictorial scales (nonlinear) in pediatrics since children and adolescents are less able to distinguish between numerous gradations of sensation, as presented in a numerical instrument (linear). Similar to adults is the fact that lung function improvement does not necessarily correlate with an improved dyspnea rating. Therefore, it may be important for health professionals to pursue additional diagnostic testing despite a decrease in reported dyspnea. Observation, physical assessment, and a medical history are the tools to evaluate respiratory distress as the pediatric patient is not always able to communicate how he or she feels, especially if very young. Once a baseline measurement has been obtained, integration of dyspnea management with opioids may be introduced along with other interventions for the child’s specific condition, as indicated.

3. Explain how positioning can alleviate dyspnea.

Model Answer: Patients should be assisted to find a position of comfort. The leaningforward position has been reported to improve overall inspiratory muscle strength, increase diaphragmatic excursion, and decrease abdominal paradoxical breathing as well as reduce dyspnea in patients with COPD. While reducing participation of the chest wall and neck muscles overall, sitting and leaning forward with arms supported on a table facilitates a more focused effort on respiration rather than on the maintenance of body posture and/or arm movement. Optimal comfort as well as ventilation and perfusion may be accomplished by placing the patient’s good lung in a dependent position where gravity may assist in perfusing the healthiest area of lung tissue. In some patients, terminal dyspnea may be relieved only by an upright position where vital capacity is increased because of the lowered diaphragm. The clinician should accept the patient’s position of choice, even if it belies traditional thinking.

4. Jermaine’s physician is prescribing supplemental oxygen for him. How will the oxygen alleviate his dyspnea? What are the considerations for its use?

Model Answer: Supplemental oxygen depresses the hypoxic drive, thereby reducing ventilation and subsequently relieving dyspnea. This physiological response occurs at rest and during exertion in patients with a variety of lung diseases. Oxygen should be titrated to Jermaine’s comfort level using the least restrictive device possible (e.g., nasal cannula does not interfere with eating and communication). Humidification is recommended for comfort and to prevent the drying of mucous membranes at or above 4 L/minute. Continuous oxygen KO SPEDLL might be beneficial to JermainTeEiS f hTeBhAasNC anEdRs. evCerOeMhypoxemia. However, he may prefer to use oxygen intermittently although assurance of the immediate availability of oxygen may be of greater importance.

5. If a patient in end-of-life care is already taking morphine, why would a healthcare professional also prescribe an anxiolytic?

Model Answer: An anxiolytic may help relieve dyspnea when morphine is not completely effective; anxiety is often one of the dimensions of dyspnea. Anxiolytics should be considered in combination with opioids and nonpharmacological anxiety-reduction measures as a way to break the anxiety–shortness of breath cycle. Low-dose benzodiazepines and phenothiazines are the categories of anxiolytics most commonly used in the management of dyspnea. These drugs have hypnotic, sedative, anxiolytic, anticonvulsant, and musclerelaxant actions, therefore achieving control of dyspnea via multiple mechanisms of action.

CHAPTER 22: Anxiety, Depression, and Delirium Multiple Choice 1. What is the relationship between anxiety and depression, and severe illness?

A. In primary care, anxiety and depression primarily occur separately from other illnesses.

B. In palliative care, anxiety and depression arise from loss of independence from illness.

C. Anxiety and depression rarely signal other more serious illnesses.

D. Anxiety and depression are best treated separately from other illnesses.

Answer: B Rationale: In palliative care, anxiety and depression commonly arise from fear of death, loss of independence and fear of being a burden to others, hopelessness, and loneliness, in addition to concern about symptom burden and disease progression.

2. Which statement describes anxiety in patients with a serious illness?

A. Anxiety is a normal response.

B. Anxiety is a mental disorder.

C. Anxiety has little effect on caregivers.

D. Anxiety related to treatments is mild.

Answer: A Rationale: Anxiety is defined as fTeeElin gsBoAf NdK istSreEsL s, LwEoR rry.,CaO ndMtension from a known or ST unknown stimulus. Anxiety is a normal response to an illness.

3. Donna has been diagnosed with end-stage renal failure and has learned she is not a good candidate for a kidney transplant. Her husband and her children have been trying to talk with her about palliative care, but she either changes the subject or walks out of the room. How is her anxiety manifesting?

A. Physical symptom B. Affective symptom C. Behavioral response D. Cognitive response Answer: C Rationale: Anxiety has four types of manifestations: physical symptoms, affective symptoms, behavioral responses, and cognitive responses. Changing the subject or walking out of the room is avoidance, which is a behavioral response.

4. Who is most likely to first identify that a patient has anxiety?

A. Attending physician B. Patient C. Family member D. Nurse Answer: D

Rationale: Nurses may be the first to identify anxiety for many patients. A collaborative interdisciplinary team approach is helpful in the treatment of anxiety for patients experiencing serious life-limiting illness.

5. Calvin is 82 years old and has been experiencing severity anxiety while being treated for stomach cancer. Which category of medication should be prescribed for Calvin?

A. Selective serotonin reuptake inhibitors B. Benzodiazepines C. Tricyclics D. Beta-adrenergic agents Answer: B Rationale: Benzodiazepines are recommended for older patients. Due to its shorter half-life, lorazepam is the recommended benzodiazepine of choice with older populations. It has a double result in both relief of nausea and reduction of panic attacks. In a younger, healthier population, selective serotonin reuptake inhibitors (SSRIs) are the first drug of choice for the treatment of anxiety disorders. Generally, tricyclics and beta-adrenergic agents are not well tolerated in older populations, though a trial may be warranted if other medications do not offer relief.

6. Which action of the interprofessional team provides support to the patient and family without causing further anxiety?

A. Assessment of the home for safety B. Provision of medications C. Investigation of group dynTaEmSicTsBANKSELLER.COM D. Delineation of clear roles Answer: D Rationale: Treatment of anxiety for a patient with a life-threatening illness requires a collaborative approach by an interprofessional team. The nurse has a role in assuring team communication within the plan of care. Specifically, the team needs to review the patient history and medications and then determine symptom management together. Since treatment usually requires psychological support and medication management, clear delineation of roles should be clarified for the patient and his or her family. This provides consistent direction and support to the patient and family without provoking further anxiety.

7. What is the relationship between depression and serious illness?

A. Depression needs treatment for closure and end-of-life issues during the illness.

B. Depression is a normal coping mechanism in the process of accepting the illness.

C. Treatment of depression should be a lower priority than that of the illness.

D. Depression is an uncommon occurrence in patients with illness.

Answer: A Rationale: It is now understood that leaving depression untreated can interfere with a patient’s ability to bring closure to his or her end-of-life issues and concerns. When dealing with serious illness, it is common for patients to experience psychological distress in response to their serious or life-threatening diagnosis. For many years, grief and depression were considered to be normal

coping mechanisms in the process of accepting a terminal illness, so the treatment of depression was not prioritized. The thought was that treatment would interfere with the natural dying process and the emotional work of dying.

8. Holly is 9 years old and has been living with rheumatoid arthritis since she was 3. She has become quite depressed. How would this most likely manifest in Holly?

A. Agitation B. Confusion C. Anger D. Hopelessness Answer: C Rationale: Signs of depression in children manifest as somatic complaints, periods of anger, and other behavior as well as sadness or melancholy. For teenagers and young adults, depression may be manifested by low self-esteem, guilt, and hopelessness. Patients of all ages may express recurrent thoughts of worthlessness, excessive or inappropriate guilt, and a sense of being a burden.

9. What should be the first intervention for a seriously ill child with depression?

A. Medications B. Psychotherapy C. Movement therapy D. Herbal remedies Answer: B Rationale: The treatment of children is more complex due to the safety of medications.

Therefore, nonpharmacological therapies are encouraged as first-line interventions. However, if the therapy is unsuccessful, medications are appropriate. Psychotherapy is the mainstay of nonpharmacological interventions.

10. How should delirium be considered in the terminally patient?

A. Alterations in thought processes are unusual in the last weeks of life.

B. Confusion and agitation are a normal part of the dying process.

C. Symptoms include sadness, helplessness, and hopelessness.

D. Symptoms should be thought of as an emergency.

Answer: D Rationale: Delirium should be considered an emergent situation, particularly in older populations. Delirium is associated with higher mortality rates when it occurs in older patients, as well as longer hospital admissions, increased costs of care, greater likelihood of being placed outside the home post hospitalization, and decreased functional ability. Alterations in thought processes are very common during the last weeks of life. Historically, this confusion and agitation was thought to be a normal part of the dying process and one of the expected stages of dying. Currently, delirium is recognized as a distressing symptom that warrants treatment.

Delirium-related behaviors include thrashing, agitation, muscle twitching, tossing or turning, moaning, and talking to the air; it also includes lethargy and listlessness in its quiet forms.

Short Answer 1. What are the causes of anxiety in patients who are seriously ill?

Model Answer: Anxiety in patients with a life-limiting illness is common and may have a multitude of causes, including adjustment disorder, panic disorder, generalized anxiety disorder, phobia, or agitated depression. The etiology of anxiety includes medical conditions such as poorly managed pain, endocrine disorders including hypo- and hyperglycemia, hypoand hyperthyroidism, Cushing’s disease, and carcinoid syndrome. Cardiovascular conditions include myocardial infarctions, angina, congestive heart failure, mitral valve prolapse, and hypovolemia; respiratory conditions include asthma, chronic obstructive pulmonary disease (COPD), pneumonia, pulmonary edema, dyspnea, and hypoxia. Neoplasms and neurological conditions such as akathisia, encephalopathy, seizure disorder, and postconcussion disorders can also contribute to or exacerbate anxiety disorders.

Stimulant substances may contribute to anxiety. The most common substance is caffeine.

The stimulant ephedrine, stimulant-type drugs such as methylphenidate, and withdrawal from medications such as benzodiazepines, alcohol, and barbiturates may cause anxiety.

Psychological distress, including worries about family relationships, family strife, and financial issues, can contribute to feelings of anxiety in seriously ill patients. These worries may be exacerbated by concerns about being or becoming a burden to family members during the course of their illness. Lastly, previous history of or a family history of anxiety may be a contributory factor resulting in more pronounced anxiety in older patients as they lose physical functioning.

2. Corinne is aware that she has a great deal of anxiety while she is undergoing chemotherapy for pancreatic cancer. Prior to her illness, she had been very active and owned her own business. She has been talking with her nurse about how she can’t seem to snap out of it; the anxiety just won’t let go. The nurse suggests a pharmacological agent, but Corinne is against it. She does not want any more chemicals coming into her body. What stress management options can the nurse recommend?

Model Answer: Stress management can include exercise programs, breathing exercises, relaxation techniques, massage, touch, distraction, music therapy, and visualization. Guided imagery and hypnosis may offer the patient more control in everyday life and in stressful situations. Massage therapy can be an effective method to help Corinne relax. Distraction can be used to manage anxiety, and it may occur in many forms, including watching television; listening to the radio; reading digital devices, books, or newspapers; participating in arts and crafts; and performing hobbies. It is important to assess how Corinne spends her time and what activities are distracting and helpful for her. Music therapy has been shown to be effective in anxiety, as it can reduce pain, promote physical comfort, and induce relaxation.

3. What are the four categories of depression etiology? Give examples of each.

Model Answer: The etiology of depression is multifactorial and falls into the following overlapping four categories: physical, psychological, social, and biological. Depression may be caused by deficiencies in serotonin, norepinephrine, and prolactin, as well as abnormal cortisol and dopamine levels. However, there may be factors to produce that and certain

medical conditions that cause depression. Physical factors encompass medical conditions, specific diseases, medication effects, and sensory deprivation from loss of vision or hearing.

Medications that may cause side effects that mimic depressive symptoms include chemotherapeutic agents, opioids, and glucocorticoids. Psychological issues that may precipitate depression cover a wide spectrum, including unresolved conflicts, memory loss, loss of independence, change in living situations, and possible financial consequences incurred from a life-limiting illness. When people have a serious illness, the loss of their social network may cause depression. Patients may not have the energy to participate in hobbies or activities or may want to be private about visible aspects of their condition.

Biological factors of depression include family history of depression or other mental illness, prior episodes of depression, neurotransmission deficiencies, and central nervous effects of cytokines.

4. Richard has liver cancer and is a good candidate for a liver transplant. At first, he was happy with the news; then his family noticed him becoming more withdrawn and lethargic. He has become forgetful and confused. His family was attributing this to his cancer, but when they explained their concerns to his palliative care nurse, she suspected he might have delirium.

How should the nurse assess Richard?

Model Answer: Assessment should first include a history and review of current medical conditions, including disease; disease side effects such as a tumor; and side effects of treatment, such as chemotherapy or radiation. Second, it is essential to review medications used to treat symptoms, like corticosteroids, antibiotics, opioids, anticholinergics, CiOthMdrawal from medications like antiemetics, and anticonvulsaT ntEs,SaT ndBtAhN eK poSsE siL biL litEyRo. fw benzodiazepines or alcohol. Third, physiological causes must be assessed, including discomfort related to uncontrolled pain, urinary retention, or fecal impaction, as well as metabolic fluctuations in glucose, sodium, potassium, or calcium; organ failure including the kidneys, liver, lungs, heart, brain, thyroid, or adrenal glands; infections of CNS, urinary tract, respiratory tract, generalized and sepsis. Finally, attention should include a review of and finally nutritional deficiencies from thiamine or folate/vitamin B12. This is followed by a review of the patient’s behavior and sleep cycles from the chart, followed by a review of the complete medication regimen.

A mental status exam provides a baseline for monitoring the course of cognition and is a source of documentation for reference and repeat evaluations. The key aspects of mental status assessment include general state and appearance, orientation, state of consciousness, short- and long-term memory, language, visuospatial functions, cognitive/executive functions (calculations, abstraction, spelling), insight and judgment, thought control, and mood and affect.

Physical exam is important to rule out possible reversible and treatable causes of delirium.

5. How can a patient’s family help prevent, manage, and treat delirium?

Model Answer: Education of the family is a cornerstone in the prevention, management, and treatment of delirium. Education includes the importance of skin care; the use of glasses, hearing aids, and assistive devices when appropriate; and the importance of a well-balanced diet and hydration, if these interventions are not a burden or source of distress to the patient.

Families of seriously ill patients need to understand predisposing risk factors that can lead to

delirium, including pressure sores, poor nutrition, incontinence, sleep disturbances, and decreased functional ability. Other preventive measures include the use of cognitive assistive devices such as glasses and hearing aids; avoiding restraints for confusion; judicious use of urinary catheters; removal of unnecessary tubes (rectal tubes or g-tubes); judicious use or removal of lines (intravenous access, subcutaneous access, etc.); prevention of skin ulcers; and maximal psychosocial support and education to family caregivers. Additionally, an assessment of the home environment can be quite revealing, particularly whether the patient has the necessities such as food, finances, and medications.

When a patient becomes delirious at the end of life, ongoing support of the family is important. Delirium may be irreversible due to the various medical conditions the patient is experiencing as well as the dying process itself. When making decisions about the treatment, discussions about realistic options should occur within the context of life expectancy and the burden versus the benefit of any treatment intervention. Families often welcome a clear discussion about all current issues, particularly when a patient is thought to be close to death so they can prepare for the anticipated event.

CHAPTER 23: Posttraumatic Stress Disorder and End-of-Life Care Multiple Choice 1. Which statement describes posttraumatic stress disorder (PTSD)?

A. Feelings from the traumatic event always decrease over time.

B. Witnessing a traumatic event can create symptoms.

C. Most feel remorse and agitation after the traumatic event.

D. Direct exposure to the traumatic event creates the symptoms.

Answer: B Rationale: The likelihood of being exposed to a traumatic event, such as a natural disaster, child sexual or physical abuse, serious accident, sexual or physical assault, terrorist attack, or combat, increases across a life span. Feeling from the traumatic event may or may not decrease over time.

After experiencing a traumatic event, most people experience stress-related reactions such as fear, sadness, guilt, anger, or sleep problems. The exposure itself does not always need to be the direct experience of a traumatic event. According to DSM-5 criteria, an individual can also develop PTSD by witnessing a traumatic event in person, learning that the traumatic events occurred to a close family member or friend, or experiencing repeated or extreme exposure to aversive details of the traumatic event.

2. What qualifies symptoms to be indicative of posttraumatic stress disorder?

A. Duration of symptoms thrT eeEm ngLeL r ER.COM SoTnBthAsNoKr lo SE B. Minimum of two or more reexperiencing symptoms C. Duration of symptoms two months or longer D. Minimum of two cognitive alteration symptoms Answer: C Rationale: Following the exposure, the individual must experience one or more symptoms in specific symptom clusters. The duration of the symptoms must be for a month or longer, cause clinically significant impairment, and cannot be due to substances or another medical condition.

The symptom clusters are: (a) reexperiencing (e.g., recurrent distressing memories or dreams); (b) avoidance (e.g., evasion of memories or cues related to traumatic event); (c) negative alterations in cognitions or mood (e.g., inability to remember details related to traumatic event, increased negative beliefs, persistent negative mood state); and (d) changes in arousal and reactivity (e.g., irritability, hypervigilance, poor sleep). The reexperiencing and avoidance symptom clusters require a minimum of one symptom in each cluster, while the other symptom clusters require two or more symptoms to be present to meet diagnostic criteria.

3. Ever since Travis got back from his tour of duty, he jumps at every little sound and has bouts of insomnia. Which DSM-5 category are these symptoms?

A. Reexperiencing B. Avoidance C. Negative alterations in cognitions or moods D. Changes in arousal and reactivity

Answer: D Rationale: According to the DSM-5, a posttraumatic stress disorder diagnosis means following the exposure, the individual must experience one or more symptoms in each of the following symptom clusters: (a) reexperiencing (e.g., recurrent distressing memories or dreams); (b) avoidance (e.g., evasion of memories or cues related to traumatic event); (c) negative alterations in cognitions or mood (e.g., inability to remember details related to traumatic event, increased negative beliefs, persistent negative mood state); and (d) changes in arousal and reactivity (e.g., irritability, hypervigilance, poor sleep).

4. What is the correlation between PTSD symptoms and life-threatening illnesses?

A. PTSD occurs at a lower rate in those with a life-threatening illness than the general population.

B. PTSD occurs at a higher rate in those with a life-threatening illness than the general population.

C. PTSD occurs at the same rate in those with a life-threatening illness as the general population.

D. PTSD rates are unable to be calculated in those with a life-threatening illness compared to the general population.

Answer: B Rationale: Compared to 8% in the general population, PTSD symptoms occurs at a significantly higher rate among individuals receiving care in a medical setting for potentially life-threatening illnesses. The prevalence of PTSD among patients treated in an ICU, regardless of diagnosis, LeLthEoRd.oC was found to be as high as 64% dTepEeS nT diB ngAoNnKtS heEm f aOsM sessment.

5. What challenge can PTSD manifest in family members of a patient with a serious illness?

A. Unlikely to develop symptoms themselves B. Acceptance of the symptoms C. Anger, guilt, and health problems D. Increased support in palliative care Answer: C Rationale: PTSD can negatively impact interpersonal relationships. The National Center for PTSD’s website documents that family members themselves may have a number of reactions to their family member having PTSD, including sympathy, negative feelings, avoidance, depression, anger, guilt, or health problems. As a result, individuals with severe PTSD in palliative care settings may have very limited social support networks and existing family relations may be strained. Family members of critically ill individuals are also susceptible to developing PTSD. 6. Randy is 58 years old and in palliative care. He experienced childhood sexual abuse, which he has received counseling for at certain times in his life. Now that he is in end of life care, and he has been resistant to most of the treatments that can provide comfort. Specifically, these are treatments that involve being touched such as having IVs put in, or even a visit from the massage therapist on staff. The nurses and Randy are on good terms, but the nurses

are concerned as to why Randy does not elaborate on why he is refusing these treatments.

Which reason is most likely why Randy is silent about his choices?

A. He thinks the abuse is irrelevant to what is currently happening B. He finds the nurses untrustworthy to talk to about the abuse C. He has difficulty recalling many parts of the abuse D. He wants to avoid talking about the abuse Answer: A Rationale: Randy is experiencing later-adulthood trauma reengagement. As people engage with their trauma memories as they age in later life, the developmental task of meaning-making and coherence may facilitate a reworking of their trauma, which may result in more adaptive functioning. On the other hand, patients may not offer information pertaining to traumatic events or their current understanding of these events freely, possibly because they may not consider the information relevant to their current circumstances, may not want to discuss the event, may not remember many aspects of the event (in the case of childhood trauma or dementia), or do not trust the provider. A thorough assessment should focus on the age of onset, duration, severity, and course of symptoms.

7. If a patient is reluctant to share information about a traumatic event that could be indicative of PTSD, which approach is the most effective first step?

A. Clinical interview B. Trauma exposure measure C. Comprehensive chart review D. Self-report measure Answer: C Rationale: There are numerous approaches to the assessment of PTSD or associated symptoms that includes chart review, screening measures, interviews, self-report measures, and trauma exposure measures. A comprehensive chart review can be an invaluable tool in assessing a patient for PTSD. The patient’s medical illness may inhibit him or her from being able to share his or her mental health history with you. Also, given that avoidance is a core symptom of PTSD, the patient may not readily share this information, even when asked if he or she has a mental health history.

8. Which method provides the most comprehensive assessment of PTSD? A. Clinical interview B. Trauma exposure measure C. Comprehensive chart review D. Self-report measure Answer: A Rationale: A clinical interview is considered to be the most comprehensive assessment of PTSD. 9. Juan has been dealing with PTSD most of his life. He is without family support. Which treatment would be most effective for the nurse to recommend for assisting Juan in having quality of life?

A. Nutritional counseling to alleviate insomnia B. Music therapy to increase relaxation C. Pharmacological approach to relieve depression D. Cognitive behavioral therapy to work through anxiety Answer: D Rationale: Cognitive behavioral therapies are the most effective treatment for PTSD. Cognitive behavioral therapies involve a multifaceted approach including psycho-education, anxiety management, exposure, and cognitive restructuring. Nutritional counseling, music therapy, and pharmacological management may assist Juan with certain aspects of his PTSD, but cognitive behavioral therapy will most directly address Juan’s PTSD. 10. Education and training on the symptoms of PTSD are given to the patient, family, and interprofessional treatment team members during which stage of treating PTSD symptoms at the end of life?

A. Stage I B. Stage II C. Stage III D. Stage IV Answer: B Rationale: In a staged model for treating PTSD at the end of life, Stage I involves providing immediate comfort and social supports. Stage II involves providing psycho-education and enhanced coping skills. Stage III T inEvS olT veBsAtrNeaKtiSnE gL spLeE ciR fic.tCraOuM ma issues. There is no Stage IV. Short Answer 1. What complicating behaviors could palliative nurses encounter in a patient with PTSD who is at the end of life?

Model Answer: The very nature of the symptoms, including hyperarousal and avoidance, may complicate end-of-life care. The simple distress associated with being confronted with a life-threatening illness may exacerbate PTSD symptoms and provoke similar responses to the original trauma. Normal life review is an important part of the dying process in order to resolve unfinished business, but it may also result in symptoms such as intense anxiety, anger, guilt, or sadness due to traumatic memories. As a result, individuals with PTSD may avoid traumatic memories and may be unable to come to terms with unresolved life events.

Avoidance symptoms may also interfere with processes, such as communication with medical providers, which are paramount to successful end-of-life care. PTSD symptoms can impede the ability for the healthcare practitioner to engage in direct, problem-focused communication regarding the patient’s care. Refusal of care or excessive questioning of providers’ actions or distrust of authority may result. It has been documented that people with PTSD diagnoses tend to have poor medical adherence. In addition, individuals with PTSD may experience decreased social support or a lack of caregivers as a result of social isolation and avoidance.

2. Alicia is being evaluated for PTSD by a palliative care nurse. What are the five factors the nurse will need to take into consideration to accurately assess Alicia’s symptoms?

Model Answer: Accurately assessing symptoms, providing appropriate treatment, monitoring symptom change, communicating, and evaluating the effectiveness of an intervention are all crucial. When determining the most appropriate measure to utilize in assessing PTSD at the end of life, there are several factors that are important to consider.

First, due to the varied nature of life-threatening or life-limiting illnesses, the amount of time required to administer the measure is a critical factor. There are numerous measures that vary in the amount of time required to administer, ranging from 5 to 120 minutes. Second, not all measures are written at the same comprehension level; therefore, the reading level of the patient and English language fluency are important considerations. Third, the clinician needs to evaluate for a single event or multiple traumatic events. Another important consideration when assessing patients for PTSD is whether the assessment focuses on determining the specific diagnosis of PTSD or if the objective is to identify PTSD symptoms. Finally, the level of training and competency of the clinician administering and interpreting the results will impact the validity of the findings.

3. What are the components of a comprehensive chart review in a patient suspected of having PTSD? Model Answer: A comprehensive chart review can be conducted by evaluating the following: history of a preexisting mental health diagnosis, use of prescribed psychotropic medication (past/present), andTaEnS yTdB ocAuN mK enStaEtL ioL nE peRr. taC inO inM g to the patient’s mental health.

Once the patient’s chart has been reviewed, a brief note including the findings from the chart review and a discussion of the clinical implications for end-of-life care should be documented. After reviewing the mental health history in the medical record, the next phase of assessment is to talk with the patient to discuss his or her symptoms and background to fill in missing data from the chart review. Any of the remaining approaches (screening, interview, self-report, and trauma exposure measure) can be utilized after the chart review has been conducted.

4. Carrie works at a community hospital in a small town. Several times a year, patients are admitted with serious illnesses whom they have difficulty treating because these patients have PTSD. Carrie would like to do more for these patients, but the hospital has limited resources and only one mental health professional on staff. What can Carrie do?

Model Answer: Carrie can work toward an interprofessional team approach.

Interprofessional treatment providers can directly implement portions of the stage-based model to manage PTSD symptoms. For example, in Stages I and II, practitioners outside of mental health should be able to assist in the identification of PTSD symptoms and implement effective environmental interventions. In order to facilitate this, both active and passive approaches to staff education need to be implemented in palliative care settings. An active approach to staff education is to require general training on PTSD symptoms by palliative care staff. Free, online educational resources are accessible to the general public.

Interprofessional treatment practitioners with some expertise in the management of PTSD

can educate staff during interprofessional treatment team meetings and even through their charting notes. For example, when a chart review reveals a potential or confirmed diagnosis of PTSD, the provider can alert others to possible symptoms of PTSD and their impact on patient care.

5. How can pharmacological approaches to treatment of PTSD be used in palliative care?

Model Answer: Pharmacological approaches to the treatment of PTSD are important to consider in conjunction with psychosocial approaches, particularly when life expectancy is limited. Patient preference regardless of life expectancy may also dictate the use of pharmacological approaches. Therefore, interprofessional practitioners should know that there are two major classes of medications that have been shown to be effective for alleviating symptoms of PTSD. The first major class of drugs is selective serotonin reuptake inhibitors (SSRIs), which have been found to alleviate the avoidance and numbing symptoms associated with PTSD. The second class of medications are tricyclic antidepressants (TCAs), which have been shown to alleviate intrusive symptoms, anxiety, and depressed affect.

In conjunction with SSRIs or TCAs, practitioners may also choose to prescribe other medications such as benzodiazepines. Benzodiazepines can be prescribed in combination with SSRIs in order to alleviate anxiety, panic, and hyperarousal symptoms. It is important to note that benzodiazepines are not recommended for long-term treatment of PTSD because they have not been found to treat the core symptoms of PTSD and have additive properties, although they can be effective for end-of-life care.

CHAPTER 24: Gastrointestinal Symptoms Multiple Choice 1. Which gastrointestinal conditions do patients find more debilitating than pain?

A. Anorexia and cachexia B. Diarrhea and constipation C. Dysphagia and malnutrition D. Nausea and vomiting Answer: D Rationale: Nausea and vomiting (N&V) are unpleasant gastrointestinal symptoms that often are described by patients as more severe and disabling than pain.

2. What is cachexia?

A. Loss of appetite as well as the reduction of oral intake B. Loss of skeletal muscle mass due to protein and energy imbalance C. Unpleasant sensation in the stomach D. Inability to swallow Answer: B Rationale: Cachexia is a syndrome where protein and energy balance are affected, leading to a loss of skeletal muscle mass. Anorexia is loss of appetite as well as the reduction of oral intake.

TESTB ANKSELLER.COM Nausea is a non-observable subjective symptom involving an unpleasant sensation experienced in the back of the throat and the epigastrium that precedes but may or may not result in vomiting.

Dysphagia is inability to swallow.

3. What is the nurse doing if he is describing to an anorexic patient side effects of a medication designed to stimulate appetite as well as increased quality of life from better nutrition?

A. Allowing the patient to consider balance between curative treatment, palliation, and symptom support B. Explaining to the patient why curative treatment and symptom support are more important than palliation C. Focusing on the patient’s goals and preferences while providing support D. Assessing the patient’s physical and emotional needs and support Answer: A Rationale: Support of patients with anorexia should primarily be directed at treating underlying causes when appropriate. Being considerate of the impact of treatment on the symptom of anorexia should be addressed. Likely there is a balance of the need to offer curative treatment, palliation, and symptom support, each of which needs to be discussed with any patient and their family.

4. What is an example of a chemoreceptor trigger zone–mediated stimulus of the vomiting center?

A. Medication

B. Anxiety C. Gastritis D. Meningitis Answer: A Rationale: Chemoreceptor trigger zone–mediated stimuli include certain medications and metabolic conditions.

5. Kelsie has AIDS and has asked her nurse for a way to manage her nausea and vomiting without taking more medication. The nurse suggests that she focus her mind on images of a relaxing place. Which nonpharmacological method is the nurse recommending?

A. Biofeedback B. Desensitization C. Imagery D. Distraction Answer: C Rationale: Imagery involves mentally taking oneself away by focusing the mind on images of a relaxing place. Biofeedback is control of specific physiological responses by receiving information about changes in response to induced state of relaxation. Desensitization is a threestep process involving relaxation and visualization to decrease sensitization to aversive situations. Distraction is learning to divert attention from a threatening situation to relaxing sensations.

6. What is a typical cause of systemic dysphagia?

A. Neoplasm B. Inflammatory factor C. Multiple sclerosis D. Dementia Answer: B Rationale: Causes of dysphagia are systemic dysphagia as a result of inflammatory and infectious factors; neoplasm (includes brain tumors, head and neck cancer, and esophageal tumors); progressive neuromuscular diseases such as ALS, Parkinson’s disease, and MS; connective tissue disorders like scleroderma; dementia; and general deconditioning that may include multisystem disease and failure; and the side effects of medications and/or polypharmacy.

7. What is the most emergent issue with dysphagia?

A. Heartburn from esophageal reflux B. Malnutrition and loss of body weight C. Food feeling stuck in the esophagus D. Aspiration of food and liquids Answer: D Rationale: Because foods and liquids are entering the lungs, aspiration is the most emergent issue and needs to be treated immediately.

8. How is constipation involved in palliative care?

A. It rarely occurs.

B. It is usually treated.

C. It is defined by the patient.

D. It rarely causes morbidity.

Answer: C Rationale: There is a wide variation of the “normal” frequency for passage of stool, anywhere from three times daily to three times weekly, and therefore, assigning a precise definition is difficult, although fundamentally it is defined by the patient. Similar to the concept of pain, constipation is a subjective complaint and often undertreated. It is a common complaint in all populations and typically refers to persistent, difficult, infrequent, or the sensation of incomplete passage of stool. Constipation is a common cause of morbidity in the palliative care setting and the numbers increase if the patient is treated with opioids.

9. What is considered a functional obstruction of the bowel?

A. Dysmotility B. Adhesion C. Inflammation D. Neoplasm Answer: A Rationale: Functional obstruction, also known as ileus and pseudo-obstruction, can occur when dysmotility prevents intestinal coTnE teS ntTs BfrAoN mKbSeiEnL gL prEoR pe.llC edOM through the lumen and there is no existing mechanical blockage. Mechanical bowel obstruction may be caused by extrinsic processes such as adhesions and neoplasms; intrinsic abnormalities of the bowel wall like congenital, inflammatory, neoplastic, or traumatic; or intraluminal abnormalities.

10. A patient has been prescribed a diuretic. Which condition does this patient have?

A. Xerostomia B. Ascites C. Diarrhea D. Constipation Answer: B Rationale: The use of diuretics to decrease sodium reabsorption and urinary retention, along with increasing urinary excretion, is the primary intervention for ascites.

Short Answer 1. How is the Malnutrition Universal Screening Tool (MUST) used for a patient at risk for malnutrition?

Model Answer: The MUST screening tool is a five-step approach that includes management guidelines for developing a care plan. It is used in hospitals, community, and other care settings where patients are acutely ill and there has been or is likely to be no nutritional

intake for greater than 5 days. Step 1 involves measurement of a patient’s height and weight to get a BMI score. If these measurements are not possible to obtain, an alternate approach can estimate height by using forearm length and estimate weight by mid–upper arm circumference. Step 2 calculates the percentage of unplanned weight loss and creates a score using tables provided. Step 3 establishes the impact of acute disease and the potential effect on a patient’s nutrition. Step 4 then takes the cumulative score from the scores of steps 1, 2, and 3 to obtain the overall risk of malnutrition for the patient. Using the results of the MUST scoring, patients are categorized into low (0), medium (1), or high risk (≥2) for malnutrition.

Management guidelines are suggested after the assessment of that patient’s nutritional status.

Importantly, the guidelines suggest routine reassessment of patients identified at risk as they move through care settings so that ongoing support can be addressed.

2. Harold has been struggling with nausea and vomiting from chemotherapy for lung cancer. He knew before he started treatment that he was likely to experience nausea and vomiting but had no idea it would be this bad. What are the seven steps his healthcare professional should use to determine which medication would be best for him?

Model Answer: The seven steps in choosing the appropriate antiemetic include (a) identify the cause of the nausea and vomiting, (b) identify the pathway triggering the vomiting reflex, (c) identify the neurotransmitter receptor involved in the pathway, (d) choose the most potent antagonist to the receptor identified, (e) choose a route of administration that ensures optimalaction, (f) titrate the dosage, and (g) if symptoms persist, review the cause.

3. Roberta has just entered hospT icE eS foTr B aA raN reKfS orEmLoLfEsaRr. coCmOaM . She is having some difficulty swallowing food. Her family is very concerned that she maintains adequate nutrition so that she can have a high quality of life for as long as possible. Roberta would like that too but is feeling more fatigued every day. How should the management of Roberta’s dysphagia proceed?

Model Answer: If the patient has a very short prognosis (days), it may be determined by the patient, family, and caregivers that hydration and/or feeding are not warranted. If the patient has a longer prognosis, medically assisted feeding and hydration may be attempted. The following factors can help determine the appropriateness of interventions: 1.

2.

3.

4.

5.

Anticipated decline of Roberta Roberta’s opinion Opinions of Roberta’s significant other and family Opinions of formal caregivers Feasibility/advantages/disadvantages of alternative feeding routes

Transnasal intubation, percutaneous endoscopic gastronomy or jejunostomy, esophagogastroduodenoscopy (EGD), or surgical gastrostomy or jejunostomy may be considered if Roberta’s prognosis determines that these interventions will provide optimal palliation. Any surgical intervention must be undertaken with significant input from Roberta and her family and is determined by the overall goals of care.

4. What are treatment strategies for a patient with constipation?

Model Answer: Prevention of constipation is an essential strategy in providing palliative care. A mix of dietary alterations in addition to pharmacological agents may be required.

Bulk-forming agents and stool-softening agents assist with normal peristaltic function. All patients beginning opioid therapy should be started on a laxative. Generally, a combination of a stool softener and laxative offers the most relief from constipation.

5. How can nurses improve symptom management and quality of life for patients with a bowel obstruction?

Model Answer: Nurses could improve symptom management and quality of life for patients that are experiencing malignant bowel obstruction by frequent assessments and being aware that patients with intra-abdominal tumors are at the highest risk for bowel obstruction.

Physical assessment that reveals dehydration, dry mucosa, tachycardia, and hypotension are all signs of possible bowel obstruction. Examination of the abdomen may reveal distention, pain, and varied bowel sounds. Bowel obstruction from a malignant source is a pivotal point in the patient’s illness and nurses should have an active role in helping the patient through the decisions that need to be made about aggressive treatment or a more palliative approach to the bowel obstruction.

CHAPTER 25: Fatigue Multiple Choice 1. How can fatigue be characterized in patients needing palliative care?

A. It is due to exertion from muscular force.

B. It is a natural part of the aging process.

C. It comes from emotional effort related to work.

D. It comes from the interplay of many different factors.

Answer: D Rationale: Chronic, unrelenting fatigue is a common symptom in patients with chronic disease at the end of life, with a complex array of complaints including variations in the level of irritability, nighttime sleeplessness, and daytime sleepiness. The clinical definition of fatigue at this stage of life includes lacking physical or mental energy. Fatigue affects how patients interact with others, their self-perception, ability to function, and sense of hopefulness. Its impact compounds the suffering associated with life-threatening illness.

2. How does fatigue associated with illness typically manifest in comparison to healthy exertion?

A. Comes on after a longer period of time B. Relieved relatively quickly by rest C. Daily feeling of tiredness D. Feels less severe Answer: C Rationale: The concept of fatigue also encompasses emotional, cognitive, and behavioral dimensions. Psychosocial etiologic factors of fatigue across an ethnically diverse population include social adversity, social support, physical inactivity, anxiety, and depression (Bhui et al., 2011). In healthy individuals, overexertion may produce ordinary fatigue, which is relieved relatively quickly by rest; fatigue may also be interpreted as satisfaction given the accomplishment of hard work. However, fatigue associated with illness is perceived as more severe and comes on after a shorter period of time and with less exertion than ordinary fatigue. It is often described as a general feeling of tiredness or “sapped” energy that occurs on a daily basis and is present intermittently throughout the day or during the evening after a day of normal activities.

3. What is the term for fatigue that occurs without any exertion or activity?

A. Chronic B. Acute C. Physiologic D. Central Answer: A Rationale: Chronic fatigue has no known physiologic purpose and can occur without any relationship to exertion or activity. Chronic fatigue is commonly associated with severe

deconditioning or limited mobility as seen in patients with anemia and diminished aerobic capacity, including those with heart failure, chronic lung conditions, and neurological disorders.

Acute or physiologic fatigue is a protective state that is identifiably linked to a single cause, in usually healthy individuals. Acute fatigue has a rapid onset and short direction, is viewed as normal in the usually healthy person, and can be alleviated by restorative techniques such as rest, diet, exercise, and stress management. In central fatigue, the motor pathways in the central nervous system (CNS) fail to sustain recruitment and/or frequency of motor units or the generation of descending volleys in the motor cortex due to neurotransmitter modulation.

4. Which type of fatigue occurs from depletion of body stores from stress and pathology of having a disease?

A. Primary B. Secondary C. Acute D. Physiologic Answer: B Rationale: When a person is experiencing the stress and pathology of chronic disease or cancer, the body reserves can become depleted and ultimately unable to counterbalance the physiologic insults. Primary fatigue comes from having the disease itself. Acute or physiologic fatigue is a protective state that is identifiably linked to a single cause, in usually healthy individuals. Acute fatigue has a rapid onset and short direction, is viewed as normal in the usually healthy person, and can be alleviated by restorative techniques such as rest, diet, exercise, and stress management.

5. Which patient is most likely to experience the most fatigue?

A. A child with cancer in the last month of life B. An adult experiencing the second round of chemotherapy C. An adult who was just diagnosed with HIV infection D. A child who is living with sickle cell disease Answer: A Rationale: For children with advanced cancer, fatigue is the most common symptom reported in the last month of life. An adult experiencing the second round of chemotherapy, an adult who was just diagnosed with HIV infection, and a child who is living with sickle cell disease will all experience fatigue, but the most severe fatigue comes toward end of life from a serious disease.

6. Ronald is 69 years old and is being treated for a nonaggressive form of leukemia. He has been experiencing fatigue quite a bit lately. What considerations around Ronald’s fatigue apply?

A. Fatigue is a normal part of the aging process.

B. Underlying cause will determine treatment.

C. Quality of life will remain the same.

D. Methods to cope with it are unreliable.

Answer: B

Rationale: Many elders and their families erroneously consider fatigue to be an inevitable aspect of aging, and therefore not a symptom to be treated. In fact, older adults may not even report symptoms of weakness and fatigue to their primary care provider. Even for the older adult in palliative care, many causes of fatigue can be successfully treated by examining for and treating the underlying cause. The goal for the healthcare provider related to the symptom fatigue is to improve the patient’s quality of life by treating the symptom and teaching the older adult coping mechanisms and lifestyle changes.

7. If the nurse asks a patient where he or she feels fatigue in his or her body, which dimension of the Fatigue Assessment is being used?

A. Behavioral B. Temporal C. Affective D. Sensory Answer: D Rationale: The sensory dimension of the Fatigue Assessment focuses on how the fatigue feels in the body. For example, is the fatigue localized (e.g., tired eyes, arms, legs) or generalized (e.g., whole body tiredness, weariness, weakness, lethargy), and what is the intensity or severity of fatigue (using 0–10 scale)? Additional assessment questions include what exacerbates the fatigue (e.g., pain, nausea, vomiting, environmental heat, or noise). What helps the patient feel better or alleviates the symptoms (e.g., rest, food, listening to music etc.)?

8. What is the goal of fatigue maTnEagSeTmBeA ntNfK orSaEpL atL ieEnR t i. nC paOlM liative care?

A. Return to pre-illness feeling of well-being B. Have enough energy to combat disease C. Achieve best quality of life possible D. Ease gently into last stages of end of life Answer: C Rationale: The goal of the management of fatigue is to achieve the best quality of life that is possible given the patient’s specific circumstances. Having the energy to do what is important to the person so that they may finalize specific tasks or interact in special relationships is a valuable outcome for treatment.

9. Which dietary consideration will help alleviate fatigue?

A. Avoiding high-sugar foods B. Decreasing fluid intake C. Decreasing protein intake D. Eating large meals Answer: A Rationale: Nutritional status is also an important consideration; eating low-fat foods, several small meals in a day, and avoiding high-sugar foods results in less energy used for digestion.

Given that nutrition and hydration are important in preventing fatigue, increasing fluids may be

of benefit, unless contraindicated by other medical problems. Protein intake and supplements can also be encouraged if the patient is having trouble with regular food.

10. Which medication would be used to treat fatigue in a patient who has anemia from chemotherapy?

A. Erythropoietin B. Methylphenidate C. Prednisone D. Trazodone Answer: A Rationale: If the patient has had chemotherapy, the fatigue may be a result of anemia or vitamin deficiency. Treatment with recombinant erythropoietin has been shown in randomized studies to increase hemoglobin level, which improves the patient with cancer-related fatigue energy levels and quality of life. Methylphenidate is a psychostimulant. Prednisone is a corticosteroid.

Corticosteroids can improve appetite and elevate mood, resulting in an improved sense of wellbeing, although the duration of effect may be limited. Trazodon reduces depressive symptoms associated with fatigue.

Short Answer 1. Joanna has been exhausted daily for almost a year, which she has found very frustrating. She was finally diagnosed with fibromyalgia. What approach should her healthcare professional take?

Model Answer: Patients with chronic conditions, such as fibromyalgia, may manifest progressive symptoms of psychogenic fatigue, physiologic fatigue, pain, depression, sleep disorders, and loss of adaptability. Given the unknown etiology of fibromyalgia, there are limited treatment options for this disease, with relief primarily achieved by the palliation of symptoms. There have been positive results from treatment with complementary and alternative medicines. Exercise is also recommended in levels that help sufferers to feel better without initially aiming at training or conditioning.

2. What are at least five risk factors for cancer-related fatigue?

Model Answer: Multiple risk factors, rather than a single risk factor, appear to put patients with cancer at risk for cancer-related fatigue. These risk factors include poor nutrition, sleep disorders, stress, cancer comorbidities (i.e., cardiac, pulmonary, renal, liver, neurologic, thyroid, and endocrine, and associated medications), hypoxia, pain, infection, deconditioning, and ongoing therapy.

3. How can a nurse empower a patient to cope with fatigue to promote quality of life?

Model Answer: Energy-conserving strategies may be used to manage and alter the fatigue.

These include avoiding unnecessary or excessive use of energy by pacing oneself and taking extra rest periods; energy restoration to avoid further deconditioning and deterioration in

physical functioning through keeping muscles strong through exercising; continuing to be self-reliant by asking for help only when necessary, while taking into account the possibility of escalating fatigue at the end of life; encouraging patients to rejuvenate their energy through relaxation strategies such as reading, watching television, or taking relaxing baths.

4. Maureen is 57 and has had lupus since she was in her 30s. Recently, several exacerbations of lupus have left her exhausted. What advice can her healthcare provider give her to manage her fatigue?

Model Answer: Although patients may believe that more rest and sleep will increase energy, sleep is not restorative of energy in chronic conditions associated with fatigue. Maureen should sleep no longer than 8 hours, which establishes a more solid, less fragmented sleep pattern. Waking up and going to sleep at the same time each day strengthens the circadian cycles, the disruption of which can contribute to depression.

Maureen will need to save her energy and plan for activities that are very important to her. She should schedule activities she enjoys the most for the time of the day that she has the most energy. Breaks should be scheduled during activities to help restore energy levels, and taking short therapeutic naps (15–20 minutes) between the hours of 3 p.m. and 5 p.m. tends to be more restoring than getting into a longer, deeper sleep. Energy conservation techniques should be reinforced, such as doing activities sitting down, using a power scooter for grocery shopping, storing frequently used items at the chest level to avoid bending and stretching, putting a terry robe on after the shower instead of using energy to dry off, or wearing slip-on shoes. Having devices such as a raised toilet seat, a reaching device, or a walker can also help conserve energy. Maureen shT ouEldSaTlsBoAbNeKenScE oL urL agEeR d. toCaOskMfor help with specific chores.

Spending time with family and friends is also very important in promoting a sense of well-being, which may lessen the perception of fatigue. Prioritizing who she would like to visit with can be helpful, as well as planning such visits at a time of day when Maureen has the most energy to avoid excessive fatigue.

5. What causes family fatigue? How can palliative care nurses assist the caregivers?

Model Answer: Severe family fatigue is commonly experienced in four situations: inadequate relief of patient’s pain and suffering; inadequate resources to cope with home care; unrealistic expectations of family caregivers of themselves or professional healthcare supports; and emotional distress that persists even when there is adequate relief of patient suffering. Palliative care nurses recognize the patient and family as the unit of care, and therefore, assessment and interventions to relieve caregiver burden are essential. Validating the needs and concerns of family caregivers is important. Helping family caregivers to set priorities with regard to competing demands, optimizing stress and coping strategies, encouraging relaxation and rest, while assisting caregivers with respite care are important interventions in preventing or alleviating caregiver fatigue.

CHAPTER 26: Minimizing Skin Alterations Multiple Choice 1. Which statement describes a nonhealable wound?

A. Patient has too much blood supply for the area to mend.

B. The area can mend, but the patient is unable to tolerate treatment.

C. The area can mend, but treatment is unavailable to the patient.

D. Patient has too little protein for the area to mend.

Answer: D Rationale: In this population, wound healing is not often the goal; nonetheless, realistically classifying a wound as healable, maintenance, or nonhealable (heal ability) is important. A healable wound has adequate blood supply and the cause can be corrected. A maintenance wound is healable, but either patient factors (unable to tolerate compression bandaging for venous leg edema) or system factors (protective footwear or pressure-relieving devices not covered for patients in the home) are not available. A nonhealable wound is a pressure injury with a patient in a negative protein balance or has inadequate blood supply to facilitate healing.

2. Focus on which aspect of wound care should be in the patient’s palliative care plan?

A. Color of injury B. Bacterial colonization C. Amount of itching D. Duration of injury Answer: B Rationale: Many wounds are treated as maintenance, with important aspects of patient-centered care being the important focus of the patient care plan, including wound odor, excessive exudate, superficial critical bacterial colonization (responds to topical antimicrobials) and deep/surrounding infection (requires systemic therapy), bleeding, and wound-associated pain.

3. Harriet is hospitalized for end-stage heart failure. Which condition is she most likely to develop if her skin assessment is neglected?

A. Treatment injury B. Basal cell carcinoma C. Pressure injury D. Integument tear Answer: C Rationale: Skin changes do occur at life’s end and can be part of the dying process. Studies show that the patients confined to bed present with pressure injuries more often than skin injuries from treatment, skin tumors, and tears in the integument.

4. A Braden scale score of 15 to 18 means the patient is at what level of risk for developing a pressure injury?

A. Mild

B. Moderate C. High D. Severe Answer: A Rationale: According to the Braden scale, a score of 15 to 18 means the patient is at mild risk for developing a pressure injury. A score of moderate risk is 13 to 14. A score of high risk is 10 to 12. A score of severe risk is less than 9.

5. Which guideline is recommended for preventing pressure injury in a patient in end-of-life care?

A. Providing medication after repositioning B. Adhering to a strict repositioning schedule C. Predetermining the most comfortable position D. Providing medication before repositioning Answer: D Rationale: For palliative care patients, following a rigid set time interval for a repositioning schedule may cause the patients undue pain. Caregivers should negotiate a flexible time interval, premedicating prior to repositioning, determine which positions provide the most comfort, and focus on the support surface used, coupled with the preference, needs, and tolerance of the patient.

6. Roger is in hospice for end-ofT-lE ifS eT caBreAaNnK d ShE asLdLevEeR lo.pC edOaMn infected pressure injury. Which treatment method is recommended for the injury?

A. Mechanical debriding B. Using a cytotoxic cleanser C. Using a normal saline cleanser D. Covering with a film dressing Answer: B Rationale: Cytotoxic agents, instead of normal saline cleansers, are typically not recommended for cleaning of pressure ulcers that are healable. For PC patients, the use of these solutions may be warranted, because the goal is no longer healing. The benefits of odor control from these solutions may make them an appropriate choice for persons who are at the end of their lives.

Mechanical debriding would likely cause too much discomfort to the patient. Film dressings are not recommended for infected wounds.

7. Where on the patient’s body are most skin tears likely to occur?

A. Legs and feet B. Back and buttocks C. Arms and hands D. Neck and head Answer: C

Rationale: Eighty percent of skin tears occur on the extensor surface of the upper extremities (arms and hands) over areas of sun damage that also predisposes these regions to senile purpura.

8. Which method demonstrates appropriate peristomal care?

A. Using alcohol-based products for infection control B. Protecting the skin by avoiding the use of a skin barrier C. Using adhesive removers to avoid skin stripping D. Changing the pouch–skin barriers very frequently Answer: C Rationale: Peristomal skin must be protected from mechanical trauma that can occur from inappropriate cleaning. To avoid skin stripping, use adhesive removers to remove skin barriers and pouching systems. Alcohol-based products should never be used, especially if the peristomal skin is denuded. If solvents are used, the skin should be cleaned, and the solvent removed before applying the ostomy pouch. A variety of skin barriers can be used to protect the peristomal skin from effluent. Avoid too frequent or unnecessary changing of the pouch–skin barrier.

9. Which option is most effective for the management of odorous fistulas in elderly patients?

A. Pouching system B. Trough system C. Drainage tube with suction D. Drainage tube without suction Answer: A Rationale: A pouching system may be the primary choice for management for older adults with odorous fistulas. Using a clear pouch will enable the caregiver or nurse to easily see the type and amount of effluent. Pouching is superior to dressings because it provides better protection for the skin. High-output enterocutaneous fistulas can be managed using a Jackson–Pratt (JP) drain connected to low-wall suction (60 mmHg of pressure) covered with saline-soaked gauze and a large surgical plastic drape. When using this technique, be careful in placing the catheter tube so it does not inadvertently cause injury to the tissue. The trough procedure is used for fistulas that are deep within wounds. It is made up of several layers of transparent dressing with an ostomy pouch on the bottom of the wound.

10. Tanis is undergoing radiation therapy. Which approach by the nurse is appropriate to use on Tanis’s treatment area?

A. Shaving and rubbing the skin B. Using a lotion to moisturize the skin C. Sprinkling talcum powder on the skin D. Using a gel with aloe vera on the skin Answer: D Rationale: While undergoing radiation therapy, products with vitamin A and E or aloe vera gels may be used for treating erythema, although topical steroids should also be considered with the presence of a topical contact irritant dermatitis. Avoid activities that could cause mechanical skin damage such as vigorous rubbing, heat, or shaving of the skin in the treatment area. Use of any

topical products, such as lotions, creams, or deodorants, is generally discouraged. Talcum, cornstarch, and baby powder use is controversial as they often contain heavy metals; however, if they are applied, an even layer can be obtained with a cotton ball dabbed on the affected area rather than sprinkling the powder from a container. Sprinkling often leads to local clumping.

Short Answer 1. Deepak is a new nurse who has been assigned to assess the skin integrity of each of the patients in the hospice unit of the hospital he works in. What elements does he need to check with each patient?

Model Answer: Actual physical examination of the skin is needed to identify patients at risk for skin injury and to initiate prevention protocols. There is, however, no consensus in the literature as to what constitutes a minimum skin assessment. Baranoski and Ayello have suggested five elements to include in a basic skin assessment: skin temperature, color, moisture, turgor, and whether the skin is intact or has areas of injury including open areas.

2. What are patient risk factors for pressure injuries according to the Skin Changes at Life’s End (SCALE) Panel Statements?

Model Answer: Risk factors, symptoms, and signs associated with SCALE have not been fully elucidated, but may include:

TESTBANKSELLER.COM

Weakness and progressive limitation of mobility Suboptimal nutrition, including loss of appetite, weight loss, cachexia and wasting, low serum albumin/prealbumin level, and low hemoglobin, as well as dehydration Diminished tissue perfusion, impaired skin oxygenation, decreased local skin temperature, mottled discoloration, and skin necrosis Loss of skin integrity from any of a number of factors, including equipment or devices, incontinence, chemical irritants, chronic exposure to body fluids, skin tears, pressure, shear, friction, and infections Impaired immune function 3. What is an effective skin tear treatment protocol?

Model Answer: An effective skin tears treatment protocol is as follows: Gently clean the skin tear with normal saline.

Let the area air dry or pat dry carefully.

Approximate the skin tear flap.

Apply petroleum-based ointment, steri-strips, or a moist nonadherent wound dressing.

Calcium alginate dressings facilitated closing in 7 to 10 days.

Use caution if using film dressings as skin damage can occur when removing this dressing.

Consider using silicone dressings with low tack to avoid tearing the skin.

Consider putting an arrow on the dressing to indicate the direction of the skin tear to minimize any further skin injury during dressing removal.

Always assess the size of the skin tear; consider doing a wound tracing.

Document assessment and treatment findings.

4. Now that Marlene is reaching the end stages of Alzheimerʼs disease, one of her family’s concerns about her comfort and care is whether or not the skin around her stoma is healthy and properly taken care of. They do not want her suffering unduly from an infection. What would the nurse look for in terms of peristomal skin complications?

Model Answer: Peristomal skin complications are described according to three criteria: discoloration, erosion, and hyperplasia, or raised lesions that can be measured with size and severity for a maximum score of 5 points for each. Normal peristomal skin should be intact without discoloration and no difference between the peristomal skin and adjacent skin surfaces. Peristomal skin damage has erythema, maceration, denudation, skin rash, ulceration, or blister formation. In darkly pigmented patients, the damaged skin may appear lighter or darker than the surrounding skin.

5. What palliative care considerations need to be given for patients whose tumors have invaded the skin?

Model Answer: Frequent irrigation of the wound with large amounts of fluid may be important to reduce the bacterial burden on the wound surface. Wound exudate needs to be managed with absorbent dressings, and debridement may be necessary because of necrotic tissue. Bleeding commonly occurs. Calcium alginate dressings and topical thrombin have a hemostatic effect and are a goToE dS chToB icAe N foKrSbE leL edLinEgRw.oCuO ndMs. Silver nitrate sticks can be used to control small amounts of blood. Pain also results from the tumor growing on the skin and from treatment procedures. Ice packs or topical anesthetic aerosol spray (Hurricane) may alleviate wound pain. Topical extemporaneously compounded opioids or preparations containing amide local anesthetics pyridoxine have also been used to relieve wound pain.

Odor may be one of the most distressing problems for the patients and their caregivers. There are commercially available wound gel deodorizers; however, some patients may experience burning with the application of these products. The use of Metrogel (1% topical antibiotic wound-deodorizing gel) to control even the most noxious odors has been reported. Topical application of yogurt or buttermilk has been used to combat the extensive odors from tumor necrosis. Antimicrobial cadexomer iodine or silver dressings are also excellent at reducing odor with the added plus of also controlling the bacterial burden in the surface compartment wound.

Clinicians should be aware of their nonverbal and verbal communication to patients during dressing changes. Patients and/or family members may have difficulty coping with wound odor or appearance and will look to the clinician to see their reaction. Seeing the extensive death of their own body, coupled with overpowering smells and weeping feces, may be extremely overwhelming to patients. The clinician’s resolve to problem solve and provide the patient with the physical comfort from appropriate wound management is vital in helping these patients overcome their (sometimes self-imposed) isolation and hiding.

CHAPTER 27: Peri-Death Nursing Care Multiple Choice 1. Which factor is part of pain management during the dying process?

A. Patients will always request pain medication for suffering.

B. Patients may be suffering more from pain than they are saying.

C. Families determine survival potential risks and benefits for the patient.

D. Inadequate pain management for the patient has been resolved by opioids.

Answer: B Rationale: There may be gaps between a patient’s preferred level of comfort and how a patient describes suffering. The patient may seek pain relief or may view pain as a way to atone for sins and refuse to be medicated. Healthcare providers must help alleviate that suffering, but examine survival potential, risks, and benefits of therapy. Pain management has improved; the prevalence of inadequate pain management at the end of life (EOL) remains a key issue. Identifying the appropriate dose and frequency, especially of opioids, can be challenging and may require creativity.

2. Jocelyn is 46 years old and dying from metastatic breast cancer. She feels that she battled it for as long as she could but now is just tired and wants a peaceful end of life. Jocelyn has decided to refuse nutrition and asks the palliative care nurse what will happen in her body from this decision. What can T thE eS nuTrB seAtN elK l hSeE r?LLER.COM A. Ketone levels will increase causing endorphins to increase, providing analgesia.

B. Electrolytes will likely become imbalanced, decreasing analgesia.

C. Decreased fluid intake stimulates mucus production, causing coughing.

D. Decreased fluid intake stimulates tumor growth, causing more pain.

Answer: A Rationale: With calorie deprivation comes an increased production of ketones, which results in an elevation of naturally occurring opioid peptides or endorphins that provide analgesia. An electrolyte imbalance, if present, will also result in increased analgesia. Decreased fluid intake will result in fewer pulmonary fluids, which ease respiration, lessen coughing, and reduce the drowning sensations. If a tumor is present, dehydration may make it smaller in size by reducing the edematous layer around the tumor, resulting in less pressure and pain.

3. If a patient at the end of life alternates between being agitated and drowsy, and moans and grimaces, what could the patient be experiencing?

A. Dyspnea B. Nausea C. Pain D. Delirium Answer: D Rationale: Individuals at the end of life can manifest symptoms of end-stage multiorgan failure and other irreversible factors that result in a disturbance of fluctuating consciousness, cognition,

and perception known as delirium, but it is often underdiagnosed in the terminally ill. Delirium can be classified into three subtypes: hyperactive (restless and agitated), hypoactive (drowsy and inactive), and a combination of these two. These are typical symptoms that are indicative that the patient is close to death. Moaning and grimacing can accompany agitation and restlessness and may be misinterpreted by the nurse as pain.

4. Which action is a responsibility of a palliative care nurse?

A. Avoiding talking with the patient about death B. Determining food and activity choices for the patient C. Helping the patient work through any unfinished business D. Telling the family to be realistic about a miracle cure for the patient Answer: C Rationale: Two very important goals of PC nursing are to help patients live until they die and to encourage hope. First, the nurse can help patients live until they die by encouraging socialization, listening, being honest, and helping them finish any unfinished business. The nurse can also help families find meaning in the situation. Dialogues about death with healthcare professionals, families, and friends can benefit all involved. By offering patients choices regarding routines, food, and activities, nurses promote continued independence and the ability to help maintain control over their lives. There may be hope for the miracle of a complete cure; it is not acceptable for the nurse to take this hope away or to tell the patient and family to be realistic.

5. What is a consideration for thT eE paSllTiaBtiA veNcKaS reEnLuL rsE eR ta. kiC ngOM care of a terminally ill child?

A. The priority is the child, and family’s needs come second.

B. The parent’s wishes always supersede the child’s wishes.

C. Someone needs to be with the child until the end of life.

D. Discussing end of life will cause depression in the child.

Answer: C Rationale: Palliative care for the child encompasses a holistic approach to physical, psychological, and spiritual care. Offering time for discussion related to death and the dying process helps the child recognize that he or she will not be alone in the process and will be loved and remembered. Consideration for both the dying child and his or her family supporting optimal functioning until the time of death is a vital role for the nurse. The child needs to make as many decisions about his or her end-of-life care as possible to feel some sense of control. Children are often very perceptive and may know far more than adults assume. End-of-life communication will not typically send a dying child into a deep depression.

6.

Which sign indicates death?

A. Eyes are slightly closed.

B. Pupils are fixed.

C. Body color turns pink.

D. Jaw is closed.

Answer: B

Rationale: Signs of death include cessation of a heartbeat and respiration, release of bowel and bladder, eyelids slightly open and not blinking, the eyes glaze, and pupils are fixed and dilated.

There is a drop in body temperature, and as the blood settles, the body color turns to a waxen pallor, the jaw is relaxed and slightly open, and there is no response from the patient.

7. Which statement describes embalming?

A. It is commonly done for health reasons.

B. It is a legal requirement.

C. It is necessary for viewing of the body.

D. Five methods are used to preserve the body.

Answer: A Rationale: Embalming is the process by which the corpse is preserved and prepared for viewing; it is common for health reasons and protects mourners from being in the presence of a decaying body, but is not legally required, even if it is to be viewed. There are four embalming methods that all involve the injection of chemicals to preserve the body.

8. What role does the palliative care nurse play in the family’s customs, values, practices, and traditions regarding the patient’s death?

A. Inform families of the rites that are performed in the United States B. Allow only rituals that are permitted by hospital policy C. Participate as much as possible in the rituals D. Understand the need for the rituals Answer: D Rationale: Throughout the dying process, and particularly at the very end of life, the nurse must be aware of cultural and religious values, practices, and traditions of the patient and the family.

Customs and rituals have tremendous significance in the healing process following death, and the grief response is often structured by these rituals. The nurse’s role is to help the family carry out the rites and practices that provide solace and support. The nurse should be open minded and understanding of the physical, psychosocial, and spiritual needs of the dying patient and his or her family and offer them respect and privacy.

9. While each Native American tribe has its own unique traditions regarding death of a member, which action do they all have in common?

A. Embalming is done after the body undergoes a cleansing ceremony.

B. The deceased is buried without any jewelry on the body.

C. Spirit of the deceased remains where the person dies.

D. The deceased needs to die alone in preparation for the next world.

Answer: C Rationale: Native Americans have different traditions in each tribe. There is a belief that the spirit of the deceased remains where the person has died; therefore, family may not want the person to die at home. At the same time, it is considered inappropriate for the person to die alone. If the person dies at home, the house must be abandoned or a ceremony is held to cleanse it. Families gather together at the time of death and material possessions are dispersed. When a person dies, a cleansing ceremony is performed or else the spirit of the deceased may try to take

over someone else’s spirit. Those who work with the dead also must have a ceremonial cleansing to protect themselves from the dead person’s spirit. No embalming is done; the deceased are buried in sacred ground with their shoes on the wrong feet, rings on their index fingers, and with many gifts surrounding them; or the body is cremated.

10. Bereaved family members are talking about the deceased and voicing their feelings. Which therapeutic part of the funeral process does this describe?

A. Therapy of direct expression B. Therapy of language C. Therapy of sharing D. Therapy of activity Answer: B Rationale: Seven specific therapeutic values have been assigned to the funeral process as delineated by Raether. First, the “therapy of direct expression” denotes that the funeral furnishes the setting and opportunity for the bereaved to express their grief physically. Funerals offer “therapy of language” by providing the bereaved an opportunity to talk about what has happened, voice their feelings, and begin to feel relief in the telling. The “therapy of sharing” is the coming together of the family and significant others to provide emotional and physical support to each other. Immersion in the many aspects of the funeral process also encompasses the “therapy of activity.” The funeral also provides the “therapy of ceremony” that is both glorifying and ennobling. Given that accepting the reality of the death is difficult for many people, the “therapy of viewing” establishes a final and amended view of the deceased. This revised image replaces those comTpE osSedTB duAriNnK gS thE eL ilL lnE esRs . orCaOt M the time of death and may bring comfort to the mourner. Finally, the “therapy of suffering” addresses the guilt that mourners may be experiencing and provides the occasion to verbalize what had been left unsaid previously.

Short Answer 1. Edmond has begun the stages of dying. His family has gathered to be with him during his last days. Edmond’s breathing pattern has started to change, upsetting some of his family members. What should the palliative care nurse tell Edmond and his family about his breathing?

Model Answer: Families should be warned that dyspnea and loud respirations are a possibility during the peri-death period. Patients may fear they will suffocate while they are dying, and families fear they will have to watch their loved one struggle to breathe. Nurses should educate the patient and family regarding what they can expect and give assurances that medications will be used to effectively palliate these symptoms. Nursing interventions include positioning Edmond on his side, semi-prone or in brief Trendelenburg, to prevent the accumulation of secretions in the back of his throat and upper airways. Edmond can be given a low-dose opiate, such as morphine 5 mg PO every 4 hours, to alleviate the sensation of breathlessness. Oxygen is typically only effective if the dyspnea is secondary to hypoxia, although it may provide a placebo effect. A fan blowing a gentle breeze toward Edmond’s face can also be very effective. Suctioning is usually not recommended as it may incidentally increase secretion production. Emotion-focused interventions such as relaxation techniques,

prayer and meditation, and distraction may alleviate the anxiety Edmond and his family associate with dyspnea.

2. What is most helpful for the palliative care nurse to tell an end-of-life patient’s family when the patient exhibits delirium?

Model Answer: The family is in need of education and support regarding the cause and the irreversible nature of the behavior. Maintaining a calm environment, spiritual comfort, and emotional support are vital at this time. The family can be advised to continue to talk to the patient and calm the patient with their words. Light massage of the arms, back, or forehead can be very soothing. Soft music and low lights can also be effective. It may be suggested that the number of people in the room be decreased if there is a lot of activity. Refraining from asking the patient many questions can diminish agitation.

Eventually the patient’s level of consciousness will decrease and he or she may even become unable to be aroused. This is typically a very upsetting time for family because the patient may seem unresponsive and withdrawn, but it is a normal aspect of the dying process.

At this time, the patient is starting to “let go” in preparation for death and is detaching from relationships and the physical environment. A patient may ask to be with only one person toward the end or seem distracted from the family. Reassure the family that this is not a personal rejection, only another aspect of the dying process. A dying person may talk about seeing people who have already died or talk about taking a trip with a long-deceased relative.

Patients may describe feeling separate from their body. This is a normal experience and is not considered a hallucination.

Even if the patient is unresponsive, encourage family members to talk with him or her.

Assume that the patient hears everything; this is the time for loved ones to say “Good-bye,” “I’m sorry,” “I love you,” or “Thank you.” The patient may have difficulty letting go and the nurse may need to encourage the family to give the patient permission to die. Encourage the family to show affection to the patient, touch the patient, and let the patient know he or she will be missed.

3. What post-death care does the nurse perform when a patient dies?

Model Answer: Post-death nursing care involves preparing the body for the morgue or funeral home and helping the family through decisions regarding autopsy and burial. Care of the body by the nurse should include closing the eyes, inserting dentures and closing the mouth, and elevating the head of the bed so that the blood does not drain into the face and discolor it. Any IV or catheter can be removed at this time, and the physical environment should be straightened. Removal of tubes and equipment is dependent on institutional protocol. Follow the agency protocol regarding jewelry; if there is a wedding ring, secure it on the finger with tape. The body should be bathed in plain water and dried; a bed protector should be placed under the body. If there are dressings on wounds, they should be replaced with clean ones. The hair should be combed, the extremities straightened, and the right great toe tied with an identification tag. When the family has given permission for the body to be moved, the nurse should follow the institutional protocol regarding shrouding the body. If a person has died at home and it is an expected death, the undertaker is called and they remove the body as it is. In a hospital or nursing home setting, the body is wrapped in a shroud or

body bag. The shroud should be secured with safety pins or ties and a second identification tag should be attached to the shroud or body bag. The body is then taken to the morgue.

4. Amjad is Muslim and has just died in a hospital. What should the palliative care nurse be aware of regarding rituals for Amjad’s body?

Model Answer: Following the death, non-Muslims should wear gloves when touching the body. If there is no family available to carry out postmortem care, the nurse should wear gloves in administering care of the body. However, the body is not washed and hair and nails are not cut; the eyes are closed. The normal Muslim procedure is that the body is straightened immediately after death. This is done by flexing the elbows, shoulders, knees, and hips first, before straightening them. This is thought to ensure that the body does not stiffen, thus facilitating its washing and shrouding. Turn the head toward the right shoulder. This is so the body can be buried with the face toward Mecca.

The body is then covered with a sheet that cloaks the whole body until a Muslim is available to perform the ritual bath. The ritual bath includes washing the body three times, first with lotus water, then with camphor water, and lastly with plain water. This bathing is done from head to toe and front to back. All body orifices are closed and packed with cotton (to prevent body-fluid leakage that is considered unclean). Prayers from the Qur’an are read (especially verses of hope and acceptance) and the body is wrapped in a special cotton shroud. This shroud is made from three pieces of white unsewn cloth, 9 yards long, which are wrapped above, below, and around the midsection. Muslims are buried in a brick- or cementlined grave with the head facing east toward Mecca.

5. What role can the palliative care nurse play in helping bereaved family members form new identities?

Model Answer: Another important aspect of the post-death experience for the bereaved is the formation of a new identity within their community. The role of widow, of no longer having a child, or of one who has lost a parent brings with it a change in how the bereaved interact and correspond to society at large. Social groups may shrink, volunteer opportunities may be lost, and favorite activities may be forfeited due to the loss of the deceased. Nurses need to be aware of the difficulties inherent in these role shifts and offer alternatives and community-support referrals during this transitional stage.