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medical surgical nursing management and assessment
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(Complete) Test Bank Medical surgical Nursing Management and Assessment Chapter 10
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Chapter 10: Palliative Care at End of LifeTest Bank
MULTIPLE CHOICE
1. The nurse cares for a terminally ill patient who has 20-second periods of apnea followed by
periods of deep and rapid breathing. Which action by the nurse would be most appropriate? a.
Suction the patient.
b. Administer oxygen via face mask.
c. Place the patient in high Fowler’s position.
d. Document the respirations as Cheyne-Stokes.
ANS: D
Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and
rapid breaths. Cheyne-Stokes respirations are expected in the last days of life. There is also no
need for supplemental oxygen by face mask or suctioning the patient. Raising the head of the
bed slightly and/or turning the patient on the side may promote comfort. There is no need to
place the patient in high Fowler’s position.
DIF: Cognitive Level: Apply (application) REF: 142-143 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse cares for an adolescent patient who is dying. The patient’s parents are interested in
organ donation and ask the nurse how the decision about brain death is made. Which response
by the nurse is most appropriate?
a. “Brain death occurs if a person is flaccid and unresponsive.”
b. “If CPR is ineffective in restoring a heartbeat, the brain cannot function.”
c. “Brain death has occurred if there is no breathing and certain reflexes are absent.”
d. “If respiratory efforts cease and no apical pulse is audible, brain death is present.”
ANS: C
The diagnosis of brain death is based on irreversible loss of all brain functions, including
brainstem functions that control respirations and brainstem reflexes. The other descriptions
describe other clinical manifestations associated with death but are insufficient to declare a
patient brain dead.
DIF: Cognitive Level: Apply (application) REF: 142 TOP: Nursing
Process: Assessment MSC: NCLEX: Physiological Integrity
3. A hospice patient is manifesting a decrease in all body system functions except for a heart rate
of 124 and a respiratory rate of 28. Which statement, if made by the nurse to the patient’s
family member, is most appropriate?
a. “These symptoms will continue to increase until death finally occurs.”
b. “These symptoms are a normal response before these functions decrease.”
c. “These symptoms indicate a reflex response to the slowing of other body systems.”
d. “These symptoms may be associated with an improvement in the patient’s condition.”
, ANS: B
An increase in heart and respiratory rate may occur before the slowing of these functions in the
dying patient. Heart and respiratory rate typically slow as the patient progresses further toward
death. In a dying patient, high respiratory and pulse rates do not indicate improvement, and it
would be inappropriate for the nurse to indicate this to the family. The changes in pulse and
respirations are not reflex responses.
DIF: Cognitive Level: Apply (application) REF: 143 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
4. A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans
a trip across the country “to settle some issues with sisters and brothers.” The nurse
recognizes that the patient is manifesting which psychosocial response to death?
a. Restlessness
b. Yearning and protest
c. Anxiety about unfinished business
d. Fear of the meaninglessness of one’s life
ANS: C
The patient’s statement indicates that there is some unfinished family business that the patient
would like to address before dying. Restlessness is frequently a behavior associated with an
inability to express emotional or physical distress, but this patient does not express distress and
is able to communicate clearly. There is no indication that the patient is protesting the
prognosis, or that there is any fear that the patient’s life has been meaningless.
DIF: Cognitive Level: Apply (application) REF: 143 TOP: Nursing
Process: Assessment MSC: NCLEX: Psychosocial Integrity
5. The spouse of a patient with terminal cancer visits daily and cheerfully talks with the patient
about wedding anniversary plans for the next year. When the nurse asks about any concerns,
the spouse says, “I’m busy at work, but otherwise things are fine.” Which nursing diagnosis is
most appropriate?
a. Ineffective coping related to lack of grieving
b. Anxiety related to complicated grieving process
c. Caregiver role strain related to feeling overwhelmed
d. Hopelessness related to knowledge deficit about cancer
ANS: A
The spouse’s behavior and statements indicate the absence of anticipatory grieving, which may
lead to impaired adjustment as the patient progresses toward death. The spouse does not
appear to feel overwhelmed, hopeless, or anxious.
DIF: Cognitive Level: Apply (application) REF: 143-144
TOP: Nursing Process: Diagnosis MSC: NCLEX: Psychosocial Integrity
6. As the nurse admits a patient in end-stage kidney disease to the hospital, the patient tells the
nurse, “If my heart or breathing stop, I do not want to be resuscitated.” Which action is best
for the nurse to take?
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