Introduction To Critical Care Nursing 7th Edition By Sole – Test Bank
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Sample Questions
Chapter 04: End-of-Life Care and Palliative Care in Critical
Care Settings
Sole: Introduction to Critical Care Nursing, 7th Edition
MULTIPLE CHOICE
1. A patient
who is undergoing withdrawal of mechanical ventilation appears anxious and
agitated. The patient is on a continuous morphine infusion and has an
additional order for lorazepam (Ativan) 1 to 2 mg IV as needed (prn). The
patient has received no lorazepam (Ativan) during this course of illness. What
is the most appropriate nursing intervention to control agitation?
|
a. |
Administer fentanyl
(Duragesic) 25 mg IV bolus. |
|
b. |
Administer lorazepam
(Ativan) 1 mg IV now. |
|
c. |
Increase the rate of the morphine
infusion by 50%. |
|
d. |
Request an order for a
paralytic agent. |
ANS: B
Lorazepam (Ativan) 1 mg IV is an appropriate drug dose for a
patient who is experiencing agitation during withdrawal of life support.
Because it is ordered but not yet given, the nurse should give this drug now.
Fentanyl treats pain and morphine controls pain. Paralytic agents are not
warranted.
DIF: Cognitive Level: Apply/Application
REF: p. 46
OBJ: Describe nursing interventions to support the
patient and family during the end-of-life stage.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
2. A
75-year-old patient, who suffered a massive stroke 3 weeks ago, has been
unresponsive and has required ventilatory support since the time of the stroke.
The physician has approached the spouse regarding placement of a permanent feeding
tube. The spouse states that the patient never wanted to be kept alive by tubes
and personally didn’t want what was being done. After holding a family
conference with the spouse, the medical team concurs, and the feeding tube is
not placed. This situation is an example of
|
a. |
euthanasia. |
|
b. |
palliative care. |
|
c. |
withdrawal of life support. |
|
d. |
withholding life support. |
ANS: D
Because the tube feeding had not been yet placed in the care of
this patient, this scenario is an example of withholding of life support.
Withholding of life support does not constitute euthanasia. Withdrawal of life
support involves the discontinuation of previously established therapies in a
terminally ill patient.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 43
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or
withdrawing therapy; and psychological support of the patient, family members,
and health care
providers.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
3. What
were the findings of the Study to Understand Prognoses and Preferences for
Outcomes and Risks of Treatment (SUPPORT)?
|
a. |
Clear communication is
typical in the relationships between most patients and health care providers. |
|
b. |
Critical care units often
meet the needs of dying patients and their families. |
|
c. |
Disparities exist between
patients’ care preferences and the actual care provided. |
|
d. |
Pain and suffering of
patients at end of life is well controlled in the hospital. |
ANS: C
Disparities and lack of communication are common in the
relationships between patients and health care providers. Critical care units
are often poorly equipped to meet the needs of dying patients. The SUPPORT
study demonstrated that pain and suffering are widespread in hospitals.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 40
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or
withdrawing therapy; and psychological support of the patient, family members,
and health care providers.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
4. A
statement that provides a legally recognized description of an individual’s
desires regarding care at the end of life is a (an)
|
a. |
advance directive. |
|
b. |
guardianship ad litem. |
|
c. |
health care proxy. |
|
d. |
power of attorney. |
ANS: A
Legally recognized documents that provide guidance on an
individual’s end-of-life choices are advance directives. Advance directives
include living wills, durable powers of attorney for health care, and health
care surrogate designations. A guardianship ad litem is a parent who files
legal action on the behalf of a child. A health care proxy is an individual who
is legally designated through statute to make decisions for an incapacitated
person. A power of attorney is an individual who is, through filing of legal
papers, authorized to act on the behalf of an incapacitated person in legal
matters.
DIF: Cognitive Level:
Understand/Comprehension
REF: p. 47
OBJ: Describe ethical and legal concerns related to
end-of-life care.
TOP: Integrated Process: Communication and
Documentation
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
5. A
patient with metastatic lung carcinoma has been unresponsive to chemotherapy.
The medical team has determined that there are no additional treatments
available that will prolong life or improve the quality of life in any
meaningful way. Despite the poor prognosis, the patient continues to receive
chemotherapy and full nutritional support. This is an example of which
end-of-life concept?
|
a. |
Medical futility |
|
b. |
Palliative care |
|
c. |
Terminal weaning |
|
d. |
Withdrawal of treatment |
ANS: A
Medical futility is a situation in which therapy or
interventions will not provide a foreseeable possibility of improvement in the
patient’s health status. Palliative care focuses on symptom relief and is not
limited to the dying. Terminal weaning refers to withdrawal of artificial
ventilation interventions. Withdrawal of treatment refers to the removal of
established therapies in a terminally ill patient.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 41
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or
withdrawing therapy; and psychological support of the patient, family members,
and health care providers.
TOP: Integrated Process: Communication and
Documentation
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
6. Designated
health care surrogates should base health care decisions on
|
a. |
personal beliefs and
values. |
|
b. |
recommendations of family
members and friends. |
|
c. |
recommendations of the physician
and health care team. |
|
d. |
wishes previously expressed
by the patient. |
ANS: D
Health care surrogates attempt to have decisions match the
wishes of the patient. Although suggestions of family and friends may provide
insight into patient desires, actual decisions should be based upon known
patient wishes. The physician and health care team may provide recommendations,
but decisions should be based on the patient’s wishes.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 41
OBJ: Describe ethical and legal concerns related to
end-of-life care.
TOP: Integrated Process: Communication and
Documentation
MSC: NCLEX Client Needs Category: Psychosocial Integrity
7. Which
statement made by a staff nurse identifying guidelines for palliative care
would need to be corrected?
|
a. |
Basic nursing care is a
critical element in palliative care management. |
|
b. |
Common conditions that
require palliative management are nausea, agitation, and sleep disturbance. |
|
c. |
Palliative care practices
are reserved for the dying client. |
|
d. |
Palliative care practices
relieve symptoms that negatively affect the quality of life of a patient. |
ANS: C
The purpose of palliative care is to relieve negative symptoms
that affect the quality of life of a patient. Palliative care is an integral
part of every injured or ill patient’s care. Basic nursing care, including
repositioning, skin care, and provision of a peaceful environment, promote
comfort. These conditions all commonly require palliative care techniques.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 41
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or withdrawing
therapy; and psychological support of the patient, family members, and health
care
providers.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
8. Which
statement is true regarding the impact of culture on end-of-life decision
making?
|
a. |
Cultural beliefs should not
take precedence over health care team decisions. |
|
b. |
It is easy and common to
assess cultural beliefs affecting end-of-life care in the intensive care
unit. |
|
c. |
Culture and religious
beliefs may affect end-of-life decision making. |
|
d. |
Perspectives regarding
end-of-life care are similar between and within religious groups. |
ANS: C
Religious doctrines and cultural beliefs have profound impact on
end-of-life decisions.
Patient and family culture and preferences in end-of-life care
should guide treatment and not be overruled by the wishes of medical personnel.
It is difficult to assess end-of-life desires in the intensive care unit due to
many constraints, and nurses need to become more proficient at this. Language
barriers make it even more difficult and time consuming, but nurses should
strive to respect the patient’s and family’s wishes. Perspectives on
end-of-life care vary within and between religious groups.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 48
OBJ: Discuss cultural considerations in end-of-life
care.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Psychosocial Integrity
9. The
most critical element of effective early end-of-life decision making is
|
a. |
control of distressing
symptoms, such as nausea, anxiety, and pain. |
|
b. |
effective communication
among the patient, family, and health care team throughout the course of the illness. |
|
c. |
organizational support of
palliative care principles. |
|
d. |
the relocation of the dying
patient from the critical care unit to a lower level of care. |
ANS: B
The failure of clinicians, family members, and patients to
openly discuss prognoses, end-of-life wishes, and preferences contributes to
care conflicts such as in the Schiavo case. Early discussion of end-of-life
wishes is required to promote positive outcomes for the patient and family;
such discussions actually should predate illness. Even though symptom control
is a significant dimension of palliative care, it is not involved in initial
end-of-life decision making. Adequate staffing and facility policies that
support the dying patient are critical but should not impact family decision
making. The patient should be cared for in an environment that best supports
the needs of the patient and family. Even though organizational support of
palliative principles is important, it should not drive individual decision
making.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 42
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or
withdrawing therapy; and psychological support of the patient, family members,
and health care providers.
TOP: Integrated Process: Communication and
Documentation
MSC: NCLEX Client Needs Category: Psychosocial Integrity
10. A
patient with end-stage heart failure is experiencing considerable dyspnea.
Appropriate palliative management of this symptom includes:
|
a. |
administration of midazolam
(Versed). |
|
b. |
administration of morphine. |
|
c. |
an increase in the amount
of oxygen being delivered to the patient. |
|
d. |
aggressive use of inotropic
and vasoactive medications to improve heart function. |
ANS: B
Morphine is an excellent agent to control the symptom of
dyspnea. Midazolam is used for anxiety. An increase in oxygen or aggressive use
of medications to improve the patient’s heart function is inappropriate in this
case.
DIF: Cognitive Level:
Apply/Application
REF: p. 46 | Fig 4-2
OBJ: Describe nursing interventions to support the
patient and family during the end-of-life stage.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
11. Which
statement is consistent with societal views of dying in the United States?
|
a. |
Dying is viewed as a
failure on the part of the system and providers. |
|
b. |
Most Americans would prefer
to die in a hospital to spare loved ones the burden of care. |
|
c. |
People die of distinct,
complex illness for which a cure is always possible. |
|
d. |
The purpose of the health
care system is to prevent disease and treat symptoms. |
ANS: A
Death is viewed as a failure by society and health care
providers, a view that results in aggressive management of disease, even in
unfavorable situations. Research has indicated that most Americans would prefer
to die at home. There is a commonly held belief that people die of distinct
diseases, implying that a cure is possible. There is a commonly held belief
that the health care system exists to treat illness, disease, and injury and to
“save” lives.
DIF: Cognitive Level: Understand/Comprehension
REF: p. 41
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or
withdrawing therapy; and psychological support of the patient, family members,
and health care providers.
TOP: Nursing Process Step: N/A
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
12. Which
nursing intervention would need to be corrected on a care plan for a patient in
order to be consistent with the principles of effective end-of-life care?
|
a. |
Control of distressing
symptoms such as dyspnea, nausea, and pain through the use of pharmacological
and nonpharmacological interventions |
|
b. |
Limitation of visitation to
reduce the emotional distress experienced by family members |
|
c. |
Patient and family
education on anticipated patient responses to withdrawal of therapy |
|
d. |
Provision of spiritual care
resources as desired by the patient and family |
ANS: B
Active involvement of family is a critical dimension of
end-of-life care. Family members should have access to the patient and
inclusion in care to the degree they desire. Limitation of visitors is not
consistent with effective end-of-life care practices.
Control of distressing symptoms is a dimension of end-of-life
care. Family education and anticipatory guidance are critical elements of
end-of-life care. Meeting the emotional and psychological needs of the patient
and family through provision of spiritual resources and bereavement care is a
critical element of end-of-life care.
DIF: Cognitive Level:
Apply/Application
REF: p. 47 | Box 4-4
OBJ: Describe nursing interventions to support the
patient and family during the end-of-life stage.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Psychosocial Integrity
13. In
which of the following situations would a health care surrogate or proxy assume
the end-of-life decision-making role for a patient?
|
a. |
When a dying patient requires
extensive heavy sedation, such as benzodiazepines and narcotics, to control
distressing symptoms |
|
b. |
When a dying patient who is
competent requests to withdraw treatment against the wishes of the family |
|
c. |
When a dying patient who is
competent requests to continue treatment against the recommendations of the
health care team |
|
d. |
When a dying patient who is
competent is receiving prn treatment for pain and anxiety |
ANS: A
A patient who requires heavy sedation, such as IV infusions of
pain medications or anxiolytic medications, would not be competent to make
health care decisions. A health care proxy or surrogate would be required in
this situation. A patient who is deemed competent by the medical team may be
responsible for health care decisions even if these are not consistent with
family beliefs. A surrogate would not assume decision-making responsibilities
in this situation. A health care team member who cannot support decisions would
be responsible for finding an alternative care provider who could support the
patient’s wishes.
DIF: Cognitive Level:
Analyze/Analysis
REF: p. 40
OBJ: Describe ethical and legal concerns related to
end-of-life care.
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
14. Which
statement is true regarding the effects of caring for dying patients on nurses?
|
a. |
Attendance at funerals is
inappropriate and will only create additional stress in nurses who are
already at risk for burnout. |
|
b. |
Caring for dying patients
is an expected part of nursing and will not affect the emotional health of
the nurse if he or she maintains a professional approach with each patient
and family. |
|
c. |
Most nurses who work with
dying patients are able to balance care needs of patients with personal
emotional needs. |
|
d. |
Provision of aggressive
care to patients for whom they believe it is futile may result in personal
ethical conflicts and burnout for nurses. |
ANS: D
Burnout may occur when nurses must provide aggressive care to
patients for whom they believe it is futile or when the care choices made by
patients and/or surrogates differ from those of clinicians. Attendance at
funerals may relieve emotional strain in some situations. Meeting the emotional
needs of patients and families often requires that the nurse invest emotionally
while providing care. Maintaining a professional, healthy distance and being
human when working with the dying is a difficult task that requires a great
deal of balancing.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 41
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or withdrawing
therapy; and psychological support of the patient, family members, and health
care
providers.
TOP: Integrated Process: Caring
MSC: NCLEX Client Needs Category: Psychosocial Integrity
15. The
family is considering the withdrawal of life-sustaining measures from the
patient. The nurse knows that ethical principles for withholding or withdrawing
life-sustaining treatments include which of the following?
|
a. |
Any treatment may be
withdrawn and withheld, including nutrition, antibiotics, and blood products. |
|
b. |
Doses of analgesic and
anxiolytic medications must be adjusted carefully and should not exceed usual
recommended limits. |
|
c. |
Life-sustaining treatments
may be withdrawn while a patient is receiving paralytic agents. |
|
d. |
The goal of withdrawal and
withholding of treatments is to hasten death and thus relieve suffering. |
ANS: A
Any treatment that is used to sustain life, including nutrition,
fluids, antibiotics, blood products, and respiratory support, may be withdrawn
in consultation with the patient and/or surrogate provided that the patient has
been deemed terminal or persistently vegetative. Any dose of anxiolytics or
analgesics may be used to relieve suffering, although these may have the
potential to hasten death. Life-sustaining treatment should not be withdrawn
while the patient is receiving paralytic treatments. Death occurs as a
consequence of the underlying disease, and the goal of care is to relieve
suffering, not to hasten death.
DIF: Cognitive Level:
Analyze/Analysis
REF: p. 44
OBJ: Describe ethical and legal concerns related to
end-of-life care.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
16. The
patient’s spouse is terrified by the prospect of removing life-sustaining
treatments from the patient and asks why anyone would do that. The nurse
explains,
|
a. |
“It is to save you money so
that you won’t have such a large financial burden.” |
|
b. |
“It will preserve limited
resources for the hospital so that other patients may benefit from them.” |
|
c. |
“It is to discontinue
treatments that are not helping your loved one and that may be very
uncomfortable.” |
|
d. |
“We have done all we can
for your loved one, and any more treatment would be futile.” |
ANS: C
The goal of withdrawal of life-sustaining treatments is to
remove treatments that are not beneficial and that may be uncomfortable.
DIF: Cognitive Level:
Understand/Comprehension
REF: p. 43
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or
withdrawing therapy; and psychological support of the patient, family members,
and health care providers.
TOP: Integrated Process: Communication and
Documentation
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
17. All
of the patient’s children are distressed by the possibility of removing
life-support treatments from their mother. The child who is most upset tells
the nurse, “This is the same as killing her! I thought you were supposed to
help her!” The nurse explains to the family,
|
a. |
“This is a process of
allowing your mother to die naturally after the injuries that she sustained
in a serious accident.” |
|
b. |
“The hospital would never
allow us to do that kind of thing.” |
|
c. |
“Let’s talk about this calmly,
and I will explain why assisted suicide is appropriate in this case.” |
|
d. |
“She’s lived a long and
productive life.” |
ANS: A
Forgoing life-sustaining treatments is not the same as active
euthanasia or assisted suicide. Killing is an action causing another’s death,
whereas allowing dying is avoiding any intervention that interferes with a
natural death following illness or trauma. Telling the family that the hospital
would not allow this, or asking the family to talk calmly belittles their feelings
and does not provide useful information.
DIF: Cognitive Level:
Apply/Application
REF: p. 43
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or
withdrawing therapy; and psychological support of the patient, family members,
and health care providers.
TOP: Integrated Process: Communication and
Documentation
MSC: NCLEX Client Needs Category: Psychosocial Integrity
18. To prevent
any unwanted resuscitation after life-sustaining treatments have been
withdrawn, the nurse should ensure that:
|
a. |
“do not resuscitate” (DNR)
orders are written before the discontinuation of the treatments. |
|
b. |
the family is not allowed
to visit until the death occurs. |
|
c. |
DNR orders are written as
soon as possible after the discontinuation of the treatments. |
|
d. |
the change-of-shift report
includes the information that the patient is not to be resuscitated. |
ANS: A
DNR orders should be written before withdrawal of life support;
this will prevent any unfortunate errors in unwanted resuscitation during the
time period between initiation of withdrawal and the actual death.
DIF: Cognitive Level:
Apply/Application
REF: p. 44
OBJ: Describe ethical and legal concerns related to
end-of-life care.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care
Environment
19. The
patient’s spouse is very upset because his loved one, who is near death, has
dyspnea and restlessness. The nurse explains that there are some ways to
decrease this discomfort, including:
|
a. |
respiratory therapy
treatments. |
|
b. |
opioid medications given as
needed. |
|
c. |
incentive spirometry. |
|
d. |
increased hydration. |
ANS: B
Dyspnea is best managed with close evaluation of the patient and
the use of opioids, sedatives, and nonpharmacologic interventions (oxygen,
positioning, and increased ambient air flow).
DIF: Cognitive Level:
Apply/Application
REF: p. 46
OBJ: Describe nursing interventions to support the
patient and family during the end-of-life stage.
TOP: Integrated Process: Communication and
Documentation
MSC: NCLEX Client Needs Category: Physiological Integrity
20. The
patient’s spouse tells the nurse that there is no point in continuing to visit
at the bedside because the patient is unresponsive. The best response by the
nurse is
|
a. |
“You’re right. Your loved
one is not aware of anything now.” |
|
b. |
“This seems to be very
difficult for you.” |
|
c. |
“I’ll call you if she
starts responding again.” |
|
d. |
“Why don’t you check to see
if any other family member would like to visit?” |
ANS: B
The most therapeutic response by the nurse is to acknowledge the
distress of the spouse.
DIF: Cognitive Level:
Apply/Application
REF: p. 47 | Box 4-4
OBJ: Describe nursing interventions to support the
patient and family during the end-of-life stage.
TOP: Integrated Process: Caring
MSC: NCLEX Client Needs Category: Psychosocial Integrity
21. Which
of the following statements about palliative care is accurate?
|
a. |
Withholding and withdrawing
life-sustaining treatment are distinctly different in the eyes of the legal
community. |
|
b. |
Reducing distressing
symptoms is the primary goal of palliative care. |
|
c. |
Only the patient can
determine what constitutes palliative care for him or her. |
|
d. |
Withdrawing life-sustaining
treatments is considered euthanasia in most states. |
ANS: B
The goal of palliative care is to reduce the distressing
symptoms many patients experience due to serious illnesses.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 41
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or
withdrawing therapy; and psychological support of the patient, family members,
and health care
providers.
TOP: Nursing Process Step: N/A
MSC: NCLEX Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
1. Select
interventions that may be included during “terminal weaning” include which of
the following? (Select all
that apply.)
|
a. |
Complete extubation
following ventilator withdrawal |
|
b. |
Discontinuation of
artificial ventilation but maintenance of the artificial airway |
|
c. |
Discontinuation of
anxiolytic and pain medications |
|
d. |
Titration of ventilator
support based upon blood gas determinations |
|
e. |
Titration of ventilator
support to minimal levels based upon patient assessment of comfort |
ANS: A, B, E
“Terminal weaning” may include titration of ventilator support
to minimal levels, removal of the ventilator with maintenance of the artificial
airway, and complete extubation. Pain and anxiolytic medications may be
required to control dyspnea and anxiety that may accompany ventilator
withdrawal. Blood gas determinations would be used in therapeutic ventilator
management.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 44 | p. 46 | Fig 4-2
OBJ: Describe nursing interventions to support the
patient and family during the end-of-life stage.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
2. Which
therapeutic interventions may be withdrawn or withheld from the terminally ill
client? (Select all that
apply.)
|
a. |
Antibiotics |
|
b. |
Dialysis |
|
c. |
Nutrition |
|
d. |
Pain medications |
|
e. |
Simple nursing
interventions such as repositioning and hygiene |
ANS: A, B, C
Any treatment that is life sustaining may be withheld from a
terminally ill patient during the end of life. These treatments include nutrition,
dialysis, fluids, antibiotics, respiratory support, therapeutic medications,
and blood products. Any dose of analgesic or anxiolytic medication may be used
to prevent suffering and should not be withdrawn.
Dignity should be maintained during the course of dying. This
would include ongoing provision of basic nursing care and comfort.
DIF: Cognitive Level:
Analyze/Analysis
REF: p. 43
OBJ: Describe ethical and legal concerns related to
end-of-life care.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
3. Which
interventions can the nurse use to facilitate communication with patients and
families who are in the process of making decisions regarding end-of-life care
options? (Select all that
apply.)
|
a. |
Communication of uniform
messages from all health care team members |
|
b. |
An integrated plan of care
that is developed collaboratively by the patient, family, and health care
team |
|
c. |
Facilitation of continuity
of care through accurate shift-to-shift and transfer reports |
|
d. |
Limitation of time for
families to express feelings in order to control family grief |
|
e. |
Reassuring the patient and
family that they will not be abandoned as the goals of care shift from
aggressive treatment to comfort care |
ANS: A, B, C, E
Effective and consistent communication among the patient,
family, and health care team members is required to promote positive outcomes
during end-of-life care.
Family members should be provided ample time to express feelings
in order to improve the level of satisfaction and prevent dysfunctional
bereavement patterns.
DIF: Cognitive Level:
Apply/Application
REF: pp. 42-43
OBJ: Describe nursing interventions to support the
patient and family during the end-of-life stage.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Psychosocial Integrity
4. Palliation
may include (Select all
that apply.)
|
a. |
relieving pain. |
|
b. |
relieving nausea. |
|
c. |
psychological support. |
|
d. |
withdrawing life-support
interventions. |
|
e. |
withholding tube feedings. |
ANS: A, B, C
Palliation includes the relief of symptoms that may have a
negative effect on the family or the patient.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 41
OBJ: Discuss concepts of end-of-life care, including
palliative care; communication and conflict resolution; withholding or
withdrawing therapy; and psychological support of the patient, family members,
and health care
providers.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
5. When
providing palliative care, the nurse must keep in mind that the family may
include which of the following? (Select
all that apply.)
|
a. |
Unmarried life partners of
same sex |
|
b. |
Unmarried life partners of
opposite sex |
|
c. |
Roommates |
|
d. |
Close friends |
|
e. |
Parents |
ANS: A, B, C, D, E
The definition of family varies and may include unmarried life
partners of the same or opposite sex, close friends, and other close
individuals who have no legal relationship with the patient. The patient gets
to define who will be regarded as “family.”
DIF: Cognitive Level: Remember/Knowledge
REF: p. 47
OBJ: Describe nursing interventions to support the
patient and family during the end-of-life stage.
TOP: Integrated Process: Caring
MSC: NCLEX Client Needs Category: Psychosocial Integrity
Chapter 07: Dysrhythmia Interpretation and Management
Sole: Introduction to Critical Care Nursing, 7th Edition
MULTIPLE CHOICE
1. The
nurse is caring for a patient who is on a cardiac monitor. The nurse realizes
that the sinus node is the pacemaker of the heart because it is
|
a. |
the fastest pacemaker cell
in the heart. |
|
b. |
the only pacemaker cell in
the heart. |
|
c. |
the only cell that does not
affect the cardiac cycle. |
|
d. |
located in the left side of
the heart. |
ANS: A
The cardiac cycle begins with an impulse that is generated from
a small concentrated area of pacemaker cells high in the right atria called the
sinoatrial node (sinus node or SA node). The SA node has the fastest rate of
discharge and thus is the dominant pacemaker of the heart. The AV node has
pacemaker properties and can discharge an impulse if the SA node fails. The
ventricles have pacemaker capabilities if the sinus node or the AV node ceases
to generate impulses.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 90
OBJ: Explain the relationships between electrical
and mechanical events in the heart.
TOP: Nursing Process Step: N/A
MSC: NCLEX Client Needs Category: Physiological Integrity
2. One
of the functions of the atrioventricular (AV) node is to
|
a. |
pace the heart if the
ventricles fail. |
|
b. |
slow the impulse arriving
from the SA node. |
|
c. |
send the impulse to the SA
node. |
|
d. |
allow for ventricular
filling during systole. |
ANS: B
The impulse from the SA node quickly reaches the atrioventricular
(AV) node located in the area called the AV junction, between the atria and the
ventricles. Here the impulse is slowed to allow time for ventricular filling
during relaxation or ventricular diastole. The AV node has pacemaker properties
and can discharge an impulse if the SA node (not the ventricle) fails. The
electrical impulse is then rapidly conducted through the bundle of His to the
ventricles (not the SA node) via the left and right bundle branches.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 90
OBJ: Explain the relationships between electrical
and mechanical events in the heart.
TOP: Nursing Process Step: N/A
MSC: NCLEX Client Needs Category: Physiological Integrity
3. The
normal rate for the SA node when the patient is at rest is
|
a. |
40 to 60 beats per minute. |
|
b. |
60 to 100 beats per minute. |
|
c. |
20 to 40 beats per minute. |
|
d. |
more than100 beats per
minute. |
ANS: B
The sinus node reaches threshold at a rate of 60 to 100 times
per minute. Because this is the fastest pacemaker in the heart, the SA node is
the dominant pacemaker of the heart. The AV node has an inherent rate of 40 to
60 beats per minute and the His-Purkinje system can fire at a rate of 20 to 40
beats per minute. Sinus tachycardia results when the SA node fires faster than
100 beats per minute.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 90
OBJ: Explain the relationships between electrical
and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
4. The
nurse caring for patients with cardiac monitoring understands that when an
electrical signal is aimed directly at the positive electrode, the inflection
will be:
|
a. |
negative. |
|
b. |
upside down. |
|
c. |
upright. |
|
d. |
equally positive and
negative. |
ANS: C
When an electrical signal is aimed directly at the positive
electrode, an upright inflection is visualized. If the impulse is going away
from the positive electrode, a negative deflection is seen; and if the signal
is perpendicular to the imaginary line between the positive and negative poles
of the lead, the tracing is equiphasic, with equally positive and negative
deflection.
DIF: Cognitive Level:
Understand/Comprehension
REF: p. 92
OBJ: Explain the relationships between electrical
and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
5. The patient
is admitted with a condition that requires cardiac rhythm monitoring. To apply
the monitoring electrodes, the nurse must first
|
a. |
apply a moist gel to the
chest. |
|
b. |
make certain that the
electrode gel is dry. |
|
c. |
avoid soaps to avoid skin
irritation. |
|
d. |
clip chest hair if needed. |
ANS: D
Adequate skin preparation of electrode sites requires clipping
the hair, cleansing the skin, and drying vigorously (moisture gels are not
applied). Cleansing includes washing with soap and water, or alcohol, to remove
skin debris and oils. Before application, the electrodes are checked to ensure
that the gel is moist. It is difficult for electrodes to adhere to the chest in
the presence of chest hair. Clipping, not shaving, is recommended since shaving
may create small nicks that can become a portal for infection.
DIF: Cognitive Level:
Apply/Application
REF: p. 96
OBJ: Explain the relationships between electrical
and mechanical events in the heart.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
6. The
nurse using cardiac monitoring understands that each horizontal box on the
electrocardiogram (ECG) paper indicates
|
a. |
200 milliseconds or 0.20 seconds
duration. |
|
b. |
40 milliseconds or 0.04
seconds duration. |
|
c. |
3 seconds duration. |
|
d. |
millivolts of amplitude. |
ANS: B
ECG paper contains a standardized grid where the horizontal axis
measures time and the vertical axis measures voltage or amplitude.
Horizontally, the smaller boxes denote 0.04 seconds each or 40 milliseconds;
the larger box contains five smaller boxes and thus equals 0.20 seconds or 200
milliseconds.
DIF: Cognitive Level:
Understand/Comprehension
REF: p. 97
OBJ: Explain the relationships between electrical
and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
7. The
nurse is examining the patient’s cardiac rhythm strip in lead II and notices
that all of the P waves are upright and look the same except one that has a
different shape and is inverted. The nurse realizes that the P wave with the
abnormal shape is probably
|
a. |
from the SA node because
all P waves come from the SA node. |
|
b. |
from some area in the atria
other than the SA node. |
|
c. |
indicative of ventricular
depolarization. |
|
d. |
normal even though it is
inverted in lead II. |
ANS: B
Normally a P wave indicates that the SA node initiated the
impulse that depolarized the atrium. However, a change in the shape of the P
wave may indicate that the impulse arose from a site in the atria other than
the SA node. The P wave represents atrial depolarization. It is usually upright
in leads I and II and has a rounded, symmetrical shape. The amplitude of the P
wave is measured at the center of the waveform and normally does not exceed
three boxes, or 3 millimeters, in height.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 98
OBJ: Explain the relationships between electrical
and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
8. The
nurse caring for patients on cardiac monitors assesses the patient with a
prolonged QT interval for
|
a. |
electrolyte disturbances
such as hypokalemia. |
|
b. |
symptomatic bradycardias. |
|
c. |
the development of lethal
dysrhythmias. |
|
d. |
difficulty maintaining the
blood pressure. |
ANS: C
The QT interval is measured from the beginning of the QRS
complex to the end of the T wave. This interval measures the total time taken
for ventricular depolarization and repolarization. Abnormal prolongation of the
QT interval increases vulnerability to lethal dysrhythmias, such as ventricular
tachycardia and fibrillation. The nurse monitors the patient for the
development of these rhythms and is prepared to intervene should they occur. A
prolonged QT is not associated with bradycardias, hypokalemia, or blood
pressure irregularities.
DIF: Cognitive Level:
Apply/Application
REF: p. 100
OBJ: Explain the relationships between electrical
and mechanical events in the heart.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
9. The
patient has an irregular heart rhythm. To determine an accurate heart rate, the
nurse would first
|
a. |
identify the markers on the
ECG paper that indicate a 6-second strip. |
|
b. |
count the number of small
boxes between two consecutive P waves. |
|
c. |
count the number of small
boxes between two consecutive QRS complexes. |
|
d. |
divides the number of
complexes in a 6-second strip by 10. |
ANS: A
The optimal method of determining a heart rate from an ECG strip
when the patient has an irregular heart rate is to count the number of P waves
or QRS waves within a 6-second strip to obtain both atrial and ventricular
heart rates per minute. In order to do this accurately, the nurse first
much identify the markers on the ECG paper that indicate a 6-second strip. The
other methods are not as accurate with an irregular heart rate.
DIF: Cognitive Level:
Apply/Application
REF: p. 101
OBJ: Interpret the basic dysrhythmias generated from
the sinoatrial node, the atria, the atrioventricular node, and the
ventricles.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
10. The
nurse is calculating the rate for a regular rhythm. There are 20 small boxes
between each P wave and 20 small boxes between each R wave. What is the
ventricular rate?
|
a. |
50 beats/min |
|
b. |
75 beats/min |
|
c. |
85 beats/min |
|
d. |
100 beats/min |
ANS: B
The rule of 1500 is used to calculate the exact rate of a
regular rhythm. The number of small boxes between the highest points of two
consecutive R waves is counted, and that number of small boxes is divided into
1500 to determine the ventricular rate. 1500/20 = 75 beats/min. This method is
accurate only if the rhythm is regular.
DIF: Cognitive Level:
Apply/Application
REF: p. 101
OBJ: Describe appropriate interventions for common
dysrhythmias.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
11. The
patient is admitted with a fever and rapid heart rate. The patient’s
temperature is 103° F (39.4° C). The nurse places the patient on a cardiac
monitor and finds the patient’s atrial and ventricular rates are above 105
beats per minute. P waves are clearly seen and appear normal in configuration.
QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is
regular, and blood pressure is normal. The nurse should focus on providing:
|
a. |
medications to lower heart
rate. |
|
b. |
treatment to lower
temperature. |
|
c. |
treatment to lower cardiac
output. |
|
d. |
treatment to reduce heart
rate. |
ANS: B
Sinus tachycardia results when the SA node fires faster than 100
beats per minute. All other components of the ECG are normal. Sinus tachycardia
is a normal response to stimulation of the sympathetic nervous system. Sinus
tachycardia is also a normal finding in children younger than 6 years. The fast
heart rhythm may cause a decrease in cardiac output because of the shorter
filling time for the ventricles. Lowering cardiac output further may complicate
the situation. The dysrhythmia itself is not treated, but the cause is
identified and treated appropriately. For example, if the patient has a fever
or is in pain, the fever (and infection) or pain is treated appropriately.
DIF: Cognitive Level:
Apply/Application
REF: p. 105
OBJ: Interpret the basic dysrhythmias generated from
the sinoatrial node, the atria, the atrioventricular node, and the
ventricles.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
12. The
nurse notices sinus bradycardia on the patient’s cardiac monitor. The nurse should
|
a. |
give atropine to increase
heart rate. |
|
b. |
begin transcutaneous pacing
of the patient. |
|
c. |
start a dopamine infusion
to stimulate heart function. |
|
d. |
assess for hemodynamic
instability. |
ANS: D
Sinus bradycardia may be a normal heart rhythm for some
individuals such as athletes, or it may occur during sleep. Assess for
hemodynamic instability related to the bradycardia. If the patient is
symptomatic, interventions include administration of atropine. If atropine is
not effective in increasing heart rate, then transcutaneous pacing, dopamine
infusion, or epinephrine infusion may be administered. Atropine is avoided for
treatment of bradycardia associated with hypothermia.
DIF: Cognitive Level: Apply/Application
REF: p. 106
OBJ: Interpret the basic dysrhythmias generated from
the sinoatrial node, the atria, the atrioventricular node, and the
ventricles.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
13. Which
of the following is true about a patient diagnosed with sinus arrhythmia?
|
a. |
The heart rate varies,
dependent on vagal tone and respiratory pattern. |
|
b. |
Immediate treatment is essential
to prevent death. |
|
c. |
Sinus arrhythmia is not
well tolerated by most patients. |
|
d. |
PR and QRS interval
measurements are prolonged. |
ANS: A
Sinus arrhythmia is a cyclical change in heart rate that is
associated with respiration. The heart rate increases slightly during
inspiration and slows slightly during exhalation because of changes in vagal
tone. The ECG tracing demonstrates an alternating pattern of faster and slower
heart rate that changes with the respiratory cycle. Interval measurements are
normal. This rhythm is tolerated well, and no treatment is required. The PR and
QRS intervals are normal.
DIF: Cognitive Level:
Remember/Knowledge
REF: p. 106
OBJ: Describe appropriate interventions for common
dysrhythmias.
TOP: Nursing Process Step: N/A
MSC: NCLEX Client Needs Category: Physiological Integrity
14. The
patient is admitted with sinus pauses causing periods of loss of consciousness.
The patient is asymptomatic, awake and alert, but fatigued. He answers
questions appropriately. When admitting this patient, the nurse should first
|
a. |
prepare the patient for
temporary pacemaker insertion. |
|
b. |
prepare the patient for
permanent pacemaker insertion. |
|
c. |
assess the patient’s
medication profile. |
|
d. |
apply transcutaneous
pacemaker paddles. |
ANS: C
AV nodal blocking medications (such as beta blockers, calcium
channel blockers, and digoxin) and increased vagal tone may cause sinus exit
block. Causes are explored, and prescribed medications may need to be adjusted
or discontinued. If patients are symptomatic, significant numbers of pauses may
require treatment, including temporary (including transcutaneous) and permanent
implantation of a pacemaker.
DIF: Cognitive Level:
Apply/Application
REF: pp. 106-107
OBJ: Describe appropriate interventions for common
dysrhythmias.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
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