Assessment and Intervention Flashcards
General Order of Operation for hospice/PC SW
(SAPPARAH)
- Screen in order to–
- Assess in order to–
- Plan with the interdisciplinary team in order to–
- Plan social work interventions in order to–
- Apply intervention–
(Hand off or discharge if intervention is by another discipline) - Re-assess (intervals may be determined by the nature of the intervention)–
- Adjust intervention as needed–
- Hand-off or discharge
Spiritual history tool - FICA
Faith and belief;
Importance of spirituality;
Community membership; and
Addressing these issues in health care.
Roger is a 73-year-old with a diagnosis of end-stage prostate cancer with metastasis to the spine.
He is scheduled to undergo surgical stabilization of a vertebral fracture which is causing him a
great deal of pain. Of the following, which best describes this treatment modality?
a. Cyberknife Radiosurgery
b. Prophylactic surgery
c. Palliative surgery
d. Curative surgery
C
Brian is a 65-year-old with a history of end-stage small cell lung cancer. His wife called to report
that she had to call the police because he had become increasingly confused and combative,
then grabbed his gun and ran out into the driveway. What do you suspect may be happening in
Brian’s situation?
a. He has an unreported history of domestic violence.
b. He is having a reaction to his benzodiazepines.
c. He has brain metastasis.
d. He has mixed alcohol with his opioid dosage
. c - Since small cell lung cancer often metastasizes to the brain, Brian should be evaluated for this suspected diagnosis. Patients who have changes in behavior, and have a cancer diagnosis with this known metastatic pattern should be evaluated for this complication. Palliative treatment options may include radiation, surgery and chemotherapy. Medical management focuses on control of headache, cerebral edema and seizures. The steroid of choice is dexamethasone for treatment of cerebral edema
Victor is a 65-year-old with end-stage head and neck cancer with a large pulsating neck tumor
near his carotid artery. He has signed a DNR and wishes to die at home. Of the following, which
interventions may be most helpful for Victor and his family?
a. Preparing them for carotid artery rupture
b. Instructing regarding access to emergency services after carotid artery rupture
c. Providing the number for biohazard companies
d. Encouraging Victor to spend his last days in a hospice facility to decrease trauma to his
family
- a - There is high possibility of carotid artery rupture in Victor’s situation, and both and he and his family should receive as much preparation as possible for this traumatic event. Victor’s wishes to die at home should be honored, within the framework of his family’s dynamics. If rupture occurs, events will occur rapidly, so advanced preparation is critical. Dark towels should be provided to absorb blood and manage bleeding, and prefilled syringes of pain medication and/or sedatives should be available. Areas of oozing may be treated with topical epinephrine. Both patient and family should also be educated that carotid artery rupture may not occur externally.
When assessing a patient with pulmonary disease for hospice eligibility, which of the following
would be indicators of advanced disease?
a. Uncontrolled hypertension
b. Cor pulmonale
c. Mild dyspnea after climbing stairs
d. Cardiac arrhythmias
b - Cor pulmonale is one of the indicators of advanced pulmonary disease. Both obstructive and restrictive pulmonary diseases can cause increased pulmonary pressure, which leads first to right ventricular failure (cor pulmonale), and then to left ventricular failure. Other indications of advanced pulmonary disease include respiratory failure, weight loss >10% over six months and tachycardia defined as pulse rate >100 bpm. Early respiratory failure involves hypoxia and hypercapnia, which cause breathlessness, poor activity tolerance, and poor quality of life.
Anemia is a common finding in patients with chronic renal failure due to decreased production
of erythropoietin. What symptom may be associated with this condition in the hospice patient
with end-stage renal failure?
a. Increased risk of bleeding
b. Dyspnea
c. Increased risk of deep vein thrombosis (DVT)
d. Increased risk of pulmonary embolism (PE
b - Dyspnea is a common finding in the hospice patient who has end-stage renal failure and is anemic. Since the red blood cells carry oxygen, and are reduced in patients with anemia, these patients have lower tissue oxygenation as a result. Additional associated symptoms are chest pain and weakness, due to the same pathophysiology.
Frank is a 74-year-old hospice patient who was diagnosed with non-Hodgkin’s lymphoma 8 years ago
and underwent treatment with subsequent remission. The lymphoma recurred 1 year ago and has
been unresponsive to chemotherapy and surgical intervention. He has been hospitalized, in a
rehabilitation facility or nursing home for the past 8 months, with decreasing mental and physical
capacity along with significant weight loss and dependence for all activities of daily living. He has now
been at home with hospice care for the past 4 days and has been primarily unresponsive the majority
of that time but appears comfortable.
As the hospice nurse, you receive a call from Frank’s family that after being unresponsive for 4
days; he awoke this morning, smiled at his family and tried to speak. He remains alert and
comfortable per the family. The family believes he is getting better and request you visit. What
is the best response for the nurse to address the family’s belief that he is improving?
a. “He is still dying. You should not be hopeful for any type of interaction or time with him”.
b. “He may actually be closer to death now as many patients have a brief, temporary period
of alertness prior to death”.
c. “He may be improving slightly. We will have to watch and see what happens next”.
d. “You should enjoy this time with him and not worry about what could happen”.
b - The best response for the nurse in this scenario is to honestly, carefully and compassionately explain the improvement in awareness/alertness as a common temporary event in some patients prior to imminent death and encourage them to make the most of the this uncertain, yet meaningful time with their loved one.
Which of the following conditions are associated with endocrine disorders such as
hyperparathyroidism, diabetes mellitus, and Addison’s disease?
a. Depression.
b. Substance abuse.
c. Anxiety.
d. None of the above.
. a - Depression is commonly associated with these disorders. Anxiety is related to Cushing’s disease, hypo/hyperglycemia, carcinoid syndrome, pheochromocytoma and hypo/hyperthyroidism.
Of the following, which patient/family belief system would NOT be a barrier to the appropriate
assessment and treatment of a patient’s pain?
a. Physical dependence on pain medicine is common.
b. Pain is inevitable with aging.
c. Good patients do not complain.
d. Morphine should only be used as a last resort
b - Providing a thorough explanation regarding the definition and intent of palliative sedation would be most important. There are 1-2% of patients at end of life who experience refractory and intolerable symptoms who can benefit by the use of sedation with the goal of relieving distress in all realms of the pain experience
Mabel is a 72-year-old with a diagnosis of end stage breast cancer with metastasis to the bone.
She has been having increased pain, but states she is afraid to use too much pain medication for
fear she might become “addicted”. Of the following, which is the most appropriate response?
a. Addiction is age-related, and she is not at risk.
b. Addiction is different than physical dependence.
c. Addiction occurs when the drug’s effect is reduced over time.
d. Her fears are correct and dosing should be limited
. b - Mabel should be provided with an explanation of addiction, and how it differs from physical dependence. Addiction is a “primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.”52 Characteristics of addiction include inability to control drug use, compulsive use and continued use even when harm or craving occurs. In contrast, physical dependence is “a state of adaptation that is manifested by a drug class specific to withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist”. Tolerance involves decreased effectiveness of a drug over time
Of the following, which are important parameters to include in a comprehensive pain
assessment?
a. Site
b. Character
c. Intensity
d. All of the above
d - All of the above should be included in a comprehensive pain assessment, in addition to the following: onset, duration and frequency, intensity, exacerbating factors, associated symptoms, alleviating factors, medication history, impact on quality of life and physical examination. An updated method of incorporating vital information of the comprehensive pain assessment is “PQRST” and reads as follows: The “P” in PQRST stands for “Provocation” or “Palliation.” The “Q” in the pain assessment PQRST method represents “Quality” of the pain. The “R” in this useful mnemonic tool stands for “Region” or “Radiation”. The “S” measures the “Severity” of the pain and is usually gauged on a scale of 0 to 10, 10 being the worst possible pain. The final set of questions in “T” assesses time.
What is the RULE of motivational interviewing?
- Resist: resist giving suggestions to our patients for their problems
- Understand: understand the patient’s motivation by being a curious listener and attempting to elicit the patient’s own underlying motivation for change.
- Lesson: listen with a patient centered, empathic approach.
- Empower: empowering the patient helps them understand that they are in control of their actions, and any change they desire requires them to take steps towards that change.
Margaret is a 93-year-old patient with a hospice diagnosis of Alzheimer’s disease and associated
debility. What functional assessment scoring system should be used to help determine her
hospice eligibility?
a. Karnofsky score
b. Glasgow score
c. MODS score
d. AIS score
a - The Karnofsky scoring system can be used to evaluate functional status in any patient, and is particularly helpful as part of the criteria for determining hospice eligibility for the patient with a diagnosis of debility unspecified. The Karnofsky scoring ranges from 100% (normal, no complaints, no evidence of disease) to 0% (death) in increments of 10.
Joe is a retired railroader who has been diagnosed with end-stage pulmonary fibrosis. He has
had increased dyspnea, increased sleeping and decreased appetite. He has been unable to get
out of bed for the past week, and has had several bouts of urinary incontinence, which is a
change for him. His wife says that he used to love company, but recently he has been refusing
visitors, and states that he “just wants to be left alone.” In the context of his other symptoms,
what is the most likely cause for Joe’s withdrawal?
a. He is embarrassed about his incontinence.
b. He is upset with his wife.
c. He is in the dying process.
d. His medication needs adjusted.
. c - Viewed in the context of his other symptoms, Joe appears to be in the dying process, which may last for days in some cases. Physical and emotional withdrawal is a very common indicator of imminent death, and the patient’s wishes should be honored accordingly. This is often difficult for caregivers and family members to deal with, since they often would like to be able to spend as much time as possible with the patient in the limited time they have left, and may not understand the reasons behind the patient’s withdrawal
Which of the following would be an example of a cognitive-based complementary therapy?
a. Acupuncture
b. Massage
c. Music therapy
- c - Music therapy, art therapy, biofeedback, creative visualization, focused breathing, guided imagery, hypnosis, meditation, music therapy, and progressive muscle relaxation are all examples of cognitive-based complementary therapies. The others listed here along with acupressure, aromatherapy, chiropractic medicine, exercise, nutrition, polarity, Reiki, Shiatsu, therapeutic touch and yoga are examples of physical-based therapies.
Which of the following is not one of the five domains of complementary/alternative medicine
recognized by the National Center for Complementary and Alternative Medicine?
a. Alternative mental systems.
b. Mind-body interventions.
c. Energy therapies.
d. Biologically-based therapies.
. a - The 5 domains are Alternative medical systems, mind=body interventions, energy therapies, biologically-based therapies, manipulative and body-based methods, and energy therapies.
Of the following, which is the most significant benefit of the use of complementary/alternative
therapies as opposed to traditional medical methods in the hospice/palliative care population?
a. Limited cost
b. Limited side effects
c. Limited travel
d. None of the above
. b - The most significant benefit to hospice and palliative care patients is the limited side effects of these therapies as opposed to traditional medical methods of symptom management (typically pharmacological, with many side effects and interactions).
Recognized benefits of massage therapy and aromatherapy in hospice/palliative care include
which of the following?
a. Sense of well-being
b. Decreased mood swings
c. Immediate pain relief
d. All of the above
e. Both a and c only
. e - Immediate pain relief and a sense of well-being are recognized benefits of massage therapy and aromatherapy in cancer patients according to research studies. Decreased mood swings are not specifically stated as being recognized.
Of the following, which may indicate a poor prognosis for the hospice patient with a diagnosis of
end-stage cardiac disease?
a. Infection
b. Edema
c. Bleeding
d. Unexplained syncope
. d - Unexplained syncope, as well as previous cardiac arrest with resuscitation, and an embolic stroke originating from the cardiac system are all indicators of poor prognosis in this patient population.
When a hospice patient has a diagnosis which may involve anticipated hemorrhage in the home,
what should be the focus of care?
a. Access to biohazardous cleanup
b. Support of the patient and family
c. Replacing blood loss
d. Preventing hemorrhage
b - When hemorrhage is anticipated as part of disease progression for a hospice patient, treatment should focus on support of the patient and family. Providing education and preparation are vital components to helping them cope with such a traumatic event. Dark towels should be made available, as well as pre-filled syringes of pain medication and/or sedative, which can be administered if time allows.
Of the following, which is true regarding the use of morphine for the hospice patient with
terminal dyspnea?
a. May cause respiratory depression
b. Sometimes mistaken with euthanasia
c. May cause addiction
d. Easy to overdose
b - There sometimes exists the belief that the use of morphine within the hospice population for the treatment of terminal dyspnea is somehow related to euthanasia, which is not the case. This can become an ethical concern, since healthcare providers and family members may withhold treatment, mistakenly believing that use of morphine at this time may cause respiratory depression, which also is not the case. Use of morphine for the relief of dyspnea provides comfort and palliation of this very distressing symptom, and extensive education must be provided.
. Pneumothorax is a condition which may be associated with certain diagnoses seen in hospice
care. Of the following, who may be most vulnerable to sustaining a pneumothorax?
a. Patient with ovarian cancer
b. Patient with AIDS
c. Patient with colon cancer
d. Patient with prostate cance
. b - Patients with AIDS who also have pneumocystis carinii pneumonia sometimes form bronchopulmonary fistulas, which can create a persistent pneumothorax which may be difficult to resolve. These patients may have thoracic systems in place in the home for management by the hospice team. Patients with pulmonary diseases, such as emphysema (pneumothorax created by a ruptured pulmonary bleb), may also have higher risk for development of pneumothoraces.
If the current bowel regimen is not effective, when should an osmotic laxative be ordered?
a. After 5 days with no bowel movement
b. After 3 days with no bowel movement
c. After 4 days with no bowel movement
. b - If the current regimen is not effective, and there is no bowel movement after 3 days, then an osmotic laxative should be ordered. If there is liver involvement as part of the patient’s disease process, then lactulose is a good option, since it will also help to lower elevated ammonia levels. If there is no liver involvement, sorbitol is a just as effective, and less expensive
. Madge is a 69-year-old with colon cancer who has had progressive weakness and decreased
immobility. She lives alone, has been ambulatory with a walker, and is very proud of her
independence. As her condition deteriorates, she has been spending more time in bed, and is
unable to get around as she used to. When you visit, you find her tearful and struggling to clean
the floor because she was incontinent for stool on the way to the bathroom. What may be
helpful for Madge in her situation?
a. Asking her daughter to move in with her
b. Asking a neighbor to help her to the bathroom
c. Providing a bedside commode
d. Increasing her frequency of home health aide visits
. c - Providing a bedside commode would help Madge to maintain her independence and allow more convenient access to toileting facilities, which has become more difficult for her as her mobility has decreased. She will need continued monitoring for further support as her needs continue to change with disease progression
Of the following, which should be suspected if a patient has cramping and colicky pain in the mid
to upper abdomen that is relieved with vomiting?
a. Small bowel obstruction
b. Large bowel obstruction
c. Bowel strangulation
d. Fecal impaction
a - Symptoms of small bowel obstruction typically include cramping and colicky pain in the mid to upper abdomen that is relieved with vomiting. The pain associated with a large bowel obstruction is usually cramping in nature, located in the lower abdomen and increases over time. Bowel strangulation should be suspected if the patient has severe steady pain. Fecal impaction is often found when the patient has loose stool which oozes around the site of the impaction
Which of the following diagnoses would carry the greatest risk for gastrointestinal bleeding?
a. End-stage COPD
b. End-stage renal failure
c. End-stage cardiac disease
d. End-stage liver disease
- d - Of the options noted, the patient with a diagnosis of end-stage liver disease is at greatest risk for gastrointestinal bleeding, due to alterations in the production of clotting factors and initiation of the coagulation cascade.
Of the following, what is a primary concern when caring for a patient who has an indwelling
catheter and has blood in the urine from any etiology?
a. Renal hemorrhage
b. Anemia
c. Catheter migration
d. Catheter patency
d - Catheter patency is a concern when there is blood present in the urine from any source. Clots may form in the urine, which can obstruct the catheter, and therefore impede urinary outflow. It may be necessary to intermittently irrigate the catheter, or in instances of large amounts of blood, to maintain a continuous irrigation with a 3-way indwelling catheter
Fully understanding a patient’s disease trajectory and wishes for care are critical when
supporting the needs of the patient with decreasing mobility. Of the following, why are these
such important considerations?
a. The patient may be too tired to exercise
b. The patient’s family may not want extra equipment
c. Care planning may outline different goals
d. Physical therapy may be too expensive
c - When supporting the needs of the patient who is experiencing decreasing mobility, it is very important to understand the patient’s disease trajectory and the patient’s wishes for care. Care planning for a hospice patient who is in the final stages of disease progression will be vastly different than for the palliative care patient whose goals include continued mobility and optimizing of independence. T
Which of the following would NOT be an appropriate intervention for a patient who is reporting
an excessively dry mouth, which is impairing his level of comfort?
a. Artificial saliva
b. Antifungal swish and swallow
c. Increased hydration
d. Lip balm
b - Swish and swallow with an antifungal agent would not be an appropriate intervention for the patient with an excessively dry mouth, as this is the treatment for thrush. Often, medications or treatments create a dry mouth, and interventions such as artificial saliva, increased hydration and lip balm are adequate measures to increase the patient’s comfort level
. Frank is a 69-year-old with end-stage lung cancer who has a history of alcoholism and domestic
violence. His condition has deteriorated and he is now very weak, bedbound and unable to care
for himself. His wife of 50 years has taken over his care. When you visit, you find him to be
apparently well cared-for, but with increased pain. Upon assessment, he reports that his wife
told him “he deserved to be in pain after all he’d done to her” and would not give him his pain
medication. Of the following, which is the most appropriate response?
a. Report the patient’s wife to community social services
b. Meet privately with the patient’s wife to assess the situation
c. Refer the patient’s wife to a support group
d. Arrange for the patient to be removed from the home
b - Initially, meeting privately with the patient’s wife would be the best option, in collaboration with IDT members who can provide additional expertise in helping to assess and support appropriate interventions for the situation. The patient’s wife should be provided a nonjudgmental environment in which to express her feelings, with a resolution agreed upon by all parties to ensure that the patient’s needs for care and comfort are optimally met.
Jan is a 49-year-old with end-stage breast cancer with widespread metastasis to the lungs. She
has been experiencing intermittent episodes of extreme dyspnea, and states she is having
increasing anxiety, since she is afraid that she will not be able to control her symptoms. Of the
following, which intervention may immediately increase her sense of control over her situation?
a. Recommend a hand-held fan
b. Consult with the hospice social worker
c. Consult with the hospice chaplain
d. Request Reiki therapy
. a - Patients often find that use of a hand-held fan, with the air blown directly onto their cheeks, is very helpful to decrease dyspnea. Pre-drawn liquid medications, such as low-dose morphine and lorazepam that the patient can self-administer, are also often helpful. The key is to provide the patient with interventions that she can initiate independently, to increase her sense of control over her symptoms, which may help to reduce her anxiety. Anxiety is a multi-faceted symptom, and collaboration with all members of the IDT would be most helpful
Jan’s husband has refused to attend any of her healthcare appointment with her. He states he
does not believe that she actually has cancer, and is convinced that she will get well very soon.
At your most recent visit, he stated, “I’ve never trusted doctors. She just has the flu, and I know
she’ll get better soon.” Jan is tearful at times, and states she feels all alone in dealing with her
illness. Of the following, which would be the most appropriate response to this situation?
a. Read copies of Jan’s medical reports to her husband.
b. Accompany Jan’s husband in a meeting with her physician.
c. Collaborate with IDT members to arrange a family meeting with Jan and
. c - Arranging a family meeting with Jan and her husband, in collaboration with other IDT members, will provide a safe and supportive environment for them both. Denial is often used as a survival mechanism to deal with facts and emotions that the individual may believe are too painful to endure. Providing the opportunity for them both to express their feelings in an environment of expert support may lead to increased openness, and the opportunity for both to experience acceptance and closure prior to Jan’s death
Don is a 72-year-old with end-stage colon cancer who is homeless. He has stated that he is afraid
that he will not get the care he needs because everyone else has abandoned him, and “hospice
probably will, too, since I live under a bridge.” Of the following, what approach may be most
helpful to allay Don’s fears?
a. Reinforce non-abandonment in his care
b. Recommend that he sign a DNR
c. Recommend admission to an inpatient hospice facility for care
d. Recommend that he move into a shelter
a - Don needs to know that he will not be abandoned in his care, and that he will be able to maintain control over his own choices. In addition, reassurance that he will have adequate pain and symptom management, as well as continuity in his care, regardless of his circumstances, are key elements in helping to decrease his fears
Which of the following definitions is most closely associated with cachexia?
a. Inability to take in nutrients
b. Inadequate intake of nutrients
c. Impaired gastric emptying
d. Oral mucosa pain
b - Cachexia is defined as weight loss or wasting due to inadequate intake of nutrients, which can be caused by many etiologies, including those which create increased nutritional losses. Anorexia is defined as a loss of appetite or inability to take in nutrients.
A diagnosis of dementia is based on several factors. This includes memory loss (both short and
long-term), plus one or more of which of the following?
a. Apraxia
b. Ataxia
c. Amnesia
d. Agitation
. a - In addition to memory loss, a diagnosis of dementia is made when one or more of the following is also present: aphasia (language problems); apraxia (organizational problems); agnosia (unable to recognize objects or their purpose); disturbed executive function (personality and inhibition).
In assessing for level of consciousness (LOC), which of the following factors are recognized?
a. Alertness
b. Response to voice
c. Response to activity
d. Both a and c
e. Both a and b
. e - Alertness, response to voice and painful stimuli are the factors utilized in assessing for LOC. Response to activity is not one of the factors. The common mnemonic is “AVPU” Alert, Voice, Pain, Unresponsive. The levels most commonly utilized in hospice and palliative care are LOC Ialert, interactive; LOC II- lethargic, but able to respond briefly; LOC III- stuporous, minimally responsive; LOC IV- unresponsive.
Fred is a 46-year-old patient with a history of an aggressive glioblastoma who has recently been
admitted to your hospice program. He lives at home with his wife and three young children.
Which of the following potential symptoms should be immediately addressed in his plan of care
and with his family/caregivers?
a. Potential for dysphagia
b. Potential for increased weakness
c. Potential for sudden death
d. Potential for seizures
d - The most urgent potential symptom to address in this patient’s plan of care would be the potential for seizures as brain tumors typically result in an increased risk for seizure activity. Ferrell & Coyle note that seizures occur in 25% of those with brain metastases. Preventive or emergency seizure medication should be made available and the family instructed on signs of seizure activity and medication administration. The symptoms of dysphagia and increased weakness are less urgent and sudden death is not a symptom, but may need to be addressed as well given the presence of young children in the home.
What is necessary in order to fully assess a patient’s report of constipation?
a. Complete history and physical examination
b. Report of decreased stool volume/frequency
c. Report of abdominal discomfort
d. None of the above
a - A complete history and physical examination are necessary in order to fully assess a patient’s report of constipation. Diagnosis and interventions cannot be based on reports of decreased stools or abdominal discomfort.
Causes of constipation within the oncology population include all of the following except:
a. Tumor- related
b. Medication- related
c. Hypocalcemia
d. Concurrent disease
c - The causes of constipation within the oncology population include tumor-related, medicationrelated, concurrent diseases such as diabetes, hypothyroidism, colitis, diverticulitis; and secondary effects of disease such as decreased appetite, fluid intake, weakness, inactivity; and hypercalcemia. Hypocalcemia can lead to diarrhea
The goal of diarrhea management is to do which of the following?
a. Eliminating or minimizing the factors causing diarrhea.
b. Providing interventions to temporarily modify diet.
c. Replacing lost fluid volume immediately.
d. Both a and c.
a - The goals of diarrhea management are to eliminate or minimize the factors causing diarrhea, providing dietary interventions, and maintaining fluid and electrolyte balance as appropriate. Dietary interventions may or may not be temporary and fluid volume is not immediately replaced
James is a 47-year-old palliative care patient beginning radiation therapy for prostate cancer. He
has been told to anticipate radiation-induced diarrhea. What should be your education to him
regarding this potential treatment side effect?
a. Radiation-induced diarrhea is not common and he need not worry.
b. Radiation-induced diarrhea occurs within the first week and resolves quickly with proper
care.
c. Radiation-induced diarrhea can occur within the 3rd week of treatment and continue after
radiation has been completed.
d. Radiation-induced diarrhea occurs within the first week and can continue after radiation
is complete.
c - Radiation-induced diarrhea typically occurs at the end of the 3rd week of treatment and can continue after radiation has been discontinued.
Which of the following are the most likely factors associated with diarrhea in a significant
percentage of bone marrow transplant patients?
a. Infection
b. Graft vs. host disease
c. Radiation
d. Both b and c
d - Radiation and graft vs. host disease are the most likely factors related to diarrhea in 35-50% of bone marrow transplant patients.
Ascites in the presence of which of the following diagnoses does not correlate with a poor
prognosis?
a. Pancreatic cancer
b. Colon cancer
c. Ovarian cancer
d. Stomach cancer
c - Ovarian cancer is one of the few exceptions where the presence of ascites is not correlated with a poor prognosis and these patients can have an improved survival rate with surgical intervention and treatment for their ascites.
Greg is a 47-year-old hospice patient who is admitted for end-stage lung cancer. He has a previous
history of anxiety and depression which is now exacerbated by his diagnosis and symptoms of
shortness of breath. He lives alone and despite being admitted to hospice, is adamant that he is not
dying.
280. What is the most important factor the nurse should recognize and incorporate into her
assessment of Greg’s emotional status?
a. What the issues were previously that led to his anxiety and depression.
b. What coping strategies were helpful to Greg previously.
c. Was he ever hospitalized for his previous symptoms.
d. All of the above.
. b - The most important predictor of psychological adjustment to illness is the emotional stability and coping strategies used by the person prior to their diagnosis. While the other issues could be of limited benefit, it is not the nurses job to pry into patient’s history, but to gather the information that will be most helpful moving forward. Therefore, the knowledge of previous coping strategies would be the most important factor for the nurse in this case
Greg asks you if you think he is “crazy” because of his reports of high levels of anxiety and
depression related to his illness. Your best response is which of the following?
a. “No, of course not. Knowing you are going to die is very stressful and hard to cope with”.
b. “No, I don’t think you are crazy, but are you taking all your medications as prescribed”.
c. “No, I don’t, but have you thought more about your final arrangements and written your
will?”
d. “No. Anxiety and depression are normal responses to events in all our lives, especially
illness”
. d - The best response to Greg’s question is to reinforce that anxiety and depression are normal responses to life events, especially illness and that it is the intensity, duration, and associated symptoms that impact the ability to function that distinguishes these as ‘disorders’ from general symptoms in response to life events
Which of the following statements most accurately reflects the importance of the nursing
assessment of depression for Greg?
a. Depression is a normal response to illness.
b. Unrecognized depression impairs quality of life, immune response and survival.
c. Depression is not impacted by culture.
d. None of the above
b - Depression that is under-recognized, and under-treated has the potential to decrease immune response, decrease survival time, impair the ability to adhere to treatment and impair quality of life.
What would not be the best method to approach a discussion regarding Greg’s prognosis and
impending death?
a. Inquire about his knowledge related to his illness and prognosis.
b. Inquire about his wishes for continued treatment options if available.
c. Involve the social worker to confirm his wishes for final arrangements.
d. Discuss the course of his illness and its impact on his life
. c - The least effective method in approaching a discussion regarding Greg’s prognosis and impending death would be to have the social worker attempt to confirm his wishes regarding final arrangements. This would likely result in increased anger/hostility related to his already existing denial. Denial is a coping mechanism to protect from what one fears is to come. Inquiring about his knowledge of his illness, discussing the course of the illness and wishes for continued treatment if it were available are all options that allow Greg to have control of the conversation, in a situation where he has lost significant control. Giving the patient as much control, autonomy and independence as possible is essential given this is often their greatest fear
. Why is the assessment of sleep patterns in hospice and palliative care patients so important?
a. Insomnia is a prevalent, distressing and undermanaged symptom.
b. Insomnia is easily overcome.
c. Insomnia is effectively treated with medications only.
d. Insomnia requires a mental health assessment by the social worker.
a - Assessment of sleep patterns in hospice and palliative care patients is important because it is a prevalent, distressing and undermanaged symptom that can be exacerbated by illness.
Richard is a 69-year-old with end-stage esophageal cancer who is a previous alcoholic, and has been
estranged from his only daughter for all of her adult life. He has been remorseful about this, stating
that he wants things to be different in their relationship before he dies.
303. What would be an appropriate patient-centered goal for Richard’s plan of care?
a. Richard will resolve the relationship before he dies.
b. Richard will have the opportunity to attempt to resolve the relationship before he dies.
c. Richard’s daughter will accept his apology.
d. Richard will contact his daughter
b - Setting a goal that Richard will have the opportunity to attempt to resolve the relationship before he dies allows a framework that is within the patient’s control. He cannot control his daughter’s response to his efforts. Contacting his daughter would be an intervention that could take place toward achieving this goal
Which of the following would be an appropriate expected outcome of Richard’s goal of having
the opportunity to attempt to resolve the relationship before he dies?
a. Richard will experience resolution.
b. Richard’s daughter will forgive him.
c. Richard will see his daughter.
d. Richard will write his daughter a letter
. a - The expected outcome is that Richard’s efforts will allow him to experience resolution. Regardless of whether his relationship is actually resolved with his daughter, there is still the possibility that Richard’s efforts toward that end may allow him to experience emotional and spiritual peace
Of the following, what would be an appropriate intervention that could be added to Richard’s
plan of care that would include him in this process?
a. Call Richard’s daughter and tell her he is sorry.
b. Write a letter for Richard to his daughter.
c. Assist Richard in contacting his daughter.
d. Call Richard’s daughter and tell her he is terminally ill.
- c - Assisting Richard in contacting his daughter will allow him to be part of the process, and empower him in his healing. If resolution of the relationship does take place, it will most likely be more meaningful for Richard’s daughter to receive outreach directly from her father, instead of a healthcare provider
There are many interventions that may be included in Richard’s nursing plan of care. Which of
the following is most important?
a. Preparing Richard for his daughter’s response.
b. Preparing an alternate plan if she will not have contact with him.
c. Collaborating with the IDT.
d. Arranging for Richard to get a haircut before his meeting
. c - Collaboration with the hospice chaplain and social worker, as well as other members of the IDT, will provide expert support for Richard as he undertakes what may be a difficult task. Care planning for the hospice patient and family always involves an interdisciplinary approach
Of the following, which would be an appropriate outcome to measure as a means of evaluating
Richard’s plan of care for this issue?
a. Pain level
b. Richard’s stated experience
c. Appetite
d. All of the above
. d - All of the above options, as well as others, could be used for evaluating Richard’s plan of care. Many additional outcomes may also be measured, depending on his baseline status and how the situation has been impacting specific aspects of his physical and psychosocial/spiritual status
If measured outcomes do not indicate achieving the stated goal that Richard will have the
opportunity to attempt to resolve the relationship before he dies, how may that goal be
updated?
a. Richard will let go of his need for resolution with his daughter.
b. Richard will define an alternate means for inner resolution for this relationship.
c. Richard will focus on his other goals.
d. Richard will find a means to distract himself.
b - An appropriate update for the goal would be that Richard will define an alternate means for inner resolution for this relationship. This is an important issue for Richard, and will most likely continue to have an impact on his overall quality of life and dying process, if he is unable to find some means of resolving it
