HESI Loss, Grief, Death Flashcards
Scenario
A client who is elderly, suffers a stroke a year ago, remains weak, has right, sided paralysis, and dysphasia. Her spouse has been caring for her at home. At home health nurse visits every other day, and the community has been providing one meal a day. The clients adult child lives several states away.
The client was sitting upright while her spouse fed her broth from chicken noodle soup, she started coughing and spitting out the broth, then becomes short of breath the spouse stops, feeding her and padded her back forcefully. The client was able to catch her breath two days later upon the schedule, her spouse informs the home health nurse about the incident. The nurse assessment reveals the clients level of consciousness has declined. She has an oral temperature 102°F (38.9° C) and diminished breath sounds with crackles in the right lung the home health. Nurse reports the assessment findings to the HCP the HCP in the client to an acute care facility with the diagnosis of aspiration pneumonia.
Which assessment should the nurse complete immediately after hearing the client choke while eating?
Osculate the clients lungs for adventitious breath sounds
Rationale: the client lung should be assessed immediately for adventitious breath sounds, since she is at risk for aspiration, pneumonia, secondary to the choking accident
The nurse assessment reveals the clients diminished breath sounds with crackles in the right lung. Her level of consciousness has declined and she has an oral temperature of 102°F (38.9° C).
After the client assessment is complete what does the nurse determine is the best course of action?
Report the assessment findings to the HCP
Rationale: communicating with the HCP is essential in order to educate for the clients well-being
Healthcare provider orders the client to be admitted to the hospital. They also order a CMP, CBC, swallow, evaluation and sailing lock.
During the admission procedure what is the nurses responsibility regarding advanced directives?
Determine if the client has completed a living wheel in a durable power of attorney for healthcare (DPAHC)
Rationale: the patient self-determination act requires healthcare institutions to provide written information concerning the clients rights to refuse treatment formulate advanced directives. The nurse should ask the clients spouse if the client has completed a living well, and a durable power of attorney for healthcare.
The client spouse has a copy of the clients living will and a durable power of attorney for healthcare, the spouse states “ I do not want her to suffer.”
The nurses sure is the spouse that the physicians and staff will make every effort to keep the client comfortable after making sure the client and her spouse are settled and do not require anything further at this time which action should the nurse take?
Place a copy of the living well in the medical record and document its presence
Rationale: the nurses responsible for placing a copy of the living, will in the medical record, and documenting its presence
The client is diagnosed with pneumonia and is prescribed intravenous antibiotics for treatment. The client swallow study determined that she should be on honey, thick liquids and puréed foods. The spouse comes to visit the client and notices the swallow precautions, thick and liquid, signed and ask the nurse what it means. The nurse explains that the client does not have adequate swallowing ability, thin liquids may go into the trachea and then the lungs instead of the stomach and caused pneumonia. Suddenly the spouse gets a shocked look on his face and says, “ oh, no! I did that. I gave her pneumonia?”
What is the nurses response?
“Saliva entering the lungs can also cause pneumonia and you did not have any way of knowing she was aspirating.”
The nurse is correct in giving reassuring information aspiration pneumonia can also be caused by the clients and ability to swallow saliva.
Four days later, the client becomes more disoriented, and she is unable to swallow, thickened liquids or puréed foods without choking her weakness, has progressed to the point at what she cannot bear her own weight, weight or sit in a chair. The healthcare provider suggests inserting a nasal gastric tube feed to provide nutrition; however, this client will excludes two feedings and intravenous nutrition. The client spouse states they support the client in this information was shared with their adult child
Which response demonstrates that the nurse understands the underlying premise of a living will?
“We will honor directives in her living will”
 Rationale: the nurse demonstrates support and gives reassurance that the clients decision will not be ignored by her providers, which is the intent of a living will
The client has frequent episodes of coughing and choking with decreased oxygen saturation and is transferred to the hospice unit. The nurse identifies the clients nursing diagnosis of.” an effective airway clearance.”
Which nursing intervention should be implemented to care for the clients mouth ?
Clean her mouth frequently with oral swabs
Rational: client nurses to ensure that frequent care is given with oral swabs
What other interventions should the nurse implement?
Suction oral secretions from mouth and throat
Rational: oral suctioning of accumulated secretions is gently done with a tonsil tip or a yankauer suction device to maintain patency of the airway, provide more effective, breathing and add to clients comfort
 The clients adult child arrives to visit. Their last interaction was three months ago and is alarmed. Their mother has lost weight, is weaker, is not eating, and not as responsive. They comment to the nurse that their mother has talked about the living will says angrily, “ don’t you think you should do something? This is a hospital, isn’t it?”
What is the best response by the nurse?
“It must be difficult to see the changes in your mother.”
Rationale: empathetic statements are therapeutic, and can help family and moving through the grief process
The family tells the nurse they feel helpless and don’t know what to do to make the client more comfortable. Family asks the nurse if it would be all right to have a massage therapist come in and gently massage her mother’s back and limbs.
How should the nurse respond to the families request?
The family massage therapists are in the hospice unit
Rational: nontraditional therapies are encouraged in the hospice environment. If they give comfort to the client and are not harmful additionally, supporting the daughter, will give her a sense of control.
The clients adolescent family member enters the room, kisses the client, and remarks, “ I think she can get better if we just give her more time just because she was moved to this hospice unit doesn’t mean she will die.” the nurse recognizes the adolescent has already begun to grieve the loss of a family member.
According to the cobbler model, how should the nurse categorize the stage of grief being exemplified by the adolescent statement?
Denial
Rationale: that adolescent is experiencing a common initial reaction to a real or impending loss feelings of numbness, shock, and disbelief occur. This stage is healthy and permits, the individual to develop other coping mechanisms.
The nurse explains the stages of grief and weighs the family can support other family members as the client moves back-and-forth among the stages. The clients family began reading, age-appropriate books, and talking to the younger children about death. As soon as they receive the news of family member was hospitalized. They concerned because their school-age children repeatedly ask questions about what happens to the physical body after death, and want specific information about what the funeral homes will do to the body family ask the nurse what they should tell the school-age child
What is the nurses best response?
Recommend their child’s questions to be answered honestly and simple terms
Rationale: children at this age, often interested in the physical and biological aspects of death. They usually recognize that death is permanent and are very concrete, in their thinking question should be answered honestly, and simply giving the child enough information to answer the question, but not overwhelming. The child with information parents can expect that repeated explanations will be necessary.
The client becomes difficult to arouse and does not follow commands. The daughter asks the nurse what they should tell the preschool child if she dies.
Which phrase should the nurse recommend?
“She died in that makes us very sad”
The statement is truthful and acknowledges the families, feelings of sorrow and grief. The family may also want to tell the child that the person who died is not coming back and then answer any questions this process may need to be repeated many times
The client begins to sleep more, and she has less alert time over the last few days she has become more restless, has increased grimacing, And periodically conscious her fists the nurse, notes and increased and heart rate, respiration and blood pressure during these episodes. The HCP is contacted and oxycodone HCL immediate release. Concentrate solution is prescribed to be administered via the oral transmit coastal route every four hours as needed for pain. The client spouse is informed of the order and ask the nurse why oxycodone was prescribed in this manner.
Information regarding the medication order so the nurse provide to the client spouse ?
- The medication is rapidly absorbed and asks quickly.
Rationale: because the oral mucosa has a thin epithelium and abundant blood vessels drugs, admitted via the route are rapidly absorbed, passing directly into the bloodstream medication act quickly, while avoiding the damaging effects of gastric juices, and liver metabolisms - This route decreases the chance of aspiration.
Rationale: this route is particularly beneficial in the client with dysphagia
