Chapter 34 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

Chapter 34 Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE.  Choose the one alternative that best completes the statement or answers the question.

• The client is maintained on mechanical ventilation, but is found to have irreversible destruction of 1) the cerebral The nurse recognizes the client is diagnosed as experiencing:

1. A) Heart-lung B) Higher brain death.
2. C) A persistent vegetative D) Death.

Answer: B

Explanation: A)       This client would be classified as experiencing higher brain death or cerebral death because the heart is still breathing and oxygen needs are met by the mechanical ventilator. Heart-lung death is when the heart stops beating and the client no longer is breathing. Higher cerebral brain death is a specific classification of death. A persistent vegetative state indicates the loss of cognitive function and awareness, but complete and irreversible loss of the cerebral cortex has not occurred.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. This client would be classified as experiencing higher brain death or cerebral death because the heart is still breathing and oxygen needs are met by the mechanical Heart-lung death is when the heart stops beating and the client no longer is breathing. Higher cerebral brain death is a specific classification of death. A persistent vegetative state indicates the loss of cognitive function and awareness, but complete and irreversible loss of the cerebral cortex has not occurred.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. This client would be classified as experiencing higher brain death or cerebral death because the heart is still breathing and oxygen needs are met by the mechanical Heart-lung death is when the heart stops beating and the client no longer is breathing. Higher cerebral brain death is a specific classification of death. A persistent vegetative state indicates the loss of cognitive function and awareness, but complete and irreversible loss of the cerebral cortex has not occurred.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. This client would be classified as experiencing higher brain death or cerebral death because the heart is still breathing and oxygen needs are met by the mechanical Heart-lung death is when the heart stops beating and the client no longer is breathing. Higher cerebral brain death is a specific classification of death. A persistent vegetative state indicates the loss of cognitive function and awareness, but complete and irreversible loss of the cerebral cortex has not occurred.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

Objective: Learning Outcome 34-1: Define the key terms used in the skills of caring for clients at the end of

life.

 

• The nurse is providing postmortem care, and elevates the client’s head in order to avoid 2) discoloration of the face secondary to:

1. A) Rigor B) Livor mortis. C) Algor mortis.               D) Post mortis.

Answer: B

Explanation: A)      Livor mortis is caused by the breakdown of red blood cells, which settle in the most dependent area, causing discoloration. By raising the head of the bed, the nurse prevents discoloration of the head and face. Rigor mortis is rigidity of the muscles, while algor mortis is cooling of the body.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. Livor mortis is caused by the breakdown of red blood cells, which settle in the most dependent area, causing By raising the head of the bed, the nurse prevents discoloration of the head and face. Rigor mortis is rigidity of the muscles, while algor mortis is cooling of the body.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. Livor mortis is caused by the breakdown of red blood cells, which settle in the most dependent area, causing By raising the head of the bed, the nurse prevents discoloration of the head and face. Rigor mortis is rigidity of the muscles, while algor mortis is cooling of the body.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

1. Livor mortis is caused by the breakdown of red blood cells, which settle in the most dependent area, causing By raising the head of the bed, the nurse prevents discoloration of the head and face. Rigor mortis is rigidity of the muscles, while algor mortis is cooling of the body.

Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Implementation

Objective: Learning Outcome 34-1: Define the key terms used in the skills of caring for clients at the end of

life.

 

• The nurse’s role when working with families of dying clients includes all of the following except: 3)

1. Financial
2. Providing
3. Assisting with connecting families with available
4. Assessing families coping and grieving

Answer: A

Explanation: A)      While nurses may help families connect with available resources to help them deal with financial issues, the role of the nurse does not include providing financial support. A large part of the nurse’s role is assisting the family to cope with the

impending death, assessing their progress in the grieving process.

Cognitive Level: Application

Client Need: Psychosocial Integrity

Nursing Process: Planning

1. While nurses may help families connect with available resources to help them deal with financial issues, the role of the nurse does not include providing financial A large part of the nurse’s role is assisting the family to cope with the

impending death, assessing their progress in the grieving process.

Cognitive Level: Application

Client Need: Psychosocial Integrity

Nursing Process: Planning

1. While nurses may help families connect with available resources to help them deal with financial issues, the role of the nurse does not include providing financial A large part of the nurse’s role is assisting the family to cope with the

impending death, assessing their progress in the grieving process.

Cognitive Level: Application

Client Need: Psychosocial Integrity

Nursing Process: Planning

1. While nurses may help families connect with available resources to help them deal with financial issues, the role of the nurse does not include providing financial A large part of the nurse’s role is assisting the family to cope with the

impending death, assessing their progress in the grieving process.

Cognitive Level: Application

Client Need: Psychosocial Integrity

Nursing Process: Planning

Objective: Learning Outcome 34-2: Describe the role of the nurse in working with families or caregivers of dying clients.

 

• The nurse recognizes the client’s death is impending when which of the following is noted? 4)

1. Mottling and cyanosis of the extremities
2. Client requests a meeting with spiritual
3. Heart rate and blood pressure
4. Increased appetite

Answer: A

Explanation: A)      Mottling and cyanosis of the extremities are imminent signs of death. Requesting a meeting with a spiritual counselor is not indicative of death, and is more likely to occur days to weeks before death, as the client emotionally prepares for death. Heart rate, blood pressure, and appetite are more likely to decrease than increase. Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Mottling and cyanosis of the extremities are imminent signs of Requesting a meeting with a spiritual counselor is not indicative of death, and is more likely to occur days to weeks before death, as the client emotionally prepares for death. Heart rate, blood pressure, and appetite are more likely to decrease than increase. Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Mottling and cyanosis of the extremities are imminent signs of Requesting a meeting with a spiritual counselor is not indicative of death, and is more likely to occur days to weeks before death, as the client emotionally prepares for death. Heart rate, blood pressure, and appetite are more likely to decrease than increase. Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

1. Mottling and cyanosis of the extremities are imminent signs of Requesting a meeting with a spiritual counselor is not indicative of death, and is more likely to occur days to weeks before death, as the client emotionally prepares for death. Heart rate, blood pressure, and appetite are more likely to decrease than increase. Cognitive Level: Application

Client Need: Physiological Integrity

Nursing Process: Assessment

Objective: Learning Outcome 34-3: List clinical signs of impending and actual death.

• When delegating postmortem care to unlicensed assistive personnel (UAP), it is essential that the 5) nurse inform the UAP of the:

1. Tubes or other medical devices to be left in
2. Disposition of the body after postmortem care is
3. Method to contact the
4. Information to be documented in the medical

Answer: A

Explanation: A)      The nurse must inform the UAP of any tubes or medical devices to remain in place during postmortem care. Disposition of the body is relatively standard within facilities, and the nurse would not need to inform the UAP of this. The nurse would be responsible for notifying the family and documenting in the medical

record.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

1. The nurse must inform the UAP of any tubes or medical devices to remain in place during postmortem Disposition of the body is relatively standard within facilities, and the nurse would not need to inform the UAP of this. The nurse would be responsible for notifying the family and documenting in the medical

record.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

1. The nurse must inform the UAP of any tubes or medical devices to remain in place during postmortem Disposition of the body is relatively standard within facilities, and the nurse would not need to inform the UAP of this. The nurse would be responsible for notifying the family and documenting in the medical

record.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

1. The nurse must inform the UAP of any tubes or medical devices to remain in place during postmortem Disposition of the body is relatively standard within facilities, and the nurse would not need to inform the UAP of this. The nurse would be responsible for notifying the family and documenting in the medical

record.

Cognitive Level: Application

Client Need: Safe, Effective Care Environment

Nursing Process: Planning

Objective: Learning Outcome 34-4: Recognize when it is appropriate to delegate end-of-life care to

unlicensed assistive personnel.