HESI: PN LOSS, GRIEF, & DEATH_2015

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PN Loss Grief and Death
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SCENARIO: Meet the Client: Evelyn Kuntz Evelyn Kuntz, a 70-year-old female, suffered a brain attack (stroke) a year ago. She remains weak and has right-sided paralysis and dysphagia. Her husband, Jerry, has been caring for her at home. A home health nurse visits every other day. The Kuntz’s synagogue has been providing one meal a day. The Kuntz’s daughter, Cathy , lives several states away with her husband and their three children, ages 15, 8, and 3.
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1. Which concern needs immediate attention?
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A. Determine Jerry’s knowledge about feeding a dysphagic person. B. Auscultate Evelyn ‘s lungs for adventitious breath sounds. C. Assess Evelyn ‘s LOC with the mini-mental status exam. D. Determine Evelyn ‘s ability to swallow liquids.
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LEGAL CONSIDERATIONS: MRS. KUNTZ’S BREATH SOUNDS ARE DIMINISHED, AND CRACKLES ARE AUSCULTATED IN THE RIGHT LUNG. SHE IS ALSO DISORIENTED DURING THE ADMISSION PROCESS TO THE HOSPITAL. 2. What is the PN’s responsibility regarding advance directives?
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A. Ask if Mrs. Kuntz has completed a living will and a durable power of attorney. B. Explain the Patient Self-Determination Act (PSDA) requires a living will. C. Instruct Mr. Klein to have his wife sign a living will when she is no longer disoriented. D. Clarify that the healthcare provider cannot be a witness for these legal documents.
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Mr. Kluntz has a copy of his wife’s living will and durable power of attorney for health care. He states, \”I do not want her to suffer.\” 3. How should the PN respond to Jerry’s remarks?
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A. Document that the client is aware of the Patient Self-Determination Act. B. Place a copy of the living will in the medical record and document its presence. C. Notify the healthcare provider that the spouse desires euthanasia for his wife. D. Report to the charge nurse that Jerry seems to be in denial about the seriousness of his wife’s condition.
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Nutritional Issues: The HCP reviews Evelyn’s CXR results and confirms her diagnosis of aspiration pneumonia. IV antibiotics are prescribed for 10 days. The cllinical dietitian assesses Evelyn’s nutritional status. Evelyn continues to have difficulty swallowing, so the dietitian posts a \”swallow precautions” sign on the wall by Evelyn’s bed. Jerry notices the sign and asks the PN what it means. The PN explains that thin liquids can cause pneumonia because the liquids may go into the trachea and then the lungs instead of the stomach, since Evelyn does not have adequate swallowing ability. Suddenly, Jerry gets a shocked look on his face and says, \”Oh, no! I did that. I gave her pneumonia!\” 4. How should the PN reply?
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A. \”How was she positioned when you fed her? B.\”Saliva entering the lungs can also cause pneumonia.\” C. \”You know you did the best you could.\” D. \”We know it was not intentional on your part.\”
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Four days later, Evelyn becomes more disoriented and she is unable to swallow thickened liquids or pureed foods w/o choking. Her weakness has progressed to the point at which she cannot bear her own weight or sit in a chair. The healthcare provider suggests inserting a nasogastric feeding tube to provide nutrition; however, Evelyn’s living will excludes tube feedings and intravenous nutrition. Jerry says he supports Evelyn ‘s decision and that this information was shared with their daughter. 5. Which response demonstrrates that the PN understands the underlying premise of a living will?
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A. \”We will honor Evelyn ‘s directives in her living will.\” B. \”Are you sure that this is what you really want for Evelyn?\” C. \”Your healthcare provider wants to do all he can to preserve life.\” D. \”Have you spoken to your rabbi about Evelyn’s wishes?\”
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Nursing Skills: Evelyn is transferred to the hospice unit. She remains weak and disoriented, and subtle vital sign changes indicate that the dying process has begun. Under the guidelines of Evelyn’s living will, no lifesaving measure are ordered. Care measure are instituted to keep Evelyn comfortable. She develops cheilosis and stomatitis. 6. What nursing intervention should be instituted to care for Evelyn’s mouth?
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A. Giver her sips of water through a straw. B. Offer her an ounce of ice chips every hour. C. Provide mouth care daily with her bath. D. Clean her mouth frequently with oral swabs.
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Evelyn has become very difficult to arouse. 7. What is the safest manner of giving oral care to Evelyn ?
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A. Have two PN’s or UAPs perform the procedure. B. Remove dentures if the client has them. C. Demonstrate the procedure to Jerry so he can assist the nurse if he wishes. D. Moisten oral swabs with a minimal amount of water.
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Evelyn’s inability to swallow salivary secretions causes frequent episodes of coughing and choking. The PN identifies the nursing diagnosis of \”Ineffective breathing pattern\” for Evelyn. 8. What intervention will help Evelyn breathe more comfortably?
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A. Tracheal suctioning of secretions. B. Oral suctioning of secretions from mouth and throat. C. Encourage deep breathing every hour wile awake. D. Teach Evelyn how to use an incentive spirometer.
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Grief Process The Kuntzs’ daughter Cathy, arrives to visit her mother. Cathy’s husband and children accompany her. Cathy last saw her mother 3 months ago, and she is alarmed that her mother has lost weight, is weaker, and is not eating. Cathy acknowledges to the nurse that her mother talked to her about the living will but says angrily, \”Don’t you think you should do something? This is a hospital, isn’t it?\” 9. What is the best response by the PN?
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A. Yes, this is the hospice unit of the hospital. B. It must be difficult to see the changes in your mother. C. Why are you angry at the nurses and other healthcare providers? D. You are in the stage of denial in the grief process.
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Cathy tells the nurse that she feels helpless and doesn’t know what to do to make her mother more comfortable. She asks the nurse if it would be all right to have a massage therapist come in a gently massage her mother’s limbs and back. 10. How should the PN respond to Cathy’s request?
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A. Ask Cathy what purpose she thinks massage will serve. B. Inform Cathy that she must produce the therapists’s credentials first. C. Tell Cathy that massage therapists are welcome in the hospice. D. Share with Cathy that she uses alternative therapies herself.
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Cathy’s 15-year-old daughter enters the room, kisses Evelyn, and remarks, \”I think my grandmother can get better if we just give her more time. Just because she was moved to this hospice doesn’t mean she will die.\” The nurse recognizes that the adolescent has already begun to grieve the loss of the grandmother she loves. 11. According to Kubler-Ross, which stage of grief is exemplified by the adolescent’s statements?
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A. Acceptance B. Depression C. Bargaining D. Denial
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Cathy expresses concern about her daughter’s statement. The nurse invites Cathy to step out of the room to get a cup of coffee, and Cathy’s husband joins them. The nurse explains the stages of grief and ways Cathy and her husband can support their daughter as she moves back and forth among the stages. Cathy states that she and her husband began reading age-appropriate books and talking to the younger children (ages 8 and 3) about death as soon as they received the news that Evelyn was hospitalized. Cathy’s husband expresses concern because their 8-year-old son repeatedly asks questions about what happens to the physical body after death and wants specific information about what the funeral home will do to the body. 12. How should the PN respond?
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A. Tell the parents to take the child to a grief counselor immediately. B. Call the family’s rabbi to get information that is culturally appropriate. C. Recommend that their son’s questions be answered honestly in simple terms. D. Ask to speak to the child to assess what is really bothering him.
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Cathy and her husband ask the nurse what they should tell their 3-year-old daughter when Evelyn dies. 13. Which phrase should the PN recommend?
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A. \”Your grandma went to sleep and didn’t wake up. B. \”Grandma died and that makes us feel very sad.\” C. \”God wanted your grandma because she was so good.\” D. \”We’ve lost Grandma and will miss her very much.\”
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Evelyn 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 clenches her fists. The nurse notes an increase in pulse, respiration, and blood pressure during these episodes. The healthcare provider is contacted and oxycondone HCL immediate-release concentrate solution (OxyFAST) is prescribed to be administered via the oral transmucosal route every 4 hours as needed for pain. Jerry asks the nurse why oxycodone is given in this manner. 14. The PNanswers Jerry’s question based on which information? (Select all that apply)
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A. This route is least likely to produce drug addiction. B. There is no other route by which to give this medication. C. The medication is rapidly absorbed and acts quickly. D. This route decreases the chance of aspiration. E. Risk for respiratory depression is lessened using this route.
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Because Evelyn has been losing weight and she has a decreased metabolic rate due to the dying process, the healthcare provider prescribes 0.2 mg/kg oxycodone HCL (OxyFAST) of Evelyn’s weight. Evelyn weighs 110 pounds. The medication is available as 20 mg/mL in a 30 mL bottle with a measured dropper. 15. How many milliliters of medication will the PN administer? (nearest 10th)
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0.5 ml
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Evelyn rests more comfortably after the medication is initiated, and she is able to speak with her family when she is awake. Evelyn awakens while the rabbi is visiting and asks him to read from the Book of Psalms and to pray. The nurse enters the room to obtain vital signs while the rabbi is praying. Jerry asks the nurse to remain with them while the rabbi prays and then obtain the vital signs. 16. What action should the PN take?
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A. Quickly take the vital signs as prescribed. B. Stand quietly until the prayer is over. C. Express discomfort by leaving the room. D. Ask the rabbi to come back later to pray.
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Jerry tells the nurse that their faith in God has seen them through life’s problems and that he relies on that faith every day. 17. What is the best response to support Jerry and Evelyn spiritually?
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A. Do you have any wishes I should convey to the staff? B. I wish my faith was as strong as yours. C. Does your daughter share your faith? D. Would you like to visit the chapel on the first floor?
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Jerry states that he and Evelyn have been married for 52 years. He sighs and wipes his eyes, softly remarking that he won’t know what to do when he is alone. 18. Which response will encourage Jerry to talk more about his feelings?
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A. Praise Jerry for being able to stay married so long. B. Ask Jerry to share memories of the couple’s time together. C. Remark that Jerry and Evelyn are role models for the synagogue. D. Share with Jerry memories of own grandparents.
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Evelyn lies quietly with her eyes closed. She no longer responds verbally, but she smiles when her family speaks to her. 19. To assist Jerry and Evelyn in life review, what is the best intervention?
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A. Encourage Jerry to talk to Evelyn about their experiences. B. Encourage visitors to speak quietly in the corner of the room or outside. C. Encouragethat Jerry bring photo albums to show Evelyn. D. Instruct visitors to use touch when communicating with Evelyn.
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20. What other physical symptom should the nurse anticipate?
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A. Hyperreflexia in legs and arms. B. Increased urinary output. C. Mottling of hands and feet. D. Head turned away from light.
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21. Based on the assessment findings, what action should the PN take?
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A. Inform Cathy that Evelyn’s condition is worsening. B. Suggest that Cathy tell Jerry to rush back to the hospital immediately. C. Hold Cathy’s hand, but do not disclose Evelyn’s vital signs. D. Notify the family that Evelyn will probably die today.
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END OF LIFE CARE: Cathy has been observing the PN and the UAP perform oral suction for Evelyn. Cathy says, \”I know Mama is dying. I can do the suctioning. Would you watch me once?\” 22. How should the PN respond? Cathy notifies her father that her mother’s condition is worsening. Jerry arrives with his son-in-law and grandchildren. The rabbi is called ot be with the family. The family recites the Shema, which reaffirms the basic tenets of the Jewish faith. Evelyn moves her lips as they speak but does not open her eyes. As the day goes on, at least one family member remains at Evelyn’s side at all times. Members of the synagogue bring food to the waiting room for the family to eat.
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A. \”Do you think you are strong enough?\” B. \”Yes. I would be happy to watch you.\” C. \”I am not sure that is a good idea.\” D. \”I think there is a policy against it.\”
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POSTMORTEM CARE: The family members are at the bedside very early the next day when Evelyn stops breathing. The healthcare provider arrives and pronounces the death. As the rabbi is being consulted regarding the preparation of the body, a group of women from the synagogue arrive to assist with postmortem care. 23. How should the PN respond? Jerry comes to the nursing station to say goodbye and offers his thanks. He says, \”I will miss my dear wife, by it helped that we could all be with her when she died.\” Jerry and his family leave when the funeral home staff arrive to take Evelyn’s body. The nurses are able to spend time talking with one another about the experience of helping Evelyn and her family through the dying process before they return to caring for other hospice patients.
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A. Instruct the family and the rabbi to leave the room. B. Remain available to assist the women of the synagogue as needed. C. Tell the rabbi that postmortem care must be done by the hospice staff regardless of the religion. D. Remind the family that an autopsy must be performed before the burial.
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QUESTION 1 RATIONALE
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B. Auscultate Evelyn’s lungs for adventitious breath sounds. Evelyn’s lungs should be assessed immediately for adventitious breath sounds since she is at risk for aspiration pneumonia secondary to the choking incident.
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QUESTION 2 RATIONALE
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A. Determine if Mrs. Klein has completed a living will and a durable power of attorney. The Patient Self-Determination Act (1991) requires healthcare institutions to provide written information concerning the client’s rights to refuse treatment and formulate advance directives. The nurse should ask Mr. Klein if his wife has completed a living will and a durable power or attorney.
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QUESTION 3 RATIONALE
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B. Place a copy of the living will in the medical record and document its presence. The nurse is responsible for placing a copy of the living will in the medical record and documenting its presence.
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QUESTION 4 RATIONALE
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B.\”Saliva entering the lungs can also cause pneumonia.\” The nurse is correct in giving Jerry reassuring information that aspiration pneumonia can also be caused by Evelyn’s inability to swallow saliva. The pneumonia is being treated, and it will do no good at this point to speculate about the cause of the pneumonia.
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QUESTION 5 RATIONALE
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A. \”We will honor Evelyn’s directives in her living will.\” The nurse demonstrates support and gives reassurance to Jerry that Evelyn’s decision will not be ignored by her providers, which is the intent of the will.
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QUESTION 6 RATIONALE
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D. Clean her mouth frequently with oral swabs. Evelyn’s nurse is correct to ensure that frequent mouth care is given with oral swabs.
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QUESTION 7 RATIONALE
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A. Have two nurses or UAPs perform the procedure. The nurse is correct to first ensure that two staff members are available to provide safe oral care.
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QUESTION 8 RATIONALE
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B. Oral suctioning of secretions from mouth and throat. Oral suctioning of accumulated secretions is gently done with a tonsil tip or Yankauer suction device to provide more effective breathing and to add to Evelyn’s comfort.
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QUESTION 9 RATIONALE
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B. It must be difficult to see the changes in your mother. Empathetic statements are therapeutic and can help Cathy in moving through the grief process.
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QUESTION 10 RATIONALE
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C. Tell Cathy that massage therapists are welcome in the hospice. Nontraditional therapies are encourages in the hospice environment if they give comfort to the client and are not harmful. Additionally, supporting Cathy will give her a sense of control.
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QUESTION 11 RATIONALE
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D. Denial The 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.
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QUESTION 12 RATIONALE
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C. Recommend that their son’s questions be answered honestly in simple terms. Children at this age are often interested in the physical and biological aspects of death. They usually recognize that death is permanent and are very concrete in their thinking. Questions 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 explanation will be necessary.
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QUESTION 13 RATIONALE
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B. \”Grandma died and that makes us feel very sad.\” This statement is truthful and acknowledges the parents’ feelings of sorrow and grief. The parents 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.
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QUESTION 14 RATIONALE
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C. The medication is rapidly absorbed and acts quickly. Because the oral mucosa has a thin epithelium and abundant blood vessels, drugs administered via this route are rapidly absorbed. Passing directly into the bloodstream, medication acts quickly while avoiding the damaging effects of gastric juices and liver metabolisms. D. This route decreases the chance of aspiration. This route is particularly beneficial in the client with cancer who is unable to tolerate oral administration because of nausea and vomiting or the client with dysphagia.
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QUESTION 14 RATIONALE
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0.5 mL First converts lbs–>kg (110/2.2=50kg) Next, calculate how many mg Evelyn should receive: 0.2mg/kg X 50kg=10mg 10mg X 1mL/20mg=0.5mL
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QUESTION 15 RATIONALE
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B. Stand quietly until the prayer is over. This action expresses respect for the family’s spiritual needs and offers support to the family and clergy. Respecting spiritual needs is one of the many priorities of hospice care. The nurse does not need to be of the same religion/denomination as the client to remain in the room during readings and prayer.
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QUESTION 16 RATIONALE
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A. Do you have any wishes I should convey to the staff? The nurse is correct in intervening by asking what Jerry and Evelyn prefer in terms of faith and spiritual care.
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QUESTION 17 RATIONALE
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B. Ask Jerry to share memories of the couple’s time together. Asking him to talk about his memories of their time together will allow Jerry the opportunity to share his feelings and reminisce about their marriage.
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QUESTION 18 RATIONALE
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C. Urge Jerry to talk to Evelyn about their experiences. Reminiscing is a means of setting one’s life in order, which is the task of the final stage of Erikson’s developmental theory called Integrity vs. Despair. Jerry’s retelling of significant life experiences can help both of them feel a sense of meaning in their lives, which is the goal of this stage. It is also in keeping with the Jewish concept of the value of life on this earth, good deeds, and the legacy of the deceased.
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QUESTION 19 RATIONALE
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C. Mottling of hands and feet. Cyanosis and mottling occur first in the hands and feet and then progress centrally.
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QUESTION 20 RATIONALE
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A. Inform Cathy that Evelyn’s condition is worsening. The PN should keep family members informed of Evelyn’s worsening condition to provide them the opportunity to communicate with Evelyn and to notify their rabbi if desired.
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QUESTION 21 RATIONALE
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B. \”Yes. I would be happy to watch you.\” Cathy wants to participate in the care of her mother. Allowing her to help will lessen her sense of helplessness during the dying process.
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QUESTION 22 RATIONALE
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B. Remain available to assist the women of the synagogue as needed. It is not uncommon for a group of persons from the synagogue to come and prepare the body. Men will come for men who have died, and women come for women. While there are specific ways that the body must be cleansed, positioned, and wrapped, the PN can assist by removing all external catheters and medical equipment attached to the body and ensuring that all incisions and wounds are dressed.

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