Chapter 29: The Experience of Loss, Death and Grief

13. How should the nurse promote comfort for the terminally ill client, specific to nausea and vomiting? a. Provide frequent mouth care. b. Suction oral secretions. c. Increase the fluid intake. d. Offer a high-residue diet.

ANS: A To promote comfort for the terminally ill client, specific to nausea and vomiting, the nurse should administer anti-emetics, provide oral care at least every two to four hours, offer a clear liquid diet and ice chips, and avoid liquids that increase stomach acidity such as coffee, milk, and citrus acid juices. Suctioning would remove respiratory secretions. Increasing the fluid intake may help prevent constipation. A low-residue diet may help prevent diarrhea.

15. The nurse is using Bowlby's phases of mourning as a framework for assessing the client's response to the traumatic loss of her leg. During the "yearning and searching" phase, how does the nurse anticipate the client may respond? a. Crying off and on b. Becoming angry at the nurse c. Acting stunned by the loss d. Discussing the change in role that will occur

ANS: A During the "yearning and searching" phase of Bowlby's phases of mourning, the nurse anticipates that the client may have outbursts of tearful sobbing and acute distress. During Bowlby's "disorganization and despair" phase of mourning, the nurse anticipates that the client may express anger at anyone who might be responsible, including the nurse. During the "numbing" phase of Bowlby's phases of mourning, the nurse anticipates that the client may act stunned by the loss. During the "reorganization" phase of Bowlby's phases of mourning, the nurse anticipates that the client may discuss the change in role that will occur.

9. Hospice nursing care has a different focus for the dying client. Which of the following should the nurse know about client care provided through a hospice? a. It is designed to meet the client's individual wishes, as much as possible. b. It is usually aimed at offering curative treatment for the client. c. It is involved in teaching families to provide postmortem care. d. It does not include an interdisciplinary care team.

ANS: A The nurse's role in hospice nursing care is to meet the primary wishes of the dying client and to be open to the individual desires of each client. The nurse supports a client's choice in maintaining comfort and dignity. Hospice care is for the terminally ill. It is not aimed at offering curative treatment, but rather the emphasis is on palliative care. Hospice care may provide bereavement follow-up for the family after a client's death, but hospice nurses typically do not teach the family postmortem care. Hospice care programs include provision of an interdisciplinary care team of physicians, nurses, spiritual advisers, social workers, and counsellors.

6. A client has been diagnosed with terminal cancer of the liver and is receiving chemotherapy on a medical unit. In an in-depth conversation with the nurse, the client states, "It can't be happening to me." According to Kübler-Ross, with which of the following is this stage of dying associated? a. Anxiety b. Denial c. Confrontation d. Depression

ANS: B According to Kübler-Ross, the client is in the denial stage of dying. The client may act as though nothing has happened, may refuse to believe or understand that a loss has occurred and may seem stunned, as though it is "unreal" or difficult to believe. No stage of anxiety is found in Kübler-Ross's five stages of dying. No stage of confrontation is found in Kübler-Ross's five stages of dying. During depression, the individual may feel overwhelmingly lonely and withdraw from interpersonal interaction. Depression is one of Kübler-Ross's five stages of dying, but is not represented by this example.

7. Which of the following statements is true regarding cultural beliefs and death? a. The ethical decisions surrounding a client's death should be based on hospital policy and not culture. b. Maintaining rituals and practices allows a sense of acceptance of the dying process. c. The nurse must decide which cultural practices will be incorporated in care of the dying. d. Regardless of culture, following hospital practices will help focus client and family on the dying process.

ANS: B Maintaining the integrity of rituals and mourning practices gives families a sense of acceptance of the client's death and an inner peace. The nurse should be familiar with policies and procedures, but ethical decisions should be made with an understanding and appreciation of the client's culture. The nurse must assess the terminally ill client's and family's wishes for end-of-life care and develop a plan of care by integrating client culture and spiritual beliefs. On the contrary, the nurse must assess the terminally ill client's and family's wishes for end-of-life care and develop a plan of care by integrating client culture and spiritual beliefs.

14. Which of the following is a nurse-initiated or independent activity for promotion of respiratory function in a terminally ill client? a. Limiting fluids b. Positioning the client upright c. Reducing narcotic analgesic use d. Administering bronchodilators

ANS: B Positioning the client upright is an independent nursing intervention for the promotion of respiratory function in a terminally ill client. Limiting fluids may not promote respiratory function, and the nurse should not do so unless a client is on a fluid-restricted diet. Reducing narcotic analgesic use is not a nurse-initiated activity to promote respiratory function. A respiratory rate should be assessed before administering narcotics to prevent further respiratory depression. Management of dyspnea (air hunger) involves judicious administration of morphine and anxiolytics for relief of respiratory distress. The administration of bronchodilators would require a physician's order. It is not an independent nursing activity.

4. An identified outcome for the family of the client with a terminal illness is that they will be able to provide psychological support to the dying client. To assist the family to meet this outcome, which of the following should the nurse plan to include in the teaching plan? a. Demonstration of bathing techniques b. Application of oxygen devices c. Recognition of client needs and fears d. Information on when to contact the hospice nurse

ANS: C A dying client's family is better prepared to provide psychological support if the nurse discusses with them ways to support the dying person and listen to needs and fears. Demonstration of bathing techniques may help the family meet the dying client's physical needs, but not provide psychological support. Application of oxygen devices may help the family meet physical needs for the client, but not provide psychological support for the client. Information on when to contact the hospice nurse is important knowledge for the family to have and may help them feel they are being supported in caring for the dying client. However, contact information does not help the family provide psychological support to the dying client.

5. The nurse is assigned to a client who was recently diagnosed with a terminal illness. During morning care, the client asks about organ donation. How should the nurse respond? a. Have the client first discuss the subject with the family. b. Suggest the client delay making a decision at this time. c. Assist the client to obtain the necessary information to make this decision. d. Contact the physician so consent can be obtained from the family.

ANS: C No topic that a dying client wishes to discuss should be avoided. The nurse should respond to questions openly and honestly. As client advocate, the nurse should assist the client to obtain the necessary information to make this decision. The nurse should provide the client with information with which to make such a decision. Although the nurse may suggest that the client discuss the subject with the family after having obtained information, it is up to the client to discuss the subject with his family. The nurse should respect the client and provide the necessary information for him or her to make a decision, rather than dismissing the client's question. It is not necessary to contact the physician or the family for consent for organ donation if the client is capable of making this decision.

11. The nurse is working with a client on an inpatient hospice unit. Which of the following actions should the nurse take in order to maintain the client's sense of self-worth during the end of life? a. Leaving the client alone to deal with final affairs b. Calling on the client's spiritual advisor to take over care c. Spending time with the client and allowing him or her to share life experiences d. Having a grief counsellor visit .

ANS: C Taking time to let the client share his or her life experiences, particularly what has been meaningful, enables the nurse to know the client better. Knowing the client then facilitates choice of therapies that promote client decision making and autonomy. Planning regular visits also helps the client maintain a sense of self-worth, because it demonstrates that he or she is worthy of the nurse's time and attention. The client should not be left alone to feel abandoned or isolated. The nurses can help the client meet spiritual needs by facilitating connections to a spiritual practice or community and supporting the expression of culturally held beliefs. The client's spiritual advisor also may be called on, but is not the only source of spiritual support. The nurse who turns care over to the spiritual advisor is not promoting the client's sense of self-worth, as it may imply the client is not worthy of the nurse's time or attention. A grief counsellor may be requested to visit if the client is experiencing complicated grief. Having a grief counsellor visit may be less helpful than spending time with the client, to help maintain a client's sense of self-worth

1. The nurse is discussing future treatments with a client who has a terminal illness. The nurse notes that the client has not been eating and responds to the nurse's information by stating, "What does it matter?" Which of the following is the most appropriate nursing diagnosis for this client? a. Social isolation b. Spiritual distress c. Denial d. Hopelessness

ANS: D A defining characteristic for the nursing diagnosis of hopelessness may include the client stating, "What does it matter?" when offered choices or information concerning him or her. The client's behaviour of not eating also is an indicator of hopelessness. The client's behaviour and verbalization is not an example of social isolation. The client is not avoiding others or being restricted from seeing others. Spiritual distress is not the most appropriate nursing diagnosis for this client. The focus should be on the client's lack of hope. The client's behaviour and verbalization does not indicate denial.

12. Which of the following would be a nursing intervention to assist the client with a nursing diagnosis of Sleep pattern disturbance related to the loss of spouse and fear of nightmares? a. Administer sleeping medication per order. b. Refer the client to a psychologist or psychotherapist. c. Have the client complete a detailed sleep-pattern assessment. d. Sit with the client and encourage verbalization of feelings.

ANS: D A nursing intervention to facilitate grief work is to offer the client encouragement to explore and verbalize feelings of grief. This encouragement refocuses the client on current needs and minimizes dysfunctional adaptation behaviours (e.g., not sleeping) by facilitating resolution of grief through problem-solving skills. Administering sleeping medication may help the client get to sleep, but does not resolve the issue of grief. Without addressing the grief, the client may develop another dysfunctional adaptation behaviour. It is not necessary to refer the client to a psychologist or psychotherapist at this time. The client needs to be encouraged to verbalize his or her feelings. Having the client complete a detailed sleep-pattern assessment may help the nurse identify the number of hours of sleep the client is obtaining, but it does not address the issue causing the sleep disturbance, which is grief from the loss of the spouse.

2. The nurse recognizes that anticipatory grieving can be most beneficial to a client or family for which of the following reasons? a. It can be done in private. b. It can be discussed with others. c. It can promote separation of the ill client from the family. d. It allows time for the dying client and his or her loved ones to say goodbye and complete life affairs before the actual death or loss occurs.

ANS: D The benefit of anticipatory grief is that it allows time for "letting go"; the dying client and his or her loved ones are able to say goodbye and complete life affairs before the actual death or loss occurs. It is not most beneficial for grieving to take place only in private. It is important for grief to be acknowledged by others, and for those grieving to be able to receive the support of others in the grieving process. Anticipatory grieving can be discussed with others in most circumstances. However, anticipatory grief may be disenfranchised grief as well, meaning it cannot always be openly acknowledged, socially sanctioned, or publicly shared, such as grief over the death of a partner with acquired immune deficiency syndrome (AIDS). The discussion of grief with others can also take place with normal grief, after the loss has occurred. Anticipatory grieving is unique from normal grieving in that it allows time for "letting go" before the death occurs. Anticipatory grief is the process of disengaging or "letting go" that occurs before an actual loss or death has occurred. The benefit is not the separation of the ill client from the family as much as it is the process of being able to say good-bye, to put life affairs in order, and as a result, this type of grieving can help a client or family to progress to a higher emotional state.

8. Which of the following is the primary concern of the nurse in providing care to a dying client? a. Promoting optimism in the client and being a source of encouragement b. Intervening in the client's activities of daily living to allow the client to focus on his or her emotional state c. Allowing the client to be alone and expecting isolation on the part of the dying person d. Selecting interventions designed to maintain the client's dignity and self-esteem

ANS: D The focus in planning nursing care is to promote self-esteem and dignity by taking a therapeutic stance that conveys respect for the client as a whole person, with feelings, accomplishments, and passions independent of the illness experience. Optimism should not be the primary focus when caring for the dying client. The nurse should promote the client's self-esteem and allow the client to die in comfort and with dignity. The client should be allowed to make choices and perform as many activities of daily living independently as possible. This allows the client to maintain self-esteem and dignity. The client does not need to be left alone. The presence of the nurse or the family may indicate to the client that he or she is being cared for and is worthy of attention.

10. The nurse is preparing to assist the client in the end stage of her life. How should the nurse provide comfort for the client who is showing fatigue? a. Spend more time with the client. b. Limit the use of analgesics. c. Provide larger meals with more seasoning. d. Determine valued activities and schedule rest periods.

ANS: D To promote comfort in the terminally ill client, the nurse should help the client to identify values or desired tasks and then help the client to conserve energy for those tasks. Spending more time with the client conveys caring, and allows verbalization, but is not the best way to promote comfort for a fatigued client. The use of analgesics should not be limited. Controlling the terminally ill client's level of pain is a primary concern in promoting comfort. Nausea, vomiting, and anorexia may increase the terminally ill client's likelihood of inadequate nutrition. The nurse should serve smaller portions and bland foods, which may be more palatable.

3. The newly graduated nurse is assigned to his or her first dying client. How can the nurse best prepare to care for this client? a. Complete a course dealing with death and dying. b. Control his or her own emotions about death. c. Draw on the experience of the death of a loved one. d. Develop an understanding of his or her own feelings about death.

ANS: D When caring for clients experiencing grief, it is important for the nurse to assess his or her own emotional well-being and to understand his or her own feelings about death. The nurse who is aware of his or her own feelings will be less likely to place personal situations and values before those of the client. Although coursework on death and dying may add to the nurse's knowledge base, it does not best prepare the nurse for caring for a dying client. The nurse needs to have an awareness of his or her own feelings about death first, as death can raise many emotions. Being able to control one's own emotions is important; however, it is unlikely that the nurse would be able to do so if he or she has not first developed a personal understanding of his or her own feelings about death. Experiencing the death of a loved one is not a prerequisite to caring for a dying client. Experiencing death may help an individual mature in dealing with loss, or it may bring up many negative emotions if complicated grief is present. The nurse is best prepared by first developing an understanding of his or her own feelings about death.