Ch 37 The Experience of Loss, Death, and Grief

A patient who has a serious, life-limiting chronic illness wants to continue to engage in self-care and live as normally as possible. Which nursing responses reflect a helpful understanding of patient self-care at the end of life?

"Learning to accept that you can't perform some activities anymore will bring you more acceptance and peace." Correct2 "Which activities are most important to you, and how can you continue to do them?" 3 "People in your life want to help you with things; allow them to do what they want for you." 4 "Spending more of your time resting or reading will conserve your energy." Even seriously ill people want to carry on with life, doing what they can to maintain their identity and purpose. They know best how to regulate their energy and wishes for how to spend their time. The nurse should not encourage the patient to scale back on their most valued activities or suggest that the patient needs others to help them with things.

Which patient may experience intangible loss?

1 A patient who lost a hand 2 A patient who lost his parents Correct3 A patient who lacks confidence 4 A patient with transient paralysis Self-esteem, confidence, or dreams are considered intangible loss. Therefore, a patient lacking confidence is experiencing intangible loss. A body part or body function, relationship, or possessions are considered tangible things. Therefore, a patient who lost a body part such as a hand; a patient who lost parent-child relationship due to death of parents; and a patient who lost use of a body part is experiencing tangible loss.

Which loss occurs when the lost person is physically present but not psychologically available?

1 Actual loss 2 Perceived loss 3 Situational loss Correct4 Ambiguous loss Ambiguous loss is a type of disenfranchised grief which occurs when the person is physically present but psychologically unavailable. Actual loss occurs when a person no longer can see, feel, or hear a person or object. Perceived loss is uniquely defined by the person experiencing loss that is less obvious to other people. Unpredictable external events result in situational loss such as leading to loss of function due to an accident.

The nurse observes noisy breathing when caring for a terminally ill patient. Which condition in the patient would the nurse evaluate to determine the cause?

1 Anemia 2 Increased oxygen demand 3 Anticholinergic medications Correct4 Thick secretions in the airway Noisy breathing, also known as a death rattle, is caused by thick secretions in the airway and decreased muscle tone, swallow, and cough. Noisy breathing refers to the sound of secretions moving in the airway during inspiratory and expiratory phases. It indicates the last stage of life. It does not occur due to an anemic condition, increased oxygen demand, or anticholinergic medications. Anemic conditions and increased oxygen demand cause dyspnea or shortness of breath. Anticholinergic medications are helpful to relieve noisy breathing by decreasing secretions.

A patient diagnosed with terminal stage cancer says, "I will seek a second opinion and have the tests done again at another hospital." Which stage of the Kübler-Ross theory is reflected in the patient's statement?

1 Anger Correct2 Denial 3 Bargaining 4 Depression The Kübler-Ross theory of grief and mourning (1969) consists of five stages. When the patient is unable to accept the fact that he or she is in the terminal stage of cancer, it indicates denial. As a result, the patient wants to perform the tests again in another hospital. Anger is the expression of resistance or anger towards God or other people. Bargaining is characterized by postponing awareness of the loss by trying to prevent it from happening. Depression is characterized by the individual realizing the full impact of the loss. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

Which critical thinking skill does the nurse use when considering how cultural perspectives impact the meaning of loss/death in a patient?

1 Attitudes 2 Standards 3 Experience Correct4 Knowledge The nurse uses the knowledge approach to critical thinking skills to understand the cultural perspectives on the meaning of loss/death in the patient. Attitudes is the critical thinking approach that involves taking risks if necessary to develop a close relationship with the patient to understand loss. Standards is the critical thinking approach that uses applying principles outlined in professional and clinical standards. Experience is the critical thinking approach used to care a patient who experienced a physical or emotional loss.

Which type of complicated grief response is observed in a patient whose disruptive behavior interferes with normal functioning?

1 Chronic grief Correct2 Masked grief 3 Delayed grief 4 Exaggerated grief In masked grief, the patient's disruptive behavior interferes with normal functioning. The patient is unaware that the behavior is a result of loss and ineffective grief resolution. In chronic grief, the patient may experience a normal grief response that extends for an extended period of time. A person's grief response may be delayed because the loss is so overwhelming that the person must avoid the full realization of the loss. In exaggerated grief, the person may exhibit self-destructive or maladaptive behavior, obsessions, or psychiatric disorders. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

Two friends were involved in a motor-vehicle accident. One of them died, and the survivor attempted suicide due to feeling responsible for the friend's death. Which grief type is indicated by the patient's presentation?

1 Delayed grief 2 Masked grief Correct3 Exaggerated grief 4 Uncomplicated grief The patient is experiencing exaggerated grief. In exaggerated grief, people blame themselves for a loss. The person with exaggerated grief is at a high risk of suicide and should be constantly monitored. In certain situations, a loss is so overwhelming that the person takes time to realize and react to it. This is referred to as delayed grief. In masked grief, the person shows disruptive behavior but is unaware that the disruptive behavior is a result of the loss. Uncomplicated grief is a common reaction characterized by complex emotional, cognitive, social, and spiritual responses to loss.

A family member asks the home care nurse what to do if the patient's serious chronic illness worsens even with increased medical interventions. How should the nurse best begin a conversation about the goals of care at the end of life?

1 Encourage the family member to think more positively about the patient's new therapy. 2 Avoid the discussion because it has to do with medical, not nursing, diagnoses. 3 Initiate a discussion about advance directives with the patient, family, and health care team. Correct4 Ask the patient to identify beliefs about the goals of care while the family member is present. By first determining what the patient believes is best, the nurse can then discuss that option in more detail and give realistic ways of reaching the desired goal. Discussing other possible options after identifying the patient's preferences helps family members know and understand the patient's wishes. Test-Taking Tip: Always consider the patient's feelings when making your choice.

According to attachment theory, which action represents disorganization and despair?

1 Feeling lethargic and loss of appetite 2 Emotional outbursts of tearful sobbing 3 Separating oneself from the lost relationship Correct4 Endless examination of how and why the loss has occurred According to attachment theory, endless examination of how and why the loss has occurred represents disorganization and despair. Feeling lethargic, loss of appetite and emotional outbursts of tearful sobbing represents yearning and searching. In a stage of reorganization, person separates himself or herself from the lost relationship. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining.

Which theory of grief and mourning explains common grief, chronic grief, chronic depression, and depression followed by improvement of resilience?

1 Grief tasks model 2 Attachment theory 3 Dual process model Correct4 Trajectories of bereavement Trajectories of bereavement theory for grief and mourning describe common grief, chronic grief, chronic depression, depression followed by improvement, and resilience. The grief tasks model for grief and mourning by Worden (2008) describes accepting the reality of the loss, experiencing the pain of grief, adjusting to the world in which the deceased is missing, emotionally relocating the deceased and moving on with life. The attachment theory of grief and mourning by Bowlby (1980) explains numbing, yearning and searching, disorganization and despair, and reorganization. The dual process model theory for grief and mourning by Stroebe and Schut (1999) explains loss-oriented activities and restoration-oriented activities.

A patient is in the terminal stages of acquired immunodeficiency syndrome (AIDS) and reports chronic dull pain. On assessment the nurse finds that the patient does not have a family and has nobody to provide care. Which is the most appropriate nursing action in this situation?

1 Hospitalize the patient in the intensive care unit. Correct2 Provide hospice care to the patient. 3 Provide acute care to the patient. 4 Seclude the patient in a separate room. The patient is terminally ill and has chronic dull pain; therefore the patient needs hospice care to improve the quality of life during the last days of life. The patient does not need hospitalization, because the condition cannot be cured. Acute care refers to the short-term treatment for an episode of illness or severe injury. In this situation the patient has an irreversible terminal illness that cannot be managed by acute care. Seclusion would make the patient depressed. STUDY TIP: Remember that hospice care is palliative, not curative. It is appropriate when a cure is not possible and the patient's comfort becomes the highest priority.

A patient refuses to accept the death of a child. The patient no longer has a job, avoids communication with others, and remains aloof. Which grief type is indicated by the patient's presentation?

1 Normal grief Correct2 Complicated grief 3 Anticipatory grief 4 Disenfranchised grief The patient is experiencing complicated grief. In complicated grief, a person has a difficult time moving forward after a loss. The patient experiences a chronic and disruptive yearning for the deceased; has trouble accepting the death and trusting others; and/or feels excessively bitter, emotionally numb, or anxious about the future. In normal grief, the person shows a common reaction characterized by complex emotional, cognitive, social, and spiritual responses to loss and death. In anticipatory grief, the grief extends over a long period of time, beginning before the actual loss occurs; the person absorbs loss gradually and prepares for its inevitability. Disenfranchised grief occurs when the relationship of the person with the deceased is not socially sanctioned, cannot be openly shared, or seems to be of lesser significance.

A patient states, "I have been depressed since the death of my ex-husband." What type of grief does the nurse anticipate that the patient is experiencing?

1 Normal grief 2 Anticipatory grief 3 Complicated grief Correct4 Disenfranchised grief In disenfranchised grief, the patient may be depressed due to the death of his or her ex-spouse, or extramarital partner. Normal grief is a common and universal reaction and the patient may have feelings such as disbelief, yearning, anger, and depression. The patient may experience anticipatory grief before the actual loss or death occurs. In complicated grief, a person has a prolonged or significantly difficult time moving forward after a loss.

In which stage of mourning described by Bowlby's attachment theory does a person accept change, acquire new skills, and build new relationships?

1 Numbing Correct2 Reorganization 3 Yearning and searching 4 Disorganization and despair In the reorganization stage of mourning, the person accepts change, acquires new skills, and builds new relationships. In this stage the person is trying to create separation from a lost relationship. In the numbing stage, the person feels unreal. In the yearning and searching stage, the person experiences an inner and intense yearning for the lost person. In this stage the person also shows some physical symptoms. In the disorganization and despair stage, the person extends blame and expresses anger towards anyone who is responsible for the loss.

A young man is diagnosed with a serious, life-changing illness. His conversations during his first 2 days of hospitalization are abrupt, superficial, and unrelated to his illness. Which understanding about communication would enhance therapeutic communication with this patient?

1 Younger patients are usually less talkative about their diagnosis. 2 All patients benefit by talking about their feelings with another person. 3 The nurse should avoid discussing illness-related topics with quiet patients. Correct4 The nurse should remain alert for signals that the patient wants to discuss his illness. The nurse should make no presumptions about this patient other than the fact that he is not yet ready to talk about his situation but should stay alert for a time when he might want to talk. Some people do not work through their problems by talking to others. Test-Taking Tip: Look for absolute words when eliminating choices. For this question, you can eliminate the choices that use all patients and quiet patients. (The term quiet patients implies all quiet patients.)

Which statement about hospice care needs correction?

1 It is available in homes. 2 It provides care for terminally ill patients. 3 It gives priority to managing a patient's pain and other symptoms. Correct 4 It accepts the patient into the program when the survival period is 10 months. Hospice services accept the patient into the program when the survival period is less than 6 months. These services are available in home, hospital, extended care, and nursing home settings. This model of care provides care for terminally ill patients. It gives priority to managing a patient's pain and other symptoms.

The nurse is providing postmortem care. Which action is the priority?

1 Locating the patient's clothing Correct2 Providing culturally and religiously sensitive care in body preparation 3Transporting the body to the morgue as soon as possible to prevent body decomposition 4Providing all postmortem care to protect the family of the deceased from having to see the body At the end of life, religious and cultural expectations are important for the lasting memories held by the family about the way their loved one's death occurred. Sensitive care contributes to feelings of closure, appropriateness of the death rituals, and fulfilled family obligations. A body should be placed in the morgue soon after death, but it is more important to provide sensitive and dignified care to the deceased.

A patient newly diagnosed with colon cancer has withdrawn from family members. Which strategy should the nurse use to assist the patient at this time?

1 Obtain a prescription for a psychiatric evaluation. Correct 2 Encourage the patient to identify fears and verbalize feelings. 3 Allow the patient to remain withdrawn to avoid drawing attention to this behavior. 4Explain to the patient that newer treatments permit many people to survive colon cancer. The nurse recognizes that the patient could be expressing feelings of grief. The nurse should encourage the patient to verbalize feelings and identify fears. This would help the patient to move through the phases of the grief process. The patient does not need a psychiatric evaluation, as this is a normal grief process and not a psychiatric disorder. The patient should not be left alone because the patient needs support to cope with the illness. Explaining newer treatment options may not affect the grief process. Test-Taking Tip: Look for answers that focus on the patient or are directed toward feelings. Review the choices for this question again and notice that the correct answer focuses on the patient's feelings.

The registered nurse is teaching a nursing student about non-pharmacological interventions that decrease nausea for terminally ill patients. Which statement made by the nursing student nurse indicates effective learning?

1"I will provide cool air in the room." 2"I will provide massage therapy to the patient." Correct 3 "I will encourage the patient to lie on the right side." 4"I will provide background music of patient's choice." The patient is encouraged to lie on right side when he/she complains of nausea. The nurse should provide cool air in the room if the patient is suspected to have ineffective breathing pattern. The nurse should massage the body of the patient at the site of pain. The nurse should provide background music of patient's choice so that patient may divert his/her mind from pain by providing soothing environment.

A patient who lost a spouse in an accident says, "I miss my partner. I will never get my partner back." Which stage of dying, according to Kübler-Ross theory of grief and mourning, is reflected in the patient's statement?

Anger 2 Denial 3 Bargaining Correct4 Acceptance The Kübler-Ross theory of grief and mourning consists of five stages of dying. When the patient accepts the death of the partner, it indicates acceptance. When the patient expresses anger or resistance towards God or others, it indicates anger. When the patient cannot accept the loss, it indicates denial. When the patient postpones awareness of the loss by trying to prevent it from happening, it indicates bargaining.

While caring for the body of a deceased patient, the nurse attaches an eagle feather to the patient. Which culture is reflected in the nurse's action?

Chinese 2 Hispanic 3 Buddhist Correct4 Native American Native Americans are diverse tribal groups with different practices, traditions, and ceremonies. According to their culture, after cleaning the body, an eagle feather is attached to symbolize a return home. Chinese cultural rituals involve bathing the body by the eldest son or daughter under the direction of priest or elder relative. Hispanic cultural rituals involve amulets or rosary beads, healing practices (folk medicine), and prayer. Buddhist cultural rituals involve not touching the body after death.

Which critical thinking skill will the student nurse use to deliver high-quality, supportive care while planning treatment for a patient with grief and loss?

Correct1 Attitudes 2 Standards 3 Experience 4 Knowledge Critical thinking model for loss, death, and grief planning helps the nurse to plan the care for the patients. The attitudes approach in the critical thinking model helps the nurse to deliver high-quality supportive care. The standards approach is used to provide privacy for the patient and family and apply ethical principles of autonomy in supporting the patient's choice regarding treatment. The experience approach uses previous patient responses to planned nursing interventions for pain and symptom management or loss of a significant other. The knowledge approach uses spirituality as a resource for dealing with loss.

While caring for the deceased body of a patient, the nurse places the body on the floor with the head facing north. What might be the culture of the patient?

Correct1 Hindu 2 Jewish 3 Islamic 4 Buddhist The cultural or religious practices of Hindus involve placing the body on the floor with the head facing north. Jewish cultural rituals do not include placing the body on the floor with the head facing north. The dead body should be turned towards Mecca according to Islamic culture. Buddhist cultural rituals do not include placing the body on the floor with the head facing north.

If the family of a dying patient is highly emotional and critical of the nursing care, which action by the nurse is appropriate?

Correct1 Listen to concerns and provide reassurance. 2 Explain all interventions in technical terms. 3 Request that the nursing supervisor talk to the family. 4 Avoid the patient's family as much as possible to reduce confrontations. The family of a dying patient often responds emotionally due to stress and frustration. Active listening and reassurance can help reduce this reaction. Explaining interventions in highly technical terms may increase the family's sense of stress as they try to understand the process. Asking for a nursing supervisor or avoidance may actually increase the family's sense of frustration.

A 50-year-old patient discusses the recent loss of his spouse with the nurse during a routine checkup. Which findings in the patient would indicate grief? Select all that apply.

Correct1 Lack of energy Correct2 Lack of interest 3 Desire to move around 4 Increased communication Correct5 Insomnia Grief reactions include a lack of energy, lack of interest, and insomnia. Desire to move around and increased communication are not associated with grief reactions.

The nurse is caring for a terminally ill patient. Which physical changes in the patient suggest that death is near? Select all that apply.

Correct1 Noisy respirations 2 Increased urine output Correct3 Decreased muscle tone Correct4 Decreased intake of food 5 Decreased periods of sleeping As a patient nears death, body systems tend to slow down. Noisy respirations are due to pooling of secretions in the lungs. Muscle tone is reduced as the muscles become flaccid. Food intake is usually reduced because of the failure of the gastrointestinal system to function properly. Urine output is decreased because fluid intake is reduced and the urinary system stops working. The patient tends to sleep most of the time because the brain and nervous system slow down their functions. Test-Taking Tip: The key to the correct response is knowing that the body systems slow down as the patient approaches death. When evaluating questions like this one, ask yourself whether each choice is an increase in function or a decrease in function for that particular system. Both incorrect choices reflect an increase in function, one for the urinary system and the other for the nervous system. The correct choices reflect decreased function, consistent with the patient being near death.

A patient states, "I have been depressed since the death of my son 10 years ago." The nurse suspects chronic grief in the patient. Which theory of grief and mourning would explain this diagnosis?

Grief tasks model 2 Attachment theory 3 Rando's "R" process model Correct4 Trajectories of bereavement Trajectories of bereavement explains common grief, chronic grief, and chronic depression. In the grief tasks model the patient accepts the reality of loss and experiences the pain of grief. Attachment theory explains denial, anger, bargaining, depression, and acceptance. Rando's "R" process model explains recognizing, reacting, reminiscing, relinquishing, readjusting, and reminiscence.