Chapter 10: Grief and Loss

What question should nurses ask themselves to determine if the care they provide to the grieving client has been both therapeutic and client focused?

"Do I have the strength to be present and to facilitate the client who is grieving?" Explanation: Ongoing self-examination is an effective method of keeping the therapeutic relationship goal-directed and acutely attentive to the client's needs. Honestly answering if a nurse is still effective in the care he or she gives grieving clients is the most effective way to determine overall therapeutic approach. The remaining options are more nurse than client focused.

The nurse is assessing a client who reports feeling hopeless since a divorce. Which would be an appropriate question for the nurse to ask in order to determine mental health status for this client?

"Do you ever use drugs to help feel less emotional pain?" Explanation: Negative circumstances such as poverty, poor physical health, unemployment, divorce, abuse, neglect, and unresolved childhood loss generally precipitate feelings of hopelessness, helplessness, or worthlessness. These negative responses place a person at risk for depression, substance abuse, or other mental health disorders. History of mental illness, marrying again, and the client's thoughts on whether another person would love the client again are appropriate general assessment questions but not as directly focused on the client's mental health status as substance use.

The nurse explains to a client how important it is that the client is eating properly even though the client is in a personal crisis over the loss of a loved one. The client wants to know why this matters. What is the nurse's best response?

"It is important to give your body nutrition to manage this crisis." Explanation: The client in crisis needs nutrition to have the physical resources to manage a crisis- in this case, the loss of a loved one. Having a crisis affects a client by being physically exhausting and the client needs nutritional stores to help reduce the potential for injury. Eating regular meals will give the client something to focus on, and the client can spend time with other family members, who will worry less about the client, but these are not primary reasons for the client to eat.

Which phrase can do much to instill hope in the dying client?

"Let me tell you about your illness." Explanation: Hope is the ingredient of life that enables an individual to consider a future and to actively bring that future into being. One way the nurse can enable hope in the dying client is to provide honest information about the progress of the illness.

A client states to the nurse "I was just diagnosed with a terminal illness." What is the nurse's best response?

"What does that mean to you?" Explanation: The nurse should ask what the terminal illness means to the client. This is an open-ended question that allows the nurse to assess the client's understanding of the situation, and then ask follow-up questions or give information based on this. The client should not be given false reassurance that he/she is going to be just fine and asking the client about family members is a secondary question based upon the client's understanding of the illness. The client's other health problems are not relevant at the present time- it is most important to assess the nature of the terminal illness first.

The nurse is caring for a client who is extremely depressed after receiving a diagnosis of cancer. Which body language should the nurse adopt while speaking to the client in order to demonstrate an attentive presence? Select all that apply. -The nurse should keep her arms folded. -The nurse should stand facing the client. -The nurse should lean slightly toward the client. -The nurse should sit on one side of the client. -The nurse should maintain moderate eye contact while the client speaks.

-The nurse should stand facing the client. -The nurse should lean slightly toward the client. -The nurse should maintain moderate eye contact while the client speaks. Explanation: While speaking to a client who is experiencing grief, the nurse should maintain an attentive presence. The body language indicative of attentive presence includes facing the client (whether sitting or standing), slightly leaning toward the client, and maintaining moderate eye contact while speaking to the client. Keeping the arms folded while listening to the client closes off the nurse from the client. Sitting to the left or right of the client, unless the client has a hearing loss, also would close off communication between the nurse and the client.

Which assessment findings can most accurately be described as complicated grieving?

A person is unable to return to work after a sister's death 18 months ago Explanation: An inability to return to normal activities 18 months after a sibling's death is suggestive (though not definitive) of complicated grieving. Crying and having difficulties sleeping are not unusual and will often accompany healthy grieving. A feeling of "not doing enough" is common during grief and would only be considered dysfunctional if this became a long-term and all-encompassing belief.

A client diagnosed with terminal cancer is making plans to take flying lessons because that has always been the client's personal goal and it will allow the client to visit the client's elderly parents. What stage of death and dying according to Kübler-Ross is best illustrated in this description?

Acceptance Explanation: This example demonstrates characteristics of acceptance, as the client is showing evidence of coming to terms with death with the desire to fulfill wishes, make a will, visit relatives, and put affairs in order. This stage is unlike the bargaining stage where the client asks God or a higher power for more time to delay the inevitable loss. During the anger stage, the client expresses rage and hostility. In the depression stage, the client goes through a period of grief before death.

In which ways can anticipatory grief be helpful for the client and family?

Acceptance of impending death Explanation: Anticipatory grief allows the individual and others to get used to the reality of the loss or death and to complete unfinished business.

Which factor does not influence the grieving person's return to homeostasis?

Adequate self-awareness on the part of the nurse Explanation: Adequate self-awareness on the part of the nurse does not influence the grieving person's return to homeostasis as it is an individual experience. All other options do influence the grieving person's return to homeostasis.

After receiving word from the oncologist that the client's tumor is malignant, the client says to the nurse, "If you people had the faintest clue what you were doing, I wouldn't be like this." The nurse should recognize that the client may be experiencing which stage of grief?

Anger Explanation: The client's hostile statement indicates that the client may be in the anger stage of grief, during which an individual may become difficult or demanding.

A client has just been diagnosed with terminal brain cancer and given approximately 2 months to live. The client wishes to visit the client's mother soon to "say goodbye." The nurse acknowledges this reaction as what?

Anticipatory Explanation: Anticipatory grief refers to the reactions that occur when an individual, family, significant other, or friends are expecting a loss or death to occur. Bereavement is the process of grief that includes feelings of sadness, insomnia, poor appetite, deprivation, and desolation. Mourning describes an individual's outward expression of grief regarding the loss of a loved object or person. Loss is a change in the status of a significant object or situation.

A client is diagnosed with terminal kidney failure. The client's spouse demonstrates loss and grief behaviors. Which term accurately describes the spouse's experience?

Anticipatory grief Explanation: Anticipatory loss occurs when a person displays loss and grief behaviors for a loss that has yet to take place. It is often seen in the families of clients with serious or life-threatening illnesses and serves to lessen the effect of the actual loss of a family member.

A nurse is caring for a client with terminal cancer. The client states, "If I promise to change my bad habits, the cancer will go away." The nurse knows that this statement is an example of which of Kubler-Ross's stages of grief?

Bargaining Explanation: This scenario is an example of bargaining to prolong one's life. Denial serves as a temporary escape from reality. In the anger stage, the client appears difficult, demanding, and ungrateful. In the acceptance stage, the client has achieved an inner and outer peace due to a personal victory over fear.

A client is exhibiting a behavioral response to grief. When obtaining a health history, the nurse would expect which assessment finding to be noted?

Hostility Explanation: A behavioral response to grief include expressions of hostility, anger, and irritability. Stupor is not considered a behavioral response to grief. Calmness and sadness are emotional responses to grief.

The spouse of a client who died of breast cancer is still grieving 2 years later. What type of grief is the spouse experiencing?

Complicated Explanation: Unresolved grief is abnormal or distorted; it may be either unresolved or inhibited. In unresolved grief, a person may have trouble expressing feelings of loss or may deny them; unresolved grief also describes a state of bereavement that extends over a lengthy period. With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations.

The nurse is caring for a client whose spouse passed away several years ago. Upon assessment, the nurse finds that the client has a history of signs and symptoms of depression since the spouse's death. Which term correctly describes the client's response to the loss?

Complicated grief Explanation: Prolonged grieving and suffering from clinical depression may be considered outside the norm of the grieving process. The client suffering from complicated grief may suffer from these symptoms or may experience a void of emotion or suffer grief disproportionate to the event. Disenfranchised grief is the grief over the loss that cannot be expressed openly. Anger is the step in the grieving process where the client is developing awareness of the loss and expresses anger towards God, caregivers, or the health care providers. Outcry is also a phase of grief that accompanies outward expression of grief such as sobbing tearfully and crying loudly. The client starts developing awareness about the grief in this phase.

The nurse is caring for a client who has just been diagnosed with cancer. The client states that the client will "never be able to cope with this situation." What is the nurse aware that coping is?

Coping is the physiologic and psychological processes that people use to adapt to change. Explanation: Indicators of stress and the stress response include both subjective and objective measures. They are psychological, physiologic, or behavioral and reflect social behaviors and thought processes. The physiologic and psychological processes that people use to adapt to stress are the essence of the coping process. Coping is both a physiologic and psychological process, is a process used to adapt to change, and is a personal process used to adapt to change.

Which can correctly be identified as a behavioral response to grief?

Crying uncontrollably Explanation: Crying uncontrollably is a behavioral response to grief. Physiologic responses to grief include weight loss, lack of energy, and palpitations.

Which factor is likely to have the greatest impact on how a client responds to grief?

Cultural influences Explanation: Both the physical and emotional manifestations of grief may be culturally influenced. Culture also influences a how a person expresses their of grief.

The client has been recently diagnosed with cancer. When the nurse tells the client about the diagnosis, the client says, "I have been eating healthy food and working out regularly." According to the Kubler-Ross's stages of grieving, which stage of grief is the client in?

Denial Explanation: According to Kubler-Ross's stages of grieving, in the denial stage the client is in shock or disbelief about the loss. The statement by the client indicates that he or she does not believe that they have cancer, thus the client is in the denial stage. In the anger stage, the client would express anger of the loss toward God, friends, or health care providers. In the bargaining stage, the client tends to ask God or fate for more time and delay the loss. In the stage of depression, the client becomes aware of the loss.

The nurse is assessing a client who is recently divorced. The client tells the nurse that the memories of the client's former spouse are interfering with an ability to concentrate at work. According to Horowitz's stages of loss and adaptation, this is indicative of which stage?

Denial and intrusion Explanation: According to Horowitz's stages of loss and adaptation, in the stage of denial and intrusion, the client at times becomes so intensely preoccupied with the memories of the loss that they intrude into every moment and activity of the client's day. In the stage of outcry, the client realizes the loss for the first time. Outcry could be expressed outwardly or suppressed internally. Completion is the stage where the client becomes normal and the memories of the loss do not intrude in the day-to-day life any longer. In working through this stage, the client does think about the loss but also tries to find ways to manage with the loss.

Which likely takes place in the fourth stage of Kubler-Ross's stages of grieving?

Depression Explanation: Depression occurs when the person shows evidence that he or she is sad and despairing over the inevitability of loss. Denial is shock and disbelief regarding the loss. Bargaining occurs when the person asks God or fate for more time to delay the inevitable loss. Anger may be expressed toward God, relatives, friends, or health care providers.

A client's children have downplayed their grief following the death of their mother's partner, claiming that their mother and her partner were only together for a few months and that "he was no good for her anyways." The client is at risk of experiencing which type of grief?

Disenfranchised grief Explanation: Disenfranchised grief is a term that describes the experience of individuals whose grief is not acknowledged or supported by their social network or who are excluded from participating in grief-related rituals.

Which is a term used to describe grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially?

Disenfranchised grief Explanation: Disenfranchised grief is grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially. Anticipatory grieving is when people facing imminent loss begin to grapple with the very real possibility of the loss or death in the near future. Bereavement refers to the process by which a person experiences the grief. Mourning is the outward expression of grief.

When working with a grieving client, which is the most effective intervention a nurse can use?

Encourages the client to express grief verbally Explanation: The best way to help an individual who is grieving is to listen, be empathic, acknowledge the loss, and experience the event at his or her own pace. He or she should be encouraged to express grief verbally. The other methods of grieving may be effective but are likely not most effective.

Which explanation would be the nurse's best response when asked about the denial stage of grief?

It provides the individual with a temporary escape from the reality of dying Explanation: The nurse explains that the purpose of the denial stage of grief is to provide the individual with a temporary escape from the reality of dying. Its purpose is not to give all involved a chance to hope a mistake has been made, not to provide an opportunity to adjust to the realization that death will occur, and not to afford the individual a chance to prepare for the death experience.

The client expresses grief about not being able to fulfill the wish to pursue doctoral studies. Which type of loss does this indicate?

Loss related to self-actualization Explanation: The loss due to an external or internal crisis that inhibits the individual's desire for fulfillment of personal goals is referred to as loss related to self-actualization. In this case, the client is grieving about not being able to fulfill a wish to do doctoral studies, meaning the client is unable to fulfill a goal. Thus, this is a type of loss related to self-actualization. Safety loss refers to the loss of a safe environment. Loss of self-esteem refers to the change in how a person is valued at work or in relationships or by himself or herself. Loss of security and a sense of belonging refer to the changes in relationships that affect an individual's need to love and the feeling of being loved.

A woman has had a breast removed to treat cancer. What type of loss will she most likely experience?

Physiologic loss Explanation: Loss occurs when a valued person, object, or situation is changed or made inaccessible so that its value is diminished or removed. Physiologic loss can be recognized by others as well as by the person sustaining the loss.

The nurse is caring for a client who has been placed in palliative care. The nurse observes the client constantly looking at photographs from youth. According to the tasks of grieving by Rando, which task is being accomplished here?

Recollect Explanation: The client is being treated for cancer. The client looks at the photographs from youth that remind the client of earlier days when the client was healthy and beautiful. This indicates that the task of recollecting and reexperiencing is being accomplished. In the task of reacting, the client responds emotionally to the loss. In the task of recognizing, the client begins to develop the sense of awareness of the loss. In the task of relinquishing, the client starts accepting the loss and its influence in the client's life.

The nurse is informing the client about being diagnosed with cancer. Which is most likely going to be the client's initial reaction?

Shock Explanation: Upon receiving the diagnosis of the disease, the client is most likely to be in a state of shock or disbelief. Shock is considered a universal reaction to loss. During this phase, the client is unable to accept the loss. Anger is most likely the next reaction. It is where the client would express anger toward God, family, and health care providers. Anxiety occurs when the client is waiting for the diagnosis and also when the client accepts the loss and starts feeling helpless. Once the client has accepted the loss, the client starts having negative feelings such as depression.

The nurse is working with a group of clients in the prewarning phase of a disaster. Which situation best describes this phase?

The clients are reviewing evacuation routes for a flood. Explanation: The clients in the prewarning phase of a disaster would be preparing in the event of a disaster. This would involve learning evacuation routes for a flood as an example of this. The clients being rescued from a house fire would be in the phase of the disaster occurring and the clients cleaning up the site damaged as well as being transported to safety are in the recuperative effort phase of a disaster.

Which type of grief occurs when a person is stuck in a state of chronic grieving?

complicated grief Explanation: During complicated grief, the person is frozen or stuck in a state of chronic mourning. Most bereaved people experience normal or uncomplicated grief after the loss of a loved one. Traumatic grief is a more difficult and prolonged grief in which external factors influence the reactions and potential long-term outcomes. Bereavement is the process of mourning and coping with the loss of a loved one.

After losing the client's father in a car accident, a client has started practicing effective coping strategies. According to Horowitz's stages of loss and adaptation, which stage is this indicative of?

Working through Explanation: According to Horowitz's stages of loss and adaptation, in the working through stage the client begins to find new ways of managing life after loss. In this case, the client has consulted a psychologist and is trying to learn effective coping strategies. This indicates that the client has started to find ways to manage with the loss. Thus, the client is in the working through stage. In the stage of outcry, the client realizes the loss for the first time. This outcry could be expressed outwardly or suppressed internally. Completion is the stage where the client becomes normal and the memories of the loss do not intrude into the day-to-day life any longer. In the stage of denial and intrusion, the client at times becomes so intensely preoccupied with the memories of loss that they intrude into every moment and activity of the client.

A nurse is counseling a client with depression on what to do in case the client has suicidal thoughts. Which option may provide the most immediate help for the client?

a telephone hotline Explanation: A telephone hotline is an immediate solution for a client to speak with to help with mental health services if having thoughts of suicide. The client would then want to transport to an emergency clinic for face-to-face evaluation and treatment. An outpatient clinic or office visit would not provide emergency treatment for a client who is suicidal.

A nurse is conducting a visit to a client who is receiving palliative care at home for dying. The client's husband tells the nurse, "I know she needs to be with God. This is not a good place for her now." The client is experiencing which stage of Kubler-Ross' stages of grieving?

acceptance Explanation: The client's statement to the nurse indicates evidence of the fact that he is coming to terms with his inevitable loss. The client is in the acceptance stage of Kubler-Ross' stages of grieving. The stage of depression refers to the experience of symptoms such as low mood, isolation and loss of interest/pleasure in response to the pending loss. The stage of bargaining refers to when clients ask God or fate for more time to delay the inevitable loss. The stage of anger consists of the expression of angry emotion toward God, relatives, friends, or health care providers.

A nurse is facilitating a support group for family members of people who have committed suicide. One client states,"My kids and I are just not the same. It was so selfish of my husband to do this." The nurse can accurately identify this as which type of response to grief?

emotional Explanation: Feelings of anger are common when death has resulted from extreme circumstances such as suicide. In addition to despair and anger, some people may also experience feelings of loss of control in their lives. The statement made by this client is reflective of an emotional response to grief. A spiritual response to grief, a person would more likely feel or verbalize anger towards God or other religious figures. This type of response is deeply embedded in personal values related to an individual's spirituality. A behavioral response to grief is characterized by what others can observe in the grieving person for example, becoming heavily engrossed in distracting work, often sobbing uncontrollably or avoiding places that are associated with the deceased. A physiologic response to grief is characterized by physical or health problems resulting from adapting to the loss. Commonly, people report insomnia, changes in appetite, weight loss, palpitations and gastrointestinal problems.

A client is experiencing a high level of stimulation after a terrorist attack. In providing psychological first aid to the client, which intervention would be best for the nurse to select?

explaining to the client that the client is safe Explanation: The client who has arousal as a result of a crisis such as a terrorist attack needs safety, comfort and consolation. Explaining to the client that the client is safe offers comfort to help decrease the arousal or high level of stimulation that is being experienced (the A in ABCs). With the C in the ABCs of psychological first aid, the nurse is helping with cognition difficulty such as disorientation by providing orientation including information about the attack. The nurse is also helping with cognition by telling the client about needing to go to the hospital which provides clear direction.

A client with poorly controlled type 1 diabetes has just been informed that an amputation of the lower leg is required. The nurse can anticipate that the client will experience a reaction to the loss of which human need according to Maslow's hierarchy?

physiologic Explanation: The client is about to experience physiologic loss of the lower right leg. The client is most likely to experience a reaction to this loss of human need according to Maslow's hierarchy. Safety loss refers to the loss of a safe environment such as in domestic abuse, child abuse, or public violence. Loss of security and belonging refers to the loss of loved ones. This loss can accompany the changes in relationships such as births, marriage, divorce, illness and death. The loss of self-actualization refers to potential life losses as a result of internal or external inhibition of the ability to strive toward fulfillment of individual potential.

The nurse is caring for a hospitalized client who just received the news that a mass in the neck is malignant. As the nurse engages in an assessment of the client's needs, the nurse asks, "Who has been a helpful person to you in the past when you were having a difficult time?" Which component of the assessment is the nurse exploring?

support while grieving Explanation: In this situation, the nurse asks this question to assess the the quality of the client's support system. The nurse intends to provide the grieving client with an awareness of those who can meet the client's emotional and spiritual needs for security and love. Asking about who was helpful in previously difficult times can make this decision easier for the client. When exploring the perception of loss, the nurse should ask open-ended questions to determine what the loss means to the client. When exploring coping behaviors, the nurse should ask questions about how the client has coped with difficulty in the past or look for clues such as changes in appetite or avoiding visitors. Anticipatory grieving refers to when people face an imminent loss and begin to grapple with the very real possibility of the loss. Question pertaining to this concept would be asked when exploring the client's perception of loss in the assessment.

A nurse in charge on a unit with a client who is receiving postoperative care for a below the knee amputation is deciding which nurse to assign to this client. Which nurse would be most beneficial for the client?

the nurse who has worked with the client before and after the amputation Explanation: In this case, the charge nurse's best option for nursing assignment to this client is to assign the nurse who has worked with the client before and after the amputation. At present the client's ability to relate to others may be impaired. Limiting the number of new contacts initially will promote familiarity and trust and decrease the client's feelings of being overwhelmed.

A client is crying uncontrollably after having experienced an assault by a family member. The nurse is aware that the client is experiencing which type of crisis?

traumatic Explanation: The client is undergoing a traumatic crisis, which is an unexpected and unusual event that can cause injury, trauma, destruction, or sacrifice. A developmental crisis is a significant maturational event such as graduation from high school or leaving home for the first time. The client experiencing a situational crisis would experience an internal or external event that challenges biopsychosocial integrity, requiring adaptation, but is not violent; examples include moving to another city or accepting a job promotion. The familial crisis is not a specific type of crisis; a crisis involving the family could be any of the three types mentioned.