Chapter 17: Loss, Grief & Dying
According to William Worden, which task in the grieving process takes longest to achieve? 1) Accepting that the loved one is gone 2) Experiencing the pain from the loss 3) Adjusting to the environment without the deceased 4) Investing emotional energy
1) Accepting that the loved one is gone Worden described the tasks a grieving person must achieve. They progress from an initial numbness or denial through experiencing and working through pain and grief and eventually moving on with life. Shock with disbelief is not a Worden task.
Which dysrhythmia confirms death? 1) Asystole (absence of heart activity) 2) Pulseless electrical activity 3) Ventricular fibrillation 4) Ventricular tachycardia
1) Asystole (absence of heart activity) Asystole is a dysrhythmia that commonly serves as a confirmation of death. Pulseless electrical activity, ventricular fibrillation, and ventricular tachycardia are potentially lethal dysrhythmias that may respond to treatment.
The nurse has been explaining advance directives to a patient. Which response by the patient would indicate that he has correctly understood the information? "An advance directive is a document 1) Specifying your healthcare intentions should you become unable to make self-directed decisions" 2) Identifying the activities considered to be evidence of quality care" 3) Verifying your understanding of the risks and benefits associated with a procedure" 4) Allowing you the autonomy to leave the hospital when you decide, even if it is against medical advice"
1) Specifying your healthcare intentions should you become unable to make self-directed decisions" An advance directive is a group of instructions stating the patient's healthcare wishes should he become unable to make decisions. The Patient Care Partnership is a document that helps to ensure that patients receive quality care. An informed consent form verifies the patient's understanding of risks and benefits associated with a procedure. An "against medical advice" form allows the patient to leave the hospital against medical advice and releases the hospital of responsibility for the patient.
Throughout the course of his illness, a patient has denied its seriousness, even though his health professionals have explained prognosis of death very clearly. Physiologic signs now indicate that he will probably die within a short period of time, but he is still firmly in a state of emotional denial. The patient says to the nurse, "Tell my wife to stop hovering and go home. I'm going to be fine." How should the nurse respond? 1) "Your physical signs indicate that you will likely not live more than a few more days." 2) "You seem very sure that you are not going to die. Please tell me more about what you are feeling." 3) "It seems to me you would be feeling some anger and wondering why all this is happening to you." 4) "It would be best for your family if you were able to work through this and come to accept the reality of your situation."
2) "You seem very sure that you are not going to die. Please tell me more about what you are feeling."
A patient's wife tells the nurse that she wants to be with her husband when he dies. The patient's respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best? 1) "Certainly, go ahead; your husband will most likely hold on until you return." 2) "Your husband could live for days or a few hours; you should do whatever you are comfortable with." 3) "You need to take care of yourself; go home and shower, and I'll stay at his bedside while you are gone." 4) "Don't worry. Your husband is in good hands; I'll look out for him."
2) "Your husband could live for days or a few hours; you should do whatever you are comfortable with." The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husband's bedside. The nurse should not offer false reassurance by stating that the patient will most likely be fine until the wife's return. The nurse should not offer her opinion by telling the wife that she needs to take care of herself. It is also unrealistic for the nurse to stay with the patient until his wife returns. The nurse would be minimizing the wife's concern by telling her not to worry because her husband is in good hands. The issue for the family member is not trust in the competency of the healthcare provider but rather wanting to be present with her spouse at the time of death.
According to the Uniform Determination of Death Act, which bodily function must be lost to declare death? 1) Consciousness 2) Brain stem function 3) Cephalic reflexes 4) Spontaneous respirations
2) Brain stem function According to the Uniform Determination of Death Act, death can be declared when there is a loss of brain stem function. Higher-brain death occurs when there is a loss of consciousness, cephalic reflexes, and spontaneous respirations.
A home health patient previously lived with her sister for more than 20 years. Although it has been over a year since her sister died, the patient tells the nurse, "It's no worse now, but I never feel any relief from this overwhelming sadness. I still can't sleep a full night. The house is a mess; I feel too tired, even to take a bath. But, sometimes at night, she comes to me and I can see her plain as can be." The patient's clothing is not clean and her hair is not combed. She is apparently not eating adequately. What can the nurse conclude? The patient is probably 1) Grieving longer than usual because of the closeness of the relationship with her sister 2) Experiencing a depressive disorder rather than simply grieving the loss of her sister 3) Feeling guilt and worthlessness because her sister died and she is still alive 4) Interpreting the holiday as a trigger event, which is causing her to hallucinate
2) Experiencing a depressive disorder rather than simply grieving the loss of her sister The patient is likely experiencing a depressive disorder. Her symptoms include unrelieved, overwhelming sadness; insomnia; difficulty carrying out ADLs; fatigue; and visual hallucinations. Note that her sadness is pervasive, not created by a trigger event (holiday). Of those symptoms, insomnia is common to both grief and depression, but the other symptoms are signs of depressive disorder. There is, of course, no "correct" timeline for what constitutes "longer than usual" grieving; however, the patient's symptoms are typical of depression, not grief. She has not said she feels guilty or worthless, and there is nothing from which the nurse could infer that. She has specifically said that the holiday has not made her feel any worse—that is, it has not been a trigger event.
Which of the following might be a warning sign that a child needs professional help after the death of a loved one? Choose all that apply. 1) Interest in his usual activities 2) Extended regression 3) Withdrawal from friends 4) Inability to sleep 5) Intermittent sadness
2) Extended regression 3) Withdrawal from friends 4) Inability to sleep The warning signs that may indicate the need for professional help include inability to sleep, extended regression, loss of interest in daily activities, and withdrawal from friends. Interest in usual activities is a sign of coping; intermittent expressions of sadness and anger are to be expected, even over a long period of time, so they would not indicate a need for professional help.
Which of the following patient goals is most appropriate when managing the patient dying of cancer? The patient will 1) Request pain medication when needed 2) Report or demonstrate satisfactory pain control 3) Use only nonpharmacological measures to control pain 4) Verbalize understanding that it may not be possible to control his pain
2) Report or demonstrate satisfactory pain control The most important goal is that the patient will report or demonstrate satisfactory pain control. The nurse should administer pain medication on a regular schedule to ensure satisfactory pain control; pain may not be controlled if medication is administered on an "as needed" basis. Nonpharmacologic measures can be a helpful adjunct in controlling pain, but they are not likely to be adequate for pain associated with cancer. Effective pain-control medications are available and can be administered by several routes; it should be possible to control the pain.
Which patient is at most risk for experiencing difficult grieving? 1) The middle-aged woman whose grandmother died of advanced Parkinson's disease 2) The young adult with three small children whose wife died suddenly in an accident 3) The middle-aged person whose spouse suffered a slow, painful death 4) The older adult whose spouse died of complications of chronic renal disease
2) The young adult with three small children whose wife died suddenly in an accident Although it is impossible to predict with certainty and the grieving process is highly individual and personal, in general those who suffer a sudden loss typically have more difficult grieving than those who have had the time to prepare for the death. Family and friends of persons with chronic illnesses (e.g., cancer) have usually had time to emotionally prepare for the death, initiate the funeral and burial arrangements, and begin the grieving process before the death occurs.
When providing postmortem care, the nurse places dentures in the mouth and closes the eyes and mouth of the patient within 2 to 4 hours after death. Why is the timing of the action so important? 1) To prevent blood from settling in the head, neck, and shoulders 2) To perform these actions more easily before rigor mortis develops 3) To set the mouth in a natural position for viewing by the family 4) To prevent discoloration caused by blood settling in the facial area
2) To perform these actions more easily before rigor mortis develops Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures in the mouth and close the patient's eyes and mouth before that time. The nurse should place a pillow under the head and shoulders to prevent blood from settling there and causing discoloration. Closing the patient's mouth and tying a strip of soft gauze under the chin and around the head keeps the mouth set in a natural position for a viewing later. Closing the eyes after death creates a peaceful resting appearance when the body is later viewed but has nothing to do with setting the mouth. Placing dentures in the mouth and closing the eyes and mouth do not prevent discoloration in the facial area.
Which intervention by the nurse is most appropriate when she notices that her dying patient has developed a "death rattle"? 1) Perform nasotracheal suctioning of secretions. 2) Turn the patient on his side and raise the head of the bed. 3) Insert a nasopharyngeal airway as needed. 4) Administer morphine sulfate intravenously.
2) Turn the patient on his side and raise the head of the bed. If a "death rattle" occurs, turn the patient on his side, and elevate the head of the bed. Nasotracheal suctioning and inserting a nasopharyngeal airway are ineffective against a "death rattle" and may cause the patient unnecessary discomfort. The patient may require IV morphine sulfate to treat pain, but it does not help stop a "death rattle." This narcotic analgesic can also reduce the respiratory drive, leading to hypoventilation and respiratory depression or arrest.
Which intervention takes priority for the patient receiving hospice care? 1) Turning and repositioning the patient every 2 hours 2) Assisting the patient out of bed into a chair twice a day 3) Administering pain medication to keep the patient comfortable 4) Providing the patient with small frequent, nutritious meals
3) Administering pain medication to keep the patient comfortable A priority intervention for the hospice team is administering pain medications to keep the patient comfortable. Turning the patient to prevent skin breakdown and promote comfort is also important, but it does not take priority over administering pain medications. The patient may not be able to eat meals or get out of bed into the chair and may tolerate only small amounts at a meal. During the dying process, bowel activity reduces and digestion is minimal, which often results in nausea or food intolerance. Additionally, the body's need for nutrition and hydration is reduced as the body begins the desiccation process.
A patient dying of heart failure has changed his choice about his end-of-life treatment measures several times. He says, "I just can't make up my mind about it." Which nursing diagnosis is most appropriate for this patient? 1) Deficient Knowledge 2) Spiritual Distress 3) Decisional Conflict 4) Death Anxiety
3) Decisional Conflict This patient is experiencing Decisional Conflict related to his end-of-life treatment measures. Deficient Knowledge, Spiritual Distress, or Death Anxiety may be the etiology of his changing decisions, but his indecision about his treatment option clearly identifies his Decisional Conflict.
How should the nurse respond to a family immediately after a patient dies? 1) Ask the family to leave the patient's room so postmortem care can be performed. 2) Leave tubes and IV lines in place until the family has the opportunity to view the body. 3) Express sympathy to the family (e.g., "I am sorry for your loss"). 4) Tell the family that they will have limited time with their loved one.
3) Express sympathy to the family (e.g., "I am sorry for your loss"). The nurse should express sympathy to the family immediately after the patient's death. She should give the family as much time as they need with their loved one and take care to present the body in a restful pose. If family members are not present at the time of death, remove tubes and IV lines before they see the body, unless an autopsy is planned or the death is being investigated by the coroner. The body should not be removed from the patient care area until the family is ready.
The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child? 1) Take the child to the funeral even if he is frightened. 2) Notify the physician immediately if the child shows signs of regression. 3) Spend as much time as possible with the child. 4) Provide distraction whenever the child begins to express feelings of sadness.
3) Spend as much time as possible with the child. The nurse should advise the family to spend as much time as possible with the child. If the child is frightened about attending the funeral, he should not be forced to attend. Signs of regression are a normal reaction to the loss of a loved one, especially a parent. The child should be encouraged to express his feelings and fears.
Which intervention should be included in the plan of care for a patient in the end-stage death process? 1) Encourage the patient to accept as much help as possible. 2) Avoid administering laxatives. 3) Wet the lips and mouth frequently. 4) Administer pain medication on an as-needed basis.
3) Wet the lips and mouth frequently. If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently. Encourage the patient to be as independent as possible. Administer laxatives if constipation occurs. Administer pain medications on a regular schedule instead of waiting for the patient to request them.
Which intervention is appropriate for a client receiving palliative care? Choose all that apply. 1) Surgical insertion of a device to decrease the workload of the heart in a patient awaiting heart transplantation 2) Administering IV dopamine to raise blood pressure of a patient with end-stage lung cancer 3)Providing moisturizing eye drops to an unconscious patient whose eyes are dry 4) Administering a medication to relieve the nausea of a patient with end-stage leukemia
3)Providing moisturizing eye drops to an unconscious patient whose eyes are dry 4) Administering a medication to relieve the nausea of a patient with end-stage leukemia Palliative care focuses on relieving symptoms for patients whose disease process no longer responds to treatment. Providing moisturizing eye drops and administering antinausea medication in a patient with end-stage leukemia are examples of palliative care. Surgical insertion of a device to decrease heart workload and administering dopamine are aggressive treatment measures.
What emotional response is typical during the Rando's confrontation phase of the grieving process? 1) Anger and bargaining 2) Shock with disbelief 3) Denial 4) Emotional upset
4) Emotional upset During the confrontation phase, the person faces the loss and experiences emotional upset. In the avoidance phase, the person experiences shock, disbelief, denial, anger, and bargaining. During the accommodation phase, the person begins to live with the loss, feel better, and resume routine activities.
Which nursing intervention should be included in the plan of care for a patient dying of cancer? 1) Encourage at least one family member to remain at the bedside at all times. 2) Follow-up with other healthcare team members during weekly meetings. 3) Avoid discussing the dying process with family (to reduce sadness). 4) Encourage family members to participate in care of the patient when possible.
4) Encourage family members to participate in care of the patient when possible. The plan of care should include encouraging family members to help with the patient's care when they are able. Family members should also be encouraged to take care of themselves. They often need to be encouraged to take breaks to eat and rest. Provide them with anticipatory guidance about the stages of death so they know what to expect. Follow up promptly (not weekly) with other healthcare team members to address family concerns.
During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits that he drinks at least six bourbon and waters every night before going to bed. Which type of grief does this best illustrate? 1) Delayed 2) Chronic 3) Disenfranchised 4) Masked
4) Masked Masked grief occurs when the person is grieving, but it may look as though something else is occurring; in this case, the person is abusing alcohol. Delayed grief occurs when grief is put off until a later time. Chronic grief begins as normal grief but continues long term with little resolution of feelings or ability to rejoin normal life. Disenfranchised grief is experienced when a loss is not socially supported.
An elderly man lost his wife a year ago to cardiovascular disease. During a healthcare visit, he tells the nurse he has begun adjusting to life without his wife. According to John Bowlby, which stage of grief does this comment most likely indicate? 1) Shock and numbness 2) Yearning and searching 3) Disorganization and despair 4) Reorganization
4) Reorganization According to Bowlby, a person adjusts to life without the deceased during the reorganization phase. During the shock and numbness phase, the person experiences disorientation and a feeling of helplessness. The person wants to be reconnected with the deceased during the yearning and searching phase. The person feels pain and the emotions of grief during the disorganization and despair phase.
A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable to care for herself at home. Which type of loss is this patient most likely experiencing? 1) Environmental loss 2) Internal loss 3) Perceived loss 4) Psychological loss
1) Environmental loss This patient is most likely experiencing an environmental loss because she is unable to return to her familiar home setting. Instead, she is being transferred to the new environment of a nursing home. Internal, perceived, and psychological losses are internal and can only be identified by the person experiencing them.
To be eligible for insurance benefits covering hospice care, a physician must certify that which of the following apply to the patient? Choose all that apply. 1) Life expectancy is not more than 6 months. 2) Life expectancy is not more than 12 months. 3) Condition is expected to improve slightly. 4) Condition is not expected to improve.
1) Life expectancy is not more than 6 months. 4) Condition is not expected to improve. For a patient to be eligible for hospice care insurance benefits, a physician must certify that the patient is not expected to improve or will most likely die within 6 months.
A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation. As the patient's condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best? 1) "I'll call your physician right away so he can discuss this with you." 2) "You have the right to change your decision about treatment at any time." 3) "Are you sure you want to change your decision?" 4) "We must follow whatever is written in your living will."
2) "You have the right to change your decision about treatment at any time." The nurse should inform the patient that he has the right to change his decision about treatment at any time. Next, the nurse should notify the physician of the patient's decision so that the physician can speak to the patient and revise the treatment plan as needed. Questioning the patient's decision is judgmental. The patient has the right to change his living will at any time. The medical team should not follow the living will if the patient changes his decision about what is in it.
Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge of activity may occur 1) Moments before death 2) Days to hours before death 3) 1 to 2 weeks before death 4) 1 to 3 months before death
3) 1 to 2 weeks before death Days to hours before death, patients commonly experience a surge of energy that brings mental clarity and a desire to speak with family. One to 3 months before death, the dying person begins to withdraw from the world by sleeping more and eating less. One to 2 weeks before death, the body loses its ability to maintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respond to touch or sound and cannot be awakened.