Chapter 43: Loss, Grief, and Dying

A client with a terminal illness is overheard by the nurse saying, "If I promise never to smoke another cigarette in my life, please let me recover from this lung cancer." How will the nurse document this stage of grief according to the Kübler-Ross model?

bargaining Explanation: Bargaining is a psychological mechanism for delaying the inevitable, usually by negotiating with a higher power. All other choices are incorrect.

The nurse has noted that a dying client is increasingly withdrawn and is often teary at various times during the day. The nurse recognizes that the client may be experiencing which of Kübler-Ross's stages of grief?

Depression Explanation: Depression is a commonly accepted form of grief and it represents the emptiness when the client realizes the person or situation is gone or over. Signs and symptoms may be withdrawn, sadness, crying, and flat affect. Denial is the stage where client may disregard that the news of diagnosis or death is not true. Anger is the stage where the client may think "why me?" and "life's not fair!" Bargaining is the stage of false hope. The client might falsely make themselves believe that they can avoid the grief through a type of negotiation. The stages are denial, anger, bargaining, depression, and acceptance.

The nurse is caring for a client who recently lost an older adult parent. Which client statement alerts the nurse that the stage of depression may have started within the grief process?

"Please go away; I just want to be left alone." Explanation: The clinical definition of depression is anxiety and hostility turned inward. The statement asking the nurse to go away and a desire to be "left alone" indicates withdrawal, which is a characteristic of depression. "This does not seem real to me" indicates the client is in denial. Blaming oneself for the loss is an expression of guilt that may occur in the anger phase of grieving. Feeling uncertain about the future may occur as the grieving person accepts that the loved one is deceased and life will be different.

A widow develops cancer within 6 months of her husband's death. This may be a result of:

bereavement. Explanation: Physical health and psychosocial adjustment are intricately intertwined. The bereaved are known to be at greater risk for mortality and morbidity than are comparable non-bereaved people.

The nurse is caring for a woman with terminal breast cancer. Which statement made by the client reflects the bargaining stage of grief?

"Please, let me live long enough to see my grandchild." Explanation: Bargaining occurs as a client seeks to delay a dreaded event. For example, the client bargains with a higher power for enough time to see the grandchild. The statement, "Why is this happening now? I will never see my grandchild" indicates frustration and anger. Depression is evident in the statement, "I do not care about anything. Just let me sleep." Acceptance occurs when the client comes to terms with the loss and begins to detach from supportive people. As such, the statement, "I may not see my grandchild here on Earth, but I will in the afterlife" shows acceptance.

The nurse is trying to help the client cope with the dying process. Which nursing statement is most appropriate?

"It must be very difficult for you." Explanation: Use statements with broad openings such as "It must be difficult for you" and "Do you want to talk about it?" Such language encourages communication and allows the client to choose the topic or manner of response. Accept the client's behavior. Anger is part of the grieving process. Indicating that this is "awful" is not an appropriate way to promote coping. It is not the nurse's role to tell the client to make things right with the family. While this may be desired, the client should initiate it.

The nursing student is learning how to care for clients whose death is expected within a limited period of time. Which statement makes the faculty member believe the student has mastered this topic?

"Many clients know they have a terminal illness by picking up on nonverbal communication." Explanation: A terminal illness is an illness in which death is expected within a limited period of time. The nurse and other health care professionals are involved in discussions with these clients and their families. Many clients realize without being told that they have a terminal illness, picking up this knowledge from nonverbal communication by their families and health care professionals. Competent clients have the right to consent and/or refuse any and all medical treatments—even life-sustaining treatment. Cultural influences may dictate how much information is desired and which family members are to be informed. Health care personnel should be available to discuss the client's condition with family members and should offer support and care as the family begins the grieving process.

During an interview of the client at the community clinic, the nurse finds that the client is providing care for a parent, who is terminally ill. Which statement by the client indicates anticipatory grieving?

"My parent is suffering with cancer and death will be a relief of the pain." Explanation: Anticipatory grief is the characteristic pattern of psychological and physiologic responses a person makes to the impending loss of a significant person. The client's statement, "My parent is suffering with cancer and death will be a relief of the pain," is an example of anticipatory grief and is intended to facilitate coping when death occurs. The client's statement, "There is no way I can stay in the hospital because my parent is sick" demonstrates empathy for the parent and denial of a personal need for treatment. Denial is apparent when the client suggests the parent's diagnosis is incorrect. Denial is also apparent when the client relates it is "fine" if the mother expires because they were not close.

A nursing instructor has finished presenting information to a group of nursing students on the factors that influence the grieving process. Which statement by a student would indicate a need for further education?

"A death that occurs as a result of natural causes is just as stressful as a death from homicide or suicide." Explanation: A loss that occurs under violent or frightening conditions is much more difficult to cope with than is a loss that occurs under more peaceful conditions. A death that occurs as a result of homicide or suicide is usually more stressful than is a death from natural causes. Some people find strength in dealing with loss through their faith, whereas others experience greater distress due to their beliefs. Sociocultural resources include the social support that is available from family, friends, coworkers, and formal institutions. Absence of these social supports creates additional stressors for the grieving person. The age at which a loss occurs has a major impact: The loss of a parent has different meanings to an infant, a child, and an adult.

The condition of a client with a traumatic brain injury continues to deteriorate despite medical efforts. The decision is made to terminally wean the client from mechanical ventilation. Which statement by the nurse is most significant in educating the family regarding terminal weaning?

"All efforts will be taken to make sure your loved one is comfortable and out of pain." Explanation: A common and valid concern of families during terminal weaning is to make sure the client is not suffering. As such, the nurse's role is to educate the family regarding comfort measures, such as pain medication and additional sedation. It is inaccurate to tell the family that the client will no longer be able to breathe once the tube is removed. The client may continue breathing for several hours to days. When a decision is made to terminate mechanical ventilation, it should be clear that reintubation is no longer an option and death is inevitable. The nurse must be honest with the family, as the client may be aware of loved ones in the room and talking to the client is encouraged.

A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse?

"Can you tell me about why you've made this decision?" Explanation: Having the client explain his decision-making process is open-ended and allows exploration of the client's feelings. A competent client is not required to continue with treatment that has been initiated. The other options are closed-ended and stop any further conversation.

A nurse is caring for a client whose spouse died more than 4 years ago. What assessment question will the nurse ask to determine if the client is experiencing abnormal grief?

"Have you gone through and donated your spouse's clothing?" Explanation: Abnormal grief responses present beyond 3 years after a loss. The nurse can identify if a client suffers from abnormal grief through questions aimed at learning if the client has left the deceased's room and belongings intact, has reported physical symptoms similar to those the deceased had before death, and has talked about the deceased as if the individual were still alive. Remembering good times and keeping photos of loved ones are part of reminiscing and a healthy form of grieving. Crying on the anniversary of a loved one's death is part of the normal grieving response.

When reviewing a client's chart, the nurse notes that the client is in the disorganization stage of grief. Which assessment finding would support this diagnosis?

"I feel like I have absolutely no idea what to do next." Explanation: In the disorganization stage of grief, the client may exhibit difficulty making decisions, aimlessness, decreased resistance to illness, and loss of interest in people, work, and usual activities. In the protest stage of grief, the client may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others' health and safety. In the shock stage, the client may exhibit slowed and disorganized thinking, blocking of thoughts, neglect of appearance, and wish to join the deceased. In the reorganization stage of grief, the client may exhibit a realistic memory of the deceased, be comfortable when remembering the deceased, and return to previous level of ability.

A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response?

"It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition." Explanation: An advance directive is a written statement identifying a competent person's preferences regarding which medical interventions to use in the event that the client can not make a decision for themselves concerning terminal care. The other responses are not correct.

A client with end-stage chronic obstructive pulmonary disease (COPD) has reached the end of the 6-month period for hospice services and the family caregiver states, "I don't know what we will do if they cut off our hospice services." What is the best response by the hospice nurse?

"I will contact the health care provider to extend services since your family member meets the criteria." Explanation: Hospice care is generally provided to clients that have 6 months or less to live, although they are not automatically discharged when they reach 6 months after having been admitted to hospice care. The client may still receive care as long as the health care provider certifies that the client continues to meet the criteria for hospice services. The client should not be admitted to the hospital since the acceptance of palliative comfort care is required to qualify for hospice services. Based on the provided information, there is no need to admit the client to the hospital, and hospital admission may result in termination from the program due to the provision of non-palliative care.

A nurse has just finished a presentation on hospice and palliative care. Which statement by a participant would indicate a need for further education?

"In hospice care, the nurses make most of the care decisions for the clients." Explanation: The philosophy of hospice is that clients and families are empowered to achieve as much control over their lives as possible. Hospice focuses on relieving symptoms and supporting clients with a life expectancy of 6 months or less, rather than years, and their families. However, palliative care may be given at any time during a client's illness, from diagnosis to end of life.

A client diagnosed with a terminal illness is displaying periods of depression and anger alternating with acceptance. The client's spouse is concerned about the client's labile mood. When talking with the client's spouse, which statement made by the nurse best addresses principles of loss and grieving?

"Not everyone experiences grief in the same way and your loved one needs our support." Explanation: Stages of grief include denial, anger, bargaining, depression, and acceptance. The progression in which people move through stages varies from person to person. Some people may not experience each stage. Sharing with the spouse that "Not everyone experiences grief in the same way and your loved one needs our support" is the most therapeutic response. Telling the spouse that something is wrong is incorrect as this is a normal response to grieving. There is no verifying data in the question stem indicating the client is suicidal and restraints are not used in a situation such as this. Telling the spouse that "most people go through all sorts of feelings" is not therapeutic; the nurse is minimizing the loved one's feelings.

The nurse is caring for a client who recently found out he has a terminal illness. The nurse notes that the client is hostile and yelling. Which statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death?

"Sometimes a person returns to a previous stage." Explanation: Kübler-Ross (1969) studied the responses to death and dying. Her findings are as follows: Sometimes a person returns to a previous stage; the stages of dying may overlap; the duration of any stage may range from as little as a few hours to as long as months; the process varies from person to person.

"My father has been dead for over a year and my mother still can't talk about him without crying. Is that normal?" What is the best response by the nurse?

"The inability to talk about your dad without crying, even after a year, is still considered normal." Explanation: Normal responses to bereavement after 1 year include the inability to speak of the deceased without intense emotion, clinical signs of depression, and feelings of meaninglessness. Increased crying does not necessarily signal increased coping, however.

Which assessment finding would best support a nursing diagnosis of Dysfunctional Grieving?

A man is unable to return to work after his 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 Dysfunctional 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.

Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning?

Administer sedation and analgesia. Explanation: Terminal weaning is the gradual withdrawal of mechanical ventilation from a client with a terminal illness. Providing sedation and analgesia is the best way to reduce the client's discomfort during the process. The nurse participates in the process by educating the client and family about the burdens and benefits of continued ventilation and what to expect when terminal weaning is initiated. Supporting the family and having the family remain at the bedside are important roles of the nurse during terminal weaning, but do not directly affect discomfort as much as sedation and analgesia.

Assisted suicide is expressly prohibited under statutory or common law in the overwhelming majority of states. Yet public support for physician-assisted suicide has resulted in a number of state ballot initiatives. The issue of assisted suicide is opposed by nursing and medical organizations as a violation of the ethical traditions of nursing and medicine. Which scenario would be an example of assisted suicide?

Administering a lethal dose of medication Explanation: Assisted suicide refers to providing another person the means to end his or her own life, such as administering a lethal dose of a medication. This is not to be confused with the ethically and legally supported practices of withholding or withdrawing medical treatment in accordance with the wishes of the terminally ill individual. Administering a morphine infusion may be used to assist with a client's pain near the end of life. Granting a client's request not to initiate enteral feeding when the client is unable to eat is an example of wishes of a terminally ill client, and the agreed-upon measures near the end of life. Neglecting to resuscitate a client with a "do not resuscitate" status is following the prescribed, mutually agreed-upon decisions about care.

The nurse is caring for a client who has just expired. Which action will the nurse perform?

Allow the client's family to see the client's body before it is discharged. Explanation: After the client has been pronounced dead, the nurse is responsible for preparing the body. Family members may need to see the client's body to accept the death fully; allow them to see the client's body before discharging to the mortician. The body is placed in normal anatomic position (flat) to avoid pooling of blood. In most cases it is unnecessary to wash the body, and some religions strictly forbid it. The nurse is legally responsible for placing identification tags on either the shroud or garment that the body is clothed in, and on the ankle to ensure that the body can be identified even if separated from its shroud.

The nurse is assessing a client who was diagnosed with metastatic prostate cancer. Which information from the client's medical record indicates the client is experiencing depression?

Appears sullen, shakes head "yes" or "no," refuses visitors Explanation: Loss, grief, and sadness indicate depression. As such, "Appears sullen, shakes head "yes" or "no," and refuses visitors are signs of depression. The client is expressing anger when throwing the water pitcher on the floor. The family at the bedside talking about a grandchild's success in college is a normal interaction and may indicate acceptance of the current situation. If confusion is acute and sudden, it may indicate the beginning of the client's physical decline

The nurse makes a home visit for a client whose 12-year-old child died 4 years ago. The nurse finds the child's room with all belongings still intact. The client also speaks as if the child is still alive. Which action would the nurse take in this situation?

Arrange for individual counseling for the client. Explanation: Keeping the child's room intact and talking as if the child is still alive more than 3 years after the child's death are symptoms of dysfunctional grief. The nurse would refer clients experiencing dysfunctional or prolonged grief to individual counseling, psychotherapy, or to professionally led support groups. Participation in mourning rituals would have been helpful when the death occurred, not 4 years later. The client is stuck in feelings of sadness and resentment and needs professional help to work through these feelings. Peer-led Internet-based support groups fall into the self-help genre; a client with dysfunctional grieving 4 years after a death needs professional help.

A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. What is the nurse's best action?

Call a code and begin resuscitating the client. Explanation: If there is no DNR order to the contrary, the standard of care obligates professionals to attempt resuscitation if a client stops breathing or his or her heart stops. It is important for nurses to clarify a client's code status if the nurse has reason to believe a client would not want to be resuscitated. It is imperative that the client's wishes are documented in a formal document in the health record for all to view. Slow-codes are never good practice, and the nurse could be charged with negligence in the event of a slow-code and resultant client death. Calling the charge nurse or nurse manager is not appropriate because it can delay emergency care, which could result in negligence and client death.

It has been determined that a client who sustained a head injury following a motorcycle accident is brain dead. The client did not have an organ donation directive. However, the client did have records to indicate a wish not to have prolonged life support. What is the most appropriate action for the nurse?

Contact the organ procurement team to discuss organ donation with the family. Explanation: The organ procurement team should be contacted as soon as possible to discuss transplantation with the family. This discussion cannot wait, as the fragility of organs increases as time passes. While it is important to honor a client's wishes, life support cannot be withdrawn until the potential for organ donation is determined, even if doing so contradicts a person's advance directive because life support that has the potential to save lives overrides the desire to withdraw life support.

A client has been declared brain dead following a fall from a roof. The client's advance directives state they do not wish to have prolonged life measures, and that only the heart, kidneys, and liver should be donated. The client's spouse wants to also donate the client's corneas. What is the appropriate nursing action?

Contact the organ procurement team to discuss organ donation with the spouse. Explanation: The organ procurement team should be contacted as soon as possible to talk with the client's spouse. This discussion cannot wait, as the fragility of organs increases as time passes. While it is important to honor a client's wishes, life support cannot be withdrawn until the potential for organ donation is determined. The organ procurement team is specially trained to have these kinds of conversations.

The nurse enters a client's room and finds the client curled up in bed and crying. The client states, "My life is so good, and now I have cancer. Why me? I have tried to be a good person." The nurse recognizes the client as exhibiting signs of which stage of Engel's model of grief?

Developing awareness Explanation: The client is exhibiting signs of developing awareness when demonstrating anger, feelings of emptiness, and crying "Why me?" Shock and disbelief are usually defined as refusal to accept the fact of loss, followed by a stunned and numb response. Restitution involves rituals surrounding loss. Idealization is the exaggeration of the good qualities that the person or object had, followed by acceptance of the loss and a lessened need to focus on it.

The hospice nurse is visiting the wife of a client who died 10 months ago. The wife states, "My life is meaningless since my husband died." The nurse recognizes that the client is in which stage of grief?

Disorganization Explanation: In the disorganization stage of grief, the client may exhibit difficulty making decisions, aimlessness, and loss of interest in people, work, and usual activities. In the protest stage of grief, the client may exhibit preoccupation with thoughts of the deceased, searching for the deceased, dreams/nightmares, hallucinations, and concerns about others' health and safety. In the shock stage, the client may exhibit slowed and disorganized thinking, blocking of thoughts, and wish to join the deceased. In the reorganization stage of grief, the client may exhibit a realistic memory of deceased, be comfortable when remembering the deceased, and return to previous level of ability.

The husband of a client with terminal cancer is afraid of hurting his wife during sexual intercourse. Which action by the nurse is likely to be most helpful in reducing this client's fears?

Encourage discussion between the husband and wife regarding their intimacy needs Explanation: Partners of terminally ill clients may wish to be physically intimate with the dying person but are afraid of "hurting" him or her and may also be afraid that an open expression of sexuality is somehow "inappropriate" when someone is dying. Encourage discussion and suggest ways to be physically intimate that will meet the needs of both partners, such as a foot massage or embrace, and not just watching TV. Telling the client that he cannot have relations based on the fatigue of the client's spouse is not appropriate. Reassuring the client that he will not cause pain is incorrect.

A terminally ill client told her family, "I am ready to die." Her family is very upset that she has given up and wants the nurse to intervene. Which nursing intervention is most appropriate?

Explain to the family that acceptance is part of the grieving process. Explanation: Acceptance (an attitude of complacency) occurs after clients have dealt with their losses and completed unfinished business. After tying up all loose ends, dying clients feel prepared to die. Some even happily anticipate death, viewing it as a bridge to a better dimension. Nurses can help clients to pass from one stage to another by providing emotional support and by supporting the client's choices concerning terminal care. Facilitating the client's directives helps to maintain the client's personal dignity and locus of control. Accepting that death will occur and giving up are not the same thing and giving up is not expected.

A client comes to the hospital because of complications related to newly diagnosed terminal cancer. The client is concerned about how his wife is coping with the diagnosis. Which information is important for the nurse to obtain to assess factors that may affect the family member's grief? Select all that apply.

Financial concerns Cultural practices Religious beliefs Social support Explanation: Many factors, including socioeconomic position, cultural and religious influences, and social support affect a person's reaction to, and expression of, grief. The socioeconomic position is the financial elements and how it affects treatment. Cultural and religious influences may impact the client and client's wife ability to belong to a larger entity and have empathy with others. Social support also provides empathy for the client and client's wife. Like the stages of grief reaction, these factors vary from person to person. Previous relationships may be a part of healing and working through the stages of grief but it is not important for the assessment.

The nurse is receiving a change of shift report on a client who has a terminal illness and has exhibited a slow and progressive decline in the health status over the past several days. Which data supports the client's impending death? Select all that apply.

Gurgling sounds emanating from the client's throat with each breath Distended abdomen with last bowel movement documented 7 days ago Cyanotic nail beds in hands and feet bilaterally Explanation: Signs of an impending death include noisy respirations, abdominal distention, constipation, and cyanosis of the extremities. The pulse may be slow and/or irregular. The systolic blood pressure would be decreasing, not increasing.

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care. Which information would the nurse most likely include in the response?

Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness. Explanation: Hospice programs, which, in effect, are a type of insurance benefit, focus on relieving symptoms and supporting clients with a life expectancy of 6 months or less, and their families. Palliative care, on the other hand, may be given at any time during a client's illness, from diagnosis to end of life. Hospice and palliative care programs provide care that focuses on quality rather than length of life. Both hospice and palliative care share a similar foundation. Hospice and palliative care provide physical, social, psychological, and spiritual support through a team of health care professionals and lay volunteers.

The wife of a man who is dying tells the nurse: "Harold was so good to me. He was like a saint with his patience. I will miss him terribly" Which stage of grief is this woman experiencing, according to Engel?

Idealization Explanation: Idealization is the exaggeration of the good qualities that the person had, followed by acceptance of the loss and a lessened need to focus on it. Restitution involves the rituals surrounding loss—with death, it includes religious, cultural, or social expressions of mourning, such as funeral services. Developing awareness is characterized by physical and emotional responses such as anger, feeling empty, and crying. Outcome, the final resolution of the grief process, includes dealing with loss as a common life occurrence.

The client is a young mother whose spouse died 3 months ago. The client is tearful and unkempt, eats a poor diet, and has lost 50 lb (22.6 kg) since the death of the spouse. The client states, "I can't do this anymore." The nursing diagnosis best supported by these data is:

Ineffective coping related to failure of previously used coping mechanisms Explanation: The nursing diagnosis best supported by the data is Ineffective coping. Defining characteristics include poor coping skills with activities of daily living as evidenced by unkempt appearance, eating poorly and losing weight, and client statement. Death anxiety refers to an impending death or thoughts of death. Ineffective denial refers to denying the reality of the situation. Decisional conflict refers to inability to make decisions.

A nurse informs a woman that there is nothing more that can be done medically for her premature infant who is expected to die. The mother suppresses her grief and tells the nurse she is experiencing heart palpitations. What type of grief might the mother be experiencing?

Inhibited grief Explanation: With inhibited grief, a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period. Dysfunctional grief is abnormal or distorted; it may be either unresolved or inhibited.

A home hospice client who has Medicare is experiencing extreme pain at home and is refusing to receive inpatient care due to concerns over the cost of inpatient care. What teaching will the nurse include in the plan of care?

Inpatient pain management for hospice patients is covered by Medicare. Explanation: Inpatient pain management is covered by Medicare as are any other Medicare-covered services needed to manage pain and other symptoms as recommended by the hospice team. Medicare will cover pain control in the home as well, but for extreme pain, hospitalization may be required. Telling a client not to worry about payment does not educate about what services are available.

When preparing for the death of a client, the nurse should provide the client's family with which interventions? Select all that apply.

Listen to concerns, fears, and worries. Encourage rest and proper nutrition. Explain the dying process and allow grieving. Utilize therapeutic communication techniques. Explanation: The nurse can provide care for the family facing loss by listening to their concerns, fears, and worries. The nurse can do this by utilizing therapeutic communication techniques. The nurse should encourage the family to get adequate rest and nutrition. The reality of death may be less painful if the family is prepared ahead of time, which the nurse can facilitate by explaining the process and allowing the family to grieve. It is important for the family to get adequate rest, so it should not be suggested that the family never leave the bedside.

A nurse is conducting grief resolution for a client who lost his wife in a motor vehicle accident in which he was the driver. Which interventions best accomplish this goal? Select all that apply.

Listen to expressions of grief. Include significant others in discussions and decisions as appropriate. Communicate acceptance of discussing the loss. Explanation: Grief resolution involves dealing with the loss. Listening to the client's expressions of grief, including significant others in discussions, and communicating acceptance helps the client deal effectively with the loss. Encouraging the client to keep silent about the event, not being empathetic, and avoiding identification of fears does not help the client in dealing with the loss.

The nurse is caring for a client who has terminal lung cancer and is unconscious. What assessment would indicate to the nurse that the client's death is imminent?

Mottling of the lower limbs Explanation: The time of death is generally preceded by a period of gradual diminishing of bodily functions. During this time, the nurse may observe increased intervals between respirations, weakened and irregular pulse, and skin color may change or become mottled. The client will not be able to swallow secretions, so suctioning, frequent and gentle mouth care, and possibly the administration of a transdermal anticholinergic drug may be required.

A nurse is providing care to a terminally ill client. Which finding would alert the nurse to the fact that the client is dying? Select all that apply.

Pale, cool skin Decreased urine output Irregular heart rate Explanation: Signs of dying include extremely pale, cyanotic, jaundiced, mottled or cool skin; irregular heart rate; weak, rapid, irregular pulse; shallow, labored, faster, slower, or irregular respirations; and decreased urine output.

When assessing a person who is grieving using the grief cycle model, which concept would be most important for the nurse to keep in mind? Select all that apply.

People vary widely in their responses to loss. Stages occur at varying rates among people. Some people actually skip some stages of grief altogether. Explanation: In reality, the stages of the grief cycle model are not as discrete as the model indicates. However, it is helpful to use the model as a general guide, while keeping in mind that people may vary greatly in their responses to loss and still fall within the normal response range. Grieving persons may go through the stages at varying rates, go back and forth between stages, or skip stages.

The nurse provides postmortem care for a client who is not undergoing an autopsy. To achieve the desired outcome of this procedure, which nursing actions should be included? Select all that apply

Remove any tubes and replace soiled dressings. Place an identification tag on the client's ankle. Provide emotional support to the client's family. Ensure the death certificate has been signed. Explanation: When a client dies, the nurse's responsibilities include caring for the client's body, caring for the family, and discharging specific legal responsibilities. After the client has been pronounced dead, the nurse is responsible for replacing soiled dressings and removing tubes. The mortician will wash the body. The nurse is legally responsible for placing identification tags on either the shroud or the garment the body is clothed in and the ankle to ensure that the body can be identified even if it is separated from its shroud. After a client has died, the nurse provides emotional support and care to the client's family. Legal responsibilities of the nurse include ensuring that a death certificate is issued and signed.

The nurse is caring for a client that is at the end of life. After the client is pronounced dead, what actions by the nurse are essential components of care? Select all that apply.

Removing all tubes according to agency policy, unless an autopsy is to be performed Placing identification tags on the client's dentures or other prostheses Arranging for family members to view the body before it is discharged to the mortician Explanation: If acceptable to facility policy, the nurse can remove all tubes for a more natural appearance during viewing of the body by the family immediately after death has occurred, unless an autopsy is expected. The nurse should place identification tags on dentures and other prostheses, in case they become separated from the deceased. It is not necessary for the nurse to wash the client's body; only cleaning soiled areas is required in most facilities. Identification tags are necessary to place on the body to ensure the body is correctly identified, in case a shroud or garment is separated from the client.

A nurse at the health care facility cares for several clients. Some of the clients may require end-of-life care. Which case may require the service of a coroner?

The client did not have any recent medical consultation. Explanation: The services of a coroner may be needed in a case where the client did not have any recent medical consultation. A coroner is a person legally designated to investigate deaths that may not be the result of natural causes. Death following a diagnosis of acute renal failure, administration of oxygen therapy, or a history of hypertension does not call for the services of a coroner.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case?

The client should be treated with antibiotics for pneumonia. Explanation: The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death?

The client's breathing becomes noisy. Explanation: Noisy breathing, or death rattle, is common during the final stages of dying because of the accumulation of secretions in the lungs. Reduced urination is not seen during the final stages of dying. Instead, the client develops loss of control over bladder and bowels due to loss of neurological control. The peripheral parts of the client's body such as the arms and the legs are cold to touch (not warm) because the circulation is directed away from the periphery and toward the core of the body. Clients in the last stages of dying are usually not calm and peaceful; they occasionally exhibit sudden restlessness due to hunger for oxygen.

Which does not coincide with Kübler-Ross's stages related to a dying client?

The dying client usually exhibits anger first. Explanation: The dying client does not usually exhibit anger first. The client may be in several stages at once, clients don't always follow the stages in order, and some regress and then move forward.

A client that has been shot in the chest is now deceased, and the nurse is delegated to provide postmortem care. In which situation

The nurse is preparing to remove the IV lines from the deceased. Explanation: Because the client is deceased due to an unnatural or suspicious cause, an autopsy will be performed. All IV needles and lines, endotracheal, gastrointestinal tubes, drains, and airways must remain with the body. They should be firmly taped or secured so that they will not be inadvertently removed or leak. The body is not washed, even if it is soiled, to avoid removing evidence. The deceased should always be treated with dignity by providing privacy and treating the body with respect. Tags should always be used to identify the body.

What is a proper action to take when preparing a child for death? Select all that apply.

The nurse should know her own feelings and beliefs. Encourage remembrance of deceased. Expect the child to alternate between grieving and normal functioning. Explanation: When preparing a child for death, it is important for the nurse to know her own feelings and beliefs; to be honest; begin at the child's level; include the child in family rituals related to death and mourning; encourage expression of feelings; provide security and stability; encourage remembrance of the deceased; recognize that children grieve differently than adults; expect the child to alternate between grieving and normal functioning; talk openly about death and the feelings it generates; and introduce death concepts into conversations naturally.

The husband of a client who has died cannot express his feelings of loss and at times denies them. His bereavement has extended over a lengthy period. What type of grief is the husband experiencing?

Unresolved grief Explanation: In unresolved grief, a person may have trouble expressing feelings of loss, may deny them, and the bereavement may extend over a lengthy period. Anticipatory loss or grief occurs when a person displays loss and grief behaviors for a loss that has yet to take place. Inhibited grief occurs when a person suppresses feelings of grief and may instead manifest somatic (body) symptoms, such as abdominal pain or heart palpitations. Normal expressions of grief may be physical (crying, headaches, difficulty sleeping, fatigue), emotional (feelings of sadness and yearning), social (feeling detached from others and isolating oneself from social contact), and spiritual (questioning the reason for the loss, the purpose of pain and suffering, the purpose of life, and the meaning of death).

A client has recently lost a parent. The client spent about 6 months deeply mourning the loss and is just now able to function at the pre-loss level. During this process, a strong social support network was able to assist the client. What developmental stage of life does the nurse identify the client is in?

adult Explanation: Adults tend to grieve more intensely and more continuously, but for a relatively shorter period of time than children. Having a good social network helps with this process, as well as having a stable lifestyle.

A hospice nurse has developed a care plan for a client with liver cancer. The care plan focuses on providing palliative care for this client. The goal of palliative care is best described as providing clients with life-threatening illnesses a dignified quality of life through which means?

aggressive management of symptoms Explanation: The goal of palliative care is to provide clients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. There is no treatment goal for the life-threatening illness for palliative care. Aggressive management of symptoms includes medical and nursing care for the client. Providing counseling related to the stages of death and dying is pursued after aggressive management of symptoms.

The spouse of a recently deceased client states, "I just can't believe he left me. He swore he would never leave me and I feel betrayed!" Using Kübler-Ross stages of grief, what stage does the nurse identify the client is experiencing?

anger Explanation: The client is identified as being in the anger stage of the grieving process. The client has accepted the fact that the spouse is gone but is angry and betrayed at the departure from life. The client has yet to accept this death and may have some overlapping with depression as well.

A client has a diagnosis of bladder cancer with metastasis. The client asks the nurse about the characteristics of hospice care. The nurse should explain that:

care is premised on the fact that dying is a normal process. Explanation: Hospice care is premised on the fact that dying is a normal process. Symptoms are treated aggressively in order to preserve comfort. Care is interdisciplinary and admission usually requires a 6-month life expectancy or less.

Upon admission, the nurse should give priority to addressing which need of a client who is displaying symptoms of dysfunctional grief?

coping strategies Explanation: Dysfunctional grief can be 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. Coping strategies are necessary in the grieving process and for resolution of grief. Many times individuals experiencing dysfunctional grief have difficulty with self-care activities; however, the individual should be encouraged to perform these activities independently. Pain management is usually not necessary in the management of dysfunctional grief. The spiritual needs of the client are important as well and should be considered after coping strategies have been addressed.

A client is informed about the results of a biopsy, which indicate a malignant tumor that has spread. The client states, "Well once you remove the tumor, I will be just fine." What stage of the grief process does the nurse identify the client is experiencing?

denial Explanation: By making this statement, the client denies the seriousness of the malignant tumor diagnosis. Denial is often the first emotion the client will experience, as initially it helps in coping with the reality of impending death. There is nothing in the client's statement to indicate anger or acceptance. Bargaining would be indicated by the client negotiating with a higher power to extend life or delay the inevitable.

A terminally ill client is being cared for at home and receiving hospice care. The hospice nurse is helping the family cope with the client's deteriorating condition, educating them on the signs of approaching death. Which sign would the nurse include in this education plan?

difficulty swallowing Explanation: A sign that death is approaching is the client's difficulty in swallowing. People who are dying do not experience decreased pain. They may not be in a position to report pain; therefore, the caregiver should observe the client closely. Urinary output decreases when a person is approaching death due to system failure and limited intake. The client approaching death has decreased sensory stimulation.

A client's son is named to make decisions for his mother in the event she cannot speak for herself. This is an example of a(an):

durable power of attorney. Explanation: A durable power of attorney allows clients to designate another person to make decisions if they become incapacitated and cannot make decisions independently. Advanced estate planning typically involves estate tax reduction, Medicaid planning and/or special needs trust planning is for a client with a large estate. Exemplary representative and significant power are not related to health care.

When preparing the care plan for a dying client, it is important for the nurse to include a goal that addresses which needs? Select all that apply.

expression of feelings management of pain use of coping strategies Explanation: Nursing care for the dying client should be directed toward the achievement of several goals, including demonstration of the ability to express feelings, fears, and concerns. The client's pain should be managed effectively to allow the client to interact meaningfully with family. The client should also be able to identify and utilize effective coping strategies such as deep breathing, talking with family members, and rest periods. Nutritional therapy and urinary elimination are not specific to the dying client, and more assessment would be needed to determine if these are viable needs for the client.

A client diagnosed with liver failure in hospice care died 10 hours ago. The client's spouse is having difficulty leaving the room and is crying uncontrollably. What situation does the nurse identify is happening with this client's spouse?

grief reaction Explanation: The client's spouse is demonstrating behaviors related to a grief reaction. The anticipatory grief occurs prior to the death. The client's spouse has not had enough of a length of time to determine if the grief is pathologic. The spouse is experiencing the denial stage of grief and not the bargaining stage.

The nurse anticipates a dying client to exhibit which signs of impending death? Select all that apply.

incontinence restlessness loss of sensation Cheyne-Stokes respirations Explanation: Signs of impending death include incontinence, restlessness, loss of sensation, cyanotic extremities, decreased body temperature, and Cheyne-Stokes respirations. Increased body temperature occurs in infection. Flushed extremities occurs in anaphylaxis.

Which manifestation of grief by the client who lost his wife 3 years earlier is considered abnormal?

leaving the wife's room and belongings intact Explanation: Bereavement experts reported that they considered almost all bereavement manifestations to be normal during the early stages of grief, but considered most of the manifestations to be abnormal if they continue beyond 3 years.

The experience of parting with an object, person, belief, or relationship that one values is defined as

loss. Explanation: Loss is defined as the experience of parting with an object, person, belief, or relationship that one values; the loss requires a reorganization of one or more aspects of the person's life.

A couple has sent their youngest child to college in another state and both are experiencing "empty nest syndrome." This is an example of:

maturational loss. Explanation: Maturational loss is experienced as a result of natural developmental processes, such as sending children off to kindergarten or away to college. A situational loss occurs as a result of an unpredictable event. Physical loss is a loss such as a body part (amputation). Anticipatory loss involves a display of loss, and grief behaviors for a loss that has yet to take place.

A nurse is providing postmortem care. Which of the following nursing actions is a legal responsibility?

placing ID tags on the shroud and ankle Explanation: Although the nurse may place the body in a normal anatomic position and remove tubes and soiled dressings, the only legal action is placing ID tags on the shroud and ankle. The body is not usually washed by the nurse, as different cultures and religions have specific guidelines concerning cleansing the body.

What is the most important goal of care for the dying client who is receiving comfort care?

providing a comfortable, dignified death Explanation: Clients or their surrogates may request a comfort-measures-only order, which indicates that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated. Using a feeding tube and identifying appropriate coping mechanisms are not characteristics of comfort care. The presence of family members at the bedside is important for any dying client and is not specific to comfort care.

The nurse is talking with the son of a client with end-stage renal failure and late-stage dementia. The client can no longer live at home, and the son states, "I live 500 miles away. I don't know what to do." Which type of living arrangement will the nurse teach the son about?

residential care Explanation: Nursing homes or long-term care facilities can provide around-the-clock nursing care for clients who cannot live independently or do not have family that can provide in-home care. Acute care is not appropriate, as the client's condition is known and is not unstable. The client needs more monitoring than home care can provide. Respite care is used to provide rest for caregivers.

Which stage of grieving is exhibited by the husband of a victim of sudden death who refuses to accept that she is dead?

shock Explanation: In the shock and disbelief stage, the survivor either refuses to accept the loss or shows intellectual acceptance of the loss but denies the emotional impact.

The children of a male client with late-stage Alzheimer disease have informed the nurse on the unit that their father possesses a living will. The nurse should recognize that this document is most likely to:

specify the treatment measures that the client wants and does not want. Explanation: Living wills provide instructions about the kinds of health care that should be used or rejected under specific circumstances. The management of an individual's estate is specified in a will, not a living will. It is not legal for a living will to make provisions for active euthanasia. A living will may or may not include reference to organ donation, but normally this is addressed in a separate, specific consent card or document.

The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care?

to improve the client's and family's quality of life Explanation: The goal of palliative care is to improve the client's and the family's quality of life. The support should include the client's physical, emotional, and spiritual well-being. Each discipline should contribute to a single care plan that addresses the needs of the client and family. The goal of palliative care is not aggressive support for curing the client. Providing physical support for the client is also not the goal of palliative care. A separate plan of care developed by the client with each discipline of the health care team is not the goal of palliative care.

Palliative care is a structured system for care delivery. What is its aim?

to prevent and relieve suffering Explanation: Palliative care, which is conceptually broader than hospice care, is both an approach to care and a structured system for care delivery that aims to "...prevent and relieve suffering and to support the best possible quality of life for clients and their families, regardless of the stage of the disease or the need for other therapies." Palliative care goes beyond giving traditional medical care. Palliative care is considered a "bridge" not exclusively limited to hospice care. "Hope" is something clients and families have even while the client is actively dying.