Chapter 43: Loss, Grief, and Dying

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the bargaining stage? A) "The doctors must have made a mistake." B) "Why did this happen to me? I always exercised." C) "Just let me live to see my grandson born." D) "I've had a good life and I can die in peace."

Answer: "Just let me live to see my grandson born." Feedback: In the bargaining stage of the psychosocial responses to dying and death, the client tries to bargain for more time to live. It is important to meet wishes for putting personal affairs in order and fulfilling last wishes during this time, if possible, because bargaining helps clients move into later stages of dying.

Which of the following statements is typical of the first stage of grieving described by Engel? A) "No, not me." B) "Why me?" C) "My husband was the best man in the world." D) "The funeral service helped me survive."

Answer: "No, not me." Feedback: According to Engel, the first stage of grief is shock and disbelief. In this initial stage, the surviving family members often refuse to accept the fact of the loss, followed by a stunned or numb response of "No, not me."

Family members of a dying client are in the room with their loved one. As the client nears death, what should the nurse tell the family? A) "Please leave the room now. It is time to let go." B) "Only one family member at a time can stay in the room." C) "Please stay with your loved one and talk to him." D) "I will have to get an order for you to stay now."

Answer: "Please stay with your loved one and talk to him." Feedback: A fear of having to face death alone is a primary concern of dying patients. The presence of family members in the room should be encouraged and reminiscences should be shared.

A terminally ill client, in severe pain, asks a nurse to help her die. What must the nurse consider morally, ethically, and professionally before answering the client? A) ANA Code for Nurses, ethical and professional standards B) Own personal moral and ethical values and standards C) Hospital or agency procedures and protocols D) Medical Code of Ethics, belief in active euthanasia

Answer: ANA Code for Nurses, ethical and professional standards Feedback: The ANA Code of Ethics, the ethical traditions and goals of the nursing profession, and nursing's covenant with society, all affirm that it is a violation for nurses to participate in assisting in a suicide and active euthanasia (assisting a client to die).

A woman has had a breast removed to treat cancer. What type of loss will she most likely experience? A) Actual loss B) Perceived loss C) Maturational loss D) Anticipatory loss

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

A dying client is crying. She states, Why me, Lord?" and "I can't pray." What would be an appropriate nursing diagnosis based on this data? A) Psycho-spiritual distress B) Low self esteem C) Ineffective coping D) Knowledge deficit related to praying

Answer: Psycho-spiritual distress Feedback: Spiritual needs must be included in the plan of care for the dying client. Verbal cues to psycho-spiritual distress include inability to pray and lack of inability to forgive one's self.

Which one of the following statements accurately describes the process known as grief reaction? A) Reactions to grief and dying are different. B) Reactions to grief are similar for all people. C) Reactions to grief follow all stages of the grieving process. D) Reactions to grief may differ from client to family.

Answer: Reactions to grief may differ from client to family. Feedback: Reactions to grief and dying are similar. The stages of these reactions overlap and vary among individuals. One person may skip a reaction stage, whereas another may repeat an earlier stage. Each person is different, and clients and family members may be at different reaction stages. More important than the actual stages of any given grief reaction is the idea that grief is a process that varies from person to person.

The parents of a teenager who is being maintained on life support after a motorcycle crash tell the nurse, We would like to donate his organs if he dies. What is the nurse's role in organ donation? A) Realize that it is a legal responsibility to call the coroner. B) Review options and provide consent forms to the family. C) Make arrangements for protocols for retrieving the organs. D) None; organ donation is a physician's responsibility

Answer: Review options and provide consent forms to the family.

A young client died following a cardiac arrest. The nurse caring for the client and the family notes that some members of the family refuse to accept that the client has died. What stage of grief is the family experiencing? A) Shock and disbelief B) Developing awareness C) Restitution period D) Idealization

Answer: Shock and disbelief Feedback: The family members are in the "shock and disbelief" stage of grief, as they refuse to accept that a loved one has died. In the stage of developing awareness, the grieving person develops physical and emotional responses, such as feeling sick, sad, empty, or angry. In the idealization stage, the grieving person exaggerates the good qualities of thedeceased.

A nurse who provides bereavement counseling is working with the family of a child who recently died from cancer. Which of the following statements may be a common expression of grief and guilt by a family member? A) 65-year-old grandparent: It helped me prepare for my death. B) Parents: We did everything we could and we are at peace. C) Uncle: It was for the best. D) Sister: It is all my fault; I wanted him to die

Answer: Sister: "It is all my fault; I wanted him to die".

A dying patient is crying. She states, I cant pray. I cant forgive myself. What would be an appropriate nursing diagnosis based on this data? A) Noncompliance B) Knowledge Deficit C) Low Self-Esteem D) Spiritual Distress

Answer: Spiritual Distress

A hospice nurse is providing emotional care and support for a family who lost a son. The care will be provided based on what knowledge? A) All members of the family will react to loss in the same way. B) Grief is an abnormal physical reaction to a loss. C) Stages of grief reactions may overlap and are individualized. D) Bereavement is a normal process, requiring little intervention.

Answer: Stages of grief reactions may overlap and are individualized. Feedback: Although reactions to grief and dying are similar, the stages of grief reactions overlap and vary among individuals. Each person is different, and family members may be at different reaction stages.

A nurse assesses a terminally ill patient with a DNR order, with findings of decreased blood pressure, urinary and bowel incontinence, loss of reflexes, and Cheyne-Stokes respirations. Based on these findings, the nurse recognizes which of the following? A) These are signs of impending death. B) These signs do not indicate any abnormality. C) The client requires immediate resuscitation. D) The client's family should be asked to leave.

Answer: These are signs of impending death. Feedback: The clinical signs of impending or approaching death include decreased blood pressure, urinary and/or bowel incontinence, loss of reflexes, and Cheyne-Stokes respirations

While caring for a client near end of life, a student talks to her. Another student asks why she is talking to someone who is dying. Which response would be accurate? A) "It makes me feel better to talk to my clients." B) "I do this so I won't be so afraid the client will die." C) "I believe the client can hear me as long as she is alive." D) "I don't know; the nurse in charge of the client told me to."

Answer: "I believe the client can hear me as long as she is alive." Feedback: The sense of hearing is believed to be the last sense to leave the body, with many clients able to hear almost to the moment of death. The nurse should explain to the client the nursing care being given and the noises in the unit.

The client is newly diagnosed as having a terminal disease and asks, "I'm going to die soon, aren't I?" What are the most appropriate statements by the nurse? Select all that apply. A) "You should ask your health care provider that question." B) "What have you been told by your health care provider?" C) "How do you feel about that?" D) "This is something I am not comfortable discussing." E) "No, you are not actively dying."

Answer: "What have you been told by your health care provider?" "How do you feel about that?" Feedback: The questions "What have you been told?" and "How do you feel about that?" encourage the client to discuss what he does know and his feelings. The nurse needs to be comfortable about discussing issues related to dying with the client. Referring the question to the health care provider is considered passing the buck. The statement, "No, you are not actively dying" is closing the conversation and lying to the client.

A terminally ill client states to the nurse, "My situation is hopeless; I have no control over anything." The nurse implements which of the following interventions to enable hope for the client? A) State to the client, "We have explored all treatment options." B) Encourage the client to discuss his feelings. C) Sit in a chair next to the client. D) Hold the client's hand. E) Withhold information about disease progression.

Answer: Encourage the client to discuss his feelings. Sit in a chair next to the client. Hold the client's hand. Feedback: Measures to establish rapport with the client (e.g., providing time and physical contact by sitting in a chair next to the client; holding the client's hand) should be utilized. The client should be encouraged to express his feelings. The nurse avoids language that would extinguish hope as in the statement, "We have explored all treatment options." The nurse should provide information about the progress of the disease.

A dying client states in writing ahead of time what her choices would be for healthcare should certain circumstances develop. What is the term for this document? A) Living will B) Advance directives C) Durable power of attorney D) Comfort measures only

Answer: Advance directives Feedback: Two kinds of written advance directives can minimize difficulties by allowing individuals to state in advance what their choices would be for health care, should certain circumstances develop. Living wills provide specific instructions about the kinds of health care that should be provided or foregone in particular situations. A durable power of attorney for health care appoints an agent the person trusts to make decisions in the event of subsequent incapacity. Comfort measures only indicate that the goal of treatment is a comfortable, dignified death, and that further life-sustaining measures are no longer indicated.

For which persons are death certificates necessary? Select all that apply. A) Death from an infectious disease B) Death in an institutional setting C) Unexpected death D) Murder victims E) Death before age 65 years

Answer: All of the above Death from an infectious disease Death in an institutional setting Unexpected death Murder victims Death before age 65 years Feedback: U.S. law requires death certificates for all clients who die.

Which of the following are signs of a good death? Select all that apply. A) Minimal or moderate pain experienced B) The person dies according to the wishes of the family. C) The person dies with dignity. D) The person is prepared for death. E) The person has a sense of completion of life. F) The person has a good relationship with healthcare providers.

Answer: All the above except A and B.

Which of the following is an example of a perceived loss? A) A client mourns the loss of his amputated leg. B) A client grieves for the loss of his wife to cancer. C) An older client grieves for the loss of his independence. D) A client grieves for the loss of his job.

Answer: An older client grieves for the loss of his independence. Feedback: Perceived loss, such asloss of youth, of financial independence, and of a valued environment, is experienced by the person but is intangible to others. Answers A, B, and D are actual loss and can be recognized by others as well as by the person sustaining the loss; for example, loss of a limb, of a child, of a valued object such as money, and of a job.

A middle-age woman is mentally preparing for the death of her mother. What is the term for this mental preparation? A) Grieving B) Anticipatory grieving C) Bereavement D) Loss

Answer: Anticipatory grieving Feedback: Anticipatory grief is the characteristic pattern of psychological and physiologic responses a person makes to the impending loss (real or imagined) of a significant person, object, belief, or relationship.

An appropriate nursing diagnosis for the family of a client dying of cancer, whose members have expressed sorrow over the forthcoming loss, would be... A) Anticipatory grieving related to loss of family member, as evidenced by sorrow B) Dysfunctional grieving related to the loss of family member, as manifested by behaviors indicating anxiety C) Potential for grieving related to loss of family member and sorrow D) Dysfunctional grieving related to future loss of family member, manifested by family's developmental regression

Answer: Anticipatory grieving related to loss of family member, as evidenced by sorrow Feedback: Anticipatory grieving comprises the intellectual and emotional responses and behaviors by which individuals, families, and communities work through the process of modifying self-concept based on the perception of loss.

A man is diagnosed with terminal kidney failure. His wife demonstrates loss and grief behaviors. What type of loss is the wife experiencing? A) Maturational loss B) Anticipatory loss C) Dysfunctional grieving D) Bereavement

Answer: Anticipatory loss Feedback: 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.

According to the Harvard University Medical School committee, what function must be irreversibly lost to define death? A) Respiratory functions B) Reflexes C) Consciousness D) Brain function

Answer: Brain function Feedback: A Harvard University Medical School committee added that the nonreversible loss of brain function, accompanied by the more traditional signs, should be the definitive definition of death.

Although all of the following are factors that affect grief, which one is most likely to influence a person's expression of grief? A) Socioeconomic factors B) Cultural influences C) Religious influences D) Cause of death

Answer: Cultural influences Feedback: Both the physical and emotional manifestations of grief may be culturally influenced. Culture also influences a person's expression of grief.

A nurse is talking to a patient who has been told he has a terminal illness and is responding in an angry manner. What statement by the nurse would best facilitate better patient outcomes? A) "Why are you so angry? The doctor told you why you will not live". B) "I'm sorry you are in pain right now, but we have to talk about this". C) "When you feel like talking about how you feel, let me know". D) "How much do you know and what do you want to know".

Answer: D) "How much do you know and what do you want to know".

As decisions related to health care become increasingly complex, nurses need to be familiar with concepts related to advance directives. Which statement regarding advance directives is correct? A) Hospitals are legally required to inform clients about advance directives. B) The status of advance directives remains consistent from state to state. C) Advance directives should be developed with the assistance of a physician or nurse. D) Nurses can be appointed a surrogate decision maker by the client.

Answer: Hospitals are legally required to inform clients about advance directives. Feedback: The Patient Self-Determination Act of 1990 requires all hospitals to inform their clients about advance directives. Th status of advance directives varies from state to state. Clients appoint a family member or close friend as a surrogate decision maker, not a nurse or health care professional. Advance directives are developed by the client; nurses and physicians may play a role in providing education related to advance directives, but their role is not essential.

The nurse is giving palliative care to a client with a diagnosis of COPD. What is the goal of palliative care? A) Improve the client's and family's quality of life. B) Support aggressive treatment for cure. C) Provide physical support for the client. D) The client may develop a separate plan with each discipline of the health care team.

Answer: Improve the client's and family's quality of life. Feedback: The goal of palliative care is to improve the client's and the family's quality of life. The support should include the patient'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. Options B, C and D are incorrect; 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. Separate plans of care developed by the client with each discipline of the health care team are not the goal of palliative care.

A nurse is caring for a young client who is dying of renal failure. What should the nurse do when caring for the dying client's family members? A) Inform the family that the client may soon be out of danger B) Request the family members not to talk about death to the client C) Inform the family members that it is time to bid farewell to the client D) Provide respite care to the client's family members

Answer: Inform the family members that it is time to bid farewell to the client Feedback: The nurse should ask the family members to meet the client so that they can have a chance to say a final goodbye. The nurse should not provide any false hope to the client's family by telling them that the client may soon be out of danger. The nurse should not ask the client's family members to avoid talking about death, because the client would want to know that he or she is loved and will be missed by the family. Respite care is usually provided when the client is resting or out of danger.

A client asks a nurse to explain a living will. What is the nurse's best answer? A) It specifies who will inherit the client's estate. B) It determines an individual's quality of life. C) It lists specific instructions for health care provisions. D) It identifies a trusted person to make health care decisions.

Answer: It lists specific instructions for health care provisions. Feedback: A living will is a type of written advance directive that provides specific instructions about the kinds of health care that should be provided or foregone in particular situations.

Which of the following phrases can do much to instill hope in the dying patient? A) This is a hopeless situation. B) Nothing more can be done. C) Everything will be fine, so don't worry. D) Let me tell you about your illness

Answer: Let me tell you about your illness.

A dying client and family have requested that no attempts be made to resuscitate the client in the event of death. A doctor has written a DNR order. What is the nurse's responsibility if the client dies? A) Follow his or her own conscience and perform CPR. B) Make no attempt to resuscitate the client. C) Follow a verbal physician's order for a slow code. D) If the client is at home, call 911 and begin CPR.

Answer: Make no attempt to resuscitate the client. Feedback: A do not resuscitate (DNR) order means that no attempts are to be made to resuscitate a client who stops breathing or whose heart stops beating. The physician must write an order for this if the client or surrogate has expressed a wish that there be no attempts to resuscitate.

Which of the following persons is responsible for handling and filing a death certificate with proper authorities? A) Mortician B) Physician C) Nurse D) Hospital administrator

Answer: Mortician Feedback: U.S. law requires that a death certificate be prepared for each person who dies. The law specifies what information needs to be supplied. Death certificates are sent to local health departments, which compile many statistics from the information. The mortician assumes responsibility for handling and filing the death certificate with proper authorities. A physician's signature is required on the certificate, as well as that of the pathologist, the coroner, and others in special cases. The nurse's responsibility is to ensure that the physician has signed a death certificate.

A nurse is developing a plan of care for a dying client. Which of the following physiologic basic human needs should be addressed? A) Personal hygiene B) Rsk for infection C) Family support D) Spirituality

Answer: Personal hygiene Feedback: Physiologic care of the dying client involves meeting physical needs such as personal hygiene, pain control, nutritional and fluid needs, movement, elimination, and respiratory care.

A client is diagnosed with a terminal illness. Who is usually responsible for deciding what, when, and how the client should be told? A) Family B) Clergy C) Nurse D) Physician

Answer: Physician Feedback: In the case of a terminal illness in which death is expected within a limited space of time, the physician is usually responsible for deciding what, when, and how the client should be told. The nurse, along with members of the clergy and other health care professionals, may be involved with these decisions and in discussing the client's condition with him or her.

A nurse is providing postmortem care. Which of the following nursing actions is a legal responsibility? A) Placing the body in normal anatomic position B) Removing tubes and soiled dressings C) Washing the body to remove blood and excretions D) Placing ID tags on the shroud and ankle

Answer: Placing ID tags on the shroud and ankle Feedback: 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.

A nurse is caring for a young client with acute renal failure who is dying. What care should the nurse take when helping dying clients to cope? A) Avoid discussing death with the client. B) Ask the client's family not to disturb the client. C) Avoid informing the client of his or her actual health status. D) Provide opportunities for the client to express his or her feelings freely

Answer: Provide opportunities for the client to express his or her feelings freely Feedback: The nurse should provide opportunities for the client to express his or her feelings freely, as it demonstrates attention to meeting individual needs. The nurse should not avoid discussing death with the client, nor ask the client's family not to disturb him or her. The nurse should inform the client of his or her actual health status if he or she wishes to know, as the Dying Person's Bill of Rights states that the client has a right to have his or her questions answered honestly.

A nurse providing palliative care for a dying man and his family knows that the goal of palliative care is what? A) To aggressively treat the disease. B) To provide care for the dying in the home. C) To aggressively treat the symptoms of the disease. D) To support the family of the dying client.

Answer: To aggressively treat the symptoms of the disease. Feedback: Palliative care means taking care of the whole person—body, mind, and spirit, heart and soul. It views dying as something natural and personal. The goal of palliative care is to give clients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms. Hospice care is care provided for people with limited life expectancy, often in the home. While hospice care focuses on the needs of the dying, palliative care is appropriate across the spectrum of disease and illness.

A dying client is undergoing terminal weaning. What is the purpose of this intervention? A) To manage the symptoms of the illness B) To prepare for resuscitation of the client C) To initiate life-sustaining measures for the client D) To gradually withdraw mechanical ventilation

Answer: To gradually withdraw mechanical ventilation Feedback: Terminal weaning is the gradual withdrawal of mechanical ventilation from a client with a terminal illness or an irreversible condition with a poor prognosis.

Palliative care is a structured system for care delivery that has what as its aim? A) To give traditional medical care B) To prevent and relieve suffering C) To bridge between curative care and hospice care D) To provide care while there is still hope

Answer: To prevent and relieve suffering Feedback: 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, which makes option A incorrect. Palliative care is considered a bridge not exclusively limited to hospice care, which makes option C incorrect. Option D is incorrect; hope is something clients and families have even while the client is actively dying.

The husband of a client who died of breast cancer is still grieving for his wife two years later. What type of grief is he experiencing? A) Unresolved B) Situational C) Inhibited D) Maturational

Answer: Unresolved Feedback: 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.