Chp 27 Loss and Grief - Essentials

Which action demonstrates that the patient is experiencing the reorganization stage of mourning after having a stillborn baby? a. The patient volunteers at a local infant loss support group. b. The patient sits for hours and hours just looking at the empty crib. c. The patient has panic attack with shortness of breath and chest pain. d. The patient turns to alcohol to numb the overwhelming pain of the loss.

ANS: A During the final phase of reorganization, which usually requires a year or more, the person accepts unaccustomed roles, acquires new skills, and builds new relationships. In the numbing phase, a person has periods of extremely intense emotion and reports feeling "stunned" or "unreal." The numbing phase lasts from several hours to a week. The yearning and searching phase evokes emotional outbursts, tearful sobbing, and acute distress. To move forward, people need to experience this painful phase of grief. During the phase of disorganization and despair, an individual spends much time thinking about how and why the loss occurred. The person often expresses anger at anyone he or she believes to be responsible. Gradually this phase gives way to an acceptance that the loss is permanent.

Which attitude of the nurse will facilitate effective care for hospice patients? a. The patient needs the nurse's presence and personal connection. b. Remaining silent signifies a noncaring attitude toward the patient. c. Reminiscing with the patient only makes a difficult situation worse. d. The patient does not recognize the impact of the loss if no tears are shed.

ANS: A Patients need the presence and personal connection of the nurse as they progress through the dying process. By silently sharing a moment of sadness with a patient or family member, you communicate caring and send the message that you respect and accept their feelings in the moment. Do not assume that other people react to loss or grief as you do or that a particular behavior necessarily indicates grief. Encouraging patients to tell stories about their loved one gives them an opportunity to provide information in a natural, unstructured, and meaningful way.

Which nursing diagnosis is most appropriate for a patient who is having difficulty with accepting the reality of a lung cancer diagnosis by attempting to hide periods of shortness of breath from the nurse? a. Ineffective denial related to threat of unpleasant reality of lung cancer b. Noncompliance related to failure to adhere to prescribed treatment plan c. Effective therapeutic regimen management related to illness symptom reduction d. Readiness for enhanced decision making related to realignment of personal values

ANS: A The patient is experiencing ineffective denial related to threat of unpleasant reality of lung cancer by hiding episodes of shortness of breath. The patient is not displaying noncompliance with the treatment plan, effective therapeutic regimen management, or readiness for enhanced decision making.

The patient is the caregiver to the spouse with advanced dementia. The patient mourns the loss of the spouse's mind and personality even though the body is still physically functioning. Which type of grief is being experienced by the patient? a. Normal b. Anticipatory c. Complicated d. Disenfranchised

ANS: B Anticipatory grief is the pain felt before the physical death of the loved one occurs. Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away. Disenfranchised grief occurs in situations in which others view a person's loss as insignificant or invalid.

Which of the following is true for a patient to receive home hospice care? a. Caregiver support is available during normal business hours. b. A primary caregiver must be living in the home with the patient. c. If the patient goes to the hospital, all prehospital orders are canceled. d. In the hospital, the home hospice care person must provide personal care.

ANS: B For a patient to receive home hospice care, a primary caregiver must be living in the home. The primary caregiver receives support from professional and volunteer hospice team members who are available 24 hours a day. If a patient receiving home hospice care goes to the hospital for the management of acute symptoms, a hospice nurse coordinates care between the home and hospital settings, but does not provide actual patient care.

The patient concentrates on the mind-numbing details of the spouse's funeral to delay dealing with the overwhelming pain of the loss. Which stage of grief is currently being experienced by the patient? a. Anger b. Denial c. Bargaining d. Acceptance e. Depression

ANS: B Individuals in the denial stage cannot believe or understand that a loss has occurred and shut down their feelings until they are able to process the grief a little at a time. In the anger stage, a person resists the loss, is angry about the situation, and sometimes becomes angry with God. During bargaining, the individual postpones awareness of the loss and tries to prevent the loss from happening by making deals or promises. A person realizes the full significance of the loss during the depression stage. When depressed, the person feels overwhelmingly lonely or sad and withdraws from interactions with others. During the stage of acceptance, the individual begins to accept the reality and inevitability of loss and looks to the future.

The chart lists the patient's daughter as having medical durable power of attorney for the patient. How does this impact the patient's care? a. The daughter is an attorney and plans to sue to the nursing staff and hospital for malpractice after the patient's death. b. The daughter can provide consent for medical procedures if the patient becomes unresponsive or disoriented. c. The patient's daughter must be consulted before asking the patient to consent to medical procedures. d. The patient's daughter will translate medical terminology used by health care providers when communicating with the patient.

ANS: B Medical durable power of attorney allows the patient's daughter to make medical decisions for the patient in the event that the patient is unable to do so. Medical durable power of attorney does not indicate a plan to sue for malpractice or require consultation before obtaining consent for procedures. Medical translation is not part of medical durable power of attorney.

The patient grieves the security of a solid supportive marriage after the spouse has an affair. Which type of loss was experienced by the patient? a. Actual b. Perceived c. Situational d. Maturational

ANS: B Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience an actual loss when they can no longer touch, hear, see, or have near them valued people or objects. Examples include job loss. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain and changes in living arrangements.

The patient is on a ventilator and has a heartbeat, but is brain dead. What should the nurse do? a. Explain that as long as the heart is beating, the patient is still alive. b. Provide a private area for the family to discuss organ donation options. c. Inform the family that the organs will be harvested when he is off the ventilator. d. Stress the importance of leaving the patient on the ventilator to harvest the corneas.

ANS: B Provide a private area for the family to discuss organ donation if this is an option. Many people do not understand "brain death." Family members often believe that the person is still alive because his or her heart is still beating. For their loved one to donate major organs (e.g., heart, lungs, liver), the body must be kept in good functional condition so the organs will not become damaged before donation. The patient remains on a ventilator until his or her organs are removed. Nonvital tissues such as corneas, skin, long bones, and middle ear bones can be removed at the time of death without maintaining vital functions.

The nurse is caring for a patient who generally copes well after losing a child many years ago but becomes despondent each year on the anniversary of the death. Which is the best statement by the nurse? a. "That kind of reaction is very rare after so long a time. It would be best to avoid the cemetery on dates that might trigger this type of reaction." b. "What happens to you is understandable and common in people who have lost loved ones." c. "I find that hard to believe. We all grieve basically the same way, and I know that I would not react that way after such a long time." d. "The fact that you reacted so strongly is concerning to me. This could be the beginning of some psychological issues."

ANS: B Reinforce the understanding that people grieve differently and that feelings change or resolve over time. Some people have "anniversary reactions" (heightened or renewed feelings of loss or grief) months or years after a loss. They worry that they are losing ground when signs of grief reappear after a period of relative calm. Offer reassurance that anniversary reactions are common, and encourage pleasant reminiscence.

Which nursing diagnosis is most appropriate for a patient whose friends and family have grown distant after the death of the patient's spouse? a. Impaired verbal communication related to alteration in sensory perception b. Risk for loneliness related to insufficient interactions with friends and family c. Health-seeking behavior related to desire for increased control of personal health d. Readiness for enhanced spiritual well-being related to expressed desire for prayer

ANS: B The patient is at risk for loneliness because the patient's friends and family have grown distant after the death of the patient's spouse. The patient does not demonstrate any sensory perception, desire for increased control, or expressed desire for prayer based on the information presented.

. Which intervention is appropriate for the nursing diagnosis hopelessness related to disease progression? a. Withhold negative information about the patient's disease processes. b. Help the patient set realistic goals and then help the patient achieve them. c. Impress on the family the importance of limiting visiting hours to provide rest. d. Assure the patient that he will be well cared for and does not need to do anything.

ANS: B To help patients feel more hopeful, remind them of their strengths and reinforce their expressions of courage, positive thinking, and realistic goal setting. Patients feel more hopeful when they have a sense of control. Family members of dying people identified the importance of maintaining connections. When people have strong relationships and a sense of emotional connectedness to others, they know that help is available. Offer information to patients about their illness, correct misinformation, and clarify patient's perceptions.

Which behavior supports inclusion of the nursing diagnosis complicated grieving related to sudden death of a sibling in the patient's care plan? a. The patient donates the sibling's clothes to a local charity. b. The patient withdraws from relationships with friends and family. c. The patient adopts the sibling's dog and arranges for veterinary care. d. The patient arranges for the gravestone to be placed at the sibling's burial site.

ANS: B Withdrawing from relationships with friends and family is an unhealthy coping behavior and demonstrates complicated grieving. Adopting the dog, arranging for a gravestone, and donating clothes are all tasks to be completed after a death and indicate normal grieving.

Which assessment findings lead the nurse to inform the family that the patient's death is imminent? (Select all that apply.) a. The patient's pupils are fixed and dilated bilaterally. b. The patient is lethargic, drifting in and out of consciousness. c. The patient's breathing is harsh and congested with periods of apnea. d. The patient had only 40 mL in the urinary catheter bag for the last 8 hours. e. The patient's temperature is 102.6° F (39.2° C) but the hands and feet are cool and mottled.

ANS: B, C, D, E Lethargy, harsh breathing, low urine output, fever, and mottled skin are all signs of imminent death. Fixed, dilated pupils indicate that death has already occurred.

Which action demonstrates that the patient is experiencing the disorganization and despair stage of mourning? a. The patient puts the parent's estate and financial matters in order. b. The patient cannot eat or sleep for weeks after the loss of the parent. c. The patient sues the hospital for malpractice for not saving the parent's life. d. The patient falls sobbing to the floor when learning that the parent just died.

ANS: C Expressing anger at the hospital for not saving the parent's life is an example of the disorganization and despair stage. Expressions of anger and hostility at an individual or institution responsible for the loss are seen with the disorganization and despair stage. The person may also take long periods to reflect on how and why the loss occurred. Falling sobbing to the floor and inability to eat or sleep demonstrate the yearning and searching stage. Putting the parent's financial estate in order demonstrates completion of a necessary monetary task after death.

The patient leaves behind nightly dinners with the family, babysitting assistance from friends, and the warmth of the local church community when moving across the country. Which type of loss was experienced by the patient? a. Conditional b. Perceived c. Situational d. Maturational

ANS: C Situational loss occurs as a result of an unpredictable life event. A situational loss often involves multiple losses. A divorce, for example, begins with the loss of a life companion, but often leads to financial strain, changes in living arrangements. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had a loss. For example, a person perceives she is less loved by her parents and experiences a loss of self-esteem. People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. There is no such thing as a conditional loss.

Which behaviors support inclusion of the nursing diagnosis compromised family coping related to loss of home in a fire in the care plan? (Select all that apply.) a. The children missed school and the parents missed work during the first few days after the fire. b. All of the family members were able to stay at the home of a neighbor for the first week after the fire. c. The parents have not been able to speak to each other without screaming in anger for the last 2 weeks. d. The children still have occasional nightmares about the fire and the damage to the family home. e. The parents are so preoccupied with insurance frustration that they have not noticed that the oldest child is failing school.

ANS: C, E Inability to speak to each other without screaming and not noticing the needs of other family members demonstrate the appropriateness of compromised family coping as a nursing diagnosis. It is expected that the family members would miss work and school for the first few days after the fire. The family is fortunate that they were able to stay with a neighbor. Occasional nightmares are to be expected following a house fire and do not demonstrate compromised family coping skills.

The nurse is caring for a patient who has just passed away. Which is the priority action of the nurse? a. Ask the family to leave the room so that postmortem care can be provided. b. Have the patient's family members sign consent forms for organ donation. c. Remove all drainage tubes and IV lines in case an autopsy is to be performed. d. Provide postmortem care in a manner consistent with religious or cultural beliefs.

ANS: D A nurse assumes responsibility for postmortem care (i.e., care of the body after death). Give postmortem care with dignity and sensitivity and in a manner consistent with a patient's religious or cultural beliefs. Ask family members if and how they would like to help care for the body. Make arrangements for a member of the professional staff (e.g., spiritual care provider) to stay with family members if they do not wish to participate in body care. Remove all catheters, tubes, or indwelling devices from the patient's body, except in the case of autopsy. In that case all medical devices should be left in place.

The female patient grieves the loss of her child to adoption and finds it difficult to cope because the pregnancy was kept a secret from the family and community. Which type of grief is being experienced by the patient? a. Delayed b. Complicated c. Anticipatory d. Disenfranchised

ANS: D Disenfranchised grief occurs in situations in which others view a person's loss as insignificant or invalid or when the patient's friends and family are unaware of the loss. Complicated grief happens when a person has difficulty progressing through the loss experience. The person does not accept the reality of the loss, and the intense feelings associated with acute grief do not go away. Normal or uncomplicated grief consists of commonly expected emotional and behavioral reactions to a loss (e.g., resentment, sorrow, anger, crying, loneliness, and temporary withdrawal from activities). The process of "letting go" before an actual loss or death has occurred is called anticipatory grief.

Which assistance is provided to the patient and family by the hospice care providers? a. Education about resuscitation techniques if the patient stops breathing b. Options for ending the patient's life when the pain becomes too severe c. Financial support for funeral and burial services after the patient's death d. Volunteers to stay with the patient to give the family a break from caregiving

ANS: D Hospice care provides supportive services for patients who are at the end of life. This includes volunteers who can provide respite care to give the family a break from caregiving. Hospice care does not provide financial support for burial, assistance for ending the patient's life, or education about resuscitation.

Which treatment would be refused by a patient who has requested palliative care? a. Therapeutic touch b. Supplemental oxygen c. Narcotic pain medications d. Knee-replacement surgery

ANS: D Palliative care is practiced in any setting and focuses on the prevention, reduction, or relief of physical, emotional, social, and spiritual symptoms of disease or treatment at the end of life when cure is no longer possible. Knee-replacement surgery would not be appropriate for an end-of-life patient.

A nurse is caring for a patient who is depressed because her children have gone away to college. Which type of loss is experienced by the patient? a. Perceived b. Situational c. Conditional d. Maturational

ANS: D People experience maturational losses as they go through a lifetime of normal developmental processes. For example, when a child goes to school for the first time she will spend less time with her parents, leading to a change in the parent-child relationship. Perceived losses are uniquely experienced by a grieving person and are often less obvious to others. A perceived loss is very real to the person who has had the loss. For example, a person perceives that she is less loved by her parents and experiences a loss of self-esteem. Situational loss occurs as a result of an unpredictable life event. There is no such thing as a conditional loss.

Which action by the patient demonstrates reminiscence of a lost parent? a. The patient obtains a copy of the parent's will and inventories all assets. b. The patient returns to school to start a new career in business administration. c. The patient sues the hospital for malpractice after reviewing the medical record. d. The patient creates a scrapbook to remember special times spent with the parent.

ANS: D The patient demonstrates reminiscence by taking the time to remember the lost loved one through creation of a scrapbook. Suing the hospital for malpractice does not remember individual characteristics of the loved one or shared experiences. Returning to school indicates that the patient has reached the acceptance stage of grief and is moving on to new activities. Obtaining the will and completing inventory of assets demonstrates completion of necessary monetary tasks after death.