Chapter 10: Loss, Grief and Dying

The nurse is caring for a patient who is hospitalized with a terminal illness diagnosis. Which statement by the patient indicates to the nurse that the patient is in the bargaining phase of death and dying?

"I just want to live long enough to be at my daughter's wedding." Rationale: The patient's statement is indicative of bargaining; the patient is stating that death is okay if a certain event can take place first.

The nurse in a long-term care facility is caring for a middle-aged patient diagnosed with a progressive neuromuscular disease. The patient seems distraught and asks the nurse to sit and talk. Which comment would the nurse least expect from the patient during their conversation?

"I just want to live long enough to see a cure for this horrible disease." Rationale: Concerns about pain, being a burden to family and expressing a desire to not die alone are expected comments from patient's dealing with a life-threatening disease.

The hospice nurse notices that a patient appears to be exhibiting signs of increasing terminal restlessness. The patient's family appears anxious about the patient's behavior. Which comment is most appropriate for the nurse to make?

"I will give the patient a sedative so he can rest." Rationale: The nurse is aware that terminal restlessness is related to fear or unfinished business; it is severe and long-lasting. Hypoxia may cause a patient to be restless, and if oxygen is not being used, it can be administered.

The nurse is providing care for a patient with a terminal illness. The nurse is aware of loud, angry voices in the patient's room. The patient shares that his religion does not believe in life support, but the patient will accept the intervention to avoid dying on a son's wedding day. Which statement by the nurse is best?

"My focus is on providing you with care that meets your specific needs." Rationale: No matter the patient's religious or cultural beliefs, the nurse's focus is always on providing the patient care that meets the patient's specific needs. The nurse needs to remember that cultural and religious differences among family members are not an area where the nurse should get involved unless the issue causes physical risk or emotional harm to the patient. The nurse needs to convey to the patient that the nurse's focus is always on meeting the patient's needs by providing patient-specific care.

An unlicensed assistive personnel (UAP) asks the nurse about the history of when to use cardiopulmonary resuscitation (CPR). Which answer by the nurse is incorrect?

"The process is not used on the terminally ill because it violates the right to die." Rationale: Initially, CPR was not intended for the terminally ill because it violated the right to die with dignity; however, CPR is now a standard-of-care for all patients unless there is a do not attempt resuscitation (DNAR) order.

The hospice nurse frequently comforts patients and family members with promises identified by Dr. Ira Byock. Which statement by the nurse will provide assurance of physical comfort?

"We will keep you warm and dry." Rationale: This speaks to the maintenance of physiological (physical) comfort.

The nurse is providing care for a patient who just received a diagnosis of a serious, aggressive disease. The patient states, "I know that time is short and I will decline quickly. How will I ever keep control of my medical care?" Which suggestion by the nurse is correct?

"You can ask someone you trust to follow your wishes to be your health-care proxy." Rationale: Talking to family about health-care wishes is not enough. In order to avoid conflicts and misunderstandings, the patient needs to appoint one person as a health-care proxy. The durable power of attorney can be anyone the patient trusts, and can include a family member, a friend, a lawyer, or an institution, such as a bank.

The nurse is researching ideas about assisting patients who are dying. The nurse comes across a theory from Dr. Ira Byock. Which things does Dr. Byock list as needing to be said as a person approaches death? Select all that apply. - "Thank you." - "I forgive you." - "I will miss you." - "Forgive me." - "Remember me."

- "Thank you." - "I forgive you." - "Forgive me."

The nurse needs to be aware of the patient situations that cause loss. Which patients will the nurse identify as being at risk for feelings of loss? Select all that apply. - A patient who is told that a neuromuscular condition is progressing. - A patient who has a temporary colostomy from the repair of a bowel blockage. - A patient undergoing dental surgery to replace teeth lost in an accident. - A patient who is having diagnostic testing to determine if cancer has reoccurred. - A patient who is being placed in a long-term care facility because of advanced age.

- A patient who is told that a neuromuscular condition is progressing. - A patient who is having diagnostic testing to determine if cancer has reoccurred. - A patient who is being placed in a long-term care facility because of advanced age.

The nurse is providing physical care for a patient who is dying. Which interventions are appropriate? Select all that apply. - Assess and treat for pain and nausea. - Provide oral care. - Address signs of spiritual distress. - Reposition for comfort. - Listen to memories and stories.

- Assess and treat for pain and nausea. - Provide oral care. - Reposition for comfort.

The nurse notes that the family members of a patient who is terminally ill frequently encourage the patient to take sips of fluids. The family voices concern about the patient becoming dehydrated. Which facts about the benefits of dehydration should the nurse share with the patient and family? Select all that apply. - Dehydration decreases the production of endorphins. - Decreased urine output decreases incontinence. - Decreased fluid intake decreases pulmonary secretions. - Dehydration ultimately decreases edema and ascites. - Dehydration results in decreased pain perception.

- Decreased urine output decreases incontinence. - Decreased fluid intake decreases pulmonary secretions. - Dehydration ultimately decreases edema and ascites. - Dehydration results in decreased pain perception.

The nurse is assessing the circulatory status of a patient who is dying. Which assessment findings does the nurse expect to see? Select all that apply. - Hands and feet that are cold and cyanotic. - Varying colors of pallor and cyanosis on dependent areas of the body. - Mottling that begins at the head and moves downward. - Peripheral pulses that are difficult to palpate. - A decrease or absence of urinary output.

- Hands and feet that are cold and cyanotic. - Varying colors of pallor and cyanosis on dependent areas of the body. - Peripheral pulses that are difficult to palpate. - A decrease or absence of urinary output. Rationale: As circulation is compromised, the hands and feet become cold to the touch and appear cyanotic. Various colors of pallor and cyanosis (mottling) appear on the hands, feet, legs and dependent parts of the body. Mottling begins distally and moves upward as circulatory function decreases. Peripheral pulses are weak and difficult to find due to decreased circulation and because of poor circulation, the kidneys begin to shut down, resulting in a decrease or absence of urinary output.

The hospice nurse notes that a patient is talking to persons who have already died, picking at the covers, and waving their arms around. Which nursing action is appropriate? Select all that apply. - Protect the patient to prevent injury. - Avoid correcting or reorienting the patient. - Medicate the patient for obvious signs of pain. - Give the patient a sedative to induce sleep and rest. - Distract the patient so that confused behaviors stop.

- Protect the patient to prevent injury. - Avoid correcting or reorienting the patient. Rationale: The observed behavior is common at the end of life. The patient does not need to be restrained or attempt to be reoriented as this may cause the patient to become agitated.

The nurse is caring for a patient who asks how a do not attempt resuscitation (DNAR) order is put in place. Which information does the nurse relay to the patient? Select all that apply. - The order can be written by the health-care provider based on the clinical situation. - The patient's spouse can sign the order. - The patient's attorney can sign the order. - The patient's health-care proxy can sign the order if the patient is unable to do so. - The patient can sign the order.

- The order can be written by the health-care provider based on the clinical situation. - The patient's health-care proxy can sign the order if the patient is unable to do so. - The patient can sign the order. Rationale: The patient's spouse or attorney cannot sign the order unless the spouse has durable power of attorney.

The hospice team begins care for a newly admitted patient. The patient and family seem uncertain about the parameters of hospice care. Which interventions will the nurse share as being part of hospice care? Select all that apply. - The team will help lessen fear and anxiety regarding death. - The team will be available to give the family members a break. - The team will make sure that every effort is made to alleviate pain. - The team will use nursing expertise to plan and provide care. - The team will assist the patient and family through the grieving process.

- The team will help lessen fear and anxiety regarding death. - The team will be available to give the family members a break. - The team will make sure that every effort is made to alleviate pain. - The team will assist the patient and family through the grieving process. Rationale: The hospice team does bring nursing expertise to the care arena; however, the patient's care is planned and provided with active input from the patient and the family.

The nurse is assigned care for multiple patients. Which patient does the nurse recognize as dealing with the most difficult loss?

A patient who has a history of cancer 5 years prior. Rationale: For the patient who survives cancer, the patient's sense of security and wellness is lost forever. This patient is dealing with the most difficult loss.

The nurse is caring for a terminally ill patient rapidly approaching death. The patient shares that it is the spouse's birthday. For which uncanny behavior will the nurse monitor the patient?

An attempt to control the timing of death. Rationale: Terminally ill patients will exert an uncanny control over their time of death. The nurse may notice a severe decline after the cause for delay is over.

The nurse enters a patient's room and notes that the patient is dressed in street clothes. The patient states, "I am leaving. They cannot do anything to help a dying man anyway." Which traditional stage of death and dying does the nurse recognize?

Anger

The nurse is assigning the care of a patient who is dying to the unlicensed assistive personnel (UAP). Which comfort measure should the nurse instruct the UAP to provide to the patient?

Apply moisturizer to the patient's lips. Rationale: Due to probable dehydration, the patient's lips and mucus membranes may be dry. Applying moisturizer to the lips is a comfort measure and within the UAP's scope of practice.

The nurse is caring for a patient with a terminal illness at the end stage of life. The nurse notices that the patient is experiencing skin breakdown on various areas of the body. Which nursing interventions are appropriate for this patient? Select all that apply. - Perform passive range of motion to improve circulation. - Promote healing by increasing protein and vitamin C intake. - Change the focus of wound care from healing to comfort. - Assist the health-care provider during the debridement process. -Keep the area clean and allow the wound to dry.

Change the focus of wound care from healing to comfort. Rationale: When caring for a patient at the end of life, the nurse should focus wound care on comfort because healing is not going to occur.

The nurse is caring for a patient who has a chronic lung condition, diabetes mellitus, and history of heart attacks. The patient was recently diagnosed with bowel cancer. The nurse understands that the patient's treatment options may be limited due to which of the following?

Comorbidity Rationale: Comorbidity refers to a patient who has multiple diseases

The nurse is providing care for an adult patient in the end stages of a terminal disease. The patient is the parent of minor children. The patient's spouse states, "The children don't know how bad things are. I don't want them to worry." Which advice from the nurse is best?

Details should be based on each child's developmental stage and ability to understand.

The patient, who is terminally ill, asks the nurse, "Please give me a little extra pain medicine to end my suffering." The nurse is aware the patient is asking the nurse to participate in which of the following?

Euthanasia Rationale: The nurse should remember that assisted suicide, i.e., euthanasia, is illegal. The nurse needs to manage the patient's pain without intentionally overdosing the patient.

The nurse is providing end-of-life care for a dying patient. The family is at the bedside, but the patient is unresponsive. Which action by the nurse demonstrates appropriate care?

Explaining patient changes to the family members who are present. Rationale: The family will want to know and needs to know what is happening. Never forget that all care is provided for the purpose of fulfilling a patient's needs. In this scenario, the patient of greatest need is the family. While providing comfort care to the patient, the family still has the greater need of knowing and understanding what is happening to the patient.

The nurse is providing care for a patient in the end stages of a terminal illness. The patient expresses a pain level of 9 on a scale of 0 to 10. The patient is prescribed pain management with an opioid drug. Which action should the nurse take next?

Give the patient the prescribed pain medication. Rationale: When a patient who is terminal expresses a high level of pain, the nurse should give the prescribed medication.

The nurse is providing care for a patient with a terminal illness. The nurse frequently notices nonverbal signs indicating that the patient is experiencing pain. Which interaction will be helpful in the management of the patient's pain?

Help the patient to understand that there is no benefit to suffering with pain. Rationale:

The nurse works in an extended nursing facility. The nurse finds the spouse of a resident lying in the hallway. The spouse is not breathing and does not have a pulse. Which action should be taken by the nurse?

Immediately start cardiovascular pulmonary resuscitation (CPR). Rationale: This is an emergency situation and there is not information that states that no intervention should be made.

A patient is placed in hospice care. Which care is the hospice nurse unlikely to provide for the patient or family members?

Make patient care decisions with the assigned staff. Rationale: The patient's care decisions are made by including the patient and family in the decision-making process. It is unlikely that these decisions would be made with input from only the assigned staff.

The nurse is providing care for a patient after surgery for a blocked bowel related to colon cancer. The health-care provider places the patient on palliative care. Which action does the nurse anticipate taking with this patient?

Medicate the patient for pain, nausea, vomiting, and dyspnea as prescribed. Rationale: During palliative care, the nurse should anticipate providing comfort to the patient by giving medication for pain, nausea, vomiting, and dyspnea.

The nurse transfers to a unit that provides palliative care. Which factor does the nurse understand about the patient care provided in this setting?

Patients may receive advanced, aggressive treatment. Rationale: In this care, the physician directs care and treatments are not intended to be life-saving measures. Medical interventions are aimed at maintaining patient comfort and slowing the progression of the disease.

The nurse observes the room of a dying patient. The nurse notes that the family is present, the lights are dimmed, the room is neat and tidy, the patient is resting without signs of distress, and soft music is on the radio. Which personal feeling will the nurse experience when the patient dies?

Self-satisfaction Rationale: When the nurse helps a patient and the patient's family pass through the process of death without fear, pain, or struggle, the nurse will feel self-satisfaction about a job well done.

The nurse notes that a dying patient is becoming more quiet and withdrawn. The family is upset because of the limited interaction with the patient. Which activity will the nurse recommend to family members?

Sit quietly and occasionally stroke the patient's hand. Rationale: The patient has no need for conversation or interaction at this time. Just knowing that a family member is present is adequate.

The hospice nurse notices that the patient's spouse has been at the patient's bedside every day for long hours. The hospice nurse encourages the spouse to consider______________ to rest and rejuvenate.

Taking some respite time Rationale:

The nurse is providing care for a patient diagnosed with advanced metastatic cancer. After the patient has a discussion with the health-care provider, a do not attempt resuscitation (DNAR) order is written. Later, the nurse finds the patient unresponsive with no pulse and not breathing. A family member shouts, "Do something. Save him." Which action should the nurse take?

Tell the family member that the patient made legal plans for no heroic life-saving measures. Rationale: The nurse needs to explain to the family member about the legality of the DNAR order and the patient's role in making this decision. The nurse is always an advocate for the patient. The nurse should always consider the patient's rights and the legal, moral, and ethical responsibilities of the nurse. Nurses are to honor the patient's wishes, even if the nurse does not agree with them.

The nurse is a new member of a hospice team. As a team member, which function does the nurse recognize?

The nurse is expected to fill the role of a teacher. Rationale: The patient and family will need information about the patient and the care.The hospice nurse plays a key role in the care of a patient at the end of life. The nurse is expected to bring confidence, knowledge, and skills to promote comfort and peace to the dying patient and family members.

The nurse works in a unit where many patients are terminal. Which intervention by the nurse will assist patients to approach death without fear and with a sense of peace?

The nurse listens to a patient talk about fears related to illness and death. Rationale: When a patient is able to talk about and resolve the fear that is associated with illness and death, the patient is more likely to approach death with a sense of peace.

The nurse is providing care for a patient diagnosed with an end-stage terminal illness. The patient asks the nurse about what kind of decisions are made with a living will. Which information should the nurse provide?

The patient can state the type of medical care that can be administered as their end of life approaches. Rationale: The living will is the patient's opportunity to decide what kind of care can be provided should an end-of-life condition or disability occur and can prevent the use of surgeries, medications, intubation, ventilation, or other life-sustaining measures as listed by the patient. The living will can include the withholding of IV fluids or food delivered by artificial means when the patient is unable to eat or drink naturally.

A patient just received the diagnosis of a terminal illness. The patient states to the nurse, "Please give me some medication to help end this now. There is no reason for me to suffer." Which conclusion by the nurse is correct?

The patient is asking the nurse to assist with suicide. Rationale: Most nurses are drawn to the profession of nursing because of feelings of compassion and care toward patients who are ill and/or distressed. However, the answer to this question is based on the nurse's understanding of what is right and wrong. Remember that nurses should never choose to do the wrong thing. Use your professional knowledge and decide how to help patients ethically and legally.

The nurse is providing care for a patient immediately after the patient learned about a terminal illness. The patient states, "I don't believe this. I cannot possibly be dying so soon." Which stage does the nurse recognize when considering the traditional stages of death and dying?

The patient is in the stage of denial and disbelief. Rationale: Patients move through the five stages of death in random order. The nurse cannot accurately predict which stage will be experienced next. All stages may not manifest.

The hospice nurse is attending a dying patient. A family member tells the nurse, "I don't think he wants to talk to me, he seems to not hear me." Which change will the nurse explain to the family member?

The patient is involved in introspection. Rationale: As the patient mentally processes their life, more and more time is spent on introspection and reflection. The patient may not appear to hear or notice those who are present.

The nurse is aware that as a patient approaches death, verbal communication decreases. Which observed behavior will the nurse interpret as an expression of pain?

The patient moves restlessly without any physical stimulation. Rationale: Look for nonverbal expressions of pain

The nurse is caring for an Amish patient diagnosed with ovarian cancer. The patient tells the nurse, "I hope to die soon for the benefit of my community." Which understanding about the Amish culture will the nurse apply to the patient's statement?

The patient wants to avoid the use of community resources on her death and dying. Rationale: The Amish culture believes that resources are best spent on the living. End-of-life care may be rationed, and the patient is not comfortable with the use of resources on her.

The nurse works in an acute care setting. Which hospitalized patient does the nurse identify as being at least risk for experiencing loss?

The patient who is having surgery to replace a fractured hip joint. Rationale: the surgery should improve the patient's functionality.

The hospice nurse provides care for a patient who is dying. Besides the expected physical changes, which other change does the nurse expect in this patient?

The patient will begin to withdraw from the world around them. Rationale: The patient is more likely to withdraw into their own thoughts and is rarely interested in worldly thoughts or processes like the news or world events close to the time of death. They will withdraw form the world around them and begin to separate form the people and things around them.

The nurse is assessing a patient who appears close to death. Which change does the nurse expect to see in the patient's vital signs?

The patient will experience periods of apnea. Rationale: The patient will have significant changes in respiratory rate and patterns. Some patterns of breathing will be accompanied by periods of apnea lasting 15 to 50 sec.

An adult patient is declared brain dead as a result of an accident. The patient has no advance directives. The family is in disagreement over removing the patient from life support. Which resolution to this dilemma will the nurse anticipate?

The state court can appoint a guardian to make medical decisions. Rationale: The state court can, and will, appoint a guardian; however, the process is expensive, time consuming, and stressful for the patient's loved ones. The court may appoint a person the patient or family would not choose.