Chapter 37. The Bereaved Individual

Order the stages of normal grief, according to J. William Worden. ________ Finding an enduring connection with the lost entity in the mist of embarking on a new life ________ Accepting the reality of the loss ________ Adjusting to a world without the lost entity ________ Processing the pain of grief

ANS: 2, 4, 3, 1 Rationale: Worden views the bereaved person as active and self-determining rather than a passive participant in the grief process. He proposes that bereavement includes a set of tasks that must be reconciled in order to complete the grief process. 1. Accepting the reality of the loss 2. Processing the pain of grief 3. Adjusting to a world without the lost entity 4. Finding an enduring connection with the lost entity in the mist of embarking on a new life

When Frank's wife of 34 years dies, he is very stoic, handles all the funeral arrangements, doesn't cry or appear sad, and comforts all of the other family members in their grief. Two years later, when Fran's best friend dies, Frank has sleep disturbances, difficulty concentrating, loss of weight, and difficulty performing his job. This is an example of which of the following maladaptive responses to the loss? a. Delayed grieving b. Distorted grieving c. Prolonged grieving d. exaggerated grieving

A

Which of the following is thought to facilitate the grief process? a. The ability to grieve in anticipation of the loss b. the ability to grieve alone without interference from others c. Having recently grieved for another loss d. Taking personal responsibility for the loss

A

Which is the most accurate description of the nursing diagnosis of dysfunctional grieving? 1. Inability to form a valid appraisal of a loss and to use available resources 2. The experience of distress, with accompanying sadness, which fails to follow norms 3. A perceived lack of control over a current loss situation 4. Aloneness perceived as imposed by others and as a negative or threatening state

ANS: 2 Rationale: The nurse should define dysfunctional grieving as the experience of distress, with accompanying sadness, which fails to follow norms. Three types of pathological grief reactions are delayed or inhibited grief, distorted (exaggerated) grief response, and chronic or prolonged grieving. One crucial difference between normal and dysfunctional grieving is the loss of self-esteem marked my feelings of guilt or worthlessness that may precipitate depression

A nurse assigns a client the nursing diagnosis of complicated grieving. According to Bowlby, which long-term outcome would be most appropriate for this nursing diagnosis? 1. The client will accomplish the recovery stage of grief by year one. 2. The client will accomplish the acceptance stage of grief by year one. 3. The client will accomplish the reorganization stage of grief by year one. 4. The client will accomplish the emotional relocation stage of grief by year one.

ANS: 3 Rationale: The nurse should identify that, according to Bowlby, an appropriate long-term outcome for this client is to accomplish the reorganization stage of grief by year one. Until the client can recognize and accept personal feelings regarding the loss, grief work cannot progress. The reorganization stage of grieving is the final stage in which the individual accepts the loss and new goals and patterns are established.

Order the stages of normal grief, according to John Bowlby._ _______ Reorganization ________ Disequilibrium ________Disorganization and despair ________ Numbness/protest

ANS: 4, 2, 3, 1 Rationale: John Bowlby hypothesized four stages in the grief process. He implies that these behaviors can be observed in all individuals who have experienced the loss of something or someone of value, even in babies as young as 6 months of age. 1. Numbness/Protest 2. Disequilibrium 3. Disorganization and despair 4. Reorganization

A woman returns home after delivering a stillborn infant to find that neighbors have dismantled the nursery that she and her husband planned. According to Worden, how should a nurse expect the neighbor's action to affect the woman's grieving task completion? A. This action may hamper the woman from accepting the reality of the loss. B. This action would help the woman forget the sorrow and move on with life. C. This action communicates full support from her neighbors. D. This action would motivate the woman to look to the future and not the past.

ANS: A The nurse should anticipate that this action could hinder the woman from accepting the reality of the loss. The first task in Worden's grief process is to accept the reality of the loss. It is common for individuals to refuse to believe that the loss has occurred. Behaviors may include misidentifying an individual in the environment as their loved one, retaining possessions of the lost loved one, and removing all reminders of the loved one so as not to have to face reality. The bereaved person is considered an active participant in the grief process and the above-mentioned behaviors are part of that process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

What term should a nurse use when describing a response to grieving that includes a sudden physical collapse and paralysis, and which cultural group would be associated with this behavior? A. "Falling out" in the African American culture B. "Body rocking" in the Vietnamese American culture C. "Conversion disorder" in the Jewish American culture D. "Spirit possession" in the Native American culture

ANS: A The nurse should use the term "falling out" to describe a sudden physical collapse and paralysis. This behavior is associated with the African American culture. The individuals may also experience an inability to see or speak yet maintain hearing and understanding. KEY: Cognitive Level: Application | Integrated Process: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nursing instructor is teaching about the typical grieving behaviors of Chinese Americans. Which student statement would indicate that more instruction is needed? A. "In this culture, the color red is associated with death and is considered bad luck." B. "In this culture, there is an innate fear of death." C. "In this culture, emotions are not expressed openly." D. "In this culture, death and bereavement are centered on ancestor worship."

ANS: A The nursing instructor should evaluate that more instruction is needed if a student states that the color red is associated with death and bad luck. Chinese Americans consider the color white as associated with death and both the colors black and white are considered bad luck. Red is the ultimate color of luck in this culture. Chinese Americans also avoid purchasing insurance because of the fear that they may be inviting death. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A nurse is leading a bereavement group. Which of the following group members should the nurse identify as being at high risk for having difficulty grieving? Select all that apply. A. A widower who has recently experienced the death of two good friends B. A man whose wife died suddenly after a cerebrovascular accident C. A widow who, after a year, allowed removal of life support from her terminally ill husband D. A woman who had a competitive relationship with her recently deceased brother E. A young couple whose child recently died of a genetic disorder

ANS: A, B, D, E Several factors have been identified that may make the grief response more difficult: grieving when the bereaved person was strongly dependent on the lost entity, the relationship with the lost entity was highly ambivalent, the individual experienced a number of recent losses, the loss is that of a young person, the individual's physical or psychological health is unstable, and the bereaved person perceived responsibility for the loss. A widow who has experienced the process of loss for an extended period of time is more likely in the stage of acceptance and resolution of grief. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

An instructor is teaching nursing students about Worden's grief process. According to Worden, which of the following client behaviors would delay or prolong the grieving process? Select all that apply. A. Refusing to allow self to think painful thoughts B. Indulging in the pain of loss C. Using alcohol and drugs D. Idealizing the object of loss E. Recognizing that time will heal

ANS: A, C, D The nurse should identify that refusing to allow self to think painful thoughts, using alcohol and drugs, and idealizing the object of loss will delay or prolong the grieving process. Task II of Worden's grief process is working through the pain or grief. Pain must be acknowledged and resolved in order to move on. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Psychosocial Integrity

Which of the following types of care should the interdisciplinary team of hospice provide? Select all that apply. A. Physical care available on a 24/7 basis B. Counseling on the addictive properties of pain-management medications C. Discussions related to death and dying D. Explorations of new, aggressive treatments E. Assistance with obtaining spiritual support and guidance

ANS: A, C, E The nurse should identify that the interdisciplinary team of hospice provides physical care available on a 24/7 basis, discussions related to death and dying, and assistance with obtaining spiritual support and guidance. Hospice is a program that provides palliative and supportive care to meet the needs of people who are dying. Support is also provided to client families. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which is the most accurate description of the nursing diagnosis of spiritual distress? A. The client reports no church affiliations. B. The client struggles to identify meaning and purpose in life. C. The client reports seeing the spirit of his deceased wife. D. The client reports that meditation helps him feel connected spiritually.

ANS: B One common nursing diagnosis in relation to complicated grief (and some authors would argue that all grief is complicated) is the risk for spiritual distress, which addresses the person's sense of meaning, purpose, and outlook for the future. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

A nurse is caring for an Irish client who has recently lost a spouse. The client states to the nurse, "I'm planning an elaborate wake and funeral." According to George Engel, what purpose would these rituals serve? A. To delay the recovery process initiated by the loss of the client's spouse B. To facilitate the acceptance of the loss of the client's spouse C. To avoid dealing with grief associated with the loss of the client's spouse D. To eliminate emotional pain related to the loss of the client's spouse

ANS: B The nurse should anticipate that the purpose of these rituals is to facilitate the acceptance of the loss of the client's spouse. Resolution of the loss is the fourth stage in Engel's grief process, in which the bereaved experiences a preoccupation with the loss, which gradually decreases over time. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

. A client is diagnosed with terminal cancer. Which situation would the nurse assess as reflecting Kübler-Ross's grief stage of "anger"? A. The client registers for an iron-man marathon to be held in 9 months. B. The client is a devoted Catholic but refuses to attend church and states that his faith has failed him. C. The client promises God to give up smoking if allowed to live long enough to witness a grandchild's birth. D. The client gathers family in order to plan a funeral and make last wishes known.

ANS: B The nurse should assess that the client is in the "anger" stage of grieving when the client refuses to attend church and states that his faith has failed him. Anger is the second stage of Kübler-Ross's grief process, in which the reality of the situation is realized and the individual has feelings of sadness, guilt, shame, helplessness, and hopelessness. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

Which grieving behaviors should a nurse anticipate when caring for a Southwest Navajo Indian client? A. Celebrating the life of a deceased person with festivities and revelry B. Not expressing grief openly and reluctance to touch a dead body C. Holding a prayerful vigil for a week following the person's death D. Expressing grief openly and publicly and erecting an altar in the home to honor the dead

ANS: B The nurse should identify that a Navajo client would not express grief openly and would be reluctant to touch a dead body. Navajo Indians do not bury the body of a deceased person for 4 days after death, and they conduct a cleaning ceremony prior to burial. The dead are buried with their shoes on the wrong feet and rings on their index fingers. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

The nurse assesses a client as experiencing maladaptive grieving. Which of the following factors confirms the nurse's assessment? A. The client's spouse died 12 months ago. B. The client still cries when recalling memories of the deceased. C. The client reports feelings of worthlessness. D. The client reports intermittent anxiety.

ANS: C Several authors identify loss of self-esteem as the differentiating factor between normal and maladaptive grieving. The length of time needed to grieve is variable, so it is difficult to establish a time frame as indicative of maladaptive grief. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse assesses a woman whose husband died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless and aimless. According to Bowlby, this widow is in which stage of the grieving process? A. Stage I: Numbness or protest B. Stage II: Disequilibrium C. Stage III: Disorganization and despair D. Stage IV: Reorganization

ANS: C The nurse should identify that this client is in the third stage of Bowlby's grief process, called disorganization and despair. This stage is characterized by feelings of despair in response to the realization that the loss has occurred. The individual experiences helplessness, fear, and hopelessness. Perceptions of visualizing or being in the presence of the lost individual may occur. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A teenager has recently lost a parent. Which grieving behavior should a school nurse expect when assessing this client? A. Denial of personal mortality B. Preoccupation with the loss C. Clinging behaviors and personal insecurity D. Acting-out behaviors, exhibited in aggression and defiance

ANS: D The school nurse should anticipate that this teenager would exhibit aggression and acting-out behaviors. Adolescents have the ability to understand death on an adult level yet have difficulty tolerating the intense feelings associated with the death of a loved one. It is often easier for adolescents to express sorrow by acting out rather than typical emotional expressions of the grieving process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client tells the nurse "I am worried about my 70-year-old mother. My father died almost 9 months ago, and she is still not her old self. She says she is lonely, but she doesn't do anything about getting out and being with others." The most helpful remark for the nurse would be A. "I think you are right in being concerned about your mother. Restitution should be taking place." B. "At about this time in the grieving process people experience disorganization and aimlessness." C. "It's odd that she is not talking a lot about your father and the good life they shared as a way of holding on." D. "Because of her age, she may never release from her husband and be ready to take on a new relationship."

B. "At about this time in the grieving process people experience disorganization and aimlessness." Rationale: Teaching the family about the normal phenomena experienced during bereavement is helpful. This statement is the only option that reflects a fact about the bereavement process. Disorganization, depression, restlessness, and aimlessness precede reorganization of behavior and are generally most pronounced at 6 to 9 months.

At what age do children understand that death is final and affects everyone? a. Age 3 to 5 b. Age 6 to 9 c. Age 10 to 12 d. Adolescents

C

Gloria, a recent widow, states, "I'm going to have to learn to pay all the bills. Hank always did that. I don't know if I can handle all of that." This is an example of which of the tasks described by Worden? a. Task I. Accepting the reality of the loss b. Task II. Processing the pain of grief c. Task III. Adjusting to a world without the lost entity d. Task IV. Finding an enduring connection with the lost entity in the midst of embarking on a new life

C

Nancy, who is dying of cancer, says to the nurse, "I just want to see my new grandbaby. If only God will let me live until she is born. Then I'll be ready to go." This is an example of which of Kubler-Ross's stages of grief? a. denial b. anger c. bargaining d. acceptance

C

Which grief reaction can the nurse anticipate in a 10 year old child? a. statements that the deceased person will soon return b. regressive behaviors, such as loss of bladder control c. a preoccupation with the loss d. Thinking that they may have done something to cause the death

C

Which of the following is not true regarding grieving by an adolescent? a. Adolescents may not show their true feelings about the death b. Adolescents tend to have an immortal attitude c. adolescent do not perceive death as inevitable d. adolescents may exhibit acting out behaviors as part of their grief

C

Nursing interventions that facilitate the grieving process include A. insisting that the bereaved seek spiritual guidance. B. helping the bereaved suppress strong emotions. C. making eye contact and listening attentively. D. not letting long periods of silence occur.

C. making eye contact and listening attentively. Rationale: Eye contact lets the bereaved know you are there and share their sadness. Patient listening helps the bereaved express feelings, both positive and negative.

A patient's grieving would be considered maladaptive if: a. The patient shows anger towards the grief b. The patient feels depressed for more than a week c. The patient does not go through all stages of bereavement d. The patient loses all self-esteem

D

Engel identifies which of the following as successful resolution of the grief process? a. When the bereaved person can talk about the loss without crying b. When the bereaved person no longer talks about the lost entity c. When the bereaved person puts all remembrances of the loss out of sight d. When the bereaved person can discuss both positive and negative aspects about the loss entity

D

A woman whose mother has just died a painful death from cancer tearfully tells the nurse that she does not think she will ever get over her mother's death. The most appropriate response would be A. "The next few months will be very hard for you, but in a year you will feel fine again." B."It was for the best. She was in such great pain." C. "Time heals all wounds, and yours will heal also." D. "The loss must be very painful for you."

D. "The loss must be very painful for you. Rationale: The most therapeutic response acknowledges the loss without offering banalities.

A grieving husband tells the nurse "There were so many things I should have told her before she died. How much she meant to me, what a good wife and mother she was." Which of the normal phenomena experienced during the mourning process does this statement exemplify? A. Preoccupation with the deceased B. Disorganization and depression C. Anger D. Guilt

D. Guilt Rationale: Guilt is exemplified in this statement. The husband blames himself for failing to take specific actions.