Chapter 39: Loss and Grieving

The cardiac nurse, who has been caring for a hospitalized terminally ill client for 3 days, finds that the client has expired. The nurse manager knows that the nurse can legally care for these clients when the nurse states which of the following?

"Hospitals are mandated to notify transplant programs of potential donors." Why? The scarcity of organs has resulted in legislation mandating hospitals to notify transplantation programs of potential donors. Consent for autopsy is legally required, usually from the closest surviving family member. It is usually the physician's responsibility to obtain permission for an autopsy. If death is caused by accident, suicide, homicide, or illegal therapeutic practice or if it occurs within 24 hours of admission to the hospital, the coroner must be notified. Organs can be obtained from brain-dead clients and non-heart-beating cadavers.

The nurse is providing care to a group of terminally ill clients. The client who is most likely experiencing the bargaining stage of grief is the one who states:

"I just want to see my son have a family of his own." Why? The client is expressing the bargaining stage of grief when the client tries to barter for more time, as in the statement, "I just want to see my son have a family of his own." The other statements are reflective of other stages of grief.

The psychiatrist is evaluating a client who has recently learned she has a terminal illness. Which of the following statements indicated to the psychiatrist that the client is in the Kugler-Ross stage of bargaining?

"Just let me go on vacation with my wife; then I'll be satisfied." Why? According to Ross, the five stages of dying, with common reactions are denial, and ("why me" questions), bargaining (the client tries to barter for more time ("just let me go on vacation..."), depression ("I waited years to see my grandchildren and now I won't"), and acceptance ("I am at peace.")

Which of the following phrases can do much to instill hope in the dying patient?

"Let me tell you about your illness." Why? Hope is the ingredient of life that enables an individual to consider a future and to actively bring that future into being. One way the nurse can enable hope in the dying patient is to provide honest information about the progress of the illness.

A nurse is interviewing an older adult client who experienced a recent loss of his son due to an unexpected illness. Which question would be most appropriate for the nurse to ask when assessing the client's sociocultural stressors and resources?

"What are the traditional rituals for dealing with loss?" Why? To assess the sociocultural stressors and resources in the client, the nurse should ask about the traditional rituals for dealing with loss. The other questions ask the client to identify the personal stressors and resources.

A nurse is teaching a client about problem-focused coping methods. Which example would the nurse most likely include?

-"Make a time schedule and stick to it." -"Try finding out more about a situation." Why? Problem-focused coping examples include making a time schedule and sticking to it, and trying to find out more about a situation. Crying, meditating, taking a walk, or accepting the understanding of a friend are examples of solution-focused coping.

A nurse is providing care to a client in the protest stage of grief. Which interventions would be most appropriate? Select all that apply.

-Encourage expression of diverse feelings -Help identify new support systems -Teach client about the normal grief process Why? During the protest phase, the nurse should encourage expressions of diverse feelings, help the client use existing support systems and identify new support systems, and teach the client about the normal grief process. Referring the client to self-help groups is appropriate during the disorganization stage. Referring the client for career counseling is appropriate during the reorganization stage.

A group of nursing students is reviewing information about children and their perceptions about death. The students demonstrate understanding of the information when they state that a child's concept about death matures at about which age?

9 years Why? Typically, at about 9 years, a child's concept of death matures and the child perceives death realistically as irreversible, universal, inevitable, and natural.

Which of the following assessment finding would best support a nursing diagnosis of Dysfuntion Grieving?

A man is unable to return to work after his sister's death 18 months ago. Why? An inability to return to normal activities 18 months after a sibling's death is suggestive (tough not definitive) of Dysfuntion Grieving. Crying and having difficulties sleeping are not unusual and will often accompany healthy grieving. A feeling of "not doing enough" is common during grief and would only be considered dysfunctional if this became a long-term and all-encompassing belief.

A woman has has a breast removed to treat cancer. What type of loss will she most likely experience?

Actual loss Why? 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.

Which of the following is an example of a perceived loss?

An older client grieves for the loss of his independence. Why? Perceived loss, such as loss of youth, of financial independence, and of a valued environment, is experienced by the person but is intangible to other. Other answers of 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 man is diagnosed with terminal kidney failure. His wife demonstrates loss and grief behaviors. What type of loss is the wife experiencing?

Anticipatory loss Why? 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 actually loss of a family member.

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

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

A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform post-mortem care for the client. Which of the following interventions should the nurse perform when providing post-mortem care?

Cleanse drainage from the skin Why? The nurse should cleanse secretions and drainage from the skin to ensure delivery of a hygienic body. The dentures should be replaced in the mouth as they maintain the natural contour of the face. A small rolled towel is placed beneath the chin of the client to close the mouth; it is not placed under the head. The nurse should remove all hairpins or clips to prevent accidental trauma to the client's face

The nurse is assessing a client who was diagnosed with metastatic prostate cancer. The nurse notes that the client is exhibiting signs of loss, grief, and intense sadness. Based upon this assessment data, the nurse will document that the client is in what stage of death and dying?

Depression Why? Loss, grief, and intense sadness indicated depression. Denial is indicated by the refusal to admit the truth or reality. Anger is indicated by rage and resentment. Acceptance is indicated by a gradual, peaceful withdrawal from life.

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

Improve the client's and family's quality of life. Why? 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 need of the client and family. The goal of palliative care is not aggressive support for curing the client. Providing physical support for the client is also not the goal of palliative care. Separate plans of care developed by the client with each discipline of the health care team are not the goal of palliative care.

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

Mottling of the lower limbs Why? The time of death is generally preceded by a period of gradual diminishment of bodily functions in which increasing intervals between respirations, weakened and irregular pulse, and skin color changes or mottling may be observed. The patient will not be able to swallow secretions, so suctioning, frequent and gentle mouth care, and possibly the administration of a transdermal anticholinergic drug may be required.

When providing end-of-life care for clients, what will the nurse most often need to prioritize?

Pain control and emotional support Why? End-of-life care requires comprehensive blended nursing skills and is unique to each client's circumstances. Common priorities, however, include the need to provide vigilant pain control and emotional support.

A nurse is developing a plan of care for a dying client. Which of the following physiologic basic human needs should be addressed?

Personal hygiene Why? 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 nurse is caring for a client with a terminal illness. Which of the following is true of a terminal illness?

Recovery is beyond reasonable expectation. Why? A terminal illness is a condition from which recovery is beyond reasonable expectation. Clients with terminal illness do not recover from the illness; they may be treated symptomatically and provided care and comfort.

An elderly client at a health care facility dies after a prolonged illness. Which of the following is a psychological reaction associated with the different stages of grief?

Refusal to accept death. Why? The most common psychological reaction is shock and disbelief or the refusal to accept that a loved one is about to die or has died. Some grieving people report physical symptoms such as difficulty breathing or tightness in the throat, whereas some people show signs of pathologic grief through morbid behaviors.

With the help of the nurse, the parents of an infant who died shortly after birth arrange for a funeral service. What stage of grief, according to Engel, involves the rituals surrounding loss, including funeral services?

Restitution Why? Restitution is the stage of grief that involves the rituals surrounding loss; with death, it includes religious, cultural, or social expressions of mourning, such as funeral services. Shock and disbelief involve the person being in denial or having a numbed response to the death. Developing awareness is characterized by physical and emotional responses such as anger, feeling empty, and crying Resolving the loss involves dealing with the void left by the loss.

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?

Shock and disbelief Why? 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 the decreased.

Kubler-Ross defines five stages of psychosocial responses to dying and death. Which statement is characteristic of the bargaining stage?

"Just let me live to see my grandson born." Why? 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.

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

"Sometimes a person returns to a previous stage." Why? Ross (1969) studied the responses to death and dying. Her finding are as follows: Sometimes a person returns to a pervious stage, the stages of dying may overlap, the duration of any stage may range from as little as a few hours to as long as months, and the process varies from person to person.

A terminally ill client states to the nurse, "My situation his hopeless; I have no control over anything." The nurse implements which of the following interventions to enable hope for the client?

-Hold the client's hand -Sit in a chair next to the client -Encourage the client to discuss his feelings Why? 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

A home care nurse is providing care to an older adult client who is dying. The client's son asks the nurse how, when the time comes, he should tell his own children about their grandfather's death. Which suggestion by the nurse would be most appropriate? Select all that apply.

-Include the children in any rituals -Encourage the children to remember their grandfather -Help make the children feel loved and safe Why? To help children deal with death, the nurse should suggest that the son include the children in any rituals, encourage them to remember their grandfather, and help them feel loved and safe. Stoicism should not be praised. The children also should not be compared to their grandfather.

Which of the following are signs of a "good death?" Select all that apply

-The person dies with dignity. -The person is prepared for death -the person has a sense of completion of life. Why? A good death is one that allows a person to die on his or her own terms, relatively free of pain with dignity. It is free from avoidable distress and suffering for patients, families, and caregivers; in general accord with patients' families wishes; and reasonably consistent with clinical, cultural, and ethical standards (Institute of Medicine, 1997). The definition of a good death varies for each patient, but there are factors important for a good death, including control of symptoms, preparation for death, opportunity to have a sense of completion of one's life, and a good relationship with healthcare professionals.

A woman has responded to her recent diagnosis of lung cancer by making extensive plans for overseas travel with her children, despite the fact that her oncologist has informed her of her extremely poor prognosis. The client is adamant that she does not want to discuss her cancer and the nurse consequently recognizes that the client is likely in the denial stage of grief. How can the nurse best facilitate the client's healthy grieving?

Address the client's diagnosis and prognosis at a later time or date Why? In the absence of the client's readiness to become more aware of her situation, the nurse should respect the client's current position and revisit the matter when the client is more ready. It is disrespectful, and likely counterproductive, to have others reiterate the message, to provide written material, or to increase the amount of detail if the client is not ready to engage at this time.

A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross?

Anger Why? Anger is the second stage and is exhibited by statement similar to "Why me?" Denial occurs when the person refuses to believe certain information. Bargaining is and attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make preach spiritually and with those to whom they are close.

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

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

A patient who has died an unexplained death has numerous catheters and drainage tubes in place and is being prepared for an autopsy. In providing care to the body after the patient has been pronounced dead, how shall the nurse manage the tubes prior to the autopsy?

The nurse will not remove any tubes from the body Why? If an autopsy is to be performed, and tubes that were in place should not be removed.

The nurse is providing care to a group of terminally ill clients. The client who exhibits signs of impending death is the client who has

distended abdomen, Cheyne-Stokes respirations Why? Signs of impending death include abdominal distention and Cheyne-Stokes respirations. Other signs are decreasing blood pressure, slow or irregular pulse, restlessness, decreasing temperature, cooling and cyanosis of the extremities, and urinary incontinence. The other clients exhibit normal vital signs or do not exhibit these signs.

A nurse is assessing a dying patient for realism of expectations and perception of condition. Which interview questions address this concern?

-Have you had any previous experience with this condition before? -How do you see the next few weeks playing out? -What do you think may be happening in the midst of all of this? Why? A focused assessment regarding realism of expectations and perception of condition include the following questions: Have you had any previous experiences with this condition or with the death of someone you love? What are your expectations in this case? How do you see the next few weeks (days) playing out? What are your fears, hopes, concerns, worries? What good do you think might be happening in the midst of all this? The objective is to discover whether the patient and family have unrealistic expectations or misperceptions about the diagnosis, prognosis, and care options that will interfere with their decision making and coping. Asking the patient if he knows how to contact his doctor, what he has been told about his condition, and how well others around him are coping don't address these objectives.

A nurse is assessing the wife of a client who has just died unexpectedly. According to Demi's model, what would the nurse expect to assess in the wife? Select all that apply.

-Thought blocking -disorganized thinking -physical numbing Why? The wife is most likely yin the shock stage of grief and as such would most likely exhibit thought blocking, disorganized thinking, and physical numbing. Hallucinations and preoccupation with thoughts of her husband would reflect the protest stage.

Palliative care is a structured system for care delivery that has what as its aim?

To prevent and relieve suffering Why? 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.