Experiencing Loss

A 55-year-old client is upset and discussing recent losses. Which type of losses is this client most likely experiencing based on age? Select all that apply.

Changes in relationships Rationale: A young adult aged 20 to 45 years is more likely to experience relationship changes. Loss and death of friends Rationale: A person over the age of 65 is likely to experience the loss and death of friends. *Children leaving the home Rationale: A 55-year-old client is likely to experience the loss of children as they leave the home to establish their own independent lives. *Stress and job-related issues Rationale: A 55-year-old client may experience stress and issues related to their job. *New-onset medical problems Rationale: A 55-year-old client may experience the onset of new medical problems.

The nurse is caring for a client who does not respond when touched or pinched and seems to be unaware of the environment. How should the nurse document this mental state?

Coma Rationale: A coma is a prolonged state of unconsciousness that may last months or years, but not all higher brain function is lost. Brain death Rationale: Death is a complete cessation of all brain function, including involuntary action and reflexes. Anticipatory grief Rationale: Anticipatory grief is a grief response that occurs before the loss itself. *Persistent vegetative state Rationale: A persistent vegetative state occurs when all higher cerebral function is lost, including all awareness of the person's environment.

Which term describes the period of time after a spouse dies when a person adjusts to the change in their life?

Loss Rationale: Loss is an unwanted change or removal of a valued object, person, or situation. This occurs at the actual time the spouse passed away. Grief Rationale: Grief is the physical, psychological, and spiritual responses to the loss. This includes emotions but does not describe the period of time after a loss. Mourning Rationale: Mourning consists of the actions related to grief, such as wearing black or crying. This does not denote a period of time. *Bereavement Rationale: The bereavement period is the time frame after the spouse dies when the person adjusts to the change in their life.

In states where assisted suicide is legal, what is the role of the nurse?

The nurse assists with the process. Rationale: The American Nurses Association (ANA) prohibits nurses from assisting with the process, as it violates the code of ethics. The nurse monitors vital signs throughout. Rationale: The nurse is not to participate in any way, as assisted suicide violates the code of ethics and the principle of nonmaleficence. *The nurse does not participate in any way. Rationale: The ANA has established that assisted suicide violates the ethical principal of nonmaleficence and prohibits nurses from participation. The nurse provides education to the client and family about assisted suicide. Rationale: The nurse is not to participate in assisted suicide in any way because it represents an ethical violation.

The nurse is caring for a client who has passed away, and the family is leaving the room after spending 30 minutes with the deceased client. Which processes would the nurse expect to find occurring in the deceased client? Select all that apply.

Rigor mortis Rationale: Rigor mortis does not set in for 2 to 4 hours; therefore, the client would not yet be in rigor mortis. *Livor mortis Rationale: Livor mortis occurs when blood stops circulating, breaks down, and releases hemoglobin. This accounts for a bluish and mottled skin appearance. *Algor mortis Rationale: Algor mortis happens when blood ceases circulating. This allows for the body temperature to drop 1.88°F (1°C) every hour until the body reaches room temperature. Skin breakdown Rationale: Skin may break down prior to death as circulation decreases; however, this does not occur in the immediate period after death. Neck hyperextension Rationale: The neck will not begin to hyperextend for at least 2 hours after death.

Which factor most affects the intensity of grief after a loss?

The coping skills of the person experiencing the loss Rationale: A person's coping skills can affect how strongly a loss is felt, but this is not the strongest determinant of how grief is felt. *The meaning the person attaches to the loss Rationale: Grief and loss are very individual, and a person's reaction to the loss and intensity of grief is related to the meaning attached to the loss. The length of the relationship with the person lost Rationale: The loss of a longer relationship may have additional meaning attached, but this is not the strongest factor affecting grief. Support systems available after the loss Rationale: Support systems are important as a person recovers from grief, but this is not the strongest factor in the intensity of the loss. Test-Taking Tip Consider the answer that is most patient-centered.

Which factor can both support and hinder a person's ability to grieve the loss of a family member?

The deceased person was elderly. Rationale: When a person dies at a younger age, it is usually more difficult to accept because it may be viewed as unfair and the younger person had untapped potential that will never be fulfilled, but this does not necessarily affect the grieving process itself. *The family members have strong spiritual beliefs. Rationale: A person's spirituality or religious beliefs may provide comfort that the deceased is in a better place and in no more pain. It can also hinder grieving if the family believes in an afterlife and that the deceased is not at rest. The family has given the person permission to die. Rationale: When the family gives the dying person permission to die, this is a healthy way of handling grief. It will not prolong the grieving process. The members of the family have a good support system. Rationale: When family members have a good support system, it makes the grieving process less complicated. Test-Taking Tip Most cultures engage in rituals (e.g., funerals) that allow the bereaved to openly express their grief and pain, whereas others may limit expressions of grief to private settings. Having a strong spiritual belief may cause the family to accept the death or feel unsettled about the deceased's future in the afterlife.

According to Elisabeth Kübler-Ross's five stages of grieving, which statement indicates a client is in the bargaining stage of grief?

"I do not believe the diagnostic test results. I want a second opinion. I do not have cancer." Rationale: When a client does not believe diagnostic test results that confirm cancer, this indicates the client is in the denial stage of grieving. "I do not understand this! Why is this happening to me?" Rationale: A client who cannot understand why something is happening and questions the occurrence is exhibiting signs of anger and is in the anger stage of grieving. "I know that I smoked cigarettes for over 40 years, so it is understandable I developed lung cancer." Rationale: A client who acknowledges the disease and accepts the diagnosis is in the acceptance stage of grieving. *"I know there is no cure for this disease, but I want to live long enough to see my granddaughter get married. I will be a better person in order to have that." Rationale: A client who is in the bargaining stage of grieving will bargain with a higher power for more time to live to experience a significant life event.

The nurse is caring for a client who is in a persistent vegetative state (PVS). A family member who visits notices the client is crying and tells the nurse the client is improving and responding to stimuli. What is the nurse's best response?

"Let me notify the healthcare provider of this change in the client's condition." Rationale: The nurse would not notify the healthcare provider because it is common for clients in a PVS to grimace, cry, or laugh. "Those tears are probably from eye irritation. I can instill some eye drops." Rationale: Grimacing, crying, or laughing are common in clients in a PVS and are not related to eye irritation. *"Clients in a persistent vegetative state have reflex reactions such as crying." Rationale: Crying, grimacing, and laughing are spontaneous movements and are common in clients in a PVS. This can cause the family to have false optimism and grieve all over again. "I do not think that the client cried. This does not happen for clients in a persistent vegetative state." Rationale: This statement is dismissive of the family member and would not be appropriate or accurate to tell the family. This is not a therapeutic statement. Test-Taking Tip The person in a PVS does not purposefully respond to stimuli, is unaware of the environment, and has no cognition or affective mental functions. Thus, the person cannot speak or obey commands. Patients in a PVS may look somewhat normal and may occasionally grimace, cry, or laugh.

Which are appropriate questions a nurse could ask to help establish a client's goals at end of life? Select all that apply.

*"What is your pain goal, on a scale of 0 to 10?" Rationale: If a client has pain, working together with the client to set and achieve pain goals can help the client maintain control over end-of-life care. *"Whom would you like to have in the room with you?" Rationale: Identifying the support person(s) the client would like to have with them will help put the client more at ease and avoid conflict. "What would you do to prevent dying?" Rationale: Asking about preventing death suggests that death could be prevented. This question will not help establish goals at the end of life. *"Is there anything you would still like to do?" Rationale: Understanding any unfulfilled desires or wishes can assist with end-of-life goal setting. "Why do you think you got this illness?" Rationale: Delving into causes of illness is not helpful at end of life, nor will this question support end-of-life goals. Test-Taking Tip Asking questions about goals the client may have at the end of life can help provide the most optimal care. Encourage the family and the client to be active in planning care.

The nurse is caring for a client who is recovering from a new colostomy secondary to colorectal cancer. The client received the first chemotherapy treatment 2 weeks ago and is beginning to experience alopecia. Which types of loss might this client be experiencing? Select all that apply.

*Actual Rationale: The client with alopecia secondary to chemotherapy is experiencing the actual hair loss. *Physical Rationale: A client who has a permanent colostomy formed from colorectal cancer has sustained a physical loss. External Rationale: External losses include the actual loss of items of monetary value, such as personal belongings or jewelry. Perceived Rationale: There is no evidence this client has suffered a perceived loss, as perceived losses are internal. Environmental Rationale: Examples of environmental losses are getting a new job or moving to a new home. This client has not experienced an environmental loss.

The nurse cares for a client who has lost her house and husband in a fire. Which type of loss is the client experiencing? Select all that apply.

*External Rationale: An external loss is the loss of something of sentimental or monetary value. Physical Rationale: Physical loss involves the loss of a body part, such as a limb, or functional ability. *Relationship Rationale: The loss of a relationship is an actual loss of something tangible. Perceived Rationale: Perceived loss is only identified by the person experiencing it; it is usually not tangible. *Environmental Rationale: An environmental loss is the loss of familiar surroundings or a usual living situation. Test-Taking Tip There are many types of losses; some are losses of tangible things, others are internal or perceived losses.

Which tasks will the nurse perform when preparing the client's body for the morgue? Select all that apply.

*Gently pressing on the eyelids to close the eyes Rationale: The nurse should close the client's eyes prior to rigor mortis occurring. This is done by gently pressing on the eyelids to close the eyes. Removing any pillows from underneath the head Rationale: The nurse should place pillows under the head to prevent blood from pooling and discoloration; pillows should not be removed. *Padding wrists with gauze and tying the wrists together Rationale: The wrists should be padded with gauze and tied together to prevent bruising. *Wrapping the body in a shroud or placing it in a body bag Rationale: The body should be wrapped in a shroud or placed in a body bag. Placing dentures in a cup and sending them with the body Rationale: The nurse should insert the dentures into the client's mouth prior to rigor mortis occurring.

The nurse is working with a group of clients in a grief support group for people who have lost spouses in the past 3 months. The nurse notices each person is in a different phase of grieving. Which factors can impede a person's response to loss? Select all that apply.

*Having a fight with the spouse before they died Rationale: Unresolved conflicts between the surviving spouse and the deceased can influence the speed of the grieving process. *Having lost a spouse with whom they had a close relationship Rationale: A person may take longer to grieve when they had a close relationship with the person who died. *Having other family members pass away within the past 2 years Rationale: Previous losses can influence the grieving process. Someone who has experienced multiple losses may take longer to heal and respond than someone who has not experienced multiple losses. *Having few people to assist them during the time of loss Rationale: The amount of people the person has in their support system can impact the amount of time a person experiences grieving. Having poor or limited financial resources to afford burial expenses Rationale: Finances usually do not affect the length of time spent in the grieving process. Having the funeral service performed a week later to allow family to come in from out of town Rationale: Postponing the funeral service to wait for others to come in from out of town does not typically impede the grieving process. Test-Taking Tip No two people ever grieve in the same manner because many factors play a role in the grieving process.

A client with terminal cancer is in the last few hours of life and agitated. Which factors can cause agitation in this client? Select all that apply.

*Hepatic failure Rationale: Hepatic, or liver, failure can lead to anxiety as toxins build up. This is common as clients approach death. Visual changes Rationale: Changes in vision do occur in the last few hours of life, but this does not typically lead to agitation. *Cerebral hypoxia Rationale: Lack of oxygen to areas of the brain can cause anxiety in terminally ill clients approaching death. Bowel incontinence Rationale: It is common for terminally ill clients to have bowel incontinence; however, this does not cause agitation. *Medication side effects Rationale: Medications such as narcotic analgesics can cause anxiety in a terminally ill client approaching death.

A hospice nurse observes a widower drinking heavily after the loss of a spouse. Which type of grief is this person experiencing?

*Masked Rationale: Masked grief is expressed grief through maladaptive behaviors that can include alcohol abuse, drug use, or increased fighting. Delayed Rationale: Delayed grief is demonstrated when a person puts off grieving by focusing on something else. Anticipatory Rationale: A person experiencing anticipatory grief will begin grieving while the person is still alive. An example would be a spouse beginning to grieve while their partner is dying from terminal cancer. Disenfranchised Rationale: Disenfranchised grief occurs when a person is unable to publicly grieve a loss. Examples include a terminated pregnancy or a person whose extramarital partner dies.

Which findings related to circulation would the nurse expect to find in a client within hours to days of death? Select all that apply.

*Mottling of the extremities Rationale: Mottling of the extremities occurs when circulation decreases in a client nearing death. *Decreased blood pressure Rationale: As circulation begins to decrease, so will the client's blood pressure. Bounding peripheral pulses Rationale: Peripheral pulses will not be bounding, but rather, may be absent as circulation decreases. *Diminished urinary output Rationale: Urinary output decreases when circulation is diminished, due to decreased renal perfusion. Cheyne-Stokes respirations Rationale: The client near death will experience Cheyne-Stokes respirations; however, this occurs from changes in breathing and pulmonary congestion, not changes in circulation. Test-Taking Tip As death approaches, patients tend to become dehydrated and have difficulty swallowing, which results in decreased blood volume. Dehydration during the last hours of dying is thought not to cause distress, and perhaps to stimulate endorphin release. Dehydration contributes to decreased blood pressure, urinary output, and decreased circulation.

The nurse is teaching a family about the premises of hospice care. What is important for the nurse to include? Select all that apply.

*Quality of life is as important as the length of life. Rationale: One of the main premises of hospice is to maintain the quality of life for as long as possible. All illnesses should be treated aggressively. Rationale: Hospice recognizes that not all illnesses are curable, and that aggressive treatment is not appropriate during end-of-life care. Lifesaving measures should always be implemented, even if the illness is not curable. Rationale: Hospice operates under the premise that lifesaving measures will not be implemented, and life will not be prolonged in the presence of an incurable illness. *Those who are terminally ill should be allowed to face death with dignity surrounded by family and loved ones. Rationale: Part of improving the quality of life for dying persons is allowing them to make decisions for themselves and to be with loved ones in their final days. No efforts will be made to treat or reduce symptoms of illness. Rationale: Although no lifesaving or life-prolonging treatment is rendered as part of hospice care, treatment may be given if it improves the comfort or quality of life of the client.

A nurse is explaining the benefits of hospice services to a client with end-stage COPD. Which statements best explain hospice? Select all that apply.

*Quality of life is more important than length of life. Rationale: One of the premises of hospice is that quality of life is more important than quantity. *Clients have the right to die with dignity. Rationale: All clients have the right to die with dignity, and hospice promotes dignity. *Clients should be surrounded by family when they are dying. Rationale: Hospice services believe that clients should be surrounded by family when they are dying. Emergency medical treatment can be provided for hospice clients. Rationale: Hospice services do not cover emergency medical treatment; hospice is meant to provide palliative care to clients who are not responding to treatment. *Hospice services are provided for clients with 6 months or less life expectancy. Rationale: The prescribing healthcare provider for hospice services must document that the client has a life expectancy of less than 6 months.

According to Bowlby's phases of grief, which client action indicates the yearning and searching phase of grieving?

*Spraying the deceased person's cologne on their pillow Rationale: When a person is in the yearning and searching phase of grieving, they are looking for ways to connect with the deceased person. Spraying the deceased person's cologne on the pillow indicates looking for ways to maintain a connection. Displaying feelings of helplessness and disorientation Rationale: A person exhibiting feelings of helplessness and disorientation is in the initial phase of grieving, which is shock and numbness. Beginning to forget appointments and tasks that need to be completed Rationale: According to Bowlby's phases of grief, a person experiencing disorganization and despair may forget tasks and appointments. This will resolve as the person moves through the phases of grieving. Including activities in daily life such as reading, traveling, and exercising Rationale: According to Bowlby, the reorganization phase of grieving includes the incorporation of new activities such as travel, reading, and exercise.

The nurse is talking with family members of a client who has been diagnosed with terminal cancer. Which physiological changes should the nurse tell the family to expect in the client 1 to 2 weeks prior to death? Select all that apply.

*Yellowish skin color Rationale: A week or 2 weeks prior to death, the client will experience cardiovascular changes that can cause a change in skin color, creating a yellowish pallor. *Increased perspiration Rationale: The client will develop increased perspiration within 1 to 2 weeks of death. *Nonproductive cough Rationale: Within 1 to 2 weeks of death, the client will develop a rattling pulmonary congestion with a nonproductive cough. Elevated blood pressure Rationale: A person who is within 1 to 2 weeks of death will experience a decrease, not an increase, in blood pressure due to cardiovascular changes. Anorexia and ketosis Rationale: The client will develop anorexia and ketosis 1 to 3 months prior to death. This is earlier than 1 to 2 weeks prior to death.

List in order these phases of the active dying stage of a person dying of a serious illness.

1- Withdrawal from others 2- Decreased circulatory function 3- Increased energy and mental awareness 4- Diminished respirations and changes in breathing pattern 5- Death Rationale: Early states of the dying process include withdrawal from others and decreased heart rate and blood pressure accompanied by pallor and fatigue. Hours or days before death, the person will experience a surge in energy and mental clarity and a desire to be with family members. The final states of dying are associate with diminished respirations and changes in respiratory patterns. Finally, death occurs. Test-taking tip: Although the dying experience is unique to each individual, there are several predictable physical changes that occur when a client with chronic illness approaches death.

A client's record includes an order written by a physician to not initiate resuscitative efforts in the event of a cardiopulmonary arrest. The nurse recognizes this order as which?

An advanced directive Rationale: An advanced directive is a group of instructions a client has written to direct their wishes at the end of life. *Do not resuscitate (DNR) Rationale: DNR is an order written by a physician, directing other members of the healthcare team to not initiate resuscitative efforts in the event of a client experiencing a cardiac arrest. Euthanasia Rationale: Euthanasia is the deliberate ending of life of a person who is experiencing terminal or incurable illness. Durable power of attorney (DPOA) Rationale: A DPOA for healthcare identifies an individual assigned by the client to make healthcare decisions on the client's behalf. Test-Taking Tip If a person's condition is determined to be terminal and incurable, and a poor prognosis is established, a physician may write this type of order directing the healthcare team to withhold heroic efforts in the event of a cardiac arrest.

An adolescent is talking to a nurse about the loss of a parent. Which behavior indicates a need for intervention?

Attends grief and loss counseling every 2 weeks Rationale: An adolescent who is receiving counseling is receiving appropriate assistance, and this does not indicate a need for intervention. Makes a scrapbook with photos of the family Rationale: Creating a scrapbook of memories of the deceased parent is a healthy way of managing grief and does not require intervention. *Begins to get into fights at school Rationale: Destructive behaviors such as violence indicate an inability to adapt. This behavior requires a nursing intervention. Stays in their room frequently talking on the phone with friends Rationale: Even though the adolescent is staying in their room, they are reaching out to friends to talk. This does not require the nurse to intervene. Test-Taking Tip Research indicates that adolescents who have lost a parent have a higher frequency of engaging in health-risk behaviors. Adult caregivers must be alert to these behaviors and take appropriate action to intervene and provide bereavement support.

A nurse is caring for a client who is in the dying process. He has been ill and bedridden for over a year. His wife has previously been showing signs of grief and loss, but she is now behaving in a detached manner. The nurse knows this is which type of grief reaction?

Complicated Rationale: Complicated grief is characterized by intense emotions over a long period of time. It is a maladaptive response to grief. Chronic Rationale: Chronic grief begins as uncomplicated grief but continues over a long period of time. *Anticipatory Rationale: This is grief that begins before a loss occurs. The grieving person may go through the grieving process and detach before the actual loss. Delayed Rationale: Delayed grief occurs when the grieving person is busy with other things to do or focus on and avoids grieving at the time of the loss. Test-Taking Tip There are numerous types of grief. Most types are normal and uncomplicated. Some types of grief are maladaptive.

An elderly client is admitted to the hospital for treatment of heart failure. The client tells the nurse about the recent loss of a child and several friends in the past few years. Which findings should the nurse use to assess the client based on these multiple losses? Select all that apply.

Elevated blood glucose levels Rationale: An elderly client who has sustained multiple losses, including that of a child, would not necessarily develop abnormal blood glucose levels. *Decreased cognitive performance Rationale: Elderly clients who have suffered the loss of a child are shown to have decreased cognitive performance. Increased appetite and weight gain Rationale: Many people who have lost a child develop a decreased appetite and weight loss, not gain. *Decreased independent functioning Rationale: An elderly client may sustain decreases in independent functioning after experiencing the loss of a child. *Accelerated onset of physical disabilities Rationale: When an elderly client experiences the loss of a child, the nurse should observe for faster onset of physical disabilities.

According to the Uniform Determination of Death Act of 1981, which factors must be present to declare an individual dead? Select all that apply.

No response to painful stimuli Rationale: A person who does not respond to painful stimuli may still be alive. This is not an indicator of death. *Irreversible cessation of cardiac functions Rationale: The presence of irreversible cessation of cardiac functions is one indicator of death according to the Uniform Determination of Death Act of 1981. *Permanent ending of respiratory functions Rationale: According to the Uniform Determination of Death Act of 1981, the permanent ending of respiratory function is an indicator of death. *Permanent cessation of all brain functions Rationale: The Uniform Determination of Death Act of 1981 states that one of the indicators of death is the permanent cessation of all brain functions. Inability to verbally communicate physical needs Rationale: A person who is unable to verbally communicate physical needs does not meet the criteria for being declared deceased.

A nurse is caring for a client who has lost a leg due to a motor vehicle crash. The client is very withdrawn and is not interested in pursuing physical therapy. The client says, "What's the point? I will never have a normal life now." The nurse knows the client is experiencing which type of loss?

Perceived Rationale: A perceived loss is experienced only by the person involved. An actual loss may or may not have occurred. Environmental Rationale: An environmental loss is a change in living situation or loss of familiar surroundings. External Rationale: An external loss is the loss of something of sentimental or monetary value. *Physical Rationale: A physical loss is the loss of a physical part or functional ability.

What is the goal of palliative care?

To aggressively treat a serious illness Rationale: Palliative care does not have a goal of aggressively treating serious illness. The focus of palliative care is comfort measures. To work collaboratively to cure an illness Rationale: Palliative care is implemented when there is no possibility of a cure. The client should be kept as comfortable as possible. *To provide comfort care to those whose illnesses are no longer curable Rationale: Palliative care is aggressively planned comfort measures implemented when a person has an illness that is not curable. To respect the client's decision to not perform heroic lifesaving efforts Rationale: Although most clients undergoing palliative care have made end-of-life decisions, this is not a goal of palliative care. Test-Taking Tip End-of-life care includes palliative care.