Fundamental of Nursing Chapter 42: Loss, Grief, and Dying

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

"Why did this have to happen to me?" Explanation: The client is expressing anger when displaying a "why me" attitude. The other statements are reflective of other stages of grief.

An appropriate nursing diagnosis for the family of a client dying of cancer, whose members have expressed sorrow over the forthcoming loss, would be:

Anticipatory Grieving related to loss of family member, as evidenced by sorrow Explanation: Anticipatory grieving comprises the intellectual and emotional responses and behaviors by which individuals, families, and communities work through the process of modifying self-concept based on the perception of loss.

A client has been receiving dialysis for years and now states, "I have been thinking about this for a long time. I no longer wish to continue dialysis. I just want to die." What is the most appropriate statement by the nurse?

"Can you tell me about why you've made this decision?" Explanation: Having the client explain his decision-making process is open-ended and allows exploration of the client's feelings. A competent client is not required to continue with treatment that has been initiated. The other options are closed-ended and stop any further conversation.

The nurse should explain to the client's family member that a comfort-measures-only order is being implemented to obtain which expected outcome?

A comfortable, dignified death for the client Explanation: A comfort-measures-only order indicates that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are no longer indicated. It does not have any bearing on organ donation.

Which priority intervention should the nurse plan to implement to reduce a client's discomfort during terminal weaning?

Administer sedation and analgesia

Which statement regarding perceptions of death by children is accurate?

At about age 9, the child perceives death as irreversible. Explanation: At about 9 years of age, the child's concept of death matures, and the child perceives death realistically as irreversible, universal, inevitable, and natural.

What is Kübler-Ross's third stage of grief?

Bargaining Explanation: Her proposed stages of grief are denial, anger, bargaining, depression, and acceptance.

A home hospice client who has Medicare is experiencing extreme pain at home and is refusing to receive inpatient care due to concerns over the cost of inpatient care. What teaching will the nurse include in the plan of care?

Inpatient pain management for hospice patients is covered by Medicare. Explanation: Inpatient pain management is covered by Medicare as are any other Medicare-covered services needed to manage pain and other symptoms as recommended by the hospice team. Medicare will cover pain control in the home as well, but for extreme pain hospitalization may be required. Telling a client not to worry about payment does not educate about what services are available.

A nurse at the health care facility cares for several clients. Some of the clients may require end-of-life care. Which case may require the service of a coroner?

The client did not have any recent medical consultation.

A client has a diagnosis of bladder cancer with metastasis. The client asks the nurse about the characteristics of hospice care. The nurse should explain that:

care is premised on the fact that dying is a normal process. Explanation: Hospice care is premised on the fact that dying is a normal process. Symptoms are treated aggressively in order to preserve comfort. Care is interdisciplinary and admission usually requires a 6-month life expectancy or less.

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 Explanation: 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 critical care nurse is aware of the legislation that surrounds organ donation. When caring for a potential organ donor, the nurse is aware that:

hospitals are mandated to notify transplantation programs of potential donors.

A hospice nurse is assessing a client with end-stage chronic obstructive pulmonary disease (COPD). Which assessment findings would suggest that the client is dying? Select all that apply.

jaundiced skin Cheyne-Stokes respirations decreased urine output

Which manifestation of grief by the client who lost his wife 3 years earlier is considered abnormal?

leaving the wife's room and belongings intact Explanation: Bereavement experts reported that they considered almost all bereavement manifestations to be normal during the early stages of grief, but considered most of the manifestations to be abnormal if they continue beyond three years.

The experience of parting with an object, person, belief, or relationship that one values is defined as:

loss. Explanation: Loss is defined as the experience of parting with an object, person, belief, or relationship that one values; the loss requires a reorganization of one or more aspects of the person's life.

A client has been declared brain dead following a motor vehicle accident. What assessment data would the nurse anticipate?

no ocular movement Explanation: All brainstem reflexes would be absent (including pupillary response, corneal reflex, ocular movements). The respiratory drive would be absent.

In the Parkes model, a person uses denial as a psychological defense in the stage of:

numbness. Explanation: In the numbness stage, which is usually brief, trauma so overwhelms the bereaved survivor that he or she must use denial as a psychological defense.

The wife of a client who has been diagnosed with a terminal illness asks the nurse about the differences between palliative care and hospice care. Which information would the nurse most likely include in the response?

Hospice care is provided for clients who have 6 months or less to live; palliative care is provided at any time during illness.

A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response?

"It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition."

The nurse is trying to help the client cope with the dying process. Which nursing statement is most appropriate?

"It must be very difficult for you." Explanation: Use statements with broad openings such as "It must be difficult for you" and "Do you want to talk about it?" Such language encourages communication and allows the client to choose the topic or manner of response. Accept the client's behavior. Anger is part of the grieving process. Indicating that this is "awful" is not an appropriate way to promote coping. It is not the nurse's role to tell the client to make things right with family. While this may be desired, the client should initiate it.

The psychiatrist is evaluating a client who has recently learned she has a terminal illness. Which statement indicates to the psychiatrist that the client is in the Kübler-Ross stage of bargaining?

"Just let me go on vacation with my wife; then I'll be satisfied." Explanation: According to Kübler-Ross, the five stages of dying, with common reactions are: denial, anger "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.".

The nurse is caring for a client who has just died after a long diagnosis of dementia. Which nursing assessment is the priority for documentation?

"No breathing and no pulse at 0840." Explanation: The priority documentation is the assessment that indicates the client is dead. The other items can occur and will be documented after establishing that death has occurred.

Explanation: If death is caused by accident, suicide, homicide, or illegal therapeutic practice, the coroner must be notified, according to law.

The coroner may decide that an autopsy is advisable, and does not need the permission of the family for the autopsy to be performed. The physician does not need to be present during the autopsy, only the designated person performing the autopsy (medical examiner or pathologist).

A client has recently lost a parent. The client spent about 6 months deeply mourning the loss and is just now able to function at the pre-loss level. During this process , a strong social support was able to assist the client. What developmental stage of life does the nurse identify the client is in?

adult. Explanation: Adults tend to grieve more intensely and more continuously, but for a relatively shorter period of time than children. Having a good social network helps with this process, as well as having a stable lifestyle.

Explanation: Physical signs that often occur when a client is dying include: skin is extremely pale, cyanotic, jaundiced, or mottled; the heartbeat is irregular and the pulse is weak, rapid, and irregular; respirations are changed, shallow, labored, faster or slower, or irregular (e.g., Cheyne-Stokes respirations);

urine output is decreased due to worsening renal function and limited fluid intake; fecal retention or impaction occurs due to reduced gastrointestinal motility; incontinence occurs due to relaxation of the sphincter muscles; there is difficulty swallowing, generalized weakness, increased somnolence, and decreased responsiveness to external stimuli. Decreased pain does not occur with people who are dying.

A client has been diagnosed with a terminal illness and has periods of depression and periods of anger. The client's spouse is concerned, feeling as though their loved one is not moving forward in the stages of grief. What teaching is most appropriate for the nurse to include? Select all that apply

Movement between stages can be progressive. Movement back and forth between stages is expected.

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 statement by the nurse shows that she has understanding of the Kübler-Ross emotional responses to impending death?

"Sometimes a person returns to a previous stage." Explanation: Kübler-Ross (1969) studied the responses to death and dying. Her findings are as follows: Sometimes a person returns to a previous 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; the process varies from person to person.

When preparing for palliative care with the dying client, the nurse should provide the family with which explanation?

"The goal of palliative care is to give clients the best quality of life by the aggressive management of symptoms."

Explanation: Palliative care involves taking care of the body, mind, spirit, heart, and soul. It views dying as something natural and personal. The goal of palliative care is to give patients with life-threatening illnesses the best quality of life they can have by the aggressive management of symptoms.

A do-not-resuscitate order means that no attempts are to be made to resuscitate a client whose breathing or heart stops. Gradual withdrawal of mechanical ventilation from a client with a terminal illness and poor prognosis is called terminal weaning. Clients do not have to be in an inpatient hospice unit to receive palliative care.

Which assessment finding would best support a nursing diagnosis of Dysfunctional Grieving?

A man is unable to return to work after his sister's death 18 months ago. Explanation: An inability to return to normal activities 18 months after a sibling's death is suggestive (though not definitive) of Dysfunctional 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.

Assisted suicide is expressly prohibited under statutory or common law in the overwhelming majority of states. Yet public support for physician-assisted suicide has resulted in a number of state ballot initiatives. The issue of assisted suicide is opposed by nursing and medical organizations as a violation of the ethical traditions of nursing and medicine. Which of the following would be an example of assisted suicide?

Administering a lethal dose of medication Explanation: Assisted suicide refers to providing another person the means to end his or her own life. This is not to be confused with the ethically and legally supported practices of withholding or withdrawing medical treatment in accordance with the wishes of the terminally ill individual.

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 Explanation: 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 an attempt to postpone death. During the acceptance stage, the dying clients accept their fate and make peace spiritually and with those to whom they are close.

A client at a health care facility has died after a prolonged illness. A nurse is assigned to perform postmortem care for the client. Which intervention should the nurse perform when providing postmortem care?

Cleanse drainage from the skin. Explanation: 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.

A graduate nurse enters a client's room and finds the client unresponsive, not breathing, and without a carotid pulse. The graduate nurse is aware that the client has mentioned that he does not wish to be resuscitated, but there is no DNR order on the client's chart. What is the nurse's best action?

Call a code and begin resuscitating the client. Explanation: If there is no DNR order to the contrary, the standard of care obligates professionals to attempt resuscitation if a client stops breathing or his or her heart stops. It is important for nurses to clarify a client's code status if the nurse has reason to believe a client would not want to be resuscitated. Slow-codes are never good practice, and the nurse could be charged with negligence in the event of a slow-code and resultant client death.

Explanation: The services of a coroner may be needed in a case where the client did not have any recent medical consultation. A coroner is a person legally designated to investigate deaths that may not be the result of natural causes.

Death following a diagnosis of acute renal failure, administration of oxygen therapy, or a history of hypertension does not call for the services of a coroner.

The nurse has noted that a dying client is increasingly withdrawn and is often teary at various times during the day. The nurse recognizes that the client may be experiencing which of Kübler-Ross's stages of grief?

Depression Explanation: Anger may prompt some individuals to cry, but crying is more likely to accompany a deep sense of depression. Denial and bargaining are less likely to underlie the client's current behaviors.

The nurse enters a client's room and finds the client curled up in bed and crying. The client states, "My life is so good, and now I have cancer. Why me? I have tried to be a good person." The nurse recognizes the client as exhibiting signs of which stage of Engel's model of grief?

Developing awareness Explanation: The client is exhibiting signs of developing awareness when demonstrating anger, feelings of emptiness, and crying "Why me?" Shock and disbelief are usually defined as refusal to accept the fact of loss, followed by a stunned and numb response. Restitution involves rituals surrounding loss. Idealization is the exaggeration of the good qualities that the person or object had, followed by acceptance of the loss and a lessened need to focus on it.

The hospice nurse is caring for a client with allow natural death (AND) orders. The nurse assesses that the client has a slow, irregular heart rate, has cooling of the extremities, and is agitated. Which interventions can the nurse implement? (Select all that apply.)

Do not perform cardiopulmonary resuscitation Allow the client to stop drinking fluids Use medication to lower client consciousness to limit awareness of suffering

A client's son is named to make decisions for his mother in the event she cannot speak for herself. This is an example of a(an) ...

Durable power of attorney Explanation: A durable power of attorney allows clients to designate another person to make decisions if they become incapacitated and cannot make decisions independently.

The husband of a client with terminal cancer is afraid of hurting his wife during sexual intercourse. Which action by the nurse is likely to be most helpful in reducing this client's fears?

Encourage discussion between the husband and wife regarding their intimacy needs Explanation: Partners of terminally ill clients may wish to be physically intimate with the dying person but are afraid of "hurting" him or her and may also be afraid that an open expression of sexuality is somehow "inappropriate" when someone is dying. Encourage discussion and suggest ways to be physically intimate that will meet the needs of both partners, such as a foot massage or embrace.

The nurse is preparing a presentation on preparing children for death. What information should the nurse include? Select all that apply.

Encourage expression of feelings. Provide for stability and safety. Talk openly about death and the feelings associated with it. Explanation: In preparing children for death, encourage expression of feelings, provide for stability and safety, talk openly about death, and encourage expression of feelings. Do not praise stoicism, nor encourage forgetting of the deceased, nor force the child to participate in mourning rituals.

Explanation: Hospice programs, which, in effect, are a type of insurance benefit, focus on relieving symptoms and supporting clients with a life expectancy of 6 months or less, and their families. Palliative care, on the other hand, may be given at any time during a client's illness, from diagnosis to end of life.

Hospice and palliative care programs provide care that focuses on quality rather than length of life. Both hospice and palliative care share a similar foundation. Hospice and palliative care provide physical, social, psychological, and spiritual support through a team of health care professionals and lay volunteers

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

Mottling of the lower limbs Explanation: The time of death is generally preceded by a period of gradual diminishing of bodily functions. During this time, the nurse may observe increased intervals between respirations, weakened and irregular pulse, and skin color may change or become mottled. The client 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.

A nurse is providing care to a terminally ill client. Which finding would alert the nurse to the fact that the client is dying? Select all that apply.

Pale, cool skin Decreased urine output Irregular heart rate Explanation: Signs of dying include extremely pale, cyanotic, jaundiced, mottled or cool skin; irregular heart rate; weak, rapid, irregular pulse; shallow, labored, faster, slower, or irregular respirations; and decreased urine output.

A nurse is providing end-of-life care to a terminally ill client. Which actions should the nurse take to remove mucus and saliva from the client's mouth?

Perform suction in the client's mouth. Explanation: Suctioning helps to remove mucus and saliva that the client cannot swallow or expectorate. A lateral, not supine, position keeps the mouth and throat free of accumulating secretions. The lips may need periodic lubrication because they may become dried from mouth breathing or administration of oxygen.

A patient who was brought to the emergency room for gunshot wounds dies in intensive care 15 hours later. Which statement concerning the need for an autopsy would apply to this patient?

The coroner must be notified to determine the need for an autopsy.

Explanation: The scarcity of organs has resulted in legislation mandating hospitals and other health care agencies to notify transplantation programs of potential donors. New protocols allow the retrieval of organs from non-heart-beating cadavers.

The family of a deceased client may decide to donate the organs, and a donor card is not necessary in this circumstance. Attention to optimal client and family care at the time of life-sustaining therapy withdrawal should remain the nurse's priority in care.

Explanation: Terminal weaning is the gradual withdrawal of mechanical ventilation from a client with a terminal illness. Providing sedation and analgesia are the best way to reduce the client's discomfort during the process.

The nurse participates in the process by educating the client and family about the burdens and benefits of continued ventilation and what to expect when terminal weaning is initiated. Supporting the family and having the family remain at the bedside are important roles of the nurse during terminal weaning, but do not directly affect discomfort as much as sedation and analgesia.

The hospice nurse is assessing the wife of a client who died 14 months ago. The nurse is concerned that the wife is still grieving the death of her husband. Which objective assessment finding would suggest that the wife is not still grieving?

The wife's hair is clean and styled. Explanation: Many of the subjective manifestations of grief have concomitant objective manifestations: dejected physical appearance, slowed motor function, weeping, outbursts of anger, emotional blunting, unkempt appearance, sleep, appetite disturbance (excessive weight loss or gain). Direct quotes are subjective data.

Explanation: Five Stages of Grief (the Kübler-Ross Model) are denial, anger, bargaining, depression, and acceptance.

These stages, which represent a pattern of adjustment, may occur in a progressive fashion, or a person can move back and forth through the stages. There is no specific time period for the rate of progression, duration, or completion of the stages.

Explanation: A client with signs of a slow, irregular heart rate, cooling of the extremities, and restlessness is showing signs of impending death. The physician has written AND orders for this client, so cardiopulmonary resuscitation should not be implemented, including a slow code.

When clients who are imminently dying have pain and suffering, palliative sedation (using medication to lower patient consciousness) may be utilized to limit awareness of suffering. Allowing the client to stop drinking fluids would be a type of passive euthanasia. Administering a lethal dose of barbiturates, or active euthanasia, is immoral and illegal.