CH 36 - GRIEF, LOSS, and P

Question 1

Grief is the

Answer 1

inner emotional response to
loss and

Question 2

grief is exhibited through

Answer 2

thoughts, feelings,
and behaviors

Question 3

Bereavement includes both

Answer 3

grief and mourning (the outward display of
loss) as the individual deals with the death of a
significant individual

Question 4

Palliative or end‑of‑life care is an important
aspect of nursing care and attempts to meet
the client’s

Answer 4

physical, spiritual, and psychosocial
needs

Question 5

Advance directives:

Answer 5

Legal documents that direct
end‑of‑life issues

Question 6

Living will:

Answer 6

Directive documents for medical treatment
per clients’ wishes

Question 7

Health care proxy

Answer 7

(also known as durable power of
attorney for health care): A document that appoints
someone to make medical decisions when clients are no
longer able to do so on their own behalf

Question 8

TYPES OF LOSS

Answer 8

necessary loss
Actual Loss
Perceived loss
Maturational or developmental loss
situational loss
anticipatory loss

Question 9

Necessary loss:

Answer 9

A loss related to a change that is part of
the cycle of life and is anticipated but still can be intensely
felt. This type of loss can be replaced by something
different or better.

Question 10

Actual loss:

Answer 10

Any loss of a valued person, item, or status
(loss of a job) that others can recognize

Question 11

Perceived loss:

Answer 11

Anything clients define as loss but that is
not obvious or verifiable to others

Question 12

Maturational or developmental loss:

Answer 12

Any loss normally
expected due to the developmental processes of life. These
losses are associated with normal life transitions and help
people develop coping skills (a child leaving home for
college).

Question 13

Situational loss:

Answer 13

Any unanticipated loss caused by an
external event (a family loses their home during tornado)

Question 14

Anticipatory loss:

Answer 14

Experienced before the loss happens

Question 15

KÜBLER‑ROSS MODEL

Answer 15

Denial
Anger
Bargaining
Depression
Acceptance

Question 16

Denial:

Answer 16

The client has difficulty believing in an expected
or actual loss.

Question 17

Anger:

Answer 17

The client directs anger toward the self, others, a
deity, objects, or the current circumstances.

Question 18

Bargaining:

Answer 18

The client negotiates for more time or a cure.

Question 19

Depression

Answer 19

The client is overwhelmingly saddened by the
inability to change the situation.

Question 20

Accetpance

Answer 20

The client acknowledges what is happening
and plans for the future by moving forward.

Question 21

In the Kubler Ross Model of Grief Clients might not experience these
stages in order, and the length of each
stage

Answer 21

varies from person to person

Question 22

FACTORS INFLUENCING LOSS,
GRIEF, AND COPING ABILITY (9)

Answer 22

Current stage of development
● Gender
● Interpersonal relationships, social support networks
● Type, significance of loss
● Culture, ethnicity
● Spiritual, religious beliefs and practices
● Prior experience with loss
● Socioeconomic status
● Coping strategies

Question 23

FACTORS THAT CAN INCREASE AN INDIVIDUAL’S RISK FOR
DYSFUNCTIONAL GRIEVING (4)

Answer 23

Being exceptionally dependent on the deceased
● Unexpected death at a young age, through violence or in
a socially unacceptable manner
● Inadequate coping skills, lack of social supports
● Lack of hope or preexisting mental health issues
(depression, substance use disorder)

Question 24

MANIFESTATIONS OF GRIEF REACTIONS -Normal Grief

Answer 24

This grief is considered uncomplicated.
● Emotions can be negative, (anger, resentment,
withdrawal, hopelessness, and guilt) but
should change to acceptance w/ time.
● Some acceptance should be evident
by 6 months after the loss.
● Somatic complaints can include chest pain, palpitations,
headaches, nausea, changes in sleep patterns, and

Question 25

MANIFESTATIONS OF GRIEF REACTIONS -Anticipatory Grief

Answer 25

This grief implies the “letting go” of an object or person
before the loss, as in a terminal illness.
● Individuals have the opportunity to start the grieving
process before the actual loss.

Question 26

Types of complicated grief include

Answer 26

chronic, exaggerated,
masked, and delayed grief.

Question 27

MANIFESTATIONS OF GRIEF REACTIONS -Complicated Grief

Answer 27

Types of complicated grief include chronic, exaggerated,
masked, and delayed grief.
● Complicated grief involves difficult progression through
the expected stages of grief.
● Usually, the work of grief is prolonged. The manifestations
of grief are more severe, and they can result in depression
or exacerbate a preexisting disorder.
● The client can develop suicidal ideation, intense feelings
of guilt, and lowered self‑esteem.
● Somatic complaints persist for an extended period of time.

Question 28

MANIFESTATIONS OF GRIEF REACTIONS -Disenfranchised Grief

Answer 28

This grief entails an experienced loss that cannot be publicly
shared or is not socially acceptable (suicide and abortion).

Question 29

Nursing interventions - Ways to faciliate mourning - allow time for

Answer 29

grieving process

Question 30

Nursing interventions - Ways to faciliate mourning - identify expected grieving behaviors

Answer 30

crying, somatic
manifestations, and anxiety

Question 31

Nursing interventions - Ways to faciliate mourning -therapeutic communication

Answer 31

● Name emotion the client is feeling. For
example, the nurse can say, “You sound as though you
are angry.
● active listening, open‑ended questions,
paraphrasing, clarifying, summarizing,
while using therapeutic communication.
● Use silence / personal presence to facilitate mourning.
● Avoid communication that inhibits open
expression of feelings .
● Assistgrieving individual to
accept reality of loss.
● Support efforts to “move on” in face of the loss.
● Encourage the building of new relationships.
● Provide continuing support. Encourage
support of family and friends.
● Share information about the tasks and stages of mourning
and grieving with the client, who might not realize that
feelings (anger toward the deceased) are expected.
● Provide information on available community resources.

Question 32

Nursing interventions - Ways to faciliate mourning -therapeutic communication - DO NOT DO THESE

Answer 32

(offering false reassurance,
giving advice, changing the subject, and taking
the focus away from the grieving individual)

Question 33

When relating to someone who is bereaved, avoid

Answer 33

cliches
(“They are in a better place now.”). Rather, encourage
the individual to share memories about the deceased.

Question 34

What is an example of ineffective coping with grieving process

Answer 34

Assess for evidence of ineffective coping (a client refusing
to leave the home months after the death of a partner).

Question 35

Palliative care
● The nurse serves as an advocate for the client’s sense of

Answer 35

dignity and self‑esteem by providing palliative care at
the end of life.

Question 36

what is goal of palliative care

Answer 36

Goal is to learn to live fully with an incurable condition

Question 37

Palliative care improves what

Answer 37

quality of life of clients and
their families facing end‑of‑life issues.

Question 38

Palliative care interventions are primarily used when
caring for clients who

Answer 38

are dying and family members
who are grieving but can be used for any client who has
a chronic or curable illness, regardless of the stage of
the disease process. Assessment of the client’s family is
very important as well

Question 39

Palliative care interventions focus on

Answer 39

the relief of
physical manifestations (pain) as well as addressing
spiritual, emotional, and psychosocial aspects of the
client’s life

Question 40

what type of team provides palliative care

Answer 40

interprofessional team of physicians, nurses, social
workers, physical therapists, massage therapists,
occupational therapists, music/art therapists, touch/
energy therapists, and spiritual support staff

Question 41

Hospice care is comprehensive care delivered in

Answer 41

variety of settings,
can be implemented when a client is not
expected to live > 6 months.

Question 42

in hopsice care, further medical care aimed toward a cure is

Answer 42

stopped

Question 43

what is focus of hospice care

Answer 43

enhancing quality of life and supporting the
client toward a peaceful and dignified death

Question 44

CHARACTERISTICS OF DISCOMFORT

Answer 44

Pain
● Anxiety
● Restlessness
● Dyspnea
● Nausea, vomiting
● Dehydration
● Diarrhea, constipation
● Urinary, fecal incontinence
● Inability to perform ADLs

Question 45

MANIFESTATIONS OF APPROACHING DEATH

Answer 45

Decreased level of consciousness
● Loss of muscle tone, with obvious relaxation of the face
● Labored breathing (dyspnea, apnea, Cheyne‑Stokes
respirations), “death rattle”
● Touch diminished, but client is able to feel the
pressure of touch
● Mucus collecting in large airways
● Incontinence of bowel and/or bladder
● Mottling, cyanosis occurring with poor circulation
● Pupils no longer reactive to light
● Pulse slow and weak, blood pressure dropping
● Cool extremities
● Perspiration
● Decreased urine output
● Inability to swallow

Question 46

PREVENTION OF ABANDONMENT
AND ISOLATION

Answer 46

Prevent fear of dying alone.
● Make your presence known - answering call lights -
timely manner / making frequent contact.
● Keep client informed of procedure /
assessment times.
● Allow family members to stay overnight.
● Determine where client is most comfortable (in a
room close to nurses’ station).
● If client chooses to be at home, consider moving
client’s bed to a central location in home rather than
isolated bedroom.

Question 47

Postmortem care - Nurses are responsible for following federal and state
laws regarding requests for

Answer 47

organ or tissue donation,
obtaining permission for autopsy, ensuring the
certification and appropriate documentation of the
death, and providing postmortem (after‑death) care.

Question 48

After postmortem care is completed, who
becomes the nurse’s primary focus

Answer 48

the client’s family

Question 49

provider certifies death by

Answer 49

pronouncing the time and documenting therapies used,
and actions taken prior to the death.

Question 50

post mortem
● Elevate the client’s head to prevent

Answer 50

facial discoloration
by raising the head of the bed and placing a pillow
under the head and shoulders. Do this as soon as
possible after the client’s death

Question 51

PREPARING THE BODY FOR VIEWING Cleanse and align the body how

Answer 51

supine with a pillow under
the head, arms with palms of hand down outside the
sheet and blanket, dentures in place, and eyes closed
fresh linens with absorbent pads on bed
and a gown.
Brush/comb the client’s hair. Replace any hairpieces.
Remove excess supplies, equipment, soiled linens
from room.
● Dim lights / minimize noise to provide a
calm environment.

Question 52

Postmortem of infant - Adhere to the same procedures as adult except for

Answer 52

Swaddle the infant’s body in a clean blanket.
◯ Transportinfant in nurse’s arms or in an
infant carrier based on facility protocol.
◯ Offer mementos of infant (identification bracelets,
footprints, the cord clamp, a lock of hair, photos)

Question 53

requests for tissue and organ donations
must be made by

Answer 53

specifically trained personnel.

Question 54

Maintain ventilatory and cardiovascular support for

Answer 54

vital organ retrieval.

Question 55

who typically approaches the family to request an autopsy

Answer 55

provider

Question 56

nurse’s role with regard to autopsy

Answer 56

answer the family members’
questions and support their choices

Question 57

Autopsies can be conducted to

Answer 57

advance scientific
knowledge regarding disease processes, which can lead
to the development of new therapies

Question 58

The law can require an autopsy to be performed if the
death is due to

Answer 58

homicide, suicide, or accidental death, or
if death occurs within 24 hr of hospital admission

Question 59

Most facilities require that all tubes

Answer 59

remain in place for
an autopsy

Question 60

autopsy Documentation and completion of forms following
federal and state laws typically includes the following.

Answer 60

Who pronounced the death and at what time
◯ Consideration of and preparation for organ donation
◯ Description of any tubes or lines left in or on the body
◯ Disposition of personal articles
◯ Who was notified, and any decisions made
◯ Location of identification tags
◯ Time the body left the facility and the destination

Question 61

Caring long‑term for clients can create____ for nurses

Answer 61

personal attachments

Question 62

Nurses can use coping strategies (with consideration of
professional boundaries) (5)

Answer 62

Going to the client’s funeral
◯ Communicating in writing to the family
◯ Attending debriefing sessions with colleagues
◯ Using stress management techniques
◯ Talking with a professional counselor

Question 63

List five physical care
interventions appropriate for the care of a client who is dying

Answer 63

Give priority to controlling findings.
● Administer medications - manage pain, air hunger, and anxiety.
● Perform ongoing assessment - determine effectiveness
of treatment, need for modifications of
treatment plan (lower or higher doses of medications).
● Manage adverse effects of medications.
● Reposition client to maintain airway patency / comfort.
● Maintain integrity of skin / mucous membranes.
● Provide an environment - promotes dignity / self‑esteem.
● Remove products of elimination ASAP - maintain clean / odor‑free environment.
● Offer comfortable clothing.
● Provide careful grooming for hair, nails, skin.
● Encourage family members to bring comforting
possessions - make client feel at home.
● If appropriate, encourage use of relaxation
techniques, (guided imagery / music).
● Promote decision‑making in food selection, activities,
health care - give client as much control as possible.
● Encourage client to perform ADLs as able / willing to do so.

Question 64

List five psychological care interventions
appropriate for the care of a client who is dying

Answer 64

Use an interprofessional approach.
● Provide care to client / family.
● Use volunteers when appropriate to provide nonmedical care.
● Use therapeutic communication - develop /
maintain nurse‑client relationship.
● Facilitate understanding of information regarding
disease progression / treatment choices.
● Facilitate communication between client, family, provider.
● Encourage client - participate in religious / other
practices - bring comfort / strength, if appropriate.
● Assist client in clarifying personal values in
order to facilitate effective decision‑making.
● Encourage client - use coping mechanisms
-worked in the past.
● Be sensitive to comments made in presence of clients who
are unconscious - hearing is last sensation lost.

Question 65

What is the last sensation lost when dying

Answer 65

hearing

Question 66

1. A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self‑care should the nurse communicate to the family?
   A. Allowing the client to function independently
   will strengthen muscles and promote healing.
   B. The client needs privacy at times for
   self‑reflecting and organizing life.
   C. The client’s sense of loss can be lessened
   through retaining control of some areas of life.
   D. Performing ADLs is a requirement prior to
   discharge from an acute care facility.

Answer 66

1. A. Strengthening of muscles is not a priority of palliative care.
   B. Privacy for periods of self‑reflection can be achieved at times apart from performance of ADLs.
   C. CORRECT: Allowing the client as much control as possible maintains dignity and self‑esteem.
   D. Performance of ADLs is not a criterion for discharge from an acute care facility.

Question 67

2. A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, “I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child’s wedding.” Based on the Kübler‑Ross model, which stage of grief is the client experiencing?
   A. Anger
   B. Denial
   C. Bargaining
   D. Acceptance

Answer 67

2. A. This statement does not reflect anger.
   B. The client is not denying the severity of the diagnosis and prognosis.
   C. CORRECT: The client is bargaining by attempting to negotiate more time to live to see the child get married.
   D. Although the client might have accepted his diagnosis and prognosis, this statement does not convey coming to terms with the situation.

Question 68

3. A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, “I hate them for leaving me.” Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.)
   A. “Would you like me to contact the chaplain to come and speak with you?”
   B. “You will feel better soon. You have been expecting this for a while now.”
   C. “Let’s talk about your children and how they are going to react.”
   D. “You know, it is quite normal to feel anger toward your loved one at this time.”
   E. “Tell me more about how you are feeling.”

Answer 68

3. A. CORRECT: Asking whether the grieving individual desires spiritual support at this time is an acceptable nursing intervention to facilitate mourning.
   B. Avoid giving false reassurance and offering assumptions while intervening to facilitate mourning.
   C. Avoid changing the subject and bringing the focus away from the grieving individual while intervening to facilitate mourning.
   D. CORRECT: Educate the grieving individual about the grieving process and emotions to expect at this time.
   E. CORRECT: Encourage the open communication of feelings by using therapeutic communication to facilitate mourning.

Question 69

4. A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client’s family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include?
   A. Regular breathing patterns
   B. Warm extremities
   C. Increased urine output
   D. Decreased muscle tone

Answer 69

4. A. Labored breathing and irregular patterns indicate imminent death.
   B. Cool extremities indicate imminent death.
   C. Decreased urine output indicates of imminent death.
   D. CORRECT: Muscle relaxation is an expected finding when a client is approaching death.

Question 70

5. A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.)
   A. Remove the dentures from the body.
   B. Make sure the body is lying completely flat.
   C. Apply fresh linens and place a clean gown on the body.
   D. Remove all equipment from the bedside.
   E. Dim the lights in the room.

Answer 70

5. A. Insert the client’s dentures so that the face looks as natural as possible.
   B. The body should not be completely flat. Place one pillow under the head and shoulders to prevent discoloration of the face.
   C. CORRECT: The body and the environment should be as clean as possible. This includes washing soiled areas of the body and applying fresh linens and a clean gown.
   D. CORRECT: The environment should be as clutter‑free as possible. The nurse should remove all equipment and supplies from the bedside.
   E. CORRECT: Dimming the lights helps provide a calm environment for the family.