Chapter 15. Loss, Grief, & Dying My Nursing Test Banks

Chapter 15. Loss, Grief, & Dying

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. A 73-year-old patient who suffered a stroke is being transferred from the acute care hospital to a nursing home for ongoing care because she is unable to care for herself at home. Which type of loss is this patient most likely experiencing?

1)

Environmental loss

2)

Internal loss

3)

Perceived loss

4)

Psychological loss

____ 2. According to William Worden, which task in the grieving process takes longest to achieve?

1)

Realizing that the loved one is gone

2)

Experiencing the pain from the loss

3)

Adjusting to the environment without the deceased

4)

Investing emotional energy

____ 3. What emotional response is typical during the Randos confrontation phase of the grieving process?

1)

Anger and bargaining

2)

Shock with disbelief

3)

Denial

4)

Emotional upset

____ 4. An elderly man lost his wife a year ago to cardiovascular disease. During a health care visit, he tells the nurse he has begun adjusting to life without his wife. According to John Bowlby, which stage of grief does this comment most likely indicate?

1)

Shock and numbness

2)

Yearning and searching

3)

Disorganization and despair

4)

Reorganization

____ 5. Which patient is at most risk for experiencing difficult grieving?

1)

The middle-aged woman whose grandmother died of advanced Parkinsons disease

2)

A young adult with three small children whose wife died suddenly in an accident

3)

The middle-aged person whose spouse suffered chronic, painful death

4)

The older adult whose spouse died of complications of chronic renal disease

____ 6. During a health history, a patient whose wife died unexpectedly 6 months ago in a motor vehicle accident admits that he drinks at least six martinis every night before going to bed. Which type of grief does this best illustrate?

1)

Delayed

2)

Chronic

3)

Disenfranchised

4)

Masked

____ 7. According to the Uniform Determination of Death Act, which bodily function must be lost to declare death?

1)

Consciousness

2)

Brain stem function

3)

Cephalic reflexes

4)

Spontaneous respirations

____ 8. A patients wife tells the nurse that she wants to be with her husband when he dies. The patients respirations are irregular, and he is congested. The wife tells the nurse that she would like to go home to shower but that she is afraid her husband might die before she returns. Which response by the nurse is best?

1)

Certainly, go ahead; your husband will most likely hold on until you return.

2)

Your husband could live for days or a few hours; you should do whatever you are comfortable with.

3)

You need to take care of yourself; go home and shower, and Ill stay at his bedside while you are gone.

4)

Dont worry. Your husband is in good hands; Ill look out for him.

____ 9. Mr. Jackson is terminally ill with metastatic cancer of the colon. His family notices that he is suddenly more focused and coherent. They are questioning whether he is really going to die. The nurse recognizes that a sudden surge of activity may occur:

1)

1 to 3 months before death

2)

1 to 2 weeks before death

3)

Days to hours before death

4)

Moments before death

____ 10. Which intervention takes priority for the patient receiving hospice care?

1)

Turning and repositioning the patient every 2 hours

2)

Assisting the patient out of bed into a chair twice a day

3)

Administering pain medication to keep the patient comfortable

4)

Providing the patient with small frequent meals

____ 11. The nurse has been explaining advance directives to a patient. Which response by the patient would indicate that he has correctly understood the information? An advance directive is a document:

1)

Specifying your health care intentions should you become unable to make self-directed decisions.

2)

Identifying the activities considered to be evidence of quality care.

3)

Verifying your understanding of the risks and benefits associated with a procedure.

4)

Allowing you the autonomy to leave the hospital when you decide, even if it is against medical advice.

____ 12. A patient with a history of chronic obstructive pulmonary disease has a living will that states he does not want endotracheal intubation and mechanical ventilation as a means of respiratory resuscitation. As the patients condition deteriorates, the patient asks whether he can change his decision. Which response by the nurse is best?

1)

Ill call your physician right away so he can discuss this with you.

2)

You have the right to change your decision about treatment at any time.

3)

Are you sure you want to change your decision?

4)

We must follow whatever is written in your living will.

____ 13. Which dysrhythmia confirms death?

1)

Asystole (absence of heart activity)

2)

Pulseless electrical activity

3)

Ventricular fibrillation

4)

Ventricular tachycardia

____ 14. A patient dying of heart failure has changed his choice about his end-of-life treatment measures several times. He says, I just cant make up my mind about it. Which nursing diagnosis is most appropriate for this patient?

1)

Deficient Knowledge

2)

Spiritual Distress

3)

Decisional Conflict

4)

Death Anxiety

____ 15. Which nursing intervention should be included in the plan of care for a patient dying of cancer?

1)

Encourage at least one family member to remain at the bedside at all times.

2)

Follow-up with other health care team members during weekly meetings.

3)

Avoid discussing the dying process with family (to prevent sadness).

4)

Encourage family members to participate in care of the patient when possible.

____ 16. Which intervention by the nurse is most appropriate when she notices that her dying patient has developed a death rattle?

1)

Perform nasotracheal suctioning of secretions.

2)

Turn the patient on his side and raise the head of the bed.

3)

Insert a nasopharyngeal airway as needed.

4)

Administer morphine sulfate intravenously.

____ 17. Which of the following patient goals is most appropriate when managing the patient dying of cancer? The patient will:

1)

Request pain medication when needed.

2)

Report or demonstrate satisfactory pain control.

3)

Use only nonpharmacologic measures to control pain.

4)

Verbalize understanding that it may not be possible to control his pain.

____ 18. When providing postmortem care, why would the nurse place dentures in the mouth and close the eyes and mouth of the patient within 2 to 4 hours after death?

1)

To prevent blood from settling in the head, neck, and shoulders

2)

To perform these actions more easily before rigor mortis develops

3)

To set the mouth in a natural position for viewing by the family

4)

To prevent discoloration caused by blood settling in the facial area

____ 19. How should the nurse respond to a family immediately after a patient dies?

1)

Ask the family to leave the patients room so postmortem care can be performed.

2)

Leave tubes and IV lines in place until the family has the opportunity to view the body.

3)

Express sympathy to the family (e.g., I am sorry for your loss).

4)

Tell the family that they will have limited time with their loved one.

____ 20. The mother of a preschool child dies suddenly of a ruptured cerebral aneurysm. What recommendation should the nurse make to the family regarding how to most therapeutically care for the child?

1)

Take the child to the funeral even if he is frightened.

2)

Notify the physician immediately if the child shows signs of regression.

3)

Spend as much time as possible with the child.

4)

Provide distraction whenever the child begins to express feelings of sadness.

____ 21. Which intervention should be included in the plan of care for a patient in the end-stage death process?

1)

Encourage the patient to accept as much help as possible.

2)

Avoid administering laxatives.

3)

Wet the lips and mouth frequently.

4)

Administer pain medication on an as-needed basis.

____ 22. Throughout the course of his illness, a patient has denied its seriousness, even though his health professionals have explained prognosis of death very clearly. Physiologic signs now indicate that he will probably die within a short period of time, but he is still firmly in a state of emotional denial. The patient says to the nurse, Tell my wife to stop hovering and go home. Im going to be fine. How should the nurse respond?

1)

Your physical signs indicate that you will likely not live more than a few more days.

2)

You seem very sure that you are not going to die. Please tell me more about what you are feeling.

3)

It seems to me you would be feeling some anger and wondering why all this is happening to you.

4)

It would be best for your family if you were able to work through this and come to accept the reality of your situation.

____ 23. During the holidays, the nurse is making a home health visit for a patient who previously lived with her sister for more than 20 years. Although it has been over than a year since her sister died, she tells the nurse, Its no worse now than any other time; I never feel any relief from this overwhelming sadness. I still cant sleep a full night through. I know the house is a mess; I feel too tired to do anything, even to take a bath. You know, though, sometimes at night, she comes to me and I can see her plain as can be. The nurse observed the patients clothing is not clean and that her hair is not combed. The patient is apparently not eating adequately. What can the nurse conclude? The patient is probably

1)

Grieving longer than usual because of the closeness of the relationship with her sister.

2)

Experiencing a depressive disorder rather than simply grieving the loss of her sister.

3)

Feeling guilt and worthlessness because her sister died and she is still alive.

4)

Interpreting the holiday as a trigger event, which is causing her to hallucinate.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. Which intervention is appropriate for a client receiving palliative care? (Choose all that apply.)

1)

Surgical insertion of a device to decrease the workload of the heart in a patient awaiting heart transplantation

2)

Administering intravenous dopamine to raise blood pressure of a patient with end-stage lung cancer

3)

Providing moisturizing eye drops to an unconscious patient whose eyes are dry

4)

Administering a medication to relieve the nausea of a patient with end-stage leukemia

____ 2. To be eligible for insurance benefits covering hospice care, a physician must certify that the patients:

Choose all that apply.

1)

Life expectancy is not more than 6 months.

2)

Life expectancy is not more than 12 months.

3)

Condition is expected to improve slightly.

4)

Condition is not expected to improve.

____ 3. Which of the following might be a warning sign that a child needs professional help after the death of a loved one? Choose all that apply.

1)

Interest in his usual activities

2)

Extended regression

3)

Withdrawal from friends

4)

Inability to sleep

5)

Intermittent sadness

Chapter 15. Loss, Grief, & Dying

Answer Section

MULTIPLE CHOICE

1. ANS: 1

This patient is most likely experiencing an environmental loss because she is unable to return to her familiar home setting. Instead, she is being transferred to the new environment of a nursing home. Internal, perceived, and psychological losses are internal and can only be identified by the person experiencing them.

PTS: 1 DIF: Easy REF: V1, p. 265

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

2. ANS: 2

Because people try to avoid pain during the grieving process, the task of experiencing pain takes the longest to achieve. Realizing that the loved one is gone, adjusting to the environment without the deceased, and investing emotional energy are tasks of the grieving process. Although they take time and energy, their duration is not typically as long as the task of experiencing the pain.

PTS: 1 DIF: Moderate REF: V1, p. 267

KEY: Client need: PSI | Cognitive level: Recall

3. ANS: 4

During the confrontation phase, the person faces the loss and experiences emotional upset. In the avoidance phase, the person experiences shock, disbelief, denial, anger, and bargaining. During the accommodation phase, the person begins to live with the loss, feel better, and resume routine activities.

PTS: 1 DIF: Moderate REF: V1, p. 267

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall

4. ANS: 4

According to Bowlby, a person adjusts to life without the deceased during the reorganization phase. During the shock and numbness phase, the person experiences disorientation and a feeling of helplessness. The person wants to be reconnected with the deceased during the yearning and searching phase. The person feels pain and the emotions of grief during the disorganization and despair phase.

PTS: 1 DIF: Moderate REF: V1, p. 267

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Application

5. ANS: 2

Although it is impossible to predict with certainty, those who suffer a sudden loss typically have more difficult grieving than those who have had the time to prepare for the death. Family and friends of persons with chronic illnesses or cancer have usually had time to emotionally prepare for the death, initiate the funeral and burial arrangements, and begin the grieving process before the death occurs.

PTS: 1 DIF: Moderate REF: V1, p. 267; in Wordens first stage

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

6. ANS: 4

Masked grief occurs when the person is grieving, but it may look as though something else is occurring; in this case, the person is drinking heavily. Delayed grief occurs when grief is put off until a later time. Chronic grief begins as normal grief but continues long term with little resolution of feelings or ability to rejoin normal life. Disenfranchised grief is experienced when a loss is not socially supported.

PTS: 1 DIF: Moderate REF: V1, p. 270

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Analysis

7. ANS: 2

According to the Uniform Determination of Death Act, death can be declared when there is a loss of brain stem function. Higher-brain death occurs when there is a loss of consciousness, cephalic reflexes, and spontaneous respirations.

PTS: 1 DIF: Moderate REF: V1, p. 271

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Recall

8. ANS: 2

The patient is exhibiting signs that typically occur days to a few hours before death. The nurse should provide information to the wife so she can make an informed decision about whether to leave her husbands bedside. The nurse should not offer false reassurance by stating that the patient will most likely be fine until the wifes return. The nurse should not offer her opinion by telling the wife that she needs to take care of herself. It is also unrealistic for the nurse to stay with the patient until his wife returns. The nurse would be minimizing the wifes concern by telling her not to worry because her husband is in good hands. The issue for the family member is not trust in the competency of the healthcare provider but rather wanting to be present with her spouse at the time of death.

PTS: 1 DIF: Moderate REF: V1, pp. 271, 283

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

9. ANS: 3

Days to hours before death, patients commonly experience a surge of energy that brings mental clarity and a desire to speak with family. One to 3 months before death, the dying person begins to withdraw from the world by sleeping more and eating less. One to 2 weeks before death, the body loses its ability to maintain itself, and body systems begin to deteriorate. Near the time of death, the dying person does not respond to touch or sound and cannot be awakened.

PTS: 1 DIF: Moderate REF: V1, p. 271

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

10. ANS: 3

A priority intervention for the hospice team is administering pain medications to keep the patient comfortable. Turning the patient to prevent skin breakdown and promote comfort is also important, but it does not take priority over administering pain medications. The patient may not be able to eat meals or get out of bed into the chair, and may tolerate only small amounts at a meal. During the dying process, bowel activity reduces and digestion is minimal, which often results in nausea or food intolerance. Additionally, the bodys need for nutrition and hydration is reduced as the body begins the desiccation process.

PTS: 1 DIF: Difficult REF: V1, pp. 273-274

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

11. ANS: 1

An advance directive is a group of instructions stating the patients health care wishes should he become unable to make decisions. The Patient Care Partnership is a document that helps to ensure that patients receive quality care. An informed consent form verifies the patients understanding of risks and benefits associated with a procedure. An against medical advice form allows the patient to leave the hospital against medical advice and releases the hospital of responsibility for the patient.

PTS: 1 DIF: Moderate REF: V1, p. 274

KEY: Nursing process: Evaluation | Client need: SECE | Cognitive level: Comprehension

12. ANS: 2

The nurse should inform the patient that he has the right to change his decision about treatment at any time. Next, the nurse should notify the physician of the patients decision so that the physician can speak to the patient and revise the treatment plan as needed. Questioning the patients decision is judgmental. The patient has the right to change his living will at any time. The medical team should not follow the living will if the patient changes his decision about what is in it.

PTS: 1 DIF: Moderate REF: V1, p. 274

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

13. ANS: 1

Asystole is a dysrhythmia that commonly serves as a confirmation of death. Pulseless electrical activity, ventricular fibrillation, and ventricular tachycardia are potentially lethal dysrhythmias that may respond to treatment.

PTS: 1 DIF: Easy REF: V1, p. 275

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

14. ANS: 3

This patient is experiencing Decisional Conflict related to his end-of-life treatment measures. Deficient Knowledge, Spiritual Distress, or Death Anxiety may be the etiology of his changing decisions, but his indecision about his treatment option clearly identifies his Decisional Conflict.

PTS: 1 DIF: Moderate

REF: V1, p. 277; High-level question; not stated verbatim in text| V2, pp. 168-169; High-level question; not stated verbatim in text

KEY: Nursing process: Nursing diagnosis | Client need: PSI | Cognitive level: Analysis

15. ANS: 4

The plan of care should include encouraging family members to help with the patients care when they are able. Family members should also be encouraged to take care of themselves. They often need to be encouraged to take breaks in order to eat or rest. Provide them with anticipatory guidance about the stages of death so they know what to expect. Follow up promptly (not weekly) with other healthcare team members to address family concerns.

PTS: 1 DIF: Moderate REF: V2, p. 159 | V1, p. 274 | V1, p. 277

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

16. ANS: 2

If a death rattle occurs, turn the patient on his side, and elevate the head of the bed. Nasotracheal suctioning and inserting a nasopharyngeal airway are ineffective against a death rattle and may cause the patient unnecessary discomfort. The patient may require IV morphine sulfate to treat pain, but it does not help stop a death rattle. This narcotic analgesic can also reduce the respiratory drive, leading to hypoventilation and respiratory depression or arrest.

PTS: 1 DIF: Moderate REF: V2, p. 161

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

17. ANS: 2

The nurse should administer pain medication on a regular schedule to ensure satisfactory pain control; pain may not be controlled if medication is administered on an as needed basis. Nonpharmacologic measures can be a helpful adjunct in controlling pain, but they are not likely to be adequate for pain associated with cancer. Effective pain control medications are available and can be administered by several routes; it should be possible to control the pain.

PTS: 1 DIF: Moderate REF: V1, p. 284 | V2, p. 160

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

18. ANS: 2

Rigor mortis develops 2 to 4 hours after death; therefore, the nurse should place dentures in the mouth and close the patients eyes and mouth before that time. The nurse should place a pillow under the head and shoulders to prevent blood from settling there and causing discoloration. Closing the patients mouth and tying a strip of soft gauze under the chin and around the head keeps the mouth set in a natural position for a viewing later. Closing the eyes after death creates a peaceful resting appearance when the body is later viewed but has nothing to do with setting the mouth. Placing dentures in the mouth and closing the eyes and mouth do not prevent discoloration in the facial area.

PTS: 1 DIF: Moderate REF: V1, pp. 285-286 | V2, pp. 162-163

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

19. ANS: 3

The nurse should express sympathy to the family immediately after the patients death. She should give the family as much time as they need with their loved one and take care to present the body in a restful pose. If family members are not present at the time of death, remove tubes and IV lines before they see the body, unless an autopsy is planned or the death is being investigated by the coroner. The body should not be removed from the patient care area until the family is ready.

PTS: 1 DIF: Moderate REF: V2, p. 173

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

20. ANS: 3

The nurse should advise the family to spend as much time as possible with the child. If the child is frightened about attending the funeral, he should not be forced to attend. Signs of regression are a normal reaction to the loss of a loved one, especially a parent. The child should be encouraged to express his feelings and fears.

PTS: 1 DIF: Moderate REF: V1, p. 286

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

21. ANS: 3

If the patient is unable to take fluids, prevent dryness and cracking of lips and mucous membranes by wetting the lips and mouth frequently. Encourage the patient to be as independent as possible. Administer laxatives if constipation occurs. Administer pain medications on a regular schedule instead of waiting for the patient to request them.

PTS: 1 DIF: Moderate REF: V2, p. 161

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

22. ANS: 2

Not all patients go through all the traditional stages of grieving. It is not the nurses responsibility to move patients sequentially through each stage of the dying and grieving process with the goal that everyone ends life accepting death. It is a nursing responsibility to accept and support people where they are and help them to express their feelings. Nurses need to understand patients, not change them. In this situation, denial may be very important to this patient, as an emotional defense and coping strategy.

You seem sure . . . tell me . . . what you are feeling restates what the patient has said (indicating understanding) and encourages expression of feelingsboth are supportive. Even though moving him through stages is not the goal in this situation, support does facilitate that.

Telling the patient that his physical signs indicate that death is imminent is presenting truth and reality; however, the exact time of death is not always predictable. Forecasting the hour of death can have negative impact on the family as they anticipate the event with emotion and exhaustion. Presenting reality is appropriate in certain circumstances earlier in the dying process, but not in this situation because it has already been tried with no change in the patient. Presenting reality does not support the patients needs at this time.

Saying It seems to me you would be feeling some anger . . . is directed toward moving the patient from denial and suggesting he should feel something he has not yet expressed. This is not therapeutic. Saying It would be best for your family . . . presumes that the nurse knows more about what is best for the patients family more than the patient himself. This statement is also judgmental.

PTS: 1 DIF: Difficult REF: V1, pp. 278, 283 | V2, p. 159 | V2, p. 162

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

23. ANS: 2

The patient is likely experiencing a depressive disorder. Her symptoms include unrelieved, overwhelming sadness; insomnia; difficulty carrying out ADLs; fatigue; and visual hallucinations. Note that her sadness is pervasive, not created by a trigger event (holiday). Of those symptoms, insomnia is common to both grief and depression; but the other symptoms are signs of depressive disorder. There is, of course, no correct timeline for what constitutes longer than usual grieving; however, the patients symptoms are typical of depression, not grief. She has not said she feels guilty or worthless, and there is nothing from which the nurse could infer that. She has specifically said the holiday has not made her feel any worsethat is, it has not been a trigger event.

PTS: 1 DIF: Difficult REF: V1, p. 269 | V1, p. 277

KEY: Nursing process: Diagnosis | Client need: PSI | Cognitive level: Application

MULTIPLE RESPONSE

1. ANS: 3, 4

Palliative care focuses on relieving symptoms for patients whose disease process no longer responds to treatment. Providing moisturizing eye drops and administering anti-nausea medication in a patient with end-stage leukemia are examples of palliative care. Surgical insertion of a device to decrease heart workload and administering dopamine are aggressive treatment measures.

PTS: 1 DIF: Moderate REF: V1, p. 273

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

2. ANS: 1, 4

To be eligible for hospice care insurance benefits, a physician must certify that the patient is not expected to improve or will most likely die within 6 months.

PTS: 1 DIF: Moderate REF: V1, p. 273

KEY: Client need: SECE | Cognitive level: Recall

3. ANS: 2, 3, 4

The warning signs that may indicate the need for professional help include inability to sleep, extended regression, loss of interest in daily activities, and withdrawal from friends. Interest in usual activities is a sign of coping; intermittent expressions of sadness and anger are to be expected, even over a long period of time, so would not indicate a need for professional help.

PTS: 1 DIF: Easy REF: V1, p. 286

KEY: Nursing process: Assessment | Client need: PSI | Cognitive level: Analysis

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