The Bereaved Individual

1. A client is diagnosed with terminal cancer. Which situation represents Kübler-Ross’s grief stage of “anger”?
1. The client registers for an iron-man marathon to be held in 9 months.
2. The client is a devout Catholic but refuses to attend church and states that his faith has failed him.
3. The client promises God to give up smoking if allowed to live long enough to witness a grandchild’s birth.
4. The client gathers family in order to plan a funeral and make last wishes known.

ANS: 2
Rationale: The nurse should assess that the client is in the “anger” stage of grieving when the client refuses to attend church and states that his faith has failed him. Anger is the second stage of Kübler-Ross’s grief process, in which the reality of the situation is realized, and the individual has feelings of sadness, guilt, shame, helplessness, and hopelessness.

Cognitive Level: Application
Integrated Process: Assessment

2. A nurse is caring for an Irish client who has recently lost his wife. The client tells the nurse that he is planning an elaborate wake and funeral. According to George Engel, what purpose would these rituals serve?
1. To delay the recovery process initiated by the loss of the client’s wife
2. To facilitate the acceptance of the loss of the client’s wife
3. To avoid dealing with grief associated with the loss of the client’s wife
4. To eliminate emotional pain related to the loss of the client’s wife

ANS: 2
Rationale: The nurse should anticipate that the purpose of these rituals is to facilitate the acceptance of the loss of the client’s wife. Resolution of the loss is the fourth stage in Engel’s grief process, in which the bereaved experiences a preoccupation with the loss, which gradually decreases over time.

Cognitive Level: Application
Integrated Process: Evaluation

3. A nurse discharges a female client to home after delivering a stillborn infant. The client finds that neighbors have dismantled the nursery that she and her husband planned. According to Worden, how could this intervention affect the woman’s grieving task completion?
1. This intervention may hamper the woman from continuing a relationship with her infant.
2. This intervention would help the woman forget the sorrow and move on with life.
3. This intervention communicates full support from her neighbors.
4. This intervention would motivate the woman to look to the future and not the past.

ANS: 1
Rationale: The nurse should anticipate that this intervention could hinder the woman from continuing a relationship with her infant. The first task in Worden’s grief process is to accept the reality of the loss. It is common for individuals to refuse to believe that the loss has occurred. Behaviors may include misidentifying an individual in the environment as their loved one, retaining possessions of the lost loved one, and removing all reminders of the loved one in order to avoid reality.

Cognitive Level: Application
Integrated Process: Evaluation

4. A teenager has recently lost a parent. Which grieving behavior should a school nurse expect when assessing this client?
1. Denial of personal mortality
2. Preoccupation with the loss
3. Clinging behaviors and personal insecurity
4. Acting-out behaviors, exhibited in aggression and defiance

ANS: 4
Rationale: The school nurse should anticipate that the teenager will exhibit aggression and acting out. Adolescents have the ability to understand death on an adult level yet have difficulty tolerating the intense feelings associated with the death of a loved one. It is often easier for adolescents to talk with peers about feelings than with other adults.

Cognitive Level: Application
Integrated Process: Assessment

5. What term should a nurse use when assessing a response to grieving that includes a sudden physical collapse and paralysis, and which cultural group would be associated with this behavior?
1. “Falling out” in the African American culture
2. “Body rocking” in the Vietnamese American culture
3. “Conversion disorder” in the Jewish American culture
4. “Spirit possession” in the Native American culture

ANS: 1
Rationale: The nurse should use the term falling out to describe a sudden physical collapse and paralysis in the African American culture. The individuals may also experience an inability to see or speak yet maintain hearing and understanding.

Cognitive Level: Application
Integrated Process: Assessment

6. Which grieving behaviors should a nurse anticipate when caring for a Navajo client who recently lost a child?
1. Celebrating the life of a deceased person with festivities and revelry
2. Not expressing grief openly and reluctance to touch the dead body
3. Holding a prayerful vigil for a week following the person’s death
4. Expressing grief openly and publicly and erecting an altar in the home to honor the dead

ANS: 2
Rationale: The nurse should identify that a Navajo client who recently lost a child would not express grief openly and would be reluctant to touch the dead body. Navajo Indians do not bury the body of a deceased person for four days after death, and they conduct a cleaning ceremony prior to burial. The dead are buried with their shoes on the wrong feet and rings on their index fingers.

Cognitive Level: Application
Integrated Process: Assessment

7. A nursing instructor is teaching about the typical grieving behaviors of Chinese Americans. Which student statement would indicate that more instruction is necessary?
1. “In this culture, the color red is associated with death and is considered bad luck.”
2. “In this culture, there is an innate fear of death.”
3. “In this culture, emotions are not expressed openly.”
4. “In this culture, death and bereavement are centered on ancestor worship.”

ANS: 1
Rationale: The nursing instructor should evaluate that more instruction is needed if a student states that the color red is associated with death and bad luck in the Chinese culture. Chinese Americans consider the color white as associated with death and is considered bad luck. Red is the ultimate color of luck in this culture. Chinese Americans also avoid purchasing insurance because of the fear that they may be inviting death.

Cognitive Level: Application
Integrated Process: Evaluation

8. A nurse assigns a client the nursing diagnosis of complicated grieving. According to Bowlby, which long-term outcome would be most appropriate for this nursing diagnosis?
1. The client will accomplish the recovery stage of grief by year one.
2. The client will accomplish the acceptance stage of grief by year one.
3. The client will accomplish the reorganization stage of grief by year one.
4. The client will accomplish the emotional relocation stage of grief by year one.

ANS: 3
Rationale: The nurse should identify that, according to Bowlby, an appropriate long-term outcome for this client is to accomplish the reorganization stage of grief by year one. Until the client can recognize and accept personal feelings regarding the loss, grief work cannot progress. The reorganization stage of grieving is the final stage in which the individual accepts the loss and new goals and patterns are established.

Cognitive Level: Application
Integrated Process: Planning

9. A nurse assesses a woman whose husband died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless. According to Bowlby, this widow is in which stage of the grieving process?
1. Stage I: Numbness or protest
2. Stage II: Disequilibrium
3. Stage III: Disorganization and despair
4. Stage IV: Reorganization

ANS: 3
Rationale: The nurse should identify that this client is in the third stage of Bowlby’s grief process, called disorganization and despair. This stage is characterized by feelings of despair in response to the realization that the loss has occurred. The individual experiences helplessness, fear, and hopelessness. Perceptions of visualizing or being in the presence of the lost one may occur.

Cognitive Level: Application
Integrated Process: Assessment

10. Which is the most accurate description of the nursing diagnosis of dysfunctional grieving?
1. Inability to form a valid appraisal of a loss and to use available resources
2. The experience of distress, with accompanying sadness, which fails to follow norms
3. A perceived lack of control over a current loss situation
4. Aloneness perceived as imposed by others and as a negative or threatening state

ANS: 2
Rationale: The nurse should define dysfunctional grieving as the experience of distress, with accompanying sadness, which fails to follow norms. Three types of pathological grief reactions are delayed or inhibited grief, distorted (exaggerated) grief response, and chronic or prolonged grieving. One crucial difference between normal and dysfunctional grieving is the loss of self-esteem marked my feelings of guilt or worthlessness that may precipitate depression.

Cognitive Level: Application
Integrated Process: Assessment

Multiple Response

11. A nurse is leading a bereavement group. Which of following members of the group should the nurse identify as being at high risk for complicated grieving? (Select all that apply.)
1. A widower who has recently experienced the death of two good friends
2. A man whose wife died suddenly after a cerebrovascular accident
3. A widow who removed life support after her husband was in a vegetative state for a year
4. A woman who had a competitive relationship with her recently deceased brother
5. A young couple whose child recently died of a genetic disorder

ANS: 1, 2, 4, 5
Rationale: The nurse should identify that individuals are at a high risk for complicated grieving when the bereaved person was strongly dependent on the lost entity, the relationship with the lost entity was highly ambivalent, the individual experienced a number of recent losses, the loss is that of a young person, the individual’s physical or psychological health is unstable, and the bereaved person perceived responsibility for the loss. Having a year to process grief while her husband was in a vegetative state would reduce the widow’s risk for the problem of complicated grieving.

Cognitive Level: Application
Integrated Process: Evaluation

12. An instructor is teaching nursing students about Worden’s grief process. According to Worden, which of the following client behaviors would delay or prolong the grieving process? (Select all that apply.)
1. Refusing to allow oneself to think painful thoughts
2. Indulging in the pain of loss
3. Using alcohol and drugs
4. Idealizing the object of loss
5. Recognizing that time will heal

ANS: 1, 3, 4
Rationale: The nurse should identify that refusing to allow oneself to think painful thoughts, using alcohol and drugs, and idealizing the object of loss will delay or prolong the grieving process. Task II of Worden’s grief process is working through the pain or grief. Pain must be acknowledged and processed in order to move on.

Cognitive Level: Application
Integrated Process: Evaluation

13. Which of the following types of care should the interdisciplinary team of hospice provide? (Select all that apply.)
1. Physical care available on a 24/7 basis
2. Counseling on the addictive properties of pain-management medications
3. Discussions related to death and dying
4. Explorations of new aggressive treatments
5. Assistance with obtaining spiritual support and guidance

ANS: 1, 3, 5
Rationale: The nurse should identify that the interdisciplinary team of hospice provides physical care available on a 24/7 basis, discussions related to death and dying, and assistance with obtaining spiritual support and guidance. Hospice is a program that provides palliative and supportive care to meet the needs of people who are dying and their families.

Cognitive Level: Application
Integrated Process: Implementation

Ordered Response

14. Order the stages of normal grief, according to John Bowlby.
________ Reorganization
________ Disequilibrium
________ Disorganization and despair
________ Numbness/protest

ANS: The correct order is 4, 2, 3, 1
Rationale: John Bowlby hypothesized four stages in the grief process. He implies that these behaviors can be observed in all individuals who have experienced the loss of something or someone of value, even in babies as young as 6 months of age.
1. Numbness/Protest
2. Disequilibrium
3. Disorganization and despair
4. Reorganization

Cognitive Level: Analysis
Integrated Process: Assessment

15. Order the stages of normal grief, according to J. William Worden.
________ Finding an enduring connection with the lost entity in the mist of embarking on a new life
________ Accepting the reality of the loss
________ Adjusting to a world without the lost entity
________ Processing the pain of grief

ANS: The correct order is 4, 1, 3, 2
Rationale: Worden views the bereaved person as active and self-determining rather than a passive participant in the grief process. He proposes that bereavement includes a set of tasks that must be reconciled in order to complete the grief process.
1. Accepting the reality of the loss
2. Processing the pain of grief
3. Adjusting to a world without the lost entity
4. Finding an enduring connection with the lost entity in the mist of embarking on a new life

Cognitive Level: Analysis
Integrated Process: Assessment

Fill-in-the-Blank

16. ______________________ grieving is the experiencing of the feelings and emotions associated with the normal grief response before the loss actually occurs.

ANS: Anticipatory
Rationale: Anticipatory grieving is the experiencing of the feelings and emotions associated with the normal grief response before the loss actually occurs. Anticipatory grieving may serve as a defense for some individuals to ease the burden of loss when it actually occurs.

Cognitive Level: Application
Integrated Process: Assessment