Care for the Dying and Those Who Grieve

MULTIPLE CHOICE

1. A nurse working with a person whose spouse recently died uses cheer and humor to lift the person’s spirits. At one point, the widowed person smiles briefly. What analysis of this scenario is correct?
a. The nurse’s technique was effective.
b. Use of humor should be added to the plan of care.
c. This approach may prove useful in other, similar situations.
d. The nurse needs supervision; the communication technique was not appropriate.
ANS: D
Clinical supervision will review the nurse’s actions and thoughts and help the nurse arrive at a more therapeutic approach. Attempts at cheering up a patient who is depressed serve only to emphasize the disparity between the patient’s mood and that of others. Active listening should be the technique used by the nurse. The incorrect options suggest the approach is therapeutic when it is not.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 484-485
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

2. A patient’s fiancé died in an automobile accident several days ago. The patient reports crying and experiencing feelings of guilt and anger. This behavior is characteristic of which stage of acute grief?
a. Denial
b. Reorganization
c. Development of awareness
d. Preoccupation with the lost object
ANS: C
As denial fades, an awareness of the finality of the loss develops and is accompanied by painful feelings of loss, anger with others, and guilt for taking or not taking specific actions. Reorganization implies the movement toward healing. Denial is manifested by the inability to believe the reality of an event. Preoccupation with the lost object would involve the patient dwelling on thoughts of the deceased.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 487-488
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

3. After the death of a spouse, an adult repeatedly says, “I should have made him go to the doctor when he said he didn’t feel well.” This individual is experiencing:
a. preoccupation with the image of the deceased.
b. sensations of somatic distress.
c. anger.
d. guilt.
ANS: D
Guilt is evident by the bereaved person’s self-reproach. Preoccupation refers to dwelling on images of the deceased. Somatic distress would involve bodily symptoms. Anger is not evident from data given in this scenario.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 489
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

4. A person whose spouse died two years earlier tells friends, “I think I’ll start going out socially, maybe even take someone to dinner.” This comment best demonstrates that the individual is:
a. denying the significance of the loss.
b. in a period of resolution of grief.
c. actively working through grief.
d. experiencing intrusion.
ANS: B
Toward the end of the grief process, the person renews his or her interest in people and activities. This behavior indicates resolution. At the same time, the person is released from the relationship with the deceased. The patient has progressed beyond grief. The patient is seeking to move into new relationships so that he or she is not alone.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 490
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

5. After the death of his wife, a man tells the nurse, “I can’t live without her. She was my whole life.” Which is the nurse’s most therapeutic reply?
a. “Each day will get a little better.”
b. “Her death is a terrible loss for you.”
c. “Remember, she’s no longer suffering.”
d. “Your friends will help you cope with this.”
ANS: B
The correct response demonstrates the use of reflection, a therapeutic communication technique. A statement that validates the bereaved person’s loss is more helpful than banalities and clichés; it signifies understanding. The other options are clichés.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 491-495
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

6. Shortly after a man’s wife dies, the man approaches the nurse who cared for his wife during her final hours of life and says angrily, “If you had given your undivided attention, she would still be alive.” Which analysis applies?
a. The comment summarizes the nurse’s inadequacies.
b. Anger is a phenomenon experienced during grieving.
c. The patient had ambivalent feelings about his spouse.
d. In some cultures, grief is expressed solely through anger.
ANS: B
Anger may protect the bereaved from facing the devastating reality of the loss. Anger expressed during mourning is not directed toward the nurse, personally, although accusations and blame may make him or her feel as though it is.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 489
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

7. After being notified that her husband died of heart failure, a wife approaches the nurse who cared for her husband. In the hospital hallway the wife shouts angrily, “He’d still be alive if you’d given him your undivided attention!” Select the nurse’s best response.
a. “I understand you’re feeling upset. Let’s go to our conference room, and I’ll stay with you until your family comes.”
b. “Your husband’s heart was severely damaged and could no longer pump. There’s nothing anyone could have done.”
c. “I will call the nursing supervisor to discuss this matter with you.”
d. “It will be all right if you cry. Crying is a normal grief response.”
ANS: A
When a bereaved family member behaves in a disturbed manner, the nurse should show patience and tact while offering sympathy and warmth. Moving the individual to a private area so as not to disturb others is important. The incorrect options are defensive, evasive, or placating.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 489-495
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

8. An adult who was widowed 18 months ago says, “I can now remember good times we shared without getting upset. Sometimes I even think about the disappointments. I’ve become accustomed to sleeping in our bed alone.” The work of mourning:
a. is beginning.
b. is progressing abnormally.
c. is at or near completion.
d. has not begun.
ANS: C
The work of mourning has been successfully completed when the bereaved can remember both the positive and negative memories about the deceased and when the task of restructuring the relationship with the deceased is completed.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 490-491
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

9. The mourning process is more difficult when the bereaved:
a. was relatively independent of the deceased.
b. has experienced a number of previous losses.
c. accepts that death is expected for older adults.
d. had few unresolved conflicts with the deceased.
ANS: B
Factors that have negative effects on the mourning process include a high dependency on the deceased, ambivalence toward the deceased, a poor or absent support system, a high number of past losses or other recent losses, poor physical or mental health, and young age of the deceased. Data do not support the incorrect options.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 488-490
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

10. A patient newly diagnosed with pancreatic cancer says, “My father also died of pancreatic cancer. I took care of him during his illness. I can’t go through that.” Select the highest priority nursing diagnosis.
a. Anticipatory grieving
b. Ineffective coping
c. Ineffective denial
d. Risk for suicide
ANS: D
The patient’s statement has a subtle message of suicide. Suicide is a risk for people with major losses, including terminal disease. The nurse will need to monitor the suicide risk vigilantly. The other diagnoses may apply but are lower priority.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 488-490
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

11. A nurse talks with a person whose spouse died suddenly while jogging. Which is the appropriate statement for the nurse?
a. “At least your spouse did not suffer.”
b. “It’s better to go quickly as your spouse did.”
c. “The loss of your spouse must be very painful for you.”
d. “You’ll begin to feel better after you get over the shock.”
ANS: C
The most helpful responses by others validate the bereaved person’s experience of loss. Avoid banalities; they increase the individual’s sense of isolation.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 491-492
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

12. A recently widowed patient tells the health care provider, “I have so much epigastric discomfort. I wonder if I have an ulcer.” Diagnostic tests are negative. The symptom demonstrates:
a. early reorganization behavior.
b. disorganization and depression.
c. preoccupation with the deceased.
d. normal phenomenon of mourning.
ANS: D
Sensations of somatic distress are often experienced during the acute stage of grieving. They include tightness in the throat, shortness of breath, exhaustion, and pain or sensations such as those experienced by the dead person.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 486 | Pages: 488-489
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

13. Which finding indicates the successful completion of an individual’s grieving process?
a. For two years, a person has kept the deceased spouse’s belongings in their usual places.
b. After 15 months, a widowed person realistically remembers both the pleasures and disappointments of the relationship with the spouse.
c. Three years after the death, a person talks about the spouse as if the spouse was still alive and weeps when others mention the spouse’s name.
d. Eighteen months after the spouse’s death, a person says, “I never cry or have feelings of loss even though we were always very close.”
ANS: B
The work of grieving is over when the bereaved can remember the individual realistically and acknowledge both the pleasure and disappointments associated with the loved one. The individual is then free to enter into new relationships and activities. The other options suggest unresolved grief.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 490 | Page: 493
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

14. A child drowned while swimming in a local lake four years ago. Which behavior indicates that the parents are effectively coping with their loss? The parents:
a. prohibit their other children from going swimming.
b. keep a place set for the dead child at the family dinner table.
c. keep their child’s room exactly as the child left it four years ago.
d. throw flowers on the lake at each anniversary date of the accident.
ANS: D
The loss of a child is among the highest risk situations for dysfunctional grieving. The parents who throw flowers across the lake on each anniversary date of the accident are effectively using a ritual to express their feelings openly. The other behaviors indicate the parents are isolating themselves or denying their feelings or both.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 490 | Page: 493
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

15. A patient diagnosed with metastatic brain cancer says, “I’m dying, but I’m still living. I want to be in control as long as I can.” Which reply shows the nurse was actively listening?
a. “Our staff will do their best to help you feel comfortable.”
b. “Most people do not know how to help and are afraid of death.”
c. “Your mind and spirit are healthy, although your body is frail.”
d. “You want people to stop focusing on your weaknesses.”
ANS: C
The patient is asking for acknowledgment that he or she is not totally sick; even in the terminal state, strengths and capabilities are present. The correct response provides that acknowledgment through use of reflection. The other responses are nontherapeutic.

DIF: Cognitive Level: Comprehension (Understanding)
REF: Pages: 483-484 | Pages: 491-495 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

16. A terminally ill patient says, “I know I’m not going to get well, but still…” and the patient’s voice trails off. Which response by the nurse would be therapeutic?
a. “What do you hope for?”
b. “No, you’re not going to get well.”
c. “Do you have questions about what is happening?”
d. “I’m happy you are being realistic about your future.”
ANS: A
This open-ended response is an example of following the patient’s lead. It provides an opportunity for the patient to speak about whatever is on his or her mind. The incorrect options are not therapeutic; they block further communication, refocus the conversation, give advice, or suggest the nurse is uncomfortable with the topic.

DIF: Cognitive Level: Comprehension (Understanding)
REF: Pages: 483-484 | Pages: 491-495 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

17. A woman whose husband is terminally ill says, “I don’t want to cry in front of him. I don’t want him to know how close he is to death or how sad I am.” Which response by the nurse would be most therapeutic?
a. “You’re right to protect him at a time when he is so vulnerable.”
b. “He might be more comforted than disturbed by your tears.”
c. “It’s important for you to know that time is running out.”
d. “You definitely need to be honest about your feelings.”
ANS: B
Many people try to protect the dying person from experiencing emotions; however, emotional honesty is important to both the patient and the family. The patient may be comforted to know that the family is facing the inevitable. Giving advice and making judgmental statements are not helpful.

DIF: Cognitive Level: Comprehension (Understanding)
REF: Pages: 482-484 | Pages: 491-495 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

18. A family of a terminally ill patient asks the nurse, “What can we say when our family member mentions death is coming soon?” Which response could the nurse suggest?
a. “We think you will be around for a long time.”
b. “We don’t want you to give up trying to get well.”
c. “We don’t think we’re ready to talk about this yet.”
d. “We feel so sad when we think of life without you.”
ANS: D
This response is emotionally honest. It will allow the family opportunities to express emotions and further resolve issues in the relationship and explore end-of-life developmental opportunities. The incorrect options are evasive.

DIF: Cognitive Level: Comprehension (Understanding)
REF: Pages: 482-483 | Pages: 491-495 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

19. As death approaches, a patient diagnosed with acquired immunodeficiency syndrome (AIDS) says, “I don’t want to see a lot of visitors anymore. Just my parents and my sibling can come in for a while each day.” What action should the nurse take?
a. Ask the patient to reconsider the decision because many interested and caring friends can be sources of support.
b. Discuss the request with the parents and sibling. Suggest that they explain the patient’s decision to friends.
c. Suggest that the patient discuss these wishes with the health care provider.
d. Place a “no visitors” sign on the patient’s door.
ANS: B
As many patients approach death, they begin to withdraw. In the stage of acceptance, many patients are exhausted and tired, and interactions of a social nature are a burden. Many prefer to have someone present at the bedside who will sit without constantly talking. The correct response demonstrates the nurse’s advocacy for the patient’s preferences.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 491-495
TOP: Nursing Process: Implementation MSC: NCLEX: Safe, Effective Care Environment

20. A nurse manager notices that a staff member spends minimal time with a patient diagnosed with AIDS who is terminally ill. The patient says, “I’m having intense emotional reactions to this illness. Sometimes I feel angry, but other times I feel afraid or abandoned.” The nurse manager can correctly hypothesize that the most likely reason for the staff member’s avoidance is:
a. fear of infection transmission.
b. feelings of inadequacy in dealing with complex emotional needs.
c. knowledge that the patient needs time alone with family and friends.
d. belief that the patient’s former lifestyle included high-risk behaviors.
ANS: B
Many nurses tend to be more comfortable with meeting physical needs than in focusing on complex emotional needs. Standard precautions are necessary for all patients. The patient’s lifestyle is irrelevant.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 484-487
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

21. A terminally ill patient tells the nurse, “Life has been good. I am proud of being self-educated. I overcame adversity with willpower. I always gave my best and expected things to turn out well. I intend to die as I lived: optimistically.” The nurse planning care for this patient recognizes a critical need to:
a. provide aggressive pain and symptom management.
b. help the patient reassess and explore existing conflicts.
c. assist the patient to focus on the meaning in life and death.
d. support the patient’s use of personal resources to meet challenges.
ANS: D
The patient whose intrinsic strength and endurance have been a hallmark often wishes to approach dying by staying optimistic and in control. Helping the patient use his or her resources to meet challenges is appropriate.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 484 | Page: 490
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

22. The spouse of a patient in hospice care angrily tells the nurse, “The care provided by the aide and other family members is inadequate, so I must do everything myself. Can’t anyone do things right?” The palliative care nurse should:
a. provide teaching about anticipatory grieving.
b. assign new personnel to the patient’s care.
c. arrange hospitalization for the patient.
d. refer the spouse for crisis counseling.
ANS: A
The behaviors described in this scenario are consistent with anticipatory grieving. The spouse needs to be taught about the process of anticipatory grieving and to receive counseling to validate what she is experiencing and to enhance coping. The incorrect options are not appropriate to the situation and do not respond to the spouse’s needs.

DIF: Cognitive Level: Analysis (Analyzing)
REF: Page: 481 | Pages: 485-486 | Pages: 489-490
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

23. An individual was killed during a store robbery 2 weeks ago. The widowed spouse, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about the death. Which is the nurse’s most therapeutic comment?
a. “I’m worried about how much you’re crying. Your grief over your spouse’s death has gone on too long.”
b. “The unexpected death of your spouse must be painful. I’m glad you’re able to talk to me about your feelings.”
c. “This loss is harder to accept because of your mental illness. Let’s refer you to the partial hospitalization program.”
d. “Your crying shows me you aren’t coping well. I made an appointment for you to see the psychiatrist for medication adjustment.”
ANS: B
The patient is expressing feelings related to the loss, and this is an expected and healthy behavior. This patient is at risk for dysfunctional grieving because of the history of a severe psychiatric illness, but the nurse’s priority intervention is to form a therapeutic alliance and support the patient’s expression of feelings. The patient’s crying 2 weeks after the spouse’s death is expected and normal.

DIF: Cognitive Level: Analysis (Analyzing)
REF: Pages: 481-483 | Pages: 491-492 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

24. Children of a widowed parent confer with the nurse; their surviving parent repeatedly relates the details of finding the deceased parent not breathing, performing cardiopulmonary resuscitation, going to the hospital by ambulance, and seeing the pronouncement of death. The family asks, “What can we do?” The nurse should counsel the family:
a. to share their own feelings with the surviving parent and ask for the retelling to stop.
b. that retelling the story should be limited to once daily to avoid unnecessary stimulation.
c. that retelling memories is to be expected as part of the aging process.
d. that repeating the story is a helpful and a necessary part of grieving.
ANS: D
Nurses are encouraged to tell bereaved patients that telling the personal story of loss as many times as needed is acceptable and healthy; repetition is a helpful and necessary part of grieving. Limits should not be placed on the retelling.

DIF: Cognitive Level: Comprehension (Understanding)
REF: Pages: 481-482 | Page: 484 | Page: 492
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

25. A widow grieving her husband’s sudden death tells the nurse, “I’m not feeling well. Yesterday, I saw my husband walk through the door, stop, and smile at me. Then he just faded away.” Which is the nurse’s most appropriate action?
a. Assess for recent substance abuse.
b. Suggest a referral to the mental health clinic.
c. Arrange for an evaluation for antidepressant medication.
d. Counsel the widow that visualizations are a normal part of grieving.
ANS: D
Grieving patients often dream about, visualize, think about, or search for the lost loved one. The patient should be told that this is considered a normal phenomenon and not a sign of mental illness. Visualization does not suggest substance abuse or mental illness in this case.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 490
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

26. A grieving patient tells a nurse, “It’s been eight months since my spouse died. I thought I would feel better by now, but lately I feel worse. I have no energy. I am lonely, but I don’t want to be around people. What should I do?” What is the nurse’s best counsel?
a. Seek psychotherapy.
b. Become active in a church.
c. Go to the spouse’s grave every day.
d. Understand this is a normal response.
ANS: D
The patient needs understanding and support that the feelings are normal. Although feelings of depression generally decline over the period of a year after the death of a loved one, the decline is not linear. Loneliness and aimlessness are most pronounced 6 to 9 months after the death. The patient should be educated about normal phenomena experienced during bereavement. The other options are not clearly indicated.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 491-495
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

27. A nurse cared for a terminally ill patient for over a month and always looked forward to spending time with the patient. When the patient died, the nurse experienced sadness and felt mildly depressed. Eventually, the nurse explains these feelings to a mentor. The mentor should counsel the nurse:
a. about stress-reduction strategies.
b. to seek therapy for dysfunctional grief.
c. about the experience of disenfranchised grief.
d. to consider taking a leave of absence to pursue healing.
ANS: C
The nurse is experiencing disenfranchised grief. Nurses often incur loss that is not openly acknowledged or publicly mourned. The loss of a patient may not be recognized or acknowledged by others; therefore the grief is solitary and uncomforted and may be difficult to resolve.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 486
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. Which actions by a nurse contribute to protecting the rights of patients who are terminally ill? Select all that apply.
a. Maintain hope for a positive prognosis.
b. Hug the patient when sadness is expressed.
c. Offer choices that promote personal control.
d. Provide interventions that convey respect.
e. Support the patient’s quest for spiritual growth.
ANS: C, D, E
The answers support the rights of the individual who is dying. Touch should be nurturing but may leave the patient uncomfortable and confused if inappropriate. Acting on false information robs a patient of the opportunity for honest dialog and places barriers to achieving end-of-life developmental opportunities.

DIF: Cognitive Level: Comprehension (Understanding)
REF: Pages: 480-481 | Pages: 485-486 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

2. Which statements by a patient who is terminally ill give the nurse information relevant to spiritual assessment? Select all that apply.
a. “I feel an inner peace with my decision to use hospice services.”
b. “I trust my health care provider to prescribe enough medication to keep me free of pain.”
c. “I have prepared advance directives to spare my children the need to make difficult decisions.”
d. “I plan to use these last weeks to experience the process of dying as fully as I experienced the richness of living.”
e. “Listening to hymns helps deepen my relaxation and the relief I get from my pain medication.”
ANS: A, D, E
Spirituality encompasses finding meaning in the process of living and dying, as well as hope and inner peace. Listening to hymns identifies an activity that connects the patient to his or her beliefs and is helpful in calming anxieties. The other options are not directly related to spiritual aspects.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 484 | Pages: 488-489
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

3. Psychotherapy for individuals at risk for complicated grief focuses on which goals? Select all that apply.
a. Exploring emotional responses to a loss
b. Identifying ways to break bonds with the deceased
c. Solving problems related to moving forward in life
d. Learning about the stages and symptoms of grieving
e. Using antipsychotic medications for dysfunctional grief
ANS: A, C, D
therapy is offered when a problem—not necessarily dysfunctional grief—exists or is anticipated. It focuses on emotional responses to loss and problem solving related to moving forward in life. Anxiety and/or depression may develop, even with normal grief, and require the short-term use of anxiolytic or antidepressant medications; however, antipsychotic drugs would not be expected. Physical symptoms such as weakness, anorexia, shortness of breath, tightness of the chest, dry mouth, and gastrointestinal disturbances may accompany acute grief, but the development of actual complications indicates dysfunctional grief.

DIF: Cognitive Level: Comprehension (Understanding) REF: Pages: 491-492
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity