Chapter 30: Dying, Death, and Grieving Halter: Varcarolis' Foundations of Psychiatric Mental Health Nursing: A Clinical Approach, 8th Edition

1. An adult says to the nurse, "The cancer in my neck spread in only 2 months. I've been cursed my whole life. Maybe if I had been more generous with others ..." Considering the stages of grief described by Kübler-Ross, which stage is evident?

a. Anger

b. Denial

c. Depression

d. Bargaining

ANS: D

The patient's comment demonstrates an attempt to regain control. Bargaining is evidenced by people reviewing what could have been done differently. While the person may also be experiencing anger and depression, the comment speaks directly to bargaining. The person shows acceptance of the disease.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 30-3, 22 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

2. Four teenagers died in an automobile accident. Six months later, which behavior by the parents best demonstrates acceptance of the tragedy? The parents who

a. isolate themselves at home.

b. return immediately to employment.

c. forbid other teens in the household to drive a car.

d. create a scholarship fund at their child's high school.

ANS: D

Loss of a child is among the highest risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-3, 21, 42 (Box 30-5) TOP: Nursing Process: Evaluation

MSC: Client Needs: Psychosocial Integrity

3. After a spouse's death, an adult repeatedly says, "I should have recognized what was happening and been more helpful." This adult is experiencing

a. depression.

b. bargaining.

c. anger.

d. guilt.

ANS: D

Guilt is expressed by the bereaved person's self-reproach. Anger, depression, and bargaining cannot be assessed from data given in the scenario.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 30-22 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

4. A widower tells friends, "I am taking my neighbor out for dinner. It's time for me to be more sociable again." Considering the stages of grief described by Kübler-Ross, which stage is evident?

a. Anger

b. Denial

c. Depression

d. Acceptance

ANS: D

As an individual accepts loss, the person renews interest in people and activities. The person is seeking to move into new relationships. The patient's comment demonstrates an attempt to regain control. Bargaining is evidenced by people reviewing what could have been done differently. While the person may also experience occasional anger or sadness, the comment speaks directly to acceptance.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 30-3, 22 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

5. After the death of his wife, a man says, "I can't live without her ... she was my whole life." Select the nurse's most therapeutic reply.

a. "Each day will get a little better."

b. "Her death is a terrible loss for you."

c. "It's important to recognize that she is no longer suffering."

d. "Your friends will help you cope with this change in your life."

ANS: B

A statement that validates the bereaved person's loss is more helpful than commonplace clichés. It signifies understanding. The other options are clichés.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-7, 33 (Table 30-1), 35 (Table 30-3)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

6. A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." Which analysis applies?

a. The comment warns of a malpractice suit.

b. Anger is a phenomenon experienced during grief.

c. The wife had conflicted feelings about her husband.

d. In some cultures, grief is expressed solely through anger.

ANS: B

Anger may be manifested toward the health care system, God, or even the deceased. Anger may protect the bereaved from facing the devastating reality of loss. Anger expressed during mourning is not directed toward the nurse personally, even though accusations and blame may make him/her feel as though it is.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 30-2, 3 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

7. A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." Select the nurse's most therapeutic action.

a. Say, "I understand you are feeling upset. I will stay with you until your family comes."

b. Say, "Your husband's heart was so severely damaged that it could no longer pump."

c. Say, "I will call my supervisor to discuss this matter with you."

d. Hold the spouse's hand in silence until the family arrives.

ANS: A

When bereaved family behaves in a disturbed manner, the nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating. Touch (holding hands) is culturally defined; it may or may not be appropriate in this situation.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-2, 3, 17, 21, 22 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

8. A patient who was widowed 18 months ago says, "I can remember good times we had without getting upset. Sometimes I even think about the disappointments. I am still trying to become accustomed to sleeping in the bed all alone." The work of mourning

a. is beginning.

b. has not begun.

c. is at or near completion.

d. is progressing abnormally.

ANS: C

The work of mourning has been successfully completed when the bereaved can acknowledge both positive and negative memories about the deceased and when the task of restructuring the relationship with the deceased is completed.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Pages 30-21 to 23 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

9. A bystander was killed during a robbery 2 weeks ago. His widow, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse's most therapeutic response.

a. "Are you hearing voices at night?"

b. "I am worried about how much you are crying. Your grief over your husband's death has gone on too long."

c. "This loss is harder to accept because of your mental illness. I will refer you to a partial hospitalization program."

d. "The unexpected death of your husband must be very painful. I am glad you are able to talk to me about your feelings."

ANS: D

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 serious mental illness, but the nurse's priority intervention is to form a therapeutic alliance and support the patient's expression of feelings. The crying 2 weeks after his death is expected and normal.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 30-7, 23, 24, 33 (Table 30-1), 35 (Table 30-3)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

10. A patient with a new diagnosis of cancer says, "My father died of pancreatic cancer. I took care of him during his illness, so I know what is ahead for me." Which nursing diagnosis applies?

a. Anticipatory grieving

b. Ineffective coping

c. Ineffective denial

d. Spiritual distress

ANS: A

The patient's experience demonstrates anticipatory grieving. The other diagnoses may apply but are not supported by the comment.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-17, 18 TOP: Nursing Process: Diagnosis/Analysis

MSC: Client Needs: Psychosocial Integrity

11. A nurse talks with a woman who recently learned that her husband died while jogging. Select the appropriate statement for the nurse.

a. "At least your husband did not suffer."

b. "It's better to go quickly as your husband did."

c. "Your husband's loss must be very painful for you."

d. "You will 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 clichés, because they are ineffective.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-7, 33 (Table 30-1), 35 (Table 30-3)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

12. Family members ask the nurse, "What can we say when our loved one says, 'Death is coming soon?'" To promote communication, which response could the nurse suggest for family members?

a. "We feel sad when we think about life without you."

b. "We have not given up on getting you well."

c. "We think you will be around for a long time yet."

d. "Let's talk about the good memories we have."

ANS: A

The correct response is emotionally honest. It allows the family opportunities to express emotions, address issues in the relationship, and say farewell. The distracters are evasive.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-7, 33 (Table 30-1), 35 (Table 30-3), 42 (Box 30-5)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

13. Which finding indicates successful completion of an individual's grief and mourning?

a. For 2 years after her husband's death, a widow has kept her husband's belongings in their usual places.

b. After 15 months, a widower realistically remembers both the pleasures and disappointments of his relationship with his wife.

c. Three years after her husband's death, the widow talks about her husband as if he is alive and weeps when others mention his name.

d. Eighteen months after a spouse's death, an adult says, "I have never cried or had feelings of loss, even though we were very close."

ANS: B

The goals of mourning have evolved from doing the grief work, getting over it, and moving on with life. The work of grieving is over when the bereaved person 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 incorrect options suggest maladaptive grief.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-21, 22 TOP: Nursing Process: Evaluation

MSC: Client Needs: Psychosocial Integrity

14. A child drowned while swimming in a local lake 2 years ago. Which behavior best indicates the child's parents are mourning in an effective way? The parents

a. forbid their other children from going swimming.

b. keep a place set for the deceased child at the family dinner table.

c. sealed their child's room exactly as the child left it 2 years ago.

d. throw flowers on the lake at each anniversary date of the accident.

ANS: D

Loss of a child is among the highest risk situations for maladaptive grieving. Depending on many factors, this process can take many months to a number of years. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The incorrect options indicate the parents are isolating themselves and/or denying their feelings.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 30-21, 22, 42 (Box 30-5) TOP: Nursing Process: Evaluation

MSC: Client Needs: Psychosocial Integrity

15. A patient with pancreatic cancer says, "I know I am dying, but I am still alive. I want to be in control as long as I can." Which reply by the nurse shows active listening?

a. "Our staff will do their best to manage your pain."

b. "Your mind and spirit are healthy, although your body is frail."

c. "It's important for you to let others help you to ease their own pain."

d. "Are you saying you want people to stop focusing on your diagnosis?"

ANS: B

The patient has strengths and capabilities and is asking for acknowledgment that he/she is not incapacitated, even though the diagnosis is likely terminal. The correct answer provides that acknowledgment. The other responses are tangential.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-7, 33 (Table 30-1), 35 (Table 30-3), 42 (Box 30-5)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

16. A terminally ill patient says, "I know I will never get well, but," and the patient's voice trails off. Select the most therapeutic response by the nurse.

a. "What do you hope for?"

b. "Do you have questions about what is happening?"

c. "You are not going to get well. It is healthy that you accept that."

d. "When you have questions, it is best to talk to the health care provider."

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 mind. The distracters are not therapeutic; they block further communication, refocus the conversation, give advice, or suggest the nurse is uncomfortable with the topic.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-7, 33 (Table 30-1), 35 (Table 30-3), 42 (Box 30-5)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

17. A hospice patient tells the nurse, "Life has been good. I am proud of being self-educated. I overcame adversity and always gave my best. I intend to die as I lived." The nurse planning care for this patient would recognize the importance of

a. providing aggressive pain and symptom management.

b. helping the patient reassess and explore existing conflicts.

c. assisting the patient to focus on the meaning in life and death.

d. supporting the patient's use of own 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 such patients use their own resources to meet challenges would be appropriate.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Pages 30-6, 9, 42 (Box 30-5) TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

18. A widow repeatedly tells details of finding her elderly husband not breathing, performing cardiopulmonary resuscitation, and seeing him pronounced dead. Family members are concerned and ask, "What can we do?" The nurse should counsel the family that

a. they should express their feelings to the widow and ask her not to retell the story.

b. the retelling should be limited to once daily to avoid unnecessary stimulation.

c. repeating the story and her feelings is a helpful and necessary part of grieving.

d. retelling of memories is expected as part of the aging process.

ANS: C

Nurses are encouraged to tell bereaved patients that telling the personal story of loss as many times as needed is acceptable and healthy because repetition is a helpful and necessary part of grieving.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-21 to 24, 43 (Box 30-6) TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

19. A staff nurse asks a hospice nurse, "Who should be referred for hospice care?" Select the best response.

a. "Hospice is for terminally ill patients diagnosed with cancer."

b. "Patients in the end stage of any disease are eligible for hospice."

c. "Hospice is designed to care for patients experiencing end-stage renal disease."

d. "Patients diagnosed with degenerative neurological diseases are eligible for hospice after paralysis occurs."

ANS: B

A hospice service cares for terminally ill patients regardless of diagnosis.

PTS: 1 DIF: Cognitive Level: Understand (Comprehension)

REF: Page 30-5 TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment

20. Which event is most likely to precipitate grief across a community?

a. A local bank is robbed twice in a single month

b. An adolescent shoots the principal of a local high school

c. The elderly pastor of the town's largest church dies of heart failure

d. Concrete pilings crumble in a bridge important to movement of local traffic

ANS: B

The correct response identifies an event likely to be perceived as a public tragedy. The distracters are occurrences that are more commonplace. They may precipitate concern but not grief.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Page 30-24 TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

1. Which actions by a nurse are most appropriate when caring for a hospice patient? (Select all that apply.)

a. Giving choices

b. Fostering personal control

c. Explaining curative options

d. Supporting the patient's spirituality

e. Offering interventions that convey respect

f. Providing answers to the patient's questions about spirituality

ANS: A, B, D, E

The correct answers support the rights and choices of the dying individual. Acting on false information robs a patient of the opportunity for honest dialogue and places barriers to achieving end-of-life developmental opportunities. The nurse supports the patient's spirituality but does not have the answers to all questions.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-6, 11 to 13, 42 (Box 30-5)

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

2. Which patients meet criteria for hospice services? (Select all that apply.)

a. A 92-year-old diagnosed with acute pneumonia and late-stage Alzheimer's disease

b. A 54-year-old diagnosed with glioblastoma and life expectancy of 8 to 10 weeks

c. A 16-year-old with type 1 diabetes, multiple infections, and substance abuse

d. A 74-year-old newly diagnosed with chronic obstructive pulmonary disease (COPD) and life expectancy of 2 years

e. A 36-year-old diagnosed with multiple sclerosis complicated by major depressive disorder and pain associated with muscle spasms

ANS: A, B

Hospice services are available to patients with terminal illnesses and a life expectancy of less than 6 months. The patient must choose hospice care, rather than curative treatments. Although patients with other health problems may experience complications, treatments focusing on cure would exclude them from hospice services.

PTS: 1 DIF: Cognitive Level: Analyze (Analysis)

REF: Page 30-5 TOP: Nursing Process: Planning

MSC: Client Needs: Safe, Effective Care Environment

3. As death approaches, a patient diagnosed with AIDS says, "I do not have enough energy for many visitors anymore and I am embarrassed about how I look. I only want to see my parents and sister." Which actions should the nurse take? (Select all that apply.)

a. Encourage the patient to reconsider this decision so that interested and caring friends can provide support.

b. Support the patient to share the request with the parents and sister.

c. Assist family to inform the patient's friends of the request.

d. Suggest that the patient discuss these wishes with clergy.

e. Place a "No Visitors" sign on the patient's door.

ANS: B, C

The correct responses empower the patient to maintain dignity, control, personal space, and confidentiality. As some 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 talking constantly.

PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-6, 9 TOP: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

4. One month ago, an adult died from cancer. Family members now gather at the adult's home to dispose of the deceased's belongings. Which comments demonstrate the family member is coping with the loss in an effective way? (Select all that apply.)

a. "Her possessions still have her scent. We should dispose of them."

b. "Let's take turns selecting items of hers we would each like to have."

c. "When I die, I hope someone who loved me goes through my things."

d. "This was her favorite jacket. If we donate it to charity, someone else can enjoy it too."

e. "We're violating her privacy by looking through her things. Let's call a charity to come pick up everything."

ANS: B, C, D PTS: 1 DIF: Cognitive Level: Apply (Application)

REF: Pages 30-21 to 23, 35 (Table 30-3) TOP: Nursing Process: Assessment

MSC: Client Needs: Psychosocial Integrity

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