Question 1

The nurse is assigning support personnel to assist the families of clients who have died in dealing with the stress related to the loss of their family members.Which family would the nurse screen as at highest risk for complicated grief? The family of a client who

Accepted Answer

The sudden and traumatic nature of death from a violent event like a robbery can increase the risk of complicated grief. While all types of loss can be difficult, sudden and unexpected deaths can make it harder for families to cope and process their grief.

Question 2

A client who has AIDS tells the nurse,"I don't know why I should even keep trying.This disease is so horrible and so many people die from it.It will get me,too." The nurse recognizes this statement as being

Accepted Answer

The statement expresses hopelessness and a possible indication of suicidal ideation. The nurse should evaluate the client further for treatment to address these issues.

Question 3

A client hospitalized for injuries from a motor vehicle crash is diagnosed with higher brain death.What findings support this client's diagnosis?
Standard Text: Select all that apply.

Accepted Answer

The absence of cephalic reflexes (such as gag or corneal reflexes) indicates a lack of brainstem function. Not breathing spontaneously also suggests brainstem involvement. The electroencephalogram (EEG) showing no activity for 30 minutes is a strong indicator of brain death. Episodic coughing and inconsistent cardiac function may be present in some cases but are not definitive indicators of brain death.

Question 4

During the bath,the client suddenly says,"I am not going to get well.I think I am going to die." What response given by the nurse is most appropriate?

Accepted Answer

The most appropriate response is to ask the client what makes them think they are dying. This can provide insight into their thought process and any underlying concerns they may have. It also allows the nurse to address any fears or misconceptions the client may have about their illness or treatment, and to provide appropriate education and support. Choices A and B are dismissive and can invalidate the client's feelings, while choice D may be perceived as fatalistic and unhelpful.

Question 5

The nurse is counseling a family in which a member is terminally ill.The family has children of varying ages.What should the nurse teach the family about the reactions of children to death?

Accepted Answer

At about age 9, children begin to understand that death is inevitable. Toddlers do not fully understand the concept of death and may view it as temporary or reversible, while preschoolers may see death as a separation of the body and soul or a spiritual release. Adolescents may struggle with intense emotions and may have difficulty adapting to changes after the loss, but they do not necessarily have better outcomes than adults.

Question 6

The nurse is caring for the family of a terminally ill client.The family members have been tearful and sad since the diagnosis was given.What is the best nursing diagnosis problem statement for this family?

Accepted Answer

Anticipatory Grieving is the best nursing diagnosis problem statement for this family. The family members have been experiencing sadness since the diagnosis was given, which suggests that they are already anticipating the loss of their loved one. This nursing diagnosis acknowledges the emotional response of the family members to the impending loss and provides an opportunity for the nurse to offer support and interventions to address their grief.

Question 7

During a home visit,an older male client tells the nurse that his wife died 3 years ago.What did the nurse observe as an indication that this client is experiencing complicated grief?

Accepted Answer

The fact that the client has kept his wife's craft room exactly as it was before she passed away may be an indication of complicated grief. This suggests that the client is having difficulty letting go of his wife's memory and accepting her death, which can be a sign of prolonged or complicated grief. The other answer choices do not necessarily indicate complicated grief.

Question 8

The nurse is caring for a client whose family does not want to tell him that he is dying.What is the nurse's best action according to these wishes?

Accepted Answer

The nurse's best action would be to talk to the family about the situation and their concerns, while also educating them about the client's right to know their diagnosis and prognosis. It is important for the family to understand the impact that withholding this information can have on the client's emotional and psychological well-being, as well as the impact it can have on decision-making and planning for end-of-life care. The nurse should work collaboratively with the family to come up with a plan that meets the client's needs while also respecting their wishes.

Question 9

The nurse critically evaluates various models of grief used for terminally ill clients and their families.What should the nurse recognize when applying these models to individual cases?

Accepted Answer

The nurse should recognize that no clear timetables exist for grief, nor are there clear-cut stages of grief. While models such as the Kübler-Ross model and other grief theories can be helpful in understanding the emotional responses of terminally ill clients and their families, it is important to remember that these models do not necessarily apply to every individual case. Each person's grief journey is unique and may not follow a set pattern or timeline.

Question 10

The nurse who is providing postmortem care for a client sees that the client is wearing a ring.What is the most important action regarding this observation?

Accepted Answer

The most important action is to document fully whatever action is taken with the ring, whether it is removed and given to the family, brought to the attention of the funeral director, or taped to the client's finger. This is important for legal and accountability reasons.

Question 11

A client recovering from back surgery is seen crying softly in bed.Upon assessment,the nurse learns that the client has been told of the future inability to perform certain sports,activities,and employment types because of the surgery.The nurse interprets this client's reaction as a response to which type of loss?

Accepted Answer

This situation is an example of situational loss, which occurs due to an unexpected event, such as surgery, leading to changes in the client's ability to perform certain activities.

Question 12

The spouse of a deceased client is working through the stages of grief.If the nurse applies Martocchio's five clusters of grief to this situation,the spouse would progress through the clusters in which order?
Standard Text: Click and drag the options below to move them up or down.

Accepted Answer

The spouse of a deceased client is likely to progress through the stages of grief in the following order:
- Shock and disbelief (D)
- Anguish, disorganization, and despair (E)
- Yearning and protest (B)
- Identification in bereavement (C)
- Reorganization and restitution (A)

Question 13

A client who has just been diagnosed with a slowly progressive terminal illness asks the nurse about the availability of hospice services.What information should the nurse share with this client?

Accepted Answer

Hospice services are generally reserved for those who have a life expectancy of 6 months or less. This is the criteria that most hospice providers use to determine eligibility for hospice care. It is important that the client understands this and that they are aware of the benefits that hospice care can provide in terms of symptom management and support for both the client and their family.

Question 14

A client is diagnosed with a terminal illness and is demonstrating anxiety.What intervention can the nurse use to help the client at this time?

Accepted Answer

Exploring the client's history with other stressful life events and how successful coping was at that time can help the nurse individualize interventions to promote effective coping with anxiety related to terminal illness. This can help the client develop a sense of control and empower them to identify coping strategies that work for them. Options B and C are not recommended as both limit communication and information sharing, which can increase anxiety and decrease client trust. Option D may be appropriate in some cases, but it is not the best first-line intervention and should be used with caution as it can increase the risk of adverse effects and addiction.

Question 15

The family of a young adult client who has recently been diagnosed with a rapidly progressing terminal illness tells the nurse,"This cannot be happening.There must be some mistake in the testing." What should be the nurse's first step in assisting this family?

Accepted Answer

The nurse's first step should be to examine their own feelings to make sure they are not in denial or projecting their emotions onto the family. This will help the nurse approach the situation with objectivity and empathy. From there, the nurse can provide support and allow the family to express their emotions while maintaining structure and continuity. Spiritual support may also be offered if the family expresses a desire for it.

Question 16

The client has a documented advance health care directive that indicates that no resuscitative measures should be employed in the event of a respiratory or cardiac arrest.The client begins to exhibit severe dyspnea and air hunger and says,"Please do something,I can't breathe." What action should be taken by the nurse?

Accepted Answer

The answer of The client has a documented advance health...

Question 17

The client tells the nurse that she has been having problems sleeping since her boss died unexpectedly 3 weeks ago.She confides that she and the boss had been having a secret extramarital affair for years.The nurse recognizes that the sleeping difficulty is most likely a result of which type of grief?

Accepted Answer

Disenfranchised grief occurs when a person experiences a loss that is not openly acknowledged, socially sanctioned, or publicly mourned. In this case, the client is experiencing grief over the loss of her boss but cannot openly mourn him due to the secret nature of their relationship. This type of grief can manifest in various ways, including difficulty sleeping.

Question 18

The nurse is caring for a child who is dying.What is the most important communication strategy for the nurse to use at this time?

Accepted Answer

Talking to the child at the appropriate level of understanding ensures that the child comprehends the situation in a way that is suitable for their age and cognitive development, providing comfort and clarity.

Question 19

An older client has just relocated from home to an assisted living facility.The nurse is concerned because the client has been withdrawn and is crying periodically throughout the day.What type of loss is this client demonstrating?

Accepted Answer

The client is demonstrating loss of their familiar environment due to the relocation to the assisted living facility. This is a common experience for older adults who have to move from their homes to assisted living facilities, and can cause feelings of sadness, mourning, and withdrawal.

Question 20

A client with end-stage renal disease knows that he is dying but refuses to talk about it with his spouse.At times the spouse talks with the nursing staff about the client's condition but adamantly refuses to discuss death with the client.What will be the outcomes of this situation?
Standard Text: Select all that apply.

Accepted Answer

The answer of A client with end-stage renal disease knows...

Quiz 43: Loss, Grieving, and Death