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?
1. The client has an album of photographs of his wife open on the liv
He shows the nurse his wife's craft room that remains just as she left it before she died.
Rationale: Leaving the deceased wifes craft room and belongings intact for over 3 years is considered outside the normal limits of the grief process.
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?
1. Anticipatory Grieving
2. Dysfunctional Grie
Anticipatory Grieving
Rationale: Grieving prior to the actual loss is termed anticipatory grieving.
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?
1. Toddlers perceive death as irreversible and unnatural.
2. Pr
At about age 9, children begin to understand that death is inevitable.
Rationale 1: Toddlers fear abandonment.
Rationale 2: Preschoolers view death as reversible.
Rationale 3: At about age 9, childrens concept of death matures and most understand that dea
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
Was killed in the robbery of a bank.
Rationale: Although all families are different and all families can respond to grief differently, research supports a greater potential for complicated grief in families whose loved one died suddenly, violently, or une
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?
1. The Kbler-Ross model is primarily used to describe anticipatory g
No clear timetables exist, nor are there clear-cut stages of grief.
Rationale: Although the models of grief are useful in guiding nursing care of clients who are experiencing loss, there are no clear-cut stages of grief, nor are there exact timetables.
A client hospitalized for injuries from a motor vehicle crash is diagnosed with higher brain death. What findings support this clients diagnosis?
Standard Text: Select all that apply.
1. Episodic coughing
2. No cephalic reflexes
3. Not breathing spontaneo
2, 3, 5
Rationale 1: Episodic coughing might be a reflex or an attempt to clear the airway. This is not a manifestation of higher brain death.
Rationale 2: Evidence of higher brain death includes absence of cephalic reflexes.
Rationale 3: Evidence of high
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?
1. Explore the clients history with other stressful life events and how successful coping was at that time.
2.
Explore the client's history with other stressful life events and how successful coping was at that time.
Rationale: It is most helpful for the nurse to know how the client has dealt with previous stressful life events so that support of positive coping m
A client who has AIDS tells the nurse, I dont 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
1. An indication of hopelessness that should be
An indication of hopelessness that should be further evaluated for treatment.
Rationale: This statement reflects hopelessness. Hopelessness is not an expected feeling at end of life and can and should be treated. Despite the inevitability of death, the go
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 difficult
Disenfranchised
Rationale: This client is unable to grieve openly for her lost relationship, as extramarital affairs are not socially sanctioned.
The nurse is working with a father and his three children, ages 10, 14, and 17. The mother recently died after a long illness. The children are doing poorly in school, and the father is having a difficult time keeping up with household chores. He has rece
2, 3, 4, 5
Rationale 1: Anticipatory grief is experienced in advance of the event, such as the wife who grieves before her ailing husband dies.
Rationale 2, 3, 4, 5: There may be numerous nursing diagnoses that should be investigated in planning care for
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?
1. Lets think of something more cheerful.
2. You are doing so well; dont talk like that.
3. What makes
What makes you think you are dying?
Rationale: The nurse should ask what it is that makes the client think about dying. This allows the nurse to collect and evaluate data before making a further response.
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 some
Initiate resuscitative measures.
Rationale: This client has the right to change decisions about resuscitation, and has asked for help. The nurse should initiate resuscitative measures.
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 clients condition but adamantly refuses to discuss death with the client. What will be th
1, 2, 5
Rationale 1: With mutual pretense, the client, family, and health care personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject. Mutual pretense permits the client a degree of dignity.
Rati
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 nurses first step in assisting this fam
Allow the family to express sadness.
Rationale: The nurse must first self-examine feelings to ensure that the nurses behaviors do not demonstrate denial of the situation.
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?
1. When clients are designated as terminally ill, they are
Hospice services are generally reserved for those who have a life expectancy of 6 months or less.
Rationale: Hospice services are generally provided only to those who are expected to live less than 6 months. Those clients whose conditions improve after re
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?
1. Talk to the child at the appropriate level of understanding.
2. Be totally open and honest with the child.
3. Avoid discu
Talk to the child at the appropriate level of understanding.
Rationale: Although it is very important to be open and honest with the child and may be appropriate to encourage the family to talk with the child about impending death, the most important stra
The nurse is caring for a client whose family does not want to tell him that he is dying. What is the nurses best action according to these wishes?
1. Arrange an encounter with the client and tell him the truth.
2. Change the subject when the client asks
Talk to the family about the situation and their concerns.
Rationale: In this situation, the best and first thing the nurse should do is talk with the family about what is happening and what their concerns are. The nurse should investigate religious, cult
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?
1. Remove the ring and give it to the family.
2. Call the presence of the ring to the attention o
Document fully whatever action is taken.
Rationale: Depending upon the circumstances and what kind of ring it is, the nurse might take any of these actions. The most important action is to document what occurred.
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 inter
Situational loss
Rationale 1: The loss of functional ability because of acute illness or injury is a situational loss.
Rationale 2: An anticipatory loss is experienced before the loss actually occurs.
Rationale 3: Psychological losses are often perceived
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?
1. External objects
2.
Familiar environment
Rationale: Separation from an environment and people who provide security can result in a sense of loss, such as in the client who has relocated from home to an assisted living facility.
A client with terminal cancer of the lung complains of being short of breath with bilateral crackles and wheezes, despite oxygen at 4 L via nasal cannula and diuretic therapy. What nursing interventions are appropriate for this client?
Standard Text: Sele
3, 5, 6
Rationale 1: The client does not need to be moved to a room closer to the nurses station.
Rationale 2: Lateral positions are appropriate for unconscious clients but not for those who are conscious.
Rationale 3: Placement of a fan to circulate air
The nurse is providing postmortem care for a client whose family would like to view the body before it is transported to the morgue. What interventions are necessary for this preparation?
Standard Text: Select all that apply.
1. Provide a total bed bath.
2, 5
Rationale 1: A total bed bath is not necessary.
Rationale 2: The nurse should place absorbent pads beneath the body.
Rationale 3: Dentures should be inserted.
Rationale 4: The client should be dressed in a clean gown.
Rationale 5: The nurse should pl
The spouse of a deceased client is working through the stages of grief. If the nurse applies Martocchios five clusters of grief to this situation, the spouse would progress through the clusters in which order?
Standard Text: Click and drag the options bel
4, 2, 5, 3, 1
Rationale: Martocchios five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution.
The nurse determines that a client, after learning of the death of a close family member, is demonstrating normal signs of grief. What did the nurse assess in this client?
Standard Text: Select all that apply.
1. Crying
2. Weakness
3. Inability to sleep
4
1, 3, 4, 5
Rationale 1: Crying is considered a normal manifestation of grief.
Rationale 2: Weakness is not a normal manifestation of grief.
Rationale 3: Inability to sleep is considered a normal manifestation of grief.
Rationale 4: Loss of appetite is con
The nurse is concerned that a client is experiencing complicated grieving after the unexpected death of a son. The nurse most likely assessed
Standard Text: Select all that apply.
1. The clients denying the sons death.
2. Depression.
3. Sudden weight loss
1, 2, 3, 5
Rationale 1: Complicated grieving might be characterized by extended time of denial.
Rationale 2: Complicated grieving might be characterized by depression.
Rationale 3: Complicated grieving might be characterized by severe physiological sympto
When observing an older clients response upon learning of the death of a close family friend, the nurse realizes that the significance of the loss to the client is dependent upon which factors
Standard Text: Select all that apply.
1. Importance of the per
1, 2, 3, 4
Rationale 1: The importance of the lost person to the client affects the significance of the loss.
Rationale 2: The degree of change required because of the loss affects the significance of the loss.
Rationale 3: The clients beliefs affect the
The nurse is planning care to help a client work through the grieving process. What would be appropriate to include in this plan of care?
Standard Text: Select all that apply.
1. Listen to the client.
2. Clarify and reflect the clients feelings.
3. Reassu
1, 2, 4
Rationale 1: The skills most relevant to situations of loss and grief are those of effective communication, such as active listening.
Rationale 2: The skills most relevant to situations of loss and grief are those of effective communication, such
The nurse is providing emotional support to a client who just learned the outcome of a biopsy. What actions will be the best for the nurse to provide at this time?
Standard Text: Select all that apply.
1. Encourage the client to resume normal activities o
2, 3, 4, 5
Rationale 1: Encouraging the client to resume normal activities on a schedule that promotes physical and psychological health would be appropriate to facilitate grief work, but would not provide emotional support.
Rationale 2: Therapeutic commu
A terminally ill client is demonstrating gurgling respirations. The nurse realizes that this client is
1. Improving.
2. Experiencing pain.
3. Trying to talk.
4. Nearing death.
Nearing death.
Rationale: A clinical manifestation of impending death is noisy breathing. This is often referred to as the death rattle, and is due to collecting of mucus in the throat.
The nurse determines that a terminally ill client is nearing death. What did the nurse assess to make this clinical decision?
Standard Text: Select all that apply.
1. Diarrhea
2. Muscle spasms
3. Slow, weak pulse
4. Decreased blood pressure
5. Cyanosis of
3, 4, 5
Rationale 1: Diarrhea is not a clinical manifestation of impending death.
Rationale 2: Muscle spasms are not a clinical manifestation of impending death.
Rationale 3: A slow, weak pulse is a clinical manifestation of impending death.
Rationale 4:
While caring for a client who is approaching death, the nurse notices the clients facial expression of extreme sadness. What should the nurse do?
1. Leave the client alone.
2. Provide physical care to increase comfort.
3. Acknowledge the clients expressio
Acknowledge the client's expression and ask whether the client would like to talk about her feelings.
Rationale: The nurse should establish a communication relationship that shows concern for and commitment to the client. Communication strategies include
The spouse of a dying client is sitting quietly in the clients room, looking at the floor. What can the nurse do to help the client and spouse during this time?
Standard Text: Select all that apply.
1. Encourage the spouse to move closer to the client, if
1, 3, 5
Rationale 1: The dying and the family must be allowed as much privacy as they desire in order to meet their needs for physical and emotional intimacy.
Rationale 2: The nurse should not ignore the spouse.
Rationale 3: The dying client and the famil
The family members of a client who has just died want to spend time with the client. What should the nurse do to prepare the client for the family?
Standard Text: Select all that apply.
1. Check the clients religion to make sure care is in compliance with
1, 2, 4, 5
Rationale 1: Because care of the body can be influenced by religious law, the nurse should check the clients religion and make every attempt to comply.
Rationale 2: It is important to make the environment as clean and pleasant as possible, so e
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with ADLs. Which of the following rationales for self-care should the nurse communicate to the family?
1. Allowing the client to function indepen
The client's sense of loss can be lessened through retaining control of certain areas of her life
Rationale: Allowing the client as much control as possible maintains dignity and self-esteem
A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my
Bargaining
Rationale: The client is displaying bargaining by attempting to negotiate more time to live to see his daughter get married
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning f
1, 4, 5
Rationale 1: Asking the grieving individual whether she would like spiritual support at this time is an acceptable nursing intervention to facilitate mourning
Rationale 2: The nurse should avoid giving false reassurance and offering assumptions wh
A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse include in the di
Decreased muscle tone
Rationale: Muscle relaxation is an expected finding when a client is approaching death
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of the procedure? (Select all that apply.)
1. "I will
3, 4, 5
Rationale 1: The nurse should insert the client's dentures so that the face looks as natural as possible
Rationale 2: The body should not be completely flat. One pillow is placed under the head and shoulders to prevent discoloration of the face
Ra