Loss, Grief, and Death Case Study
1. Which assessment should be done immediately?
A. Determine Frank’s knowledge about feeding a dysphagic person.
B. Auscultate Bertha’s lungs for adventitious breath sounds.
C. Assess Bertha’s LOC with the mini-mental status exam.
D. Determine Bertha’s ability to swallow liquids.
Bertha’s lungs should be assessed immediately for adventitious breath sounds since she is at risk for aspiration pneumonia secondary to the choking incident.
Bertha was sitting upright while Frank fed her broth from chicken noodle soup. She started spitting out the broth and turning blue around her mouth. Frank stopped feeding her and patted her back forcefully. Bertha was able to catch her breath and the blueness resolved. Two days later, Frank tells the home health nurse about the incident during a scheduled visit. The nurse notices that Bertha’s LOC has declined.
Mrs. Klein is disoriented when she is admitted to the hospital.
2. During the admission procedure, what is the nurse’s responsibility regarding advance directives?
A. Determine if Mrs. Klein has completed a living will and a durable power of attorney.
B. Explain the Patient Self-Determination Act (PSDA) requires a living will,
C. Instruct Mr. Klein to have his wife sign a living will when she is no longer disoriented.
D. Clarify that the healthcare provider cannot be a witness for these legal documents.
The Patient Self-Determination Act (1991) requires healthcare institutions to provide written information concerning the client’s rights to refuse treatment and formulate advance directives. The nurse should ask Mr. Klein if his wife has completed a living will and a durable power or attorney.
3. How should the nurse respond to Franks’s remarks?
A. Document that the client is aware of the Patient Self-Determination Act.
B. Place a copy of the living will in the medical record and document its presence.
C. Notify the healthcare provider that the spouse desires euthanasia for his wife.
D. Report to the charge nurse that Frank seems to be in denial about the seriousness of his wife’s condition.
The nurse is responsible for placing a copy of the living will in the medical record and documenting its presence.
Bertha receives intravenous antibiotics to treat the pneumonia. The clinical dietitian assesses Bertha’s nutritional status. Bertha continues to have difficulty swallowing, so the dietitian posts a “swallow precautions” sign on the wall by Bertha’s bed. Frank notices the sign and asks the nurse what it means. The nurse explains that thin liquids can cause pneumonia because the liquids may go into the trachea and then the lungs instead of the stomach, since Bertha does not have adequate swallowing ability. Suddenly, Frank gets a shocked look on his face and says, “Oh, no! I did that. I gave her pneumonia!”
4. How should the nurse reply?
A. “How was she positioned when you fed her?
B.”Saliva entering the lungs can also cause pneumonia.”
C. “You know you did the best you could.”
D. “We know it was not intentional on your part.”
The nurse is correct in giving Frank reassuring information that aspiration pneumonia can also be caused by Bertha’s inability to swallow saliva. The pneumonia is being treated, and it will do no good at this point to speculate about the cause of the pneumonia.
5. Which response demonstrates that the nurse understands the underlying premise of a living will?
A. “We will honor Bertha’s directives in her living will.”
B. “Are you sure that this is what you really want for Bertha?”
C. “Your healthcare provider wants to do all he can to preserve life.”
D. “Have you spoken to your rabbi about Bertha’s wishes?”
The nurse demonstrates support and gives reassurance to Frank that Bertha’s decision will not be ignored by her providers, which is the intent of the will.
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6. What nursing intervention should be instituted to care for Bertha’s mouth?
A. Giver her sips of water through a straw.
B. Offer her an ounce of ice chips every hour.
C. Provide mouth care daily with her bath.
D. Clean her mouth frequently with oral swabs.
Bertha’s nurse is correct to ensure that frequent mouth care is given with oral swabs.
7. What is the safest manner of giving oral care to Bertha?
A. Have two nurses or UAPs perform the procedure.
B. Remove dentures if the client has them.
C. Demonstrate the procedure to Frank so he can assist the nurse if he wishes.
D. Moisten oral swabs with a minimal amount of water.
The nurse is correct to first ensure that two staff members are available to provide safe oral care.
8. What intervention will help Bertha breathe more comfortably?
A. Tracheal suctioning of secretions.
B. Oral suctioning of secretions from mouth and throat.
C. Encourage deep breathing every hour wile awake.
D. Teach Bertha how to use an incentive spirometer.
Oral suctioning of accumulated secretions is gently done with a tonsil tip or Yankauer suction device to provide more effective breathing and to add to Bertha’s comfort.
The Kleins’ daughter Carol, arrives to visit her mother. Carol’s husband and children accompany her. Carol last saw her mother 3 months ago, and she is alarmed that her mother has lost weight, is weaker, and is not eating. Carol acknowledges to the nurse that her mother talked to her about the living will but says angrily, “Don’t you think you should do something? This is a hospital, isn’t it?”
9. What is the best response by the nurse?
A. Yes, this is the hospice unit of the hospital.
B. It must be difficult to see the changes in your mother.
C. Why are you angry at the nurses and other healthcare providers?
D. You are in the stage of denial in the grief process.
Empathetic statements are therapeutic and can help Carol in moving through the grief process.
10. How should the nurse respond to Carol’s request?
A. Ask Carol what purpose she thinks massage will serve.
B. Inform Carol that she must produce the therapists’s credentials first.
C. Tell Carol that massage therapists are welcome in the hospice.
D. Share with Carol that she uses alternative therapies herself.
Nontraditional therapies are encourages in the hospice environment if they give comfort to the client and are not harmful. Additionally, supporting Carol will give her a sense of control.
11. According to Kubler-Ross, which stage of grief is exemplified by the adolescent’s statements?
The adolescent is experiencing a common initial reaction to a real or impending loss. Feelings of numbness, shock, and disbelief occur. This stage is healthy and permits the individual to develop other coping mechanisms.
12. How should the nurse respond?
A. Tell the parents to take the child to a grief counselor immediately.
B. Call the family’s rabbi to get information that is culturally appropriate.
C. Recommend that their son’s questions be answered honestly in simple terms.
D. Ask to speak to the child to assess what is really bothering him.
Children at this age are often interested in the physical and biological aspects of death. They usually recognize that death is permanent and are very concrete in their thinking. Questions should be answered honestly and simply, giving the child enough information to answer the question but not overwhelming the child with information. Parents can expect that repeated explanation will be necessary.
13. Which phrase should the nurse recommend?
A. “Your grandma went to sleep and didn’t wake up.
B. “Grandma died and that makes us feel very sad.”
C. “God wanted your grandma because she was so good.”
D. “We’ve lost Grandma and will miss her very much.”
This statement is truthful and acknowledges the parents’ feelings of sorrow and grief. The parents may also want to tell the child that the person who died is not coming back and then answer any questions. This process may need to be repeated many times.
14. The nurse answers Frank’s question based on which information? (Select all that apply)
A. This route is least likely to produce drug addiction.
B. There is no other route by which to give this medication.
C. The medication is rapidly absorbed and acts quickly.
D. This route decreases the chance of aspiration.
E. Risk for respiratory depression is lessened using this route.
Because the oral mucosa has a thin epithelium and abundant blood vessels, drugs administered via this route are rapidly absorbed. Passing directly into the bloodstream, medication acts quickly while avoiding the damaging effects of gastric juices and liver metabolisms.
D. This route decreases the chance of aspiration.
This route is particularly beneficial in the client with cancer who is unable to tolerate oral administration because of nausea and vomiting or the client with dysphagia.
15. How many milliliters of medication will the nurse administer? (nearest 10th)
First converts lbs–>kg
Next, calculate how many mg Bertha should receive: 0.2mg/kg X 50kg=10mg
10mg X 1mL/20mg=0.5mL
16. What action should the nurse take?
A. Quickly take the vital signs as prescribed.
B. Stand quietly until the prayer is over.
C. Express discomfort by leaving the room.
D. Ask the rabbi to come back later to pray.
This action expresses respect for the family’s spiritual needs and offers support to the family and clergy. Respecting spiritual needs is one of the many priorities of hospice care. The nurse does not need to be of the same religion/denomination as the client to remain in the room during readings and prayer.
17. What is the best response to support Frank and Bertha spiritually?
A. Do you have any wishes I should convey to the staff?
B. I wish my faith was as strong as yours.
C. Does your daughter share your faith?
D. Would you like to visit the chapel on the first floor?
The nurse is correct in intervening by asking what Frank and Bertha prefer in terms of faith and spiritual care.
18. Which feedback from the nurse will encourage Frank to talk more about his feelings?
A. Praise Frank for being able to stay married so long.
B. Ask Frank to share memories of the couple’s time together.
C. Remark that Frank and Bertha are role models for the synagogue.
D. Share with Frank memories of own grandparents.
Asking him to talk about his memories of their time together will allow Frank the opportunity to share his feelings and reminisce about their marriage.
19. To assist Frank and Bertha in life review, what is the best intervention by the nurse?
A. Encourage visitors to talk quietly so Bertha is not disturbed.
B. Suggest that Frank bring photo albums to show Bertha.
C. Urge Frank to talk to Bertha about their experiences.
D. Encourage visitors to use touch when communicating with Bertha.
Reminiscing is a means of setting one’s life in order, which is the task of the final stage of Erikson’s developmental theory called Integrity vs. Despair. Frank’s retelling of significant life experiences can help both of them feel a sense of meaning in their lives, which is the goal of this stage. It is also in keeping with the Jewish concept of the value of life on this earth, good deeds, and the legacy of the deceased.
20. What other physical symptom should the nurse anticipate?
A. Hyperreflexia in legs and arms.
B. Increased urinary output.
C. Mottling of hands and feet.
D. Head turned away from light.
Cyanosis and mottling occur first in the hands and feet and then progress centrally.
A. Inform Carol that Bertha’s condition is worsening.
B. Suggest that Carol tell Frank to rush back to the hospital immediately.
C. Hold Carol’s hand, but do not disclose Bertha’s vital signs.
D. Notify the family that Bertha will probably die today.
The nurse should keep family members informed of Bertha’s worsening condition to provide them the opportunity to communicate with Bertha and to notify their rabbi if desired.
22. How should the nurse respond?
A. “Do you think you are strong enough?”
B. “Yes. I would be happy to watch you.”
C. “I am not sure that is a good idea.”
D. “I think there is a policy against it.”
Carol wants to participate in the care of her mother. Allowing her to help will lessen her sense of helplessness during the dying process.
The family members are at the bedside very early the next day when Bertha stops breathing. The healthcare provider arrives and pronounces the death. As the rabbi is being consulted regarding the preparation of the body, a group of women from the synagogue arrive to assist with postmortem care.
23. How should the nurse respond?
A. Instruct the family and the rabbi to leave the room.
B. Remain available to assist the women of the synagogue as needed.
C. Tell the rabbi that postmortem care must be done by the hospice staff regardless of the religion.
D. Remind the family that an autopsy must be performed before the burial.
It is not uncommon for a group of persons from the synagogue to come and prepare the body. Men will come for men who have died, and women come for women. While there are specific ways that the body must be cleansed, positioned, and wrapped, the nurse can assist by removing all external catheters and medical equipment attached to the body and ensuring that all incisions and wounds are dressed.