I85PREP
⌘ K
ABEM HPM study materials
ABEM HPM study resources

ABEM HPM practice questions

One question at a time. Build your ABEM HPM understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which statement best describes palliative care for a patient with advanced heart failure?

  1. It is limited to patients who have stopped all curative treatments.
  2. It requires a prognosis of less than six months to begin.
  3. It can begin at diagnosis alongside disease-directed therapy. Correct answer.
  4. It is provided only in an inpatient hospice unit.

Explanation

Palliative care addresses symptom burden, goals, and quality of life at any stage of serious illness and can be delivered alongside disease-directed therapy. Hospice is a distinct benefit that generally requires a prognosis of six months or less and a comfort-focused plan.

Question 2Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A patient with metastatic cancer asks about hospice. Which requirement must be met for Medicare hospice eligibility?

  1. The patient must agree to stop all oral medications.
  2. The patient must be unable to perform all activities of daily living.
  3. The physician certifies a prognosis of six months or less. Correct answer.
  4. The patient must have a do-not-resuscitate order.

Explanation

Medicare hospice eligibility requires physician certification that the prognosis is six months or less if the illness follows its usual course, along with the patient's election of the hospice benefit. A do-not-resuscitate order, total functional dependence, and discontinuation of all oral medications are not requirements.

Question 3Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A previously capacitated patient now lacks decision-making capacity and has no written advance directive. The patient's adult child must decide about a feeding tube. Which standard should guide the surrogate?

  1. What preserves life for the longest possible time.
  2. What the patient would have wanted, based on known values. Correct answer.
  3. What the eldest family member prefers.
  4. What the clinician believes is medically indicated.

Explanation

Surrogate decision-making uses substituted judgment: the surrogate attempts to decide as the patient would have decided, using prior statements, values, and known preferences. When prior wishes are unknown, the best-interests standard may guide decisions.

Question 4Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which document allows a patient to name someone to make healthcare decisions if the patient loses capacity?

  1. A do-not-resuscitate order
  2. A physician order for life-sustaining treatment form
  3. A durable power of attorney for healthcare Correct answer.
  4. A living will

Explanation

A durable power of attorney for healthcare names a healthcare agent or proxy to make decisions when the patient lacks capacity. A living will records treatment preferences but does not necessarily name a decision-maker.

Question 5Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A clinician asks, "Would I be surprised if this patient died within the next 12 months?" The answer is no. What is the most appropriate next step?

  1. Reassure the patient that death is not expected within a year.
  2. Defer all advance care planning until the patient asks.
  3. Initiate a goals-of-care discussion and consider palliative care referral. Correct answer.
  4. Refer the patient directly to hospice.

Explanation

The surprise question is a screening tool: answering "no" identifies patients at high risk of death and should prompt goals-of-care discussions and consideration of palliative care. Hospice requires a prognosis of six months or less and patient election, so direct referral is not automatic.

Question 6Palliative care approach to serious illness (goals of care, prognostication, care coordination)

At the start of a goals-of-care conversation with a patient newly diagnosed with advanced pancreatic cancer, which step is most appropriate?

  1. Assess the patient's understanding and information preferences. Correct answer.
  2. Ask the patient to sign a do-not-resuscitate order.
  3. Give a detailed survival estimate before asking any questions.
  4. Recommend stopping chemotherapy immediately.

Explanation

Goals-of-care conversations should begin by exploring the patient's current understanding, information preferences, and values before discussing specific decisions. This allows the clinician to tailor prognostic information and recommendations to the patient's readiness.

Question 7Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which group best represents the required Medicare hospice interdisciplinary team?

  1. A nurse and a pharmacist only
  2. A case manager and a home health aide only, with no other members
  3. A physician, nurse, social worker, chaplain, and bereavement counselor Correct answer.
  4. A physician and a physical therapist only

Explanation

The Medicare hospice interdisciplinary team includes physician, nursing, social work, chaplaincy, and bereavement services, along with other disciplines as needed. The team meets regularly to develop and revise the plan of care.

Question 8Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which statement best describes a POLST form?

  1. It replaces the need for any advance care planning discussion with the patient.
  2. It is a clinician-signed, portable order documenting preferences for life-sustaining treatment. Correct answer.
  3. It must be completed and signed by the patient's attorney.
  4. It is valid only while the patient is in an intensive care unit.

Explanation

A POLST form converts a seriously ill patient's preferences into actionable medical orders that travel across care settings. It is completed through clinician-patient discussion and does not replace broader advance care planning.

Question 9Palliative care approach to serious illness (goals of care, prognostication, care coordination)

An 84-year-old woman with advanced dementia has a FAST stage 7c, recurrent aspiration pneumonia, and a serum albumin of 2.4 g/dL. Her family asks about hospice eligibility. Which statement is most accurate?

  1. Hospice is never appropriate for dementia because it is not a terminal illness.
  2. Hospice cannot be considered until the patient stops eating entirely for 30 days.
  3. Hospice requires a documented cancer diagnosis before enrollment.
  4. Dementia stage plus a recent complication such as aspiration pneumonia can support eligibility. Correct answer.

Explanation

Medicare hospice eligibility for dementia can be supported by severe functional decline, such as FAST stage 7c, plus a recent complication such as aspiration pneumonia, sepsis, or pressure injury. Dementia is a terminal illness, and cancer is not required.

Question 10Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A 72-year-old man with NYHA class IV heart failure has recurrent hospitalizations despite optimized therapy. Which feature best supports a prognosis of six months or less and consideration of hospice?

  1. Mild ankle edema controlled with a diuretic
  2. Resting symptoms despite maximal therapy with frequent hospitalizations Correct answer.
  3. A single hospitalization for atrial fibrillation
  4. An ejection fraction of 45%

Explanation

Hospice eligibility in advanced heart failure is supported by severe symptoms at rest despite optimal therapy, frequent hospitalizations, and declining functional status. Ejection fraction alone does not determine prognosis.

Question 11Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A patient with advanced cancer is discharged from hospital to home hospice. Which action best improves care coordination at this transition?

  1. Send the discharge summary only after the patient's next clinic visit.
  2. Complete a structured handoff and medication reconciliation with hospice. Correct answer.
  3. Ask the family to obtain the medication list from a pharmacy.
  4. Discontinue all medications not directly treating the cancer.

Explanation

Structured handoffs and medication reconciliation reduce medication errors and prevent gaps in care during transitions to hospice. The hospice team should receive relevant records, active problems, and the reconciled medication list before or at discharge.

Question 12Palliative care approach to serious illness (goals of care, prognostication, care coordination)

During a family meeting, two adult children disagree about whether their mother with advanced COPD should receive reintubation. Which approach is most appropriate?

  1. Explore each person's understanding and the patient's expressed values. Correct answer.
  2. Ask the oldest child to make the final decision alone.
  3. End the meeting and schedule it for another day.
  4. Tell the family that the clinician will decide to avoid conflict.

Explanation

When family members disagree, the clinician should explore each person's understanding, emotions, and the patient's previously expressed values. Summarizing areas of agreement can help the surrogate apply substituted judgment.

Question 13Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A patient with advanced cancer asks, "How long do I have?" The clinician is uncertain about prognosis. Which response best supports the patient?

  1. Acknowledge uncertainty and offer a realistic range while planning together. Correct answer.
  2. Give a single precise estimate so the patient has a clear number.
  3. Explain that prognosis is never discussed by palliative care clinicians.
  4. Change the subject to treatment options until the patient asks again.

Explanation

When prognosis is uncertain, clinicians should acknowledge the uncertainty, offer a realistic range when possible, and commit to shared decision-making. This maintains trust without giving false precision.

Question 14Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which variable is a component of the Palliative Prognostic (PaP) score?

  1. Primary tumor stage
  2. Serum sodium concentration
  3. Platelet count
  4. Clinical prediction of survival Correct answer.

Explanation

The PaP score incorporates clinical prediction of survival, Karnofsky performance status, dyspnea, anorexia, total white blood cell count, and lymphocyte percentage. It does not use serum sodium, tumor stage, or platelet count.

Question 15Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which situation most clearly meets criteria for Medicare hospice general inpatient care?

  1. The patient lives alone and needs help with bathing.
  2. The patient wants to avoid all medications.
  3. The family needs a break from caregiving for a few days.
  4. Pain and agitation are uncontrolled and require frequent parenteral management. Correct answer.

Explanation

General inpatient hospice care is intended for symptom control that cannot be managed in the home setting, such as uncontrolled pain, agitation, or other complex symptoms requiring frequent parenteral intervention. Respite care is a separate level of hospice care.

Question 16Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which element is most important to document after a goals-of-care discussion with a patient with advanced illness?

  1. The patient's goals, code status, and identified surrogate Correct answer.
  2. The names of all family members who were not present
  3. The exact wording of every question the clinician asked
  4. The patient's insurance coverage for hospice

Explanation

Documentation should capture the patient's goals and values, specific treatment preferences such as code status, and the identified surrogate decision-maker. This allows other clinicians to honor the patient's wishes across care transitions.

Question 17Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A patient from a culture in which family members typically make serious medical decisions asks that the family be told the cancer diagnosis before the patient. What is the most appropriate approach?

  1. Refuse to discuss prognosis until the patient asks directly.
  2. Tell the family but never disclose anything to the patient.
  3. Insist that the patient must always be told first, regardless of culture.
  4. Ask the patient how much to disclose and to whom. Correct answer.

Explanation

Clinicians should explore the patient's own information preferences and cultural values rather than imposing a single disclosure model. The patient may prefer family-directed disclosure, but this should be confirmed with the patient when possible.

Question 18Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which screening question best identifies caregiver burden for a spouse caring for a patient with advanced ALS?

  1. What is your spouse's insurance status?
  2. Does your spouse currently have a feeding tube in place?
  3. How many children do you have?
  4. How often have you felt overwhelmed by caregiving? Correct answer.

Explanation

A direct question about feeling overwhelmed assesses caregiver strain and identifies spouses who may need support, respite, or counseling. Functional and equipment questions do not measure the caregiver's emotional and physical burden.

Question 19Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A 68-year-old with severe COPD has a BODE index of 7, resting dyspnea, and two intensive care admissions in the past year. What does this suggest for prognostication?

  1. The patient is likely to improve with routine inhaler adjustment alone.
  2. The patient has a benign course and needs no advance care planning.
  3. The patient should be referred for lung transplant without discussing prognosis.
  4. High risk of death; offer goals-of-care discussions and palliative care. Correct answer.

Explanation

A high BODE index, resting dyspnea, and recurrent intensive care admissions indicate advanced COPD with a high risk of death. These features should prompt goals-of-care discussions, advance care planning, and palliative care involvement.

Question 20Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which patient with metastatic cancer is most appropriate for early palliative care referral?

  1. A patient requesting only financial counseling
  2. Uncontrolled symptoms, frequent hospitalizations, and unclear goals Correct answer.
  3. A patient with well-controlled pain and no other symptoms
  4. A patient who has just completed curative-intent therapy

Explanation

Early palliative care is appropriate for patients with serious illness and high symptom burden, frequent hospitalizations, or unmet goals-of-care needs. Referral is not limited to patients who are imminently dying or have uncontrolled pain alone.

Question 21Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A patient with advanced heart failure says, "I just want to live long enough to see my granddaughter graduate." Which response best uses a wish statement?

  1. Ask what the graduation means and how care can support that goal. Correct answer.
  2. Explain that attending graduation is unlikely and redirect to comfort care.
  3. State that no promises can be made and avoid further discussion of the event.
  4. Recommend completing a living will before discussing any personal wishes.

Explanation

A wish statement can be explored to understand what matters most to the patient and to align care with a meaningful goal. This helps the clinician support realistic hopes while planning for possible decline.

Question 22Palliative care approach to serious illness (goals of care, prognostication, care coordination)

A patient with metastatic lung cancer has a PaP score of 15. Which interpretation is most appropriate?

  1. Confirmation of a diagnosis of major depression
  2. Prediction of response to chemotherapy
  3. Less than a 30% chance of surviving 30 days Correct answer.
  4. Greater than a 70% chance of surviving 30 days

Explanation

A PaP score above 11 places the patient in the highest-risk group, with a 30-day survival probability of less than 30%. The PaP score is a prognostic tool and does not diagnose depression or predict chemotherapy response.

Question 23Palliative care approach to serious illness (goals of care, prognostication, care coordination)

An adult with severe intellectual disability and no known prior wishes develops aspiration pneumonia. The surrogate must decide about a feeding tube. Which standard is most appropriate?

  1. Best interests, weighing benefits and burdens without known preferences. Correct answer.
  2. The clinician's personal view of the patient's quality of life.
  3. The family's financial interest in avoiding long-term care.
  4. Substituted judgment based on the patient's prior expressed wishes.

Explanation

When a patient has never had decision-making capacity and no prior wishes are known, the best-interests standard guides surrogate decisions by weighing benefits and burdens. Substituted judgment applies when the patient's prior values or statements are known.

Question 24Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which patient with end-stage renal disease most likely meets hospice eligibility criteria if dialysis is stopped?

  1. A patient with a creatinine of 4.0 mg/dL and no symptoms at all.
  2. Stopping dialysis with severe uremic symptoms and a prognosis under six months. Correct answer.
  3. A patient with well-controlled hypertension and normal mental status throughout.
  4. A patient awaiting a kidney transplant with stable symptoms and good function.

Explanation

Hospice eligibility in end-stage renal disease is supported by discontinuation of dialysis accompanied by severe uremic symptoms and a prognosis of six months or less. Asymptomatic elevation of creatinine or stable transplant candidacy does not meet hospice criteria.

Question 25Palliative care approach to serious illness (goals of care, prognostication, care coordination)

Which intervention most effectively reduces preventable readmissions for a patient with advanced illness transitioning from hospital to home?

  1. Scheduling the first follow-up appointment six months after hospital discharge.
  2. Structured transitional care with early follow-up, medication reconciliation, and one coordinator. Correct answer.
  3. Giving the patient a printed list of emergency department telephone numbers only.
  4. Avoiding communication with the primary care clinician to protect confidentiality.

Explanation

Effective transitional care includes early follow-up, medication reconciliation, clear handoffs, and a single accountable coordinator. These elements reduce medication errors, missed follow-up, and unmanaged symptoms after discharge.

Question 26Pain assessment and management

Which pain assessment tool is most appropriate for a cognitively intact adult who can self-report pain intensity?

  1. FLACC behavioral scale
  2. PAINAD behavioral scale
  3. 11-point numeric rating scale Correct answer.
  4. Facial Action Coding System

Explanation

Self-report is the gold standard for pain assessment, and the 11-point numeric rating scale is validated and practical for cognitively intact adults. Observational scales are reserved for patients who cannot report pain reliably.

Question 27Pain assessment and management

According to the WHO analgesic ladder, which medication class is the foundation for mild cancer pain at step 1?

  1. Acetaminophen or an NSAID Correct answer.
  2. Adjuvant anticonvulsants alone
  3. Strong opioids such as morphine
  4. Intrathecal opioid therapy

Explanation

The WHO ladder begins with non-opioid analgesics such as acetaminophen or an NSAID, with adjuvants added as needed. Strong opioids are reserved for step 3 after step 2 weak opioids.

Question 28Pain assessment and management

When initiating scheduled opioid therapy, which prophylactic measure is recommended to prevent constipation?

  1. PRN bisacodyl only after symptoms develop
  2. Scheduled senna Correct answer.
  3. Routine oral naloxone
  4. A high-fiber diet alone

Explanation

Opioids reduce bowel motility, so scheduled stimulant laxatives are recommended prophylactically rather than waiting for constipation. PRN laxatives and dietary fiber alone are inadequate.

Question 29Pain assessment and management

What is the maximum recommended daily dose of acetaminophen for a healthy adult without liver disease?

  1. 3,000 mg
  2. 6,000 mg
  3. 4,000 mg Correct answer.
  4. 2,000 mg

Explanation

The accepted maximum for a healthy adult is 4,000 mg/day; lower limits apply with hepatic impairment, heavy alcohol use, or malnutrition. Doses above this increase hepatotoxicity risk.

Question 30Pain assessment and management

Which medication is the first-line antidote for opioid-induced respiratory depression?

  1. Naloxone Correct answer.
  2. Naltrexone
  3. Flumazenil
  4. Physostigmine

Explanation

Naloxone is a competitive opioid receptor antagonist that rapidly reverses respiratory depression and sedation. It is titrated to restore ventilation without precipitating severe withdrawal.

Question 31Pain assessment and management

Which agent is a first-line treatment for neuropathic pain?

  1. Dexamethasone
  2. Ibuprofen
  3. Morphine
  4. Gabapentin Correct answer.

Explanation

Gabapentin, pregabalin, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are first-line for neuropathic pain. NSAIDs and opioids are not first-line unless specific indications exist.

Question 32Pain assessment and management

The concept of total pain in palliative care refers to which of the following?

  1. Pain measured exclusively with a numeric rating scale
  2. Pain that is always completely relieved by opioid therapy
  3. Pain involving physical, psychological, social, and spiritual factors Correct answer.
  4. Pain caused exclusively by direct tumor invasion

Explanation

Total pain describes suffering arising from physical, psychological, social, and spiritual sources, all of which must be addressed. Limiting assessment to nociception misses major contributors.

Question 33Pain assessment and management

Breakthrough pain is best defined as which of the following?

  1. Pain present only at the time of diagnosis
  2. Continuous pain present throughout the day
  3. A transient flare with controlled background pain Correct answer.
  4. Pain caused solely by diagnostic procedures

Explanation

Breakthrough pain is a transient flare of pain despite otherwise controlled background pain. It differs from persistent pain that never reaches control.

Question 34Pain assessment and management

A patient takes oral morphine 60 mg per day. Using a 3:1 oral-to-intravenous equianalgesic ratio, what is the approximate equivalent daily intravenous morphine dose?

  1. 10 mg
  2. 60 mg
  3. 20 mg Correct answer.
  4. 180 mg

Explanation

The standard oral-to-intravenous morphine ratio is 3:1, so 60 mg oral equals about 20 mg intravenous daily. This conversion is used before adjusting for incomplete cross-tolerance.

Question 35Pain assessment and management

When rotating a patient from one opioid to another because of inadequate analgesia or toxicity, what initial dose adjustment is recommended due to incomplete cross-tolerance?

  1. Use the full calculated equianalgesic dose
  2. Reduce the calculated equianalgesic dose by 90%
  3. Double the calculated equianalgesic dose
  4. Reduce by 25% to 50% Correct answer.

Explanation

Because cross-tolerance is incomplete, the calculated equianalgesic dose is usually reduced by 25% to 50% when rotating opioids. This avoids oversedation while maintaining analgesia.

Question 36Pain assessment and management

Transdermal fentanyl is contraindicated in which of the following patient groups?

  1. Patients with stable chronic pain
  2. Patients receiving more than 60 mg oral morphine equivalent per day
  3. Patients with cancer-related pain
  4. Opioid-naive patients Correct answer.

Explanation

Transdermal fentanyl is approved only for opioid-tolerant patients because its slow onset and long duration can cause fatal respiratory depression in opioid-naive patients. Tolerance generally means at least 60 mg oral morphine equivalent per day.

Question 37Pain assessment and management

Which statement about methadone is correct?

  1. It has no effect on cardiac conduction
  2. It is the preferred first opioid for opioid-naive older adults
  3. NMDA antagonist; prolongs QTc Correct answer.
  4. It is a pure mu-opioid antagonist

Explanation

Methadone is a mu-opioid agonist that also antagonizes NMDA receptors and can prolong the QTc interval, requiring ECG monitoring at higher doses. It is not a first-line opioid for opioid-naive older adults.

Question 38Pain assessment and management

A patient with widespread painful bone metastases from prostate cancer has inadequate relief with opioids alone. Which adjunctive treatment is most appropriate?

  1. Amitriptyline alone
  2. NSAIDs plus focal radiation Correct answer.
  3. Flumazenil
  4. Oral naltrexone

Explanation

Painful bone metastases often respond to NSAIDs and palliative radiation, which target local tumor and inflammation. These are added to opioids for better control.

Question 39Pain assessment and management

Which pain syndrome is most likely to benefit from dexamethasone?

  1. Malignant cord compression Correct answer.
  2. Chronic low back pain without radiculopathy
  3. Fibromyalgia
  4. Neuropathic pain from diabetic peripheral neuropathy

Explanation

Dexamethasone reduces edema and inflammation around tumors, making it effective for malignant spinal cord compression, nerve compression, and raised intracranial pressure. It is not a primary treatment for fibromyalgia or nonspecific back pain.

Question 40Pain assessment and management

Which tool is designed to assess pain in a patient with advanced dementia who cannot self-report?

  1. Visual Analog Scale
  2. PAINAD Correct answer.
  3. Numeric Rating Scale
  4. Wong-Baker Faces Scale

Explanation

The PAINAD is a behavioral observational scale validated for advanced dementia when self-report is unreliable. Scales requiring a numeric or visual rating depend on intact communication.

Question 41Pain assessment and management

A patient on escalating intravenous morphine develops myoclonus, delirium, and worsening pain despite dose increases. What is the most appropriate next step?

  1. Add naloxone infusion
  2. Start a benzodiazepine for myoclonus only
  3. Rotate to another opioid Correct answer.
  4. Continue escalating the morphine dose

Explanation

Opioid metabolites, especially from morphine, can accumulate and cause myoclonus, delirium, and hyperalgesia. Rotating to another opioid and ensuring hydration usually improves symptoms.

Question 42Pain assessment and management

Ketamine is used as an adjuvant for refractory pain primarily through which mechanism?

  1. NMDA receptor antagonism Correct answer.
  2. Cyclooxygenase inhibition
  3. Mu-opioid receptor agonism
  4. Sodium channel blockade

Explanation

Ketamine produces analgesia mainly through noncompetitive NMDA receptor antagonism, which helps refractory neuropathic and mixed pain. It is not an opioid, NSAID, or local anesthetic.

Question 43Pain assessment and management

A young adult with sickle cell disease presents with a vaso-occlusive crisis and severe pain. Which approach is most appropriate?

  1. Withhold opioids until imaging confirms infarction
  2. Give prompt parenteral opioid analgesia Correct answer.
  3. Give meperidine because it is safest
  4. Use NSAIDs alone

Explanation

Vaso-occlusive crisis pain should be treated promptly with parenteral opioids titrated to effect; delaying analgesia worsens outcomes. Meperidine is avoided because of neurotoxic metabolite accumulation.

Question 44Pain assessment and management

Which patient should avoid NSAIDs for pain management?

  1. A patient with osteoarthritis
  2. A patient with stage 4 CKD Correct answer.
  3. A patient with mild headache
  4. A patient with normal renal function

Explanation

NSAIDs can reduce renal perfusion and cause acute kidney injury, hyperkalemia, and fluid retention, so they should be avoided in advanced CKD. They are not contraindicated in normal renal function or uncomplicated osteoarthritis.

Question 45Pain assessment and management

Which opioid should be avoided in a patient with severe renal failure because of accumulation of an active metabolite?

  1. Fentanyl
  2. Hydromorphone
  3. Morphine Correct answer.
  4. Methadone

Explanation

Morphine is metabolized to morphine-6-glucuronide, which accumulates in renal failure and can cause prolonged sedation and respiratory depression. Fentanyl and methadone are safer alternatives.

Question 46Pain assessment and management

Which statement about buprenorphine is correct?

  1. It is a partial mu agonist that can precipitate withdrawal Correct answer.
  2. It is a full mu-opioid agonist with no ceiling effect
  3. It has no analgesic efficacy
  4. It is contraindicated in all cancer pain

Explanation

Buprenorphine is a partial mu-opioid agonist with high receptor affinity, producing a ceiling effect on respiratory depression. Its high affinity can displace full agonists and precipitate withdrawal.

Question 47Pain assessment and management

A patient on high-dose opioids reports diffuse pain that worsens with each dose increase, without evidence of disease progression. Which phenomenon is most likely?

  1. Opioid withdrawal
  2. Opioid-induced hyperalgesia Correct answer.
  3. Neuropathic pain
  4. Opioid tolerance

Explanation

Opioid-induced hyperalgesia is a paradoxical increase in pain sensitivity during escalating opioid therapy, often with diffuse pain. Reducing or rotating the opioid is the usual management.

Question 48Pain assessment and management

Which factor makes methadone equianalgesic conversion from another opioid complex?

  1. It has no opioid receptor activity
  2. It cannot be used for cancer pain
  3. Its ratio varies with the prior opioid dose Correct answer.
  4. Its conversion ratio is fixed at 1:1 with morphine

Explanation

Methadone's equianalgesic ratio changes with the prior opioid dose, so conversion requires specialized tables and careful titration. A fixed 1:1 ratio would cause serious overdosing.

Question 49Pain assessment and management

A patient with intractable upper abdominal pain from pancreatic cancer has inadequate relief with opioids. Which intervention is most specific?

  1. Stellate ganglion block
  2. Celiac plexus neurolysis Correct answer.
  3. Trigeminal ganglion block
  4. Lumbar epidural steroid injection

Explanation

The celiac plexus carries visceral nociceptive fibers from the upper abdominal organs, so neurolysis can relieve pancreatic cancer pain. Other blocks target different dermatomes or sympathetic regions.

Question 50Pain assessment and management

Which statement about intravenous lidocaine for refractory neuropathic pain is correct?

  1. It is contraindicated for all neuropathic pain
  2. It acts by mu-opioid receptor agonism
  3. It is safe without monitoring in all patients
  4. It requires cardiac monitoring Correct answer.

Explanation

Intravenous lidocaine is a sodium channel blocker used for refractory neuropathic pain, but it can cause arrhythmias, seizures, and hypotension. Continuous cardiac monitoring is required during infusion.