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ABFM Palliative Care study materials
ABFM Palliative Care study resources

ABFM Palliative Care practice questions

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Question 1Palliative care approach to serious illness and prognostication

Which statement best describes the core goal of palliative care for a patient with a serious illness?

  1. To give priority to life-prolonging interventions over comfort whenever a conflict arises
  2. To restrict involvement to patients who have formally discontinued all curative treatments
  3. To provide sedation that deliberately hastens death for patients with refractory symptoms
  4. To relieve suffering and improve quality of life alongside disease-directed treatment Correct answer.

Explanation

Palliative care is interdisciplinary care that focuses on relieving symptoms and improving quality of life from the time a serious illness is diagnosed. It is delivered alongside curative or life-prolonging treatment rather than only after such treatment stops.

Question 2Palliative care approach to serious illness and prognostication

Which patient is most clearly eligible for hospice care under typical United States Medicare criteria?

  1. A patient with newly diagnosed diabetes requiring insulin adjustment but no other serious illness
  2. A patient with metastatic cancer receiving chemotherapy whose estimated life expectancy is 2 years
  3. A patient with advanced dementia, life expectancy ≤6 months, electing comfort-focused care Correct answer.
  4. A patient with stable angina and no limitation in functional capacity who is not declining

Explanation

Hospice under Medicare requires a physician-certified prognosis of 6 months or less if the terminal illness follows its usual course, along with election of the hospice benefit and comfort-focused care. Palliative care itself has no such 6-month prognosis requirement and can be provided with disease-directed treatment.

Question 3Palliative care approach to serious illness and prognostication

A patient is fully active and able to carry on all predisease performance without restriction. Which ECOG performance status does this describe?

  1. ECOG 0 Correct answer.
  2. ECOG 3
  3. ECOG 2
  4. ECOG 4

Explanation

ECOG 0 denotes full activity and ability to carry on all predisease performance without restriction. ECOG 1 restricts strenuous activity, 2 permits ambulation and self-care but limits work, 3 limits self-care, and 4 denotes complete disability.

Question 4Palliative care approach to serious illness and prognostication

What does a "no" answer to the surprise question-"Would I be surprised if this patient died within the next 12 months?"-most appropriately prompt?

  1. A recommendation for intensive care unit admission
  2. Further assessment of palliative needs and goals of care Correct answer.
  3. Discontinuation of all disease-directed therapy
  4. Immediate referral for hospice enrollment regardless of treatment goals

Explanation

The surprise question is a screening tool to identify patients who may have limited survival and could benefit from palliative care assessment. A "no" response should prompt evaluation of symptoms, prognosis, and goals rather than an automatic hospice referral or treatment withdrawal.

Question 5Palliative care approach to serious illness and prognostication

Which finding is most consistently associated with poor prognosis in advanced cancer?

  1. Occasional constipation relieved by laxatives
  2. Declining performance status Correct answer.
  3. Mild localized pain controlled with acetaminophen
  4. Transient insomnia after hospitalization

Explanation

Performance status is one of the strongest and most consistent predictors of survival in advanced cancer and other serious illnesses. Symptoms such as well-controlled pain or transient insomnia are important to treat but are not strong independent prognostic markers.

Question 6Palliative care approach to serious illness and prognostication

According to current evidence, when should palliative care ideally be introduced for a patient with newly diagnosed metastatic cancer?

  1. During the last days of life when oral intake ceases
  2. Only after all chemotherapy options have been exhausted
  3. At diagnosis, integrated with ongoing cancer-directed treatment Correct answer.
  4. Only when the patient requests hospice enrollment

Explanation

Randomized trials show that early integrated palliative care improves quality of life and mood and may reduce aggressive end-of-life care without shortening survival. It should therefore be offered at diagnosis alongside cancer-directed treatment, not reserved for treatment failure or the final days.

Question 7Palliative care approach to serious illness and prognostication

Which description corresponds to a Karnofsky Performance Status of 50%?

  1. Normal activity and no evidence of disease
  2. Completely disabled and unable to carry on any self-care
  3. Requires considerable assistance and frequent medical care Correct answer.
  4. Requires occasional assistance but able to care for most personal needs

Explanation

A Karnofsky Performance Status of 50% means the patient requires considerable assistance and frequent medical care. Scores of 70-80 indicate increasing limitation but preserved self-care, while 40 or below indicates disability requiring special care.

Question 8Palliative care approach to serious illness and prognostication

Which set of domains is assessed by the Palliative Performance Scale (PPS)?

  1. Activities of daily living, cognition, and caregiver burden only
  2. Serum albumin, lymphocyte count, weight loss, and age
  3. Pain, dyspnea, nausea, depression, and anxiety
  4. Ambulation, activity, self-care, oral intake, and consciousness Correct answer.

Explanation

The Palliative Performance Scale scores patients from 0% to 100% using ambulation, activity and evidence of disease, self-care, oral intake, and consciousness. Lower scores reflect greater functional decline and generally shorter prognosis.

Question 9Palliative care approach to serious illness and prognostication

Which finding in advanced heart failure most strongly suggests a prognosis of months rather than years?

  1. Ejection fraction of 45% with mild exertional dyspnea
  2. Blood pressure of 128/76 mm Hg while taking an ACE inhibitor
  3. NYHA class IV symptoms at rest despite optimized therapy Correct answer.
  4. One hospitalization for heart failure during the past year

Explanation

Persistent NYHA class IV symptoms at rest despite optimized therapy identify advanced, refractory heart failure with a poor prognosis. A single hospitalization or a preserved ejection fraction is less specific, although recurrent admissions and worsening renal function also worsen prognosis.

Question 10Palliative care approach to serious illness and prognostication

Which clinical finding best supports hospice eligibility for a patient with advanced dementia?

  1. Mini-Mental State Examination score of 18
  2. Need for assistance with instrumental activities of daily living
  3. FAST stage 7c plus recurrent aspiration pneumonia Correct answer.
  4. A recent move to an assisted living facility

Explanation

Hospice eligibility in advanced dementia generally requires FAST stage 7c or beyond plus a recent complication such as aspiration pneumonia, sepsis, pyelonephritis, or multiple pressure ulcers. Cognitive test scores and dependence in instrumental activities alone do not establish terminal status.

Question 11Palliative care approach to serious illness and prognostication

The Palliative Prognostic (PaP) score incorporates which combination of variables?

  1. Dyspnea, anorexia, KPS, survival prediction, and WBC count Correct answer.
  2. Tumor stage, lactate dehydrogenase, hemoglobin, and weight loss
  3. Age, sex, cancer type, and prior chemotherapy
  4. Serum sodium, creatinine, bilirubin, and platelet count

Explanation

The PaP score combines clinical prediction of survival, Karnofsky Performance Status, dyspnea, anorexia, and total white blood cell count to estimate 30-day survival in advanced cancer. It does not rely on tumor stage, prior chemotherapy, or routine chemistry panels.

Question 12Palliative care approach to serious illness and prognostication

Which approach best communicates prognostic uncertainty to a patient with advanced illness?

  1. Offer plausible outcome ranges and factors that could change them Correct answer.
  2. Provide one precise survival estimate in order to reduce the patient's anxiety
  3. State that prognosis cannot be discussed until a biopsy result is available
  4. Avoid discussing prognosis until survival is certain

Explanation

Prognostic discussions should acknowledge uncertainty, provide realistic ranges, and explain the clinical factors that could change the estimate. This supports planning and hope without false precision, whereas avoidance or a single precise estimate can impair trust.

Question 13Palliative care approach to serious illness and prognostication

In a patient with cirrhosis, which score is most commonly used to estimate short-term mortality and help guide transplant or palliative discussions?

  1. Model for End-Stage Liver Disease (MELD) Correct answer.
  2. Rome IV criteria
  3. Fibrosis-4 index
  4. Child-Pugh class A score of 5

Explanation

The MELD score, now often with sodium, predicts short-term mortality in cirrhosis and is used for transplant allocation and prognostic discussions. Child-Pugh also predicts mortality, but MELD is more commonly used for short-term risk.

Question 14Palliative care approach to serious illness and prognostication

Which factor is most strongly associated with poor survival in a patient with end-stage kidney disease starting dialysis?

  1. Use of an arteriovenous fistula
  2. Well-controlled hypertension
  3. Younger age at initiation
  4. Low serum albumin and high comorbidity burden Correct answer.

Explanation

Low serum albumin, reflecting malnutrition and inflammation, and a high comorbidity burden are strong predictors of mortality in end-stage kidney disease. Age, functional status, and dialysis modality also matter, but younger age and well-controlled hypertension are not poor prognostic signs.

Question 15Palliative care approach to serious illness and prognostication

Which feature in severe COPD best predicts high 1-year mortality and should prompt palliative care discussion?

  1. Hypercapnia and recurrent exacerbations needing noninvasive ventilation Correct answer.
  2. Use of a short-acting bronchodilator as needed
  3. FEV1 of 60% predicted despite maximal bronchodilator therapy
  4. Chronic productive cough without any recent exacerbations

Explanation

Hypercapnia, recurrent exacerbations requiring noninvasive ventilation, low body mass index, cor pulmonale, and poor performance status predict high mortality in COPD. FEV1 alone correlates imperfectly with prognosis and should not be the sole trigger for palliative care discussion.

Question 16Palliative care approach to serious illness and prognostication

During a goals-of-care discussion with a patient with advanced illness, which action is most appropriate?

  1. Explore values, priorities, and illness understanding before options Correct answer.
  2. Avoid discussing death because it may cause the patient distress
  3. Complete the conversation only with the patient's health care proxy
  4. Recommend the option that the clinician believes is medically best before asking about values

Explanation

Goals-of-care discussions should first elicit the patient's understanding, values, and priorities, then integrate prognosis and treatment options. The patient should be included whenever possible, and clinicians should not avoid discussing death when the patient is willing.

Question 17Palliative care approach to serious illness and prognostication

Which tool is designed to estimate mortality for older adults using routinely available clinical variables and can support palliative care discussions?

  1. CURB-65
  2. CHA2DS2-VASc
  3. Wells score
  4. ePrognosis Correct answer.

Explanation

ePrognosis is a collection of validated prognostic indices that estimate mortality for older adults in various settings using routinely available variables. The other scores estimate stroke risk, pneumonia severity, and venous thromboembolism probability, respectively.

Question 18Palliative care approach to serious illness and prognostication

In a patient with advanced cancer, which statement about delirium is most accurate?

  1. It is usually a benign and self-limited condition in terminal illness
  2. It occurs only as a side effect of opioid medications
  3. It should be managed with physical restraints to prevent falls
  4. It is associated with increased mortality and may signal impending death Correct answer.

Explanation

Delirium in advanced cancer is associated with increased mortality and, when irreversible, may be a marker of impending death. It is multifactorial, so evaluation for reversible causes and nonpharmacologic management are essential; restraints generally worsen agitation.

Question 19Palliative care approach to serious illness and prognostication

Which combination of factors most strongly predicts survival of less than 3 months in advanced cancer?

  1. ECOG 3-4, anorexia-cachexia, and clinician estimate of weeks Correct answer.
  2. Normal performance status and mild fatigue
  3. Tumor marker elevation alone
  4. A single episode of nausea controlled with antiemetics

Explanation

Poor performance status, anorexia-cachexia, dyspnea, and a clinician's estimate of survival in weeks are consistent predictors of short survival in advanced cancer. Tumor marker elevation alone or a single controlled symptom is insufficient.

Question 20Palliative care approach to serious illness and prognostication

Which finding best supports hospice eligibility for a patient with advanced heart failure?

  1. Ejection fraction of 50% with paroxysmal atrial fibrillation
  2. NYHA class IV symptoms despite therapy plus recurrent hospitalizations Correct answer.
  3. One emergency visit for dyspnea without hospitalization
  4. Stable NYHA class II symptoms on guideline therapy

Explanation

Hospice heart failure criteria commonly include NYHA class IV symptoms despite optimized therapy plus recurrent hospitalizations or refractory symptoms. Ejection fraction alone does not determine hospice eligibility, and stable class II symptoms do not suggest a 6-month prognosis.

Question 21Pain assessment and management

Which tool is validated for assessing pain in a patient with advanced dementia who cannot reliably self-report?

  1. Braden scale
  2. PAINAD Correct answer.
  3. PHQ-9
  4. MMSE

Explanation

The PAINAD is an observational scale that scores breathing, negative vocalization, facial expression, body language, and consolability. It is designed for patients with advanced dementia who cannot use numeric self-report scales.

Question 22Pain assessment and management

According to the WHO analgesic ladder, which initial approach is appropriate for moderate to severe cancer pain?

  1. A weak opioid alone
  2. A tricyclic antidepressant alone
  3. A strong opioid such as morphine Correct answer.
  4. A nonopioid alone

Explanation

Moderate to severe cancer pain corresponds to step 3 of the WHO ladder, where a strong opioid is started and titrated. Nonopioids and adjuvants may be added for specific pain mechanisms.

Question 23Pain assessment and management

Which medication is a first-line adjuvant for neuropathic cancer pain?

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

Explanation

Gabapentin is an anticonvulsant adjuvant used for neuropathic pain and can be combined with opioids. It is titrated slowly because of sedation and dizziness.

Question 24Pain assessment and management

Which medication should usually be started prophylactically when a patient begins scheduled opioid therapy?

  1. Omeprazole
  2. Senna Correct answer.
  3. Ondansetron
  4. Loperamide

Explanation

Tolerance does not develop to opioid-induced constipation, so a stimulant laxative such as senna is commonly started with scheduled opioids. Additional laxatives may be needed if constipation persists.

Question 25Pain assessment and management

For a patient on a stable around-the-clock opioid regimen, what is an appropriate initial breakthrough pain dose?

  1. 100% of the daily opioid dose
  2. 5 mg of morphine for every patient
  3. 50% of the daily opioid dose
  4. 10% of the daily opioid dose Correct answer.

Explanation

A typical rescue dose is about 10% to 20% of the total daily opioid dose, given as needed for breakthrough pain. The dose is then adjusted based on response and adverse effects.

Question 26Pain assessment and management

What is the recommended initial IV naloxone dose for suspected opioid-induced respiratory depression in an adult?

  1. 0.04–0.4 mg IV titrated Correct answer.
  2. 0.5 mg/kg IV as a bolus
  3. 4 mg IV as a bolus
  4. 10 mg IV as a bolus

Explanation

Naloxone should be titrated in small IV doses, typically 0.04 to 0.4 mg, to restore adequate respiration without causing severe withdrawal. Larger bolus doses can precipitate agitation, seizures, and pulmonary edema.

Question 27Pain assessment and management

A patient on high-dose morphine develops myoclonus, agitation, and worsening pain with hyperalgesia. What is the best next step?

  1. Add a nonsteroidal anti-inflammatory drug
  2. Increase the opioid dose
  3. Start a naloxone infusion
  4. Rotate the opioid and reduce the dose Correct answer.

Explanation

These findings suggest opioid-induced neurotoxicity from accumulating metabolites. Rotating to a different opioid, reducing the dose, and providing hydration often improve symptoms.

Question 28Pain assessment and management

Which monitoring is especially important during methadone therapy because of a recognized adverse effect?

  1. ECG for QTc prolongation Correct answer.
  2. Weekly complete blood count
  3. Monthly chest radiography
  4. Annual bone density scan

Explanation

Methadone can prolong the QTc interval and predispose to torsades de pointes. An ECG and review of interacting medications are recommended, especially at higher doses or with other QT-prolonging drugs.

Question 29Pain assessment and management

Why should nonsteroidal anti-inflammatory drugs generally be avoided in an older adult with chronic kidney disease?

  1. Renal injury and GI bleeding Correct answer.
  2. Serotonin syndrome with agitation
  3. Respiratory depression and sedation
  4. QT prolongation and arrhythmia

Explanation

NSAIDs reduce renal prostaglandin synthesis and can precipitate acute kidney injury, especially in chronic kidney disease. They also increase the risk of gastrointestinal bleeding and are best avoided in high-risk older adults.

Question 30Pain assessment and management

What is the main role of corticosteroids in a patient with painful bone metastases?

  1. Prevents opioid-related constipation
  2. Reduces edema and pain Correct answer.
  3. Reverses spinal cord compression
  4. Cures the bony metastases

Explanation

Corticosteroids can reduce peritumoral edema and inflammation, providing analgesia in selected patients with bone metastases. They are adjunctive and do not cure the underlying malignancy.

Question 31Pain assessment and management

Which statement about transdermal fentanyl is correct?

  1. Safe for opioid-naive patients
  2. Preferred for acute nociceptive pain
  3. Requires prior opioid tolerance Correct answer.
  4. Absorption is unaffected by fever

Explanation

Transdermal fentanyl is indicated only for opioid-tolerant patients with persistent pain requiring around-the-clock opioids. Fever or external heat can increase absorption and cause overdose.

Question 32Pain assessment and management

Topical lidocaine is most appropriate for which pain problem?

  1. An open skin wound
  2. Widespread fibromyalgia pain
  3. Focal postherpetic neuralgia Correct answer.
  4. Prior lidocaine allergy

Explanation

Topical lidocaine provides localized analgesia for neuropathic pain such as postherpetic neuralgia in a limited area. It should not be applied to broken skin or used in patients with lidocaine allergy.

Question 33Pain assessment and management

Which adverse effect is characteristic of ketamine when used for refractory pain?

  1. Bone marrow suppression
  2. Psychotomimetic effects Correct answer.
  3. Severe constipation
  4. Irreversible hearing loss

Explanation

Ketamine is an NMDA receptor antagonist that can cause hallucinations, dysphoria, and dissociative symptoms. It is used at low doses for refractory pain with monitoring for these neuropsychiatric effects.

Question 34Pain assessment and management

A celiac plexus block is most appropriate for which pain syndrome?

  1. Chronic lumbar radiculopathy
  2. Thoracic postherpetic neuralgia
  3. Pain from a femoral metastasis
  4. Pancreatic cancer pain Correct answer.

Explanation

The celiac plexus carries visceral afferents from upper abdominal organs, so a block can relieve pain from pancreatic cancer. It is less useful for somatic bone pain or localized neuropathic pain.

Question 35Pain assessment and management

What is the best approach to pain assessment in a nonverbal patient with advanced dementia?

  1. Assuming no pain when the patient is calm
  2. A numeric rating scale used alone
  3. Vital signs used as the only indicator
  4. A behavioral scale plus caregiver input Correct answer.

Explanation

Behavioral pain scales combined with caregiver observations are the most reliable approach when self-report is not possible. Vital signs alone are insensitive and should not be the sole basis for treatment decisions.

Question 36Pain assessment and management

Which elements are included in the concept of total pain?

  1. Physical, emotional, social, spiritual Correct answer.
  2. Physical and emotional distress only
  3. Opioid adverse effects and tolerance only
  4. Nociceptive and neuropathic input only

Explanation

Total pain recognizes that suffering includes physical, psychological, social, and spiritual dimensions. Effective palliative care addresses all of these contributors, not just nociception.

Question 37Pain assessment and management

Which description best defines opioid tolerance?

  1. Withdrawal after abrupt discontinuation
  2. Higher dose needed for the same effect Correct answer.
  3. Compulsive use despite known harm
  4. Craving and loss of control

Explanation

Tolerance is a pharmacologic adaptation in which a higher dose is needed to maintain the same analgesic effect. It is distinct from addiction, which involves compulsive use and harmful consequences.

Question 38Pain assessment and management

What is the preferred initial analgesic approach for a severe vaso-occlusive sickle cell pain crisis?

  1. Nonsteroidal anti-inflammatory drugs alone
  2. Early IV opioid titrated to effect Correct answer.
  3. Routine intramuscular meperidine
  4. Oral codeine used as the only agent

Explanation

Severe vaso-occlusive crisis pain requires prompt parenteral opioid analgesia titrated to the patient's report. Delays in analgesia are associated with worse outcomes and prolonged hospitalization.

Question 39Pain assessment and management

Using standard equianalgesic estimates, which conversion is closest for parenteral morphine to parenteral hydromorphone?

  1. Parenteral morphine 10 mg ≈ hydromorphone 0.1 mg
  2. Parenteral morphine 10 mg ≈ hydromorphone 30 mg
  3. Parenteral morphine 10 mg ≈ hydromorphone 10 mg
  4. Parenteral morphine 10 mg ≈ hydromorphone 1.5 mg Correct answer.

Explanation

The usual equianalgesic ratio is about 10 mg of parenteral morphine to 1.5 mg of parenteral hydromorphone. Because cross-tolerance is incomplete, the calculated dose is often reduced by 25% to 50% and then titrated.

Question 40Pain assessment and management

What is the expected response to palliative radiation therapy for painful bone metastases?

  1. Contraindicated when opioids are used
  2. Immediate complete relief in all patients
  3. No relief until six months have passed
  4. Partial relief in most patients over weeks Correct answer.

Explanation

Palliative radiation to a painful bone metastasis produces partial pain relief in most patients, often beginning within one to four weeks. It is commonly combined with analgesic therapy rather than replacing it.

Question 41Non-pain symptom assessment and management

A patient starting regular oral morphine for cancer pain has no contraindication to laxatives. Which prophylactic agent is most appropriate?

  1. Loperamide, an antimotility agent
  2. Docusate, a stool softener
  3. Senna, a stimulant laxative Correct answer.
  4. Magnesium citrate, a saline laxative

Explanation

Opioids cause constipation by slowing intestinal transit through mu-receptor activation, and tolerance does not develop. A stimulant laxative such as senna is recommended prophylactically when opioids are started. Docusate has not shown meaningful benefit in this setting.

Question 42Non-pain symptom assessment and management

Which medication is first-line for persistent breathlessness in a patient with advanced COPD receiving maximal inhaler therapy?

  1. Low-dose oral morphine Correct answer.
  2. Oral theophylline
  3. Nebulized furosemide
  4. Oral prednisone

Explanation

Low-dose opioids are recommended for refractory breathlessness in advanced COPD and cancer, reducing the distress of dyspnea through effects on respiratory drive and perception. Oxygen is indicated only for hypoxemia. Oral corticosteroids and theophylline are not first-line for symptom control in this setting.

Question 43Non-pain symptom assessment and management

A dying patient has audible gurgling from oropharyngeal secretions. Which initial measure is most appropriate?

  1. Prophylactic antibiotics
  2. Intravenous furosemide
  3. Deep tracheal suctioning every hour
  4. Subcutaneous glycopyrrolate Correct answer.

Explanation

Anticholinergic agents such as glycopyrrolate reduce salivary and respiratory secretions and are first-line for noisy breathing near the end of life. Deep suctioning is distressing and usually ineffective because secretions are often beyond reach. Diuretics and antibiotics do not address the underlying mechanism.

Question 44Non-pain symptom assessment and management

A patient receiving palliative chemotherapy develops white plaques on the tongue and buccal mucosa that scrape off. Which treatment is most appropriate?

  1. Chlorhexidine mouthwash
  2. Topical lidocaine gel
  3. Oral fluconazole Correct answer.
  4. Oral acyclovir

Explanation

Scrapable white plaques are characteristic of oral candidiasis, which is common with corticosteroids, antibiotics, and chemotherapy. Oral fluconazole is first-line when systemic therapy is needed; topical nystatin is an alternative. Acyclovir treats herpes simplex, and chlorhexidine is not antifungal.

Question 45Non-pain symptom assessment and management

Which medication is preferred for distressing hyperactive delirium in a palliative care patient when nonpharmacologic measures fail?

  1. Diphenhydramine
  2. Diazepam
  3. Ondansetron
  4. Haloperidol Correct answer.

Explanation

Haloperidol is the preferred antipsychotic for hyperactive delirium in palliative care and can be given orally, subcutaneously, or intravenously. Benzodiazepines may worsen delirium and are reserved for specific situations such as alcohol withdrawal. Diphenhydramine has anticholinergic effects that can precipitate or worsen delirium.

Question 46Non-pain symptom assessment and management

Which antiemetic is most appropriate for nausea caused by raised intracranial pressure in a patient with brain metastases?

  1. Metoclopramide
  2. Dexamethasone Correct answer.
  3. Hyoscine butylbromide
  4. Ondansetron

Explanation

Raised intracranial pressure from brain metastases causes nausea through compression and cerebral edema. Dexamethasone reduces peritumoral edema and is first-line along with measures to lower intracranial pressure. Metoclopramide and ondansetron do not treat the underlying cause.

Question 47Non-pain symptom assessment and management

A patient on stable high-dose opioids has not responded to senna plus polyethylene glycol. Which agent specifically targets opioid-induced constipation?

  1. Psyllium
  2. Lactulose
  3. Methylnaltrexone Correct answer.
  4. Bisacodyl

Explanation

Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist that relieves opioid-induced constipation without reversing analgesia. It is used when stimulant laxatives and osmotic agents fail. Bulk-forming agents such as psyllium can worsen obstruction and are avoided in advanced illness.

Question 48Non-pain symptom assessment and management

A patient with advanced pancreatic cancer reports early satiety, bloating, and vomiting of undigested food. Which antiemetic best matches this mechanism?

  1. Dexamethasone
  2. Ondansetron
  3. Haloperidol
  4. Metoclopramide Correct answer.

Explanation

Early satiety, bloating, and vomiting of undigested food suggest delayed gastric emptying. Metoclopramide is a prokinetic that accelerates gastric emptying and is the best match. Ondansetron treats serotonin-mediated nausea, and haloperidol treats chemical or metabolic nausea.

Question 49Non-pain symptom assessment and management

Which nonpharmacologic measure most reliably relieves the sensation of breathlessness in a palliative patient?

  1. Supplemental oxygen regardless of saturation
  2. Deep diaphragmatic breathing exercises
  3. Complete bed rest
  4. A handheld fan directing cool air at the face Correct answer.

Explanation

Cool airflow from a handheld fan directed at the face reduces the sensation of breathlessness, likely through trigeminal stimulation. Supplemental oxygen is reserved for hypoxemic patients and does not reliably relieve dyspnea when saturation is normal. Bed rest and breathing exercises have limited immediate benefit.

Question 50Non-pain symptom assessment and management

Which benzodiazepine is preferred for acute anxiety and breathlessness in a patient with severe hepatic impairment?

  1. Lorazepam Correct answer.
  2. Clonazepam
  3. Diazepam
  4. Chlordiazepoxide

Explanation

Lorazepam undergoes glucuronidation and lacks active metabolites, making it preferred in severe hepatic impairment. Diazepam, chlordiazepoxide, and clonazepam are hepatically metabolized and can accumulate. This matters for both sedation and fall risk.