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ABIM Palliative Care study materials
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ABIM Palliative Care practice questions

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Question 1Pain assessment and management

A 78-year-old nursing home resident with advanced Alzheimer disease and severe hip osteoarthritis cannot reliably report pain. Which tool is most appropriate for assessing her pain?

  1. Visual analog scale
  2. McGill Pain Questionnaire
  3. 0-to-10 numeric rating scale
  4. PAINAD observational scale Correct answer.

Explanation

Behavioral observation scales such as PAINAD (Pain Assessment in Advanced Dementia) are validated for patients with advanced dementia who cannot self-report; they score breathing, negative vocalization, facial expression, body language, and consolability. Self-report instruments remain preferred whenever the patient can report reliably, but their validity falls as dementia advances. Pain should be assessed at rest and with movement and reassessed after each intervention.

Question 2Pain assessment and management

A 64-year-old man with painful diabetic peripheral neuropathy and normal renal and hepatic function has inadequate relief from acetaminophen. Which medication is an appropriate first-line choice?

  1. Scheduled naproxen
  2. Duloxetine Correct answer.
  3. Intravenous ketamine infusion
  4. Transdermal fentanyl

Explanation

Serotonin-norepinephrine reuptake inhibitors (duloxetine, venlafaxine), gabapentinoids, and tricyclic antidepressants are first-line for diabetic peripheral neuropathic pain. Opioids are not first-line for chronic neuropathic pain because of tolerance, adverse effects, and long-term risk. NSAIDs have no established benefit for neuropathic mechanisms and carry gastrointestinal and renal risk.

Question 3Pain assessment and management

A patient is starting scheduled oral morphine for cancer pain. Which co-prescription is recommended for most patients at the outset?

  1. Scheduled senna Correct answer.
  2. As-needed loperamide
  3. Scheduled methylnaltrexone
  4. Scheduled ondansetron

Explanation

Tolerance develops to most opioid adverse effects within days to weeks but does not develop to constipation, so a bowel regimen should be started prophylactically with the opioid. A stimulant laxative such as senna is standard, often with a stool softener added. Peripherally acting mu-opioid antagonists are reserved for laxative-refractory opioid-induced constipation.

Question 4Pain assessment and management

In palliative care, the concept of total pain refers to which of the following?

  1. Pain shaped by physical, psychological, social, and spiritual factors Correct answer.
  2. Pain that persists despite adequate opioid dosing
  3. Pain summed across all metastatic sites
  4. The highest pain score in the past 24 hours

Explanation

Total pain, described by Cicely Saunders, holds that suffering in advanced illness has physical, emotional, social, and spiritual dimensions that interact and amplify one another. Effective treatment therefore requires assessment of every domain, not just nociception. A purely analgesic approach often fails when the nonphysical components are unaddressed.

Question 5Pain assessment and management

Which of the following instruments measures only pain intensity?

  1. McGill Pain Questionnaire
  2. Numeric rating scale Correct answer.
  3. Brief Pain Inventory
  4. PEG scale

Explanation

The numeric rating scale is unidimensional: the patient rates intensity from 0 (no pain) to 10 (worst pain imaginable). The Brief Pain Inventory, McGill Pain Questionnaire, and PEG scale capture additional dimensions such as interference, quality, or affect. Unidimensional scales are quick and track response to treatment but do not characterize the pain.

Question 6Pain assessment and management

A patient with metastatic cancer reports pain of 8 out of 10 and has been taking only as-needed acetaminophen. According to the WHO analgesic ladder, which is the most appropriate next step?

  1. A strong opioid such as morphine Correct answer.
  2. Nerve block before any opioid trial
  3. Add an adjuvant alone and continue acetaminophen
  4. Codeine plus acetaminophen for one week

Explanation

The WHO ladder directs treatment by pain severity: moderate to severe pain warrants a step III strong opioid, with or without a non-opioid and adjuvants. Stepping through a weak opioid is not required and delays relief. Adjuvants and procedural options are considered in addition to, not instead of, adequate analgesia.

Question 7Pain assessment and management

Which opioid should be avoided for chronic cancer pain because accumulation of a neurotoxic metabolite can cause seizures?

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

Explanation

Meperidine is metabolized to normeperidine, a renally cleared compound that lowers the seizure threshold and can cause myoclonus, agitation, and convulsions, especially with repeated dosing or renal impairment. It also has poor oral bioavailability and a short duration of action. Other opioids are preferred for chronic pain.

Question 8Pain assessment and management

A patient receiving oral morphine has a respiratory rate of 6 breaths per minute and pinpoint pupils but is still arousable. What is the most appropriate immediate action?

  1. Increase the morphine dose
  2. Withhold the opioid and titrate IV naloxone Correct answer.
  3. Administer intravenous flumazenil to reverse the sedation
  4. Give a bolus of oral naloxone

Explanation

This is opioid toxicity; the opioid should be withheld and naloxone titrated intravenously in small aliquots to restore adequate ventilation without precipitating severe pain or withdrawal. The goal is reversal of respiratory depression, not full arousal. Patients require monitoring because naloxone's half-life is shorter than that of most opioids.

Question 9Pain assessment and management

A patient taking oral morphine 60 mg per day must switch to intravenous morphine because of dysphagia. Using an oral-to-parenteral ratio of 3:1, which daily intravenous dose is approximately equianalgesic?

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

Explanation

The standard equianalgesic ratio is 3 mg of oral morphine to 1 mg of parenteral morphine, so 60 mg orally is roughly 20 mg intravenously per day. Many clinicians then reduce the calculated dose by 25% to account for incomplete cross-tolerance and titrate with rescue doses. Reassessment within 24 hours is essential after any opioid conversion.

Question 10Pain assessment and management

A 70-year-old with metastatic cancer and an eGFR of 15 mL/min/1.73 m2 needs a strong opioid. Which is the most appropriate initial choice?

  1. Oral codeine
  2. Oral morphine
  3. Hydromorphone with cautious titration Correct answer.
  4. Meperidine

Explanation

Morphine's renally cleared metabolites accumulate in kidney disease and cause sedation, myoclonus, and respiratory depression; codeine and meperidine have similar problems. Hydromorphone also has renally cleared metabolites, so it is used cautiously at reduced doses with close monitoring. Fentanyl and methadone are alternatives because they lack renally accumulating active metabolites.

Question 11Pain assessment and management

A patient on sustained-release morphine 60 mg twice daily has well-controlled background pain but several episodes of severe pain each day. Which is the most appropriate addition?

  1. Immediate-release morphine at the onset of each episode Correct answer.
  2. An extra dose of sustained-release morphine at the time of pain
  3. A continuous intravenous morphine infusion
  4. Scheduled ibuprofen added to the regimen

Explanation

Breakthrough pain is treated with a short-acting opioid at the onset of the episode, dosed at roughly 10% to 20% of the total daily baseline opioid dose. The baseline sustained-release regimen is adjusted if breakthrough episodes become frequent. Rapid-onset transmucosal fentanyl products are an option for opioid-tolerant patients with predictable episodes.

Question 12Pain assessment and management

A patient with prostate cancer metastatic to the spine develops new severe back pain with bilateral leg weakness. Which medication should be started immediately along with urgent imaging?

  1. Naproxen
  2. Dexamethasone Correct answer.
  3. Calcitonin
  4. Gabapentin

Explanation

New back pain with leg weakness suggests malignant spinal cord compression, a neurologic emergency; high-dose dexamethasone (commonly 16 mg daily) is given immediately, together with urgent MRI and neurosurgical or radiation oncology consultation. Corticosteroids reduce peritumoral edema and pain until definitive treatment. Delay in starting steroids can lead to irreversible deficit.

Question 13Pain assessment and management

A patient with locally advanced pancreatic cancer has severe mid-abdominal pain that responds poorly to opioids and is accompanied by nausea. Which intervention is most likely to provide durable relief?

  1. Rotation to transdermal fentanyl
  2. Lumbar epidural steroid injection
  3. Celiac plexus neurolysis Correct answer.
  4. Stellate ganglion block

Explanation

Visceral pain from upper abdominal malignancy is transmitted through the celiac plexus, and celiac plexus neurolysis can produce substantial, durable analgesia and reduce opioid requirements. It is best supported in pancreatic cancer and is usually performed percutaneously or endoscopically by an experienced clinician. Opioid rotation is a reasonable adjunct but does not target the visceral mechanism.

Question 14Pain assessment and management

A 55-year-old with multiple sclerosis has sharp, lancinating pain in the right cheek and jaw lasting seconds. Which medication is first-line?

  1. Oral morphine
  2. Carbamazepine Correct answer.
  3. Amitriptyline
  4. Topical lidocaine gel

Explanation

Paroxysmal, electric-shock pain in a trigeminal distribution suggests trigeminal neuralgia, for which carbamazepine is first-line and oxcarbazepine an alternative. Therapy is titrated to effect while monitoring sodium and blood counts. Refractory cases warrant imaging and consideration of surgical decompression.

Question 15Pain assessment and management

A patient with good analgesia but bothersome sedation on oral hydromorphone is rotated to oral morphine at the calculated equianalgesic dose. Which adjustment is recommended?

  1. Stop the old opioid abruptly
  2. Use the full calculated dose and reassess in a week
  3. Reduce the new dose by 25% to 50% Correct answer.
  4. Increase the new dose by 50%

Explanation

Because cross-tolerance between opioids is incomplete, an equianalgesic table dose can be excessive after rotation; clinicians typically reduce the new opioid by 25% to 50% and titrate upward with rescue doses. The reduction is larger when pain is mild or the patient is frail or elderly. Frequent reassessment over the first 24 to 48 hours is essential.

Question 16Pain assessment and management

A 68-year-old taking sertraline develops moderate osteoarthritis pain. Which analgesic poses the greatest risk of serotonin syndrome?

  1. Acetaminophen
  2. Naproxen
  3. Topical diclofenac
  4. Tramadol Correct answer.

Explanation

Tramadol inhibits serotonin and norepinephrine reuptake in addition to its weak mu-opioid activity, so combining it with an SSRI increases the risk of serotonin syndrome and lowers the seizure threshold. Risk is highest with serotonergic polypharmacy, including other antidepressants, triptans, and linezolid. Acetaminophen and topical NSAIDs are safer in this setting.

Question 17Pain assessment and management

A patient has well-localized postherpetic neuralgia over the left T6 dermatome with intact skin. Which topical therapy is most appropriate first-line?

  1. Topical capsaicin 0.075% to a wide area
  2. Lidocaine 5% patch Correct answer.
  3. Topical morphine gel
  4. Topical ketamine cream

Explanation

The lidocaine 5% patch is first-line for localized peripheral neuropathic pain; it is well tolerated, has minimal systemic absorption, and is applied for up to 12 hours per day. Capsaicin is also evidence-based but causes burning on application and should not be applied to broken skin or near the face. Topical morphine and ketamine have limited evidence and are not first-line.

Question 18Pain assessment and management

A patient with severe cancer pain repeatedly requests early refills and says the medication runs out too soon. The prescriber suspects drug-seeking behavior. Which explanation best fits this presentation?

  1. Pseudoaddiction caused by undertreated pain Correct answer.
  2. Deliberate diversion
  3. Opioid tolerance
  4. Physical dependence

Explanation

Pseudoaddiction describes behavior that mimics addiction, such as clock-watching, early refill requests, and escalating demands, driven by inadequate analgesia; it resolves when pain is properly treated. It is distinguished from true addiction by the absence of craving, loss of control, and continued use despite harm. Reassessing and optimizing the analgesic regimen, rather than dismissing the patient, is the appropriate response.

Question 19Pain assessment and management

A dying patient with refractory pain remains distressed despite aggressive opioid and adjuvant titration, and prognosis is now hours to days. After discussion with the family about goals, which is the most appropriate next step?

  1. Begin neuromuscular blockade
  2. Proportional sedation with midazolam Correct answer.
  3. Escalate the opioid every 15 minutes until unresponsive
  4. Discontinue all analgesics to clarify consciousness

Explanation

When pain or other symptoms remain refractory at the end of life, proportional palliative sedation with a benzodiazepine such as midazolam, titrated to the minimum level needed for comfort, is accepted practice after a goals-of-care discussion and informed consent. The intent is relief of suffering, not hastening death. Neuromuscular blockade is never used for symptom control because it does not relieve distress and can paralyze a conscious patient.

Question 20Pain assessment and management

Which patient is an appropriate candidate for a transdermal fentanyl patch?

  1. A patient with acute postoperative pain
  2. A patient with rapidly escalating uncontrolled pain
  3. An opioid-naive patient with new moderate back pain
  4. A patient on stable oral morphine Correct answer.

Explanation

Transdermal fentanyl is indicated only for opioid-tolerant patients whose pain is stable, because absorption is slow (12 to 24 hours to steady state) and dose changes take days to be reflected. It is unsafe in opioid-naive patients and inappropriate for acute or rapidly changing pain. A short-acting opioid is still needed for breakthrough pain.

Question 21Pain assessment and management

A patient with advanced cancer is rotated to methadone because of poor analgesia and neurotoxicity on high-dose morphine. Which monitoring is most important after initiation?

  1. Weekly serum lipase
  2. Serial electrocardiograms for QT prolongation Correct answer.
  3. Serial liver enzymes for hepatotoxicity
  4. Monthly serum ferritin

Explanation

Methadone prolongs the QTc in a dose-dependent manner and can precipitate torsades de pointes, so a baseline ECG and periodic QTc monitoring are recommended, particularly at higher doses or with other QT-prolonging drugs. Methadone also has a long and variable half-life, so titration must be slow to avoid delayed accumulation. Potassium and magnesium should be corrected.

Question 22Pain assessment and management

A patient on high-dose parenteral hydromorphone develops diffuse myoclonus, worsening pain despite dose increases, and allodynia. What is the most likely explanation?

  1. Opioid withdrawal from underdosing
  2. Opioid-induced neurotoxicity with hyperalgesia Correct answer.
  3. Serotonin syndrome from hydromorphone
  4. Disease progression requiring further escalation

Explanation

Myoclonus, hyperalgesia, allodynia, and delirium in a patient escalating on high-dose opioids indicate opioid-induced neurotoxicity from accumulating metabolites. Treatment is opioid rotation or dose reduction, hydration, and symptomatic control of myoclonus, often with a benzodiazepine. Continuing to escalate the same opioid worsens the picture.

Question 23Pain assessment and management

A patient with refractory cancer pain reports 8 out of 10 pain despite intravenous morphine 300 mg per day plus adjuvants. Which is the most appropriate addition?

  1. A second strong opioid at a full equianalgesic dose
  2. Doubling the morphine dose every 4 hours
  3. Topical lidocaine over the most painful area
  4. A low-dose ketamine infusion Correct answer.

Explanation

Low-dose ketamine, an NMDA-receptor antagonist, is used as an adjunct for refractory cancer pain, particularly neuropathic or opioid-tolerant pain, and may reduce opioid requirements. It is started at low doses and titrated while monitoring for psychotomimetic effects such as dysphoria and hallucinations. Specialty consultation is appropriate when this is considered.

Question 24Pain assessment and management

A patient with painful osteolytic rib metastases from breast cancer has partial relief from oxycodone. Which intervention is most likely to provide durable local analgesia?

  1. Topical lidocaine at the tender site
  2. Systemic chemotherapy alone
  3. A slow corticosteroid taper over eight weeks
  4. Palliative external-beam radiotherapy Correct answer.

Explanation

External-beam radiotherapy (for example 8 Gy in a single fraction or 30 Gy in 10 fractions) relieves painful bone metastases in most patients, with response often beginning within one to two weeks and lasting months. It is targeted, well tolerated, and can be combined with analgesics and bone-modifying agents. Corticosteroids are used for cord or nerve compression rather than as primary treatment of bone pain.

Question 25Pain assessment and management

A breastfeeding mother is prescribed codeine for postpartum pain. Which concern is most relevant?

  1. Codeine's active metabolite is normeperidine
  2. Ultrarapid CYP2D6 metabolism can cause infant morphine toxicity Correct answer.
  3. Codeine is safer than morphine during breastfeeding
  4. Codeine causes neonatal hypoglycemia

Explanation

Codeine is a prodrug converted by CYP2D6 to morphine; ultrarapid metabolizers convert more efficiently and can produce high morphine concentrations in breast milk, leading to infant sedation and respiratory depression. Regulatory agencies advise avoiding codeine in breastfeeding mothers. Genetic testing is not routine, so an alternative analgesic is preferred.

Question 26Pain assessment and management

An 84-year-old nursing home resident with advanced Alzheimer disease cannot report pain. Which tool is most appropriate for assessing pain?

  1. McGill Pain Questionnaire
  2. 11-point numeric rating scale
  3. 100-mm visual analog scale
  4. PAINAD behavioral scale Correct answer.

Explanation

The PAINAD relies on observable behaviors such as breathing, facial expression, and consolability and is validated for advanced dementia. Instruments that require self-report presuppose the ability to understand and respond to a scale.

Question 27Pain assessment and management

Which medication should be started routinely when a patient begins a strong opioid for chronic cancer pain?

  1. Famotidine
  2. Loperamide
  3. Senna with docusate Correct answer.
  4. Ondansetron

Explanation

Constipation is an expected, persistent effect of strong opioids and does not resolve with tolerance. A stimulant laxative such as senna, often combined with docusate, should be started prophylactically.

Question 28Pain assessment and management

A patient with cancer reports unchanged pain intensity but is increasingly distressed by fears about dying and by financial strain. Which concept best accounts for the worsening suffering?

  1. Incident pain
  2. Referred pain
  3. Neuropathic pain
  4. Total pain Correct answer.

Explanation

Total pain describes suffering arising from physical, psychological, social, and spiritual dimensions. Addressing only nociception will not relieve the patient's distress when other domains are driving it.

Question 29Pain assessment and management

A 58-year-old with type 2 diabetes has burning pain in both feet from diabetic peripheral neuropathy. Renal function is normal. Which oral medication is a first-line treatment?

  1. Naproxen
  2. Amitriptyline
  3. Tramadol
  4. Duloxetine Correct answer.

Explanation

Duloxetine, gabapentin, and pregabalin are first-line options for painful diabetic neuropathy. Tricyclics are generally second-line in older adults because of anticholinergic and cardiac effects.

Question 30Pain assessment and management

A patient with stable cancer pain has severe pain each time a surgical wound is cleaned. The pain begins within minutes of starting the dressing change and lasts about 20 minutes. Which is the most appropriate management?

  1. Increase the long-acting opioid dose
  2. Give a short-acting opioid 20 to 30 minutes before the dressing change Correct answer.
  3. Apply a lidocaine patch after the dressing change
  4. Add a long-acting NSAID at bedtime

Explanation

This is predictable incident pain triggered by a procedure. A short-acting opioid given about 20 to 30 minutes beforehand treats the episode without escalating baseline therapy.

Question 31Pain assessment and management

A 76-year-old with osteoarthritis has an eGFR of 32 mL/min/1.73 m2 and a history of peptic ulcer disease. Which oral analgesic is most appropriate for chronic use?

  1. Ibuprofen
  2. Acetaminophen Correct answer.
  3. Naproxen plus omeprazole
  4. Indomethacin

Explanation

Acetaminophen is preferred for chronic osteoarthritis pain in a patient with renal impairment and prior ulcer disease. Oral NSAIDs increase the risk of acute kidney injury and gastrointestinal bleeding.

Question 32Pain assessment and management

A patient with painful diabetic neuropathy and an eGFR of 25 mL/min/1.73 m2 is starting gabapentin. What is the most appropriate dosing adjustment?

  1. Double the usual adult dose
  2. Reduce the daily dose and titrate slowly Correct answer.
  3. Use the usual adult dose
  4. Give the full dose only on dialysis days

Explanation

Gabapentin is eliminated renally, so accumulation can cause sedation, dizziness, and myoclonus. The daily dose should be reduced and titrated according to renal function and response.

Question 33Pain assessment and management

An 82-year-old frail woman with cancer pain is starting an opioid. She is opioid-naive. Which approach is best?

  1. Start with a transdermal fentanyl patch
  2. Start with sustained-release morphine twice daily
  3. Start at the usual adult dose and reassess weekly
  4. Start at a lower dose and titrate frequently Correct answer.

Explanation

Frail older adults have reduced clearance and greater sensitivity to opioids. Starting at a lower dose and titrating frequently reduces toxicity while allowing analgesia.

Question 34Pain assessment and management

A patient with cancer starting an opioid develops nausea. The patient has no vomiting or bowel obstruction. What is the most appropriate initial management?

  1. Increase the opioid dose
  2. Add a scheduled antiemetic and continue the opioid Correct answer.
  3. Stop the opioid permanently
  4. Give oral naloxone

Explanation

Opioid-induced nausea often improves within days as tolerance develops. A scheduled antiemetic is preferred while continuing analgesia.

Question 35Pain assessment and management

A 52-year-old with chronic pain is taking buprenorphine/naloxone 8/2 mg twice daily and is admitted with a femur fracture. Which statement about providing additional analgesia is most accurate?

  1. Adding a full agonist reliably gives additive analgesia at usual doses
  2. High mu affinity can blunt full agonists, so higher doses may be needed Correct answer.
  3. Oral naloxone in the product blocks all analgesia
  4. Buprenorphine lacks analgesic effect, so usual full-agonist doses apply

Explanation

Buprenorphine is a partial mu agonist with high receptor affinity and can attenuate the effects of added full agonists. Patients with acute pain may require higher full-agonist doses, discontinuation of buprenorphine, or specialist-guided multimodal analgesia.

Question 36Pain assessment and management

A patient with opioid use disorder on methadone maintenance is admitted with severe acute pain from pancreatitis. The patient is stable and asks for pain relief. Which is the most appropriate approach?

  1. Stop methadone and start a fentanyl patch
  2. Prescribe only as-needed tramadol because it has lower abuse potential
  3. Withhold every opioid because the patient has a substance use disorder
  4. Continue methadone and add short-acting opioids for the acute pain Correct answer.

Explanation

Acute pain should be treated aggressively while maintenance therapy is continued to prevent withdrawal. Scheduled and as-needed short-acting full agonists are appropriate, with close monitoring and a structured plan.

Question 37Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

A patient with metastatic lung cancer and an oxygen saturation of 97% on room air reports persistent breathlessness at rest. Which pharmacologic approach is the most appropriate first-line treatment?

  1. Low-dose oral morphine titrated to symptom relief Correct answer.
  2. High-flow supplemental oxygen by nasal cannula
  3. Intravenous furosemide twice daily
  4. Scheduled nebulized albuterol every 6 hours

Explanation

Breathlessness in advanced disease is driven largely by increased central ventilatory drive and altered perception rather than by hypoxemia alone, so systemic opioids are the best-evidence first-line drug. Low doses improve breathlessness even when oxygenation is normal. Oxygen is reserved for documented hypoxemia.

Question 38Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

A patient is starting scheduled oral morphine for cancer pain and has no prior history of constipation. Which intervention should be started at the same time?

  1. A scheduled stimulant laxative such as senna Correct answer.
  2. No prophylactic laxative until constipation develops
  3. Daily docusate as monotherapy
  4. A bulk-forming fiber supplement alone

Explanation

Mu-opioid agonism slows colonic transit and reduces intestinal secretion, so a stimulant laxative is recommended prophylactically at opioid initiation rather than after constipation appears. Waiting allows fecal impaction and overflow to develop.

Question 39Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

Which antiemetic is the most appropriate choice for nausea caused by delayed gastric emptying in a patient with advanced pancreatic cancer?

  1. Metoclopramide given before meals Correct answer.
  2. Dimenhydrinate every 6 hours
  3. Scopolamine transdermal patch
  4. Ondansetron orally disintegrating tablet

Explanation

Metoclopramide accelerates gastric emptying and also blocks dopamine receptors in the chemoreceptor trigger zone, so it addresses nausea from gastroparesis. It works best when given about 30 minutes before meals. Anticholinergic and antihistamine agents further slow emptying and may worsen symptoms.

Question 40Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

A hospitalized patient with advanced cancer develops agitated delirium with fluctuating attention and hyperactive behavior that is distressing to staff and family. When a medication is needed, which agent is preferred first-line?

  1. Diphenhydramine at bedtime
  2. Chlordiazepoxide twice daily
  3. Haloperidol Correct answer.
  4. Lorazepam as needed

Explanation

Typical antipsychotics such as haloperidol are first-line for hyperactive delirium because they reduce agitation and perceptual disturbance without the paradoxic worsening seen with sedatives. Benzodiazepines are reserved for delirium caused by alcohol or sedative withdrawal.

Question 41Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

Which pharmacologic option has the best supporting evidence for cancer-related fatigue in a patient who is not depressed and has no reversible cause such as anemia or hypothyroidism?

  1. High-dose vitamin B12 injections
  2. Methylphenidate started at a low dose in the morning Correct answer.
  3. Propranolol twice daily
  4. Scheduled long-acting benzodiazepines

Explanation

Psychostimulants such as methylphenidate are the best-studied drug class for cancer-related fatigue and typically produce benefit within days. Dosing early in the day limits insomnia and appetite suppression.

Question 42Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

Which adverse effect should be anticipated and addressed when a palliative care patient begins scheduled ondansetron?

  1. Constipation Correct answer.
  2. Diarrhea
  3. Excess salivation
  4. Urinary retention

Explanation

5-HT3 receptor antagonists slow colonic transit and commonly produce constipation, so the bowel regimen should be reviewed and often intensified at initiation. This is especially important in patients already receiving opioids.

Question 43Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

Which agent is the best choice for nausea accompanied by prominent vertigo in a patient with advanced illness?

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

Explanation

Vestibular nausea is mediated by acetylcholine at the vestibular apparatus, making the anticholinergic scopolamine the agent of choice. Prokinetics and serotonin antagonists do not target that pathway.

Question 44Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

A patient with brain metastases has recurrent vomiting attributed to raised intracranial pressure. Which antiemetic is the most appropriate addition to therapy?

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

Explanation

Vomiting from raised intracranial pressure is best treated by reducing peritumoral edema with a corticosteroid such as dexamethasone. Other antiemetics may be used adjunctively but do not address the underlying mechanism.

Question 45Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

A patient with advanced COPD and lung cancer describes severe breathlessness but has an oxygen saturation of 96% on room air. The patient asks for oxygen. What is the most appropriate response?

  1. Start oxygen only during sleep to prevent nocturnal desaturation
  2. Order a repeat arterial blood gas before treating the symptom
  3. Prescribe continuous high-flow oxygen because breathlessness always reflects hypoxemia
  4. Explain that oxygen is unlikely to relieve breathlessness at this saturation and offer a low-dose opioid plus a fan Correct answer.

Explanation

When oxygenation is adequate, supplemental oxygen provides no consistent benefit over room air for the sensation of breathlessness, whereas opioids and airflow do. Oxygen is indicated for documented hypoxemia, not for dyspnea alone.

Question 46Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

Which nonpharmacologic measure has the most reliable immediate benefit for a breathless patient who is not hypoxemic?

  1. Deep, rapid breathing exercises
  2. A cool air current from a fan directed at the face Correct answer.
  3. Fluid restriction to 1 liter per day
  4. Strict bed rest in a supine position

Explanation

Cool airflow over the face stimulates trigeminal afferents and reduces the central perception of breathlessness; fans, open windows, and nasal cannula oxygen often work equally well for this purpose. Upright positioning and activity pacing add further benefit.

Question 47Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

A patient with peritoneal carcinomatosis has an inoperable malignant bowel obstruction with vomiting of 2 to 3 liters per day. Which medication should be added to reduce the volume of gastrointestinal secretions?

  1. Subcutaneous octreotide Correct answer.
  2. Oral psyllium with generous fluids
  3. Bisacodyl suppositories
  4. Metoclopramide by continuous infusion

Explanation

Somatostatin analogues such as octreotide reduce gastric and intestinal secretion and are a mainstay of medical management of inoperable malignant bowel obstruction. They decrease vomiting and relieve the need for nasogastric drainage.

Question 48Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

A patient with renal failure and a corrected calcium of 13.5 mg/dL has persistent nausea despite metoclopramide. Which antiemetic class best targets this mechanism?

  1. Cannabinoids
  2. Anticholinergics
  3. Dopamine antagonists such as haloperidol Correct answer.
  4. 5-HT3 antagonists

Explanation

Metabolic nausea from hypercalcemia or uremia is generated by stimulation of the chemoreceptor trigger zone, which is rich in dopamine receptors; haloperidol or another dopamine antagonist is therefore the logical choice. Treating the underlying metabolic abnormality is also essential.

Question 49Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

A patient with opioid-induced constipation has failed an adequate trial of stimulant laxatives. Which finding would make methylnaltrexone inappropriate?

  1. Concurrent use of a proton pump inhibitor
  2. A history of type 2 diabetes
  3. Mild chronic kidney disease
  4. Known or suspected mechanical bowel obstruction Correct answer.

Explanation

Methylnaltrexone is a peripherally acting mu-opioid antagonist that increases colonic motility and can cause severe cramping and perforation when the bowel is obstructed. It is therefore contraindicated in known or suspected mechanical obstruction.

Question 50Non-pain symptom management (dyspnea, nausea and vomiting, constipation, fatigue, delirium, anorexia-cachexia)

An opioid-treated patient has not had a bowel movement in 8 days; the rectum is loaded with hard stool and the patient reports leakage of liquid stool. What is the most appropriate next step?

  1. Increase the oral stimulant laxative dose and reassess in 48 hours
  2. Add loperamide for the loose stools
  3. Clear the impaction with a rectal intervention before continuing oral laxatives Correct answer.
  4. Start methylnaltrexone without disimpaction

Explanation

Liquid stool passing around a fecal impaction is overflow incontinence, not diarrhea. The impaction must be removed with digital or enema-based disimpaction before oral laxatives can be effective; otherwise cramping and obstruction persist.