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ACHPN practice questions

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Question 1Interdisciplinary Team Collaboration and Palliative Care Practice Models

Which discipline is a required member of the hospice interdisciplinary group under the Medicare hospice Conditions of Participation?

  1. Physician Correct answer.
  2. Physical therapist
  3. Music therapist
  4. Dietitian

Explanation

The Conditions of Participation require the interdisciplinary group to include a physician, a registered nurse, a social worker, and a pastoral or other counselor. Additional disciplines are added when the individualized plan of care calls for them.

Question 2Interdisciplinary Team Collaboration and Palliative Care Practice Models

A palliative care team is describing its services to a new oncology group. Which statement best defines the scope of palliative care?

  1. Relieves symptoms at any point in the illness Correct answer.
  2. Is limited to patients with a six-month prognosis
  3. Begins only after curative treatment has stopped
  4. Focuses mainly on bereavement after death

Explanation

Palliative care is delivered from diagnosis onward alongside disease-directed treatment and centers on symptom relief, communication, and quality of life. Prognosis limits and the end of curative therapy define hospice eligibility, not palliative care.

Question 3Interdisciplinary Team Collaboration and Palliative Care Practice Models

Which activity best represents the board-certified chaplain's contribution to the interdisciplinary team?

  1. Assesses spiritual and existential distress Correct answer.
  2. Completes psychosocial discharge planning
  3. Adjusts opioid doses during a crisis
  4. Authorizes insurance for hospice services

Explanation

Chaplains assess spiritual and existential suffering, including meaning, guilt, ritual, and faith concerns, and they accompany patients and families through those issues. Medication management, discharge planning, and authorization belong to other disciplines.

Question 4Interdisciplinary Team Collaboration and Palliative Care Practice Models

A hospice patient's pain and agitation cannot be controlled at home, so the team arranges short-term inpatient care with daily physician monitoring. Which level of hospice care is this?

  1. General inpatient care Correct answer.
  2. Routine home care
  3. Respite care in a facility
  4. Continuous home care at home

Explanation

General inpatient care is a short-term level for symptom crises that cannot be managed in the home or another setting and includes daily physician oversight. Routine, continuous, and respite levels address different needs.

Question 5Interdisciplinary Team Collaboration and Palliative Care Practice Models

What is the central purpose of the hospice interdisciplinary group meeting?

  1. Update the plan of care as a team Correct answer.
  2. Complete annual staff evaluations
  3. Assign on-call coverage for next week
  4. Verify billing codes for each home visit

Explanation

The interdisciplinary group meeting is where disciplines share observations, revise the individualized plan of care, and coordinate goals for each patient and family. Billing, scheduling, and personnel evaluation are separate administrative functions.

Question 6Interdisciplinary Team Collaboration and Palliative Care Practice Models

Under the Medicare hospice benefit, bereavement support must be available to the family for at least how long after the patient's death?

  1. One year after the death Correct answer.
  2. Thirteen months after the death
  3. Six months after the death
  4. Thirty days after the death

Explanation

Hospice regulations require bereavement counseling and support for the family for up to one year following the death. This service is part of the benefit and is provided by qualified staff or trained volunteers under the plan of care.

Question 7Interdisciplinary Team Collaboration and Palliative Care Practice Models

A family meeting is scheduled for a patient with advanced dementia. The surrogate daughter and two siblings disagree about feeding tubes. What should the facilitator do first?

  1. Elicit each person's view of the goals Correct answer.
  2. Recommend a DNR order early in the meeting
  3. Let the physician decide to avoid conflict
  4. Restrict discussion to the written directive

Explanation

Effective family meetings begin by establishing what each participant understands about the illness and what matters most to the patient, creating a shared foundation before options are weighed. Leading with a specific recommendation or removing the family from the decision forecloses that process.

Question 8Interdisciplinary Team Collaboration and Palliative Care Practice Models

Which contribution is specific to the palliative care pharmacist on the interdisciplinary team?

  1. Negotiate medication coverage with payers
  2. Recommend equianalgesic conversions Correct answer.
  3. Certify the terminal prognosis for hospice
  4. Complete the psychosocial assessment

Explanation

Pharmacists apply pharmacologic expertise to opioid rotation, equianalgesic conversion, drug interactions, and deprescribing, which reduces medication error at transitions. Prognosis certification, psychosocial assessment, and coverage negotiation belong to other roles.

Question 9Interdisciplinary Team Collaboration and Palliative Care Practice Models

A hospice nurse believes a patient's pain is undertreated, while the prescriber believes the current regimen is adequate. What is the most appropriate next step?

  1. Defer to the prescriber and end the discussion
  2. Escalate to the ethics committee immediately
  3. Document the disagreement and proceed anyway
  4. Use a structured team discussion of goals Correct answer.

Explanation

Interdisciplinary teams resolve clinical disagreement first through structured communication that shares assessment data, patient goals, and clinical rationale before formal escalation. Ethics consultation is reserved for unresolved value conflicts rather than routine practice differences.

Question 10Interdisciplinary Team Collaboration and Palliative Care Practice Models

Which situation is the most appropriate trigger for a palliative care ethics consultation?

  1. A patient asks to change a scheduled visit time
  2. The team disputes whether a treatment helps Correct answer.
  3. A family requests an interpreter for a meeting
  4. A caregiver requests written hospice information

Explanation

Ethics consultation addresses unresolved value-laden conflicts such as disputes over the benefit of a treatment, decisional authority, or potentially inappropriate interventions. Logistical and educational requests are managed by the care team.

Question 11Interdisciplinary Team Collaboration and Palliative Care Practice Models

A patient without decisional capacity has no written advance directive. Which standard should guide the surrogate decision maker?

  1. Select the option that prolongs life longest
  2. Follow the majority vote of the family
  3. Apply substituted judgment from known values Correct answer.
  4. Choose the least costly treatment option

Explanation

Surrogates first use substituted judgment, deciding as the patient would based on known values and preferences, and turn to a best-interests standard only when those preferences are unknown. Cost, family voting, and length of survival are not the governing standards.

Question 12Interdisciplinary Team Collaboration and Palliative Care Practice Models

Which finding most strongly suggests that a patient with advanced heart failure should be referred to specialty palliative care?

  1. The patient is on a stable diuretic regimen
  2. The patient asks about vitamin supplements
  3. The patient has one admission in five years
  4. Three admissions in the past six months Correct answer.

Explanation

Repeated hospitalizations within a short period signal high symptom burden, declining function, and unmet support needs, which are recognized triggers for palliative care referral. Stable regimens and isolated questions do not meet typical referral triggers.

Question 13Interdisciplinary Team Collaboration and Palliative Care Practice Models

A goals-of-care conversation is planned with a patient who has limited English proficiency. Which approach should the team use?

  1. Ask a bilingual neighbor to interpret
  2. Rely on a bilingual family member
  3. Speak slowly in English with gestures
  4. Use a trained medical interpreter Correct answer.

Explanation

Trained medical interpreters preserve accuracy and confidentiality in high-stakes discussions and are expected under accreditation and civil rights standards. Family members and untrained bystanders are prone to errors, role conflict, and breaches of privacy.

Question 14Interdisciplinary Team Collaboration and Palliative Care Practice Models

Which task falls most clearly within the palliative social worker's scope on the interdisciplinary team?

  1. Certifying eligibility for hospice
  2. Adjusting the opioid infusion rate
  3. Assessing caregiver burden Correct answer.
  4. Ordering durable medical equipment

Explanation

Social workers assess psychosocial needs, caregiver strain, financial and insurance concerns, and community resources, and they support advance care planning conversations. Medication titration, certification, and equipment ordering sit outside their scope.

Question 15Interdisciplinary Team Collaboration and Palliative Care Practice Models

A hospice nurse on the team repeatedly describes exhaustion and detachment from patients. What is the team leader's most appropriate first response?

  1. Address it at the next annual review
  2. Discuss workload and offer supportive resources Correct answer.
  3. Remind the nurse that self-care is personal
  4. Permanently reassign the nurse to clerical duties

Explanation

Leaders should recognize compassion fatigue early, open a supportive conversation about workload and exposure, and connect staff with debriefing, employee assistance, or resilience resources. Punitive reassignment or delay allows distress to worsen and can affect patient care.

Question 16Interdisciplinary Team Collaboration and Palliative Care Practice Models

Which approach best reflects shared decision making in palliative care?

  1. The team follows the directive without discussion
  2. The family chooses alone among all options
  3. Clinician and patient share views and agree Correct answer.
  4. The clinician selects the plan and informs the family

Explanation

Shared decision making combines the clinician's evidence-based recommendation with the patient's values and preferences to reach a mutually endorsed plan. Neither clinician unilateralism nor unguided family choice meets that standard.

Question 17Interdisciplinary Team Collaboration and Palliative Care Practice Models

Which task may the hospice registered nurse delegate to a hospice aide?

  1. Teach the caregiver about opioid safety
  2. Provide a bath and skin observation Correct answer.
  3. Adjust the medication infusion rate
  4. Complete the pain assessment

Explanation

Unlicensed aides may provide personal care and report observations, but assessment, teaching, and medication management require a licensed clinician under delegation rules. The registered nurse retains accountability for the plan of care.

Question 18Interdisciplinary Team Collaboration and Palliative Care Practice Models

A home hospice patient is hospitalized for a hip fracture. Which action best preserves continuity of the palliative plan?

  1. Transfer the case to the hospitalist service
  2. Repeat the full admission assessment on arrival
  3. Send written goals and care plan ahead Correct answer.
  4. Suspend hospice contact during the admission

Explanation

Continuity depends on transmitting the goals of care, current medications, and individualized plan to the receiving team so treatment remains goal concordant. Abandoning or duplicating the plan fragments care and increases the risk of error.

Question 19Interdisciplinary Team Collaboration and Palliative Care Practice Models

In a consultative palliative care model, the palliative team typically:

  1. Replaces the referring oncology team for the episode
  2. Provides services only after hospice enrollment
  3. Advises the team that keeps primary responsibility Correct answer.
  4. Takes over primary responsibility for all decisions

Explanation

Consultative models add expertise in symptom management and communication while the primary team retains responsibility, which suits patients who continue disease-directed therapy. Primary-responsibility and hospice-only structures describe different models.

Question 20Interdisciplinary Team Collaboration and Palliative Care Practice Models

A patient with end-stage neuromuscular disease has refractory breathlessness and agitation despite maximal therapy. The team discusses palliative sedation. Which principle should guide the discussion?

  1. Ethics approval is needed in every case
  2. The aim is symptom relief, not hastened death Correct answer.
  3. The goal of sedation is to shorten the dying process
  4. The patient must be imminently dying

Explanation

Palliative sedation is titrated to relieve refractory suffering with the intent to comfort rather than to hasten death, a distinction supported by the doctrine of double effect. It is considered when symptoms are refractory and does not require imminent death or mandatory ethics review.

Question 21Communication, Goals-of-Care Discussions, and Advance Care Planning

A patient asks a nurse what a durable power of attorney for health care (DPOAHC) does. Which description is most accurate?

  1. It is a physician's order that limits life-sustaining treatments in an emergency.
  2. It authorizes an attorney to manage the patient's financial affairs after death.
  3. It transfers guardianship of the patient to the state once illness is terminal.
  4. It names someone to make health care decisions if the patient loses capacity. Correct answer.

Explanation

A DPOAHC is a written advance directive that appoints a health care agent to speak for the patient only when the patient cannot make or communicate decisions. It takes effect on a loss of capacity and applies to health care decisions, not finances or estate matters. It is not a physician order and does not shift guardianship to the state.

Question 22Communication, Goals-of-Care Discussions, and Advance Care Planning

A living will differs from other advance directives because it primarily:

  1. names a surrogate decision maker for health care
  2. records treatment preferences for specific future situations Correct answer.
  3. takes effect only after a court has formally determined that the patient lacks capacity
  4. is a set of physician orders that remains valid in every care setting

Explanation

A living will is an instructional directive that records the patient's preferences for treatments such as mechanical ventilation or artificial nutrition in specified future circumstances. It does not name a surrogate and is not a set of portable medical orders. It does not require a court determination of incapacity.

Question 23Communication, Goals-of-Care Discussions, and Advance Care Planning

Which characteristic distinguishes a POLST form from a standard advance directive?

  1. It is a signed medical order that travels across care settings. Correct answer.
  2. It replaces the need for any discussion of goals of care.
  3. It must be notarized before it can be honored.
  4. It can be completed only by patients who are already enrolled in hospice care.

Explanation

A POLST is a clinician-signed medical order that converts a patient's preferences into actionable instructions that follow the patient across settings, including emergency care. It is intended for people with serious illness or frailty and does not require hospice enrollment. Completing it does not remove the need for ongoing goals-of-care conversation.

Question 24Communication, Goals-of-Care Discussions, and Advance Care Planning

The SPIKES protocol for breaking bad news begins with which step?

  1. Inviting the patient's emotional response before any information is given
  2. Delivering all of the information at once in a single, detailed disclosure
  3. Summarizing a treatment plan the team has already agreed upon
  4. Setting up the interview with attention to privacy and who is present Correct answer.

Explanation

SPIKES stands for Setting up the interview, assessing the patient's Perception, obtaining an Invitation, giving Knowledge, addressing Emotions with empathy, and Strategy and Summary. The first step is preparing the setting, ensuring privacy, and deciding who should be present. Disclosure is tailored to what the patient wants to know rather than delivered all at once.

Question 25Communication, Goals-of-Care Discussions, and Advance Care Planning

A surrogate who applies the substituted judgment standard makes decisions by:

  1. following the majority opinion of the patient's adult children
  2. applying the treatment that most patients in similar circumstances choose
  3. choosing as the patient would have chosen, based on his or her values Correct answer.
  4. selecting the option that produces the greatest net benefit as judged by the care team

Explanation

Substituted judgment asks the surrogate to replicate the decision the patient would have made, using the patient's stated wishes, values, and life pattern. It is distinct from the best interest standard, which is used when the patient's wishes are unknown. It is not a team vote or a family majority vote.

Question 26Communication, Goals-of-Care Discussions, and Advance Care Planning

In the NURSE mnemonic for responding to strong emotion, the "N" stands for:

  1. Negotiating a treatment plan
  2. Notifying the family
  3. Naming the emotion Correct answer.
  4. Noting the prognosis in the chart

Explanation

NURSE stands for Name, Understand, Respect, Support, and Explore. Naming the emotion means stating what you observe, such as "it sounds as if you are frightened." It is a communication tool for acknowledging affect, not a planning or documentation step.

Question 27Communication, Goals-of-Care Discussions, and Advance Care Planning

Which patient is able to execute an advance directive?

  1. A 30-year-old with multiple sclerosis who understands the form and its consequences Correct answer.
  2. A 45-year-old who is sedated and intubated in the intensive care unit
  3. A 60-year-old who is actively delirious and disoriented to place and time
  4. A 78-year-old with moderate dementia who cannot state a choice or describe the document

Explanation

Executing an advance directive requires decision-making capacity: the ability to understand the information, appreciate how it applies, reason about options, and communicate a choice. A neurologic diagnosis alone does not disqualify a patient if capacity is intact. Sedation, delirium, and advanced dementia that prevent understanding do preclude it at that moment.

Question 28Communication, Goals-of-Care Discussions, and Advance Care Planning

A patient with capacity names her daughter as her health care agent. Which statement about information sharing is correct?

  1. The daughter may receive information only if the patient signs a separate written release at each encounter.
  2. The daughter may receive information only about financial matters, not clinical care.
  3. The daughter may receive information only after the patient dies.
  4. The daughter may receive health information relevant to care once her authority is established. Correct answer.

Explanation

Under HIPAA, a person legally authorized to make health care decisions is treated as the patient's personal representative and may receive protected health information relevant to that role. No separate release is needed for each encounter once the agent's authority is documented. A health care agent's authority is unrelated to financial matters.

Question 29Communication, Goals-of-Care Discussions, and Advance Care Planning

Which opening best follows the Ask-Tell-Ask approach when discussing goals of care with a patient newly referred to palliative care?

  1. Your scan shows the cancer has grown, so we should talk about hospice.
  2. I'm going to explain the plan the team has decided on for you.
  3. There's nothing more we can do, so let's focus on comfort.
  4. What is your understanding so far of how things are going? Correct answer.

Explanation

Ask-Tell-Ask begins by eliciting the patient's current understanding and concerns before providing information, then checking understanding afterward. This tailors the amount and content of information to the patient. Opening with an immediate disclosure or a pre-formed plan skips the assessment step.

Question 30Communication, Goals-of-Care Discussions, and Advance Care Planning

Who is responsible for determining whether a hospitalized patient has decision-making capacity for a specific medical decision?

  1. The patient's health care agent, who decides whether the patient can decide
  2. The hospital risk manager, who reviews the chart
  3. The treating clinician, at the time the decision is needed Correct answer.
  4. A judge, who must issue a ruling before treatment decisions are made

Explanation

Capacity is a clinical determination made by the treating clinician at the time of the specific decision, assessing understanding, appreciation, reasoning, and expression of choice. It is decision-specific and can change with the patient's condition. Courts are involved for competence determinations or guardianship, not routine bedside capacity assessment.

Question 31Communication, Goals-of-Care Discussions, and Advance Care Planning

The best interest standard is most appropriately applied when:

  1. the surrogate wants to override the patient's documented directive
  2. the patient never expressed wishes and they cannot be reasonably inferred Correct answer.
  3. the patient has capacity and can state a choice
  4. the patient left a clear written statement of preferences

Explanation

Best interest weighs benefits and burdens from the patient's perspective and is used when the patient's own wishes are unknown and cannot be inferred. When a patient has capacity, the patient decides. A surrogate may not use best interest to override a documented directive that applies to the situation.

Question 32Communication, Goals-of-Care Discussions, and Advance Care Planning

A family meeting is planned for a patient who speaks limited English. The most appropriate arrangement is to:

  1. speak only to the English-speaking family members and let them relay information
  2. use a trained medical interpreter, in person or by video or phone Correct answer.
  3. ask the patient's 12-year-old grandchild, who is bilingual, to interpret
  4. use the patient's adult son so that family privacy is preserved

Explanation

Trained interpreters support accuracy, confidentiality, and neutral conveyance of nuanced goals-of-care content. Using children is inappropriate and places a burden on them, and using relatives risks errors, editing, and role conflict. Relaying information secondhand through family members may distort the patient's understanding and wishes.

Question 33Communication, Goals-of-Care Discussions, and Advance Care Planning

Which statement about the timing of goals-of-care discussions is most accurate?

  1. They should be deferred until all curative treatment options have been exhausted.
  2. They should be initiated only at the request of the patient or family.
  3. They should occur only once, at the time of hospice enrollment.
  4. They should begin early in serious illness, not only in the final days of life. Correct answer.

Explanation

Goals-of-care conversations are most useful when they occur early and are revisited as illness and preferences evolve, while the patient can still participate. Waiting until dying or until all treatment options are exhausted removes the opportunity for meaningful planning. Clinicians should initiate these discussions rather than waiting for the family to ask.

Question 34Communication, Goals-of-Care Discussions, and Advance Care Planning

A hospitalized patient with capacity tells the team she wants to be "DNR." Which action is required for this preference to be honored in the hospital?

  1. The patient must repeat the request in front of two witnesses.
  2. A clinician must write a DNR order in the medical record. Correct answer.
  3. The hospital ethics committee must review the request.
  4. The family must sign a consent form agreeing to the order.

Explanation

A DNR preference becomes actionable when an authorized clinician writes and documents the order in the medical record; verbal preferences alone do not direct resuscitation practice. The patient with capacity is the decision maker, so family consent is not required. Ethics review and witness requirements are not routine steps.

Question 35Communication, Goals-of-Care Discussions, and Advance Care Planning

A patient's advance directive declines mechanical ventilation, but his adult children demand that "everything be done." What should the team do?

  1. Ask the ethics committee to appoint a guardian before acting
  2. Follow the family's request, since they are the legal next of kin
  3. Place the patient on a ventilator for a time-limited trial while the dispute is resolved
  4. Honor the patient's documented wishes and explain them to the family with empathy Correct answer.

Explanation

A valid advance directive made by a patient with capacity carries the patient's authority and takes precedence over family preferences. The team's obligation is to follow the directive and to communicate with the family compassionately about the patient's stated values. A time-limited trial requires surrogate authority consistent with the patient's wishes, which is absent here.

Question 36Communication, Goals-of-Care Discussions, and Advance Care Planning

When caring for a patient from a culture in which family members typically make medical decisions together, the nurse should first:

  1. limit the information given to the patient to avoid causing distress
  2. ask the patient how much he wants to know and who should be involved in decisions Correct answer.
  3. assume the eldest son will act as the decision maker
  4. insist that the patient state his own preference privately before the meeting

Explanation

Respecting autonomy includes asking the patient how information should be shared and who should participate in decisions, rather than imposing or assuming a family style. Assumptions about a designated decision maker can be wrong and may exclude the patient. Withholding information without the patient's direction undermines informed choice.

Question 37Communication, Goals-of-Care Discussions, and Advance Care Planning

Which is the most important reason to document a goals-of-care conversation in the medical record?

  1. It transfers legal responsibility for the decision to the clinician who documented the conversation.
  2. It is required before a patient may be enrolled in hospice.
  3. It replaces the need for a written advance directive.
  4. It makes the patient's wishes available to covering clinicians at night and on weekends. Correct answer.

Explanation

Documentation preserves the patient's stated goals across handoffs, shifts, and settings so that care remains consistent with those wishes. Documentation does not shift decision-making responsibility to the clinician. A conversation note complements rather than replaces a formal directive.

Question 38Communication, Goals-of-Care Discussions, and Advance Care Planning

A patient without capacity has no named health care agent. In most U.S. states, decision-making authority typically passes to:

  1. a court-appointed guardian or the spouse, depending on state statute Correct answer.
  2. the oldest adult child, in all states
  3. the patient's closest friend, if the friend has known the patient longest
  4. the physician, who may decide unilaterally when no agent is named

Explanation

States define a default hierarchy of surrogate decision makers, commonly beginning with a court-appointed guardian and then a spouse, followed by adult children, parents, and siblings. Exact ordering varies by statute. A physician does not decide unilaterally, and long friendship generally ranks near the end of the list, if included at all.

Question 39Communication, Goals-of-Care Discussions, and Advance Care Planning

A patient with advanced heart failure asks, "How long do I have?" Which response best reflects recommended communication practice?

  1. "Probably a few weeks, based on your most recent test results and my experience."
  2. "Don't worry - you have years ahead of you."
  3. "I can't answer that, because every patient's course is different."
  4. "I can share the range of what is known, and we can plan together." Correct answer.

Explanation

Honest prognostic information is best offered as a realistic range paired with a plan for what matters to the patient, which supports hope and planning simultaneously. False reassurance and refusal to answer both close down the conversation. A single precise estimate overstates certainty.

Question 40Communication, Goals-of-Care Discussions, and Advance Care Planning

Which document best captures a patient's values and preferences in narrative form for later use by a surrogate?

  1. A values history or a document such as Five Wishes Correct answer.
  2. A HIPAA authorization form
  3. A durable power of attorney for health care naming an adult daughter
  4. A do-not-resuscitate order signed by the attending physician

Explanation

Values-based documents record what matters to the patient, in the patient's own words, which helps a surrogate interpret wishes in unanticipated situations. A DPOAHC names an agent but may not itself state values. A DNR order and a HIPAA authorization serve different, narrower purposes.

Question 41Communication, Goals-of-Care Discussions, and Advance Care Planning

An older patient with advanced cancer and new-onset delirium tells the team he wants to stop dialysis. What is the most appropriate action?

  1. Ask the family to make the decision, since the patient is confused.
  2. Decline the request, because delirious patients never have capacity.
  3. Honor the request immediately, because patients may refuse treatment at any time.
  4. Treat the delirium and reassess capacity before acting on the request. Correct answer.

Explanation

Delirium is often reversible and capacity can fluctuate, so the priority is to identify and treat the cause and then reassess the specific decision. A request expressed during delirium may or may not reflect the patient's settled wishes. Transferring the decision to family or dismissing the request outright both bypass the patient.

Question 42Communication, Goals-of-Care Discussions, and Advance Care Planning

A patient with capacity who has a DNR order tells the nurse, "I've changed my mind - I want to be full code." Which response is correct?

  1. The patient must wait 24 hours before the order can be revoked.
  2. The nurse should notify the clinician so the DNR order can be revoked. Correct answer.
  3. Because the family agreed to the DNR, all family members must agree to revoke it.
  4. The patient must appear before the ethics committee to change the order.

Explanation

A patient with capacity may revoke a DNR order at any time, and the clinician should be notified so the order is cancelled and the change documented. No waiting period, committee review, or family consent is required. The nurse advocates for and facilitates the patient's expressed change of mind.

Question 43Communication, Goals-of-Care Discussions, and Advance Care Planning

A 16-year-old with relapsed leukemia and intact cognition wants to discuss her goals with the team, while her parents prefer to "handle the medical talk." What is the most appropriate approach?

  1. Ask what she wants to know and include her, while addressing the parents' concerns. Correct answer.
  2. Hold the discussion with the patient alone and exclude the parents.
  3. Tell the patient she may participate only after she turns 18.
  4. Defer all discussion to the parents because the patient is a minor and cannot consent.

Explanation

Adolescents with decision-making capacity should be offered information and included in discussions through assent, with parents retaining legal decision-making authority in most circumstances. Excluding the patient disregards her developing autonomy and may increase distress. Excluding the parents undermines the family unit and the parents' role.

Question 44Communication, Goals-of-Care Discussions, and Advance Care Planning

A patient's family asks the team not to tell the patient that his cancer is terminal. The patient is alert and cognitively intact and asks the nurse directly, "Am I dying?" Which response is best?

  1. Explore the family's concerns and the patient's preferences, then answer honestly. Correct answer.
  2. "Your family has asked us not to discuss this with you."
  3. "You should ask your family; they have all the information."
  4. "I'm not allowed to answer that question."

Explanation

The patient with capacity controls what information he receives, and requests for nondisclosure are best understood as a request to communicate carefully and to check what the patient wants to know. The nurse should acknowledge the family's cultural or protective concerns while honoring the patient's right to truthful information. Deferring to family or refusing to answer violates that right.

Question 45Communication, Goals-of-Care Discussions, and Advance Care Planning

A family is divided about whether to continue mechanical ventilation for a patient whose recovery is uncertain. Which approach best supports shared decision making?

  1. Continue ventilation indefinitely until the family reaches unanimous agreement.
  2. Propose a time-limited trial with explicit goals and a set review date. Correct answer.
  3. Refer the case to ethics and postpone all discussion until a decision is issued.
  4. Allow the clinician to withdraw ventilation rather than prolong disagreement.

Explanation

A time-limited trial defines the treatment goal, the duration, and the criteria that will determine whether to continue, giving the family a structured way to decide without indefinite drift. Indefinite continuation defers the decision without a plan, and unilateral clinician action bypasses the surrogate. Ethics consultation is a resource for unresolved conflict but does not replace ongoing communication.

Question 46Communication, Goals-of-Care Discussions, and Advance Care Planning

A clinician completes a POLST (Practitioner Orders for Life-Sustaining Treatment) form with a patient who has advanced illness. Which statement best describes this document?

  1. It may be completed only after the patient has been formally determined to lack decision-making capacity.
  2. It is a legal advance directive in which the patient names a health care agent and that takes effect only once the patient loses capacity.
  3. It is a set of actionable medical orders, signed by a clinician, that travels with the patient across care settings. Correct answer.
  4. It permanently replaces the patient's living will and is recognized in every state regardless of how it is formatted.

Explanation

A POLST/MOLST converts a seriously ill patient's preferences into concrete, portable medical orders (for example, about CPR and artificial nutrition) that clinicians are expected to follow in any setting. It is signed by a clinician and, unlike a living will, is a set of orders rather than a general statement of values or an agent designation.

Question 47Communication, Goals-of-Care Discussions, and Advance Care Planning

A patient's daughter, serving as his health care agent, authorizes continuing dialysis because her father repeatedly said that before losing capacity he wanted any treatment that might allow him to attend his granddaughter's wedding. She personally believes the treatment is burdensome. Which decision-making standard is she applying?

  1. Shared decision-making model
  2. Substituted judgment standard Correct answer.
  3. Therapeutic privilege
  4. Best interest standard

Explanation

Substituted judgment requires the surrogate to decide as the patient would have decided, using knowledge of the patient's previously expressed wishes, values, and goals, even if the surrogate would choose differently for herself. Surrogates are expected to set aside their personal preferences when the patient's wishes are known.

Question 48Communication, Goals-of-Care Discussions, and Advance Care Planning

A patient with capacity and untreated but treatable major depression refuses chemotherapy for a highly curable lymphoma, saying, "I just don't see the point." What should the team do first?

  1. Convene the ethics committee promptly to obtain authorization to treat over the patient's objection.
  2. Honor the refusal, because a patient who has capacity has an absolute legal right to decline any recommended treatment.
  3. Assess whether depression is impairing decision-making capacity for this choice before accepting the refusal. Correct answer.
  4. Obtain consent for chemotherapy from the patient's spouse, since the patient is not acting in his own interest.

Explanation

A refusal is authoritative only if the patient has decision-making capacity for that specific decision and is acting voluntarily with adequate understanding. Depression can distort a patient's appraisal of options and future, so the appropriate first step is to assess the effect of the depression on capacity and treat it, then revisit the decision; a sustained capacitated refusal is honored.

Question 49Pain Assessment and Management

Which statement best defines pain according to the International Association for the Study of Pain?

  1. A physical sensation that is always directly proportional to the amount of tissue injury
  2. An unpleasant sensory and emotional experience linked to actual or potential tissue damage Correct answer.
  3. A protective reflex that resolves completely once the underlying tissue has healed
  4. A psychological reaction that occurs only when no organic cause can be identified

Explanation

Pain is defined as a sensory and emotional experience, not merely a physical sensation, and it can occur with or without demonstrated tissue damage. The definition emphasizes that pain is subjective and may persist after healing.

Question 50Pain Assessment and Management

A patient with long-standing diabetes describes burning, electric-shock pain in both feet along with pain from light touch. Which pain mechanism is most likely?

  1. Nociceptive somatic pain from bone metastasis
  2. Neuropathic pain from peripheral nerve injury Correct answer.
  3. Referred pain from hip osteoarthritis
  4. Visceral pain from bowel obstruction

Explanation

Burning, electric-shock quality and allodynia are classic features of neuropathic pain caused by injury or disease of the somatosensory nervous system. Diabetic peripheral neuropathy is a common cause.