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Canada PCOC practice questions

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Question 1Patient Care and Therapeutic Decision-Making

A patient receiving long-acting opioid therapy for cancer pain reports new severe pain that is not relieved by their scheduled dose. Which action is the most appropriate first step in reassessing the pain?

  1. Immediately increase the scheduled long-acting opioid dose by 50%
  2. Perform a focused reassessment of the new pain, including location, quality, timing, and associated symptoms Correct answer.
  3. Delay reassessment until the next scheduled clinic visit
  4. Discontinue the long-acting opioid and start a non-opioid alone

Explanation

New or escalating pain during opioid therapy requires focused reassessment to identify whether the cause is disease progression, a new pathology, or inadequate analgesia before changing the regimen. Dose changes made without assessment risk missing a treatable cause and may cause harm.

Question 2Patient Care and Therapeutic Decision-Making

Which bowel regimen is standard supportive care when initiating regular opioid therapy in a palliative patient without contraindication?

  1. An as-needed antidiarrheal agent
  2. A scheduled stimulant laxative with or without a stool softener Correct answer.
  3. No prophylaxis until constipation develops
  4. A bulk-forming fiber supplement alone

Explanation

Opioids predictably cause constipation through reduced gastrointestinal motility, so prophylactic scheduled laxatives are recommended rather than waiting for symptoms. A stimulant laxative, often combined with a stool softener, is the usual first-line approach.

Question 3Patient Care and Therapeutic Decision-Making

A patient on high-dose opioids develops a respiratory rate of 7 breaths per minute with sedation and pinpoint pupils. Which intervention is the immediate priority?

  1. Administer naloxone and support ventilation while monitoring closely Correct answer.
  2. Encourage oral fluids and reposition the patient
  3. Give an additional opioid dose for comfort
  4. Start a stimulant laxative and reassess in an hour

Explanation

The triad of reduced respiratory rate, sedation, and pinpoint pupils indicates opioid toxicity, and naloxone with ventilatory support is the immediate priority. Careful titration is needed because full reversal can precipitate severe pain and withdrawal.

Question 4Patient Care and Therapeutic Decision-Making

Which statement best describes the principle of double effect in palliative sedation for refractory symptoms?

  1. A foreseen but unintended harmful outcome may be accepted when the intended action is to relieve suffering and the harm is not the means of relief Correct answer.
  2. Any action that shortens life is prohibited regardless of intent
  3. The principle applies only to opioid administration, not to sedatives
  4. Sedation is permitted only when the patient explicitly requests it in writing

Explanation

The principle of double effect holds that an action with a good intended effect may be permissible even if a harmful effect is foreseen, provided the harm is not intended or used as the means. Proportionality and lack of a less harmful alternative are central conditions.

Question 5Patient Care and Therapeutic Decision-Making

A patient with advanced illness has a glomerular filtration rate below 30 mL/min and needs analgesia. Which opioid requires the most caution because of accumulation of active metabolites?

  1. Fentanyl
  2. Morphine Correct answer.
  3. Hydromorphone at reduced doses
  4. Methadone with specialist guidance

Explanation

Morphine's active metabolites, including morphine-6-glucuronide, accumulate in renal impairment and can cause prolonged sedation and respiratory depression. Fentanyl is generally preferred in significant renal failure because it has inactive metabolites.

Question 6Patient Care and Therapeutic Decision-Making

Which assessment finding most strongly suggests that a patient's pain is neuropathic rather than nociceptive?

  1. Pain localized to a site of bony metastasis without sensory change
  2. Pain relieved promptly by acetaminophen
  3. Burning and shooting pain with allodynia in a dermatomal distribution Correct answer.
  4. Dull, aching pain that worsens with movement

Explanation

Neuropathic pain is characteristically described as burning, shooting, or electric, often with allodynia or hyperalgesia in a nerve distribution. Nociceptive pain is more often dull, aching, or pressure-like and related to tissue injury.

Question 7Patient Care and Therapeutic Decision-Making

A patient with dyspnea from advanced cancer has no relief from repositioning and oxygen. Which pharmacologic approach is most appropriate?

  1. Nebulized saline
  2. A diuretic regardless of fluid status
  3. High-dose benzodiazepine as first-line therapy
  4. Low-dose opioid titrated to relieve breathlessness Correct answer.

Explanation

Low-dose opioids are the mainstay for refractory dyspnea in advanced illness, titrated to symptom relief while monitoring for toxicity. Benzodiazepines are reserved for anxiety-predominant dyspnea and are not first-line alone.

Question 8Patient Care and Therapeutic Decision-Making

A dying patient has loud gurgling respirations from pooled secretions. Which intervention is most appropriate?

  1. Start intravenous fluids to thin secretions
  2. Suction deeply every 15 minutes
  3. Reposition and consider an anticholinergic such as glycopyrrolate Correct answer.
  4. Give a diuretic to reduce secretions

Explanation

Terminal secretions are managed by repositioning and anticholinergic medication to reduce secretion production; deep suctioning causes distress and does not address the source. Intravenous fluids can worsen pooling.

Question 9Patient Care and Therapeutic Decision-Making

Which symptom cluster is most consistent with a malignant bowel obstruction in a patient with advanced abdominal cancer?

  1. Nausea, vomiting, colicky abdominal pain, and absence of stool or flatus Correct answer.
  2. Unilateral leg swelling and erythema
  3. Painless jaundice and pruritus
  4. Hemoptysis and pleuritic chest pain

Explanation

Malignant bowel obstruction typically presents with nausea, vomiting, colicky pain, distension, and failure to pass stool or flatus. Management may include antisecretory agents, antiemetics, and corticosteroids depending on goals.

Question 10Patient Care and Therapeutic Decision-Making

A patient with delirium due to advanced illness becomes agitated and poses a risk to themselves. Which approach reflects best practice?

  1. Ignore the agitation because it is expected at end of life
  2. Give a benzodiazepine as first-line treatment for all causes of delirium
  3. Identify and treat reversible causes while using nonpharmacologic measures, reserving antipsychotics for severe distress Correct answer.
  4. Restrain the patient physically as the first intervention

Explanation

Delirium management begins with identifying reversible contributors such as medications, infection, or metabolic derangement, alongside environmental and supportive measures. Antipsychotics are used cautiously for severe distress and are not a substitute for cause-directed care.

Question 11Patient Care and Therapeutic Decision-Making

Which statement about opioid rotation is most accurate?

  1. Rotation eliminates the need to monitor for toxicity
  2. Rotation should only be done when the patient requests a different drug
  3. Equianalgesic tables allow direct one-to-one conversion without dose reduction
  4. Rotation accounts for incomplete cross-tolerance by using a reduced equianalgesic dose of the new opioid Correct answer.

Explanation

Because cross-tolerance between opioids is incomplete, rotation typically uses a calculated equianalgesic dose reduced by a safety margin, often 25 to 50 percent, with close monitoring. This reduces the risk of overdose from the new agent.

Question 12Patient Care and Therapeutic Decision-Making

A patient with advanced disease reports severe fatigue. Which evaluation step is most appropriate before attributing it solely to the underlying illness?

  1. Review for reversible contributors such as anemia, hypothyroidism, depression, and medications Correct answer.
  2. Immediately prescribe a stimulant without further assessment
  3. Advise complete bed rest to conserve energy
  4. Start high-dose corticosteroids routinely

Explanation

Fatigue in advanced illness frequently has treatable contributors, including anemia, metabolic disorders, depression, poor sleep, and sedating medications. Identifying these guides targeted management before symptomatic stimulants are considered.

Question 13Patient Care and Therapeutic Decision-Making

Which finding most suggests that a patient is in the actively dying phase?

  1. New onset of localized back pain
  2. Sudden improvement in energy and appetite
  3. Stable weight and appetite over several weeks
  4. Increasing periods of unresponsiveness, mottled extremities, and minimal oral intake Correct answer.

Explanation

The actively dying phase is characterized by progressive decline in consciousness, peripheral mottling and cooling, reduced urine output, and minimal intake. Care shifts toward comfort-focused measures and family support.

Question 14Patient Care and Therapeutic Decision-Making

A patient with a history of substance use disorder requires opioid analgesia for severe cancer pain. Which approach is most appropriate?

  1. Withhold opioids entirely because of the substance use history
  2. Provide structured analgesia with clear agreements, monitoring, and access to addiction support Correct answer.
  3. Use only non-opioid analgesics regardless of pain severity
  4. Prescribe large quantities without monitoring to avoid conflict

Explanation

Patients with substance use disorder are entitled to adequate pain control, and a structured plan with monitoring, clear expectations, and multidisciplinary support balances analgesia and safety. Withholding opioids causes unnecessary suffering.

Question 15Patient Care and Therapeutic Decision-Making

A patient with advanced heart failure has worsening dyspnea and edema despite optimized guideline-directed therapy. Which combination best reflects palliative management of this symptom?

  1. Careful diuresis with monitoring plus low-dose opioids for refractory breathlessness Correct answer.
  2. Discontinuation of all cardiac medications
  3. High-dose beta-agonist nebulizers as the primary treatment
  4. Aggressive fluid loading to improve perfusion

Explanation

In advanced heart failure, symptom control combines appropriate diuresis when congestion is present with low-dose opioids for refractory dyspnea. Goals-of-care discussion and monitoring of renal function and blood pressure guide therapy.

Question 16Patient Care and Therapeutic Decision-Making

Which statement best describes the role of palliative care alongside disease-directed treatment?

  1. Palliative care is limited to inpatient hospice settings
  2. Palliative care requires stopping all other treatments
  3. Palliative care can be provided concurrently with curative or life-prolonging therapy from the time of diagnosis Correct answer.
  4. Palliative care is appropriate only after all disease-directed options are exhausted

Explanation

Palliative care focuses on symptom relief and quality of life and can be delivered alongside curative or life-prolonging treatment at any stage of illness. This concurrent model improves outcomes and aligns care with patient goals.

Question 17Patient Care and Therapeutic Decision-Making

A patient reports nausea that is worse after meals and associated with early satiety. Which cause should be considered first?

  1. Opioid-induced constipation
  2. Vestibular disturbance
  3. Delayed gastric emptying or gastroparesis Correct answer.
  4. Raised intracranial pressure

Explanation

Postprandial nausea with early satiety suggests delayed gastric emptying, which is common in advanced illness and may respond to prokinetic agents. Different patterns point to different mechanisms and treatments.

Question 18Patient Care and Therapeutic Decision-Making

Which intervention is most appropriate for a patient with a malignant wound that has foul odor and heavy exudate?

  1. Topical metronidazole with appropriate absorbent dressings Correct answer.
  2. Occlusive dressing without change to contain odor
  3. Frequent scrubbing with antiseptic solution
  4. Systemic chemotherapy solely to treat the wound

Explanation

Odor in malignant wounds often reflects anaerobic colonization, and topical metronidazole with absorbent, nonadherent dressings reduces odor and manages exudate. Gentle care minimizes pain and trauma.

Question 19Patient Care and Therapeutic Decision-Making

A family member asks whether artificial nutrition should be started for a patient in the terminal phase who is no longer eating. Which response best reflects appropriate guidance?

  1. Explain that reduced intake is expected in dying and that artificial nutrition may add burden without improving comfort Correct answer.
  2. Avoid discussing the topic until the patient becomes unresponsive
  3. State that the patient will recover if fed adequately
  4. Insist on a feeding tube to prevent starvation

Explanation

In the terminal phase, anorexia is a normal part of dying, and artificial nutrition often adds fluid burden, aspiration risk, and discomfort without benefit. Discussion should focus on comfort and the family's concerns.

Question 20Patient Care and Therapeutic Decision-Making

Which opioid formulation is most appropriate for a patient with stable, chronic cancer pain requiring around-the-clock analgesia?

  1. Immediate-release opioid taken only when pain becomes severe
  2. Intravenous bolus dosing as needed
  3. Topical opioid applied to intact skin
  4. A long-acting formulation dosed at regular intervals with a short-acting agent for breakthrough pain Correct answer.

Explanation

Stable chronic cancer pain is best managed with scheduled long-acting opioids to maintain steady analgesia, plus a short-acting agent for breakthrough pain. As-needed-only dosing leads to fluctuating control.

Question 21Patient Care and Therapeutic Decision-Making

A patient with advanced COPD has persistent breathlessness despite optimal inhalers. Which nonpharmacologic measure has the best supportive evidence for relieving dyspnea?

  1. Routine antibiotics
  2. Pursed-lip breathing with a fan directed at the face Correct answer.
  3. High-flow oxygen regardless of oxygen saturation
  4. Bed rest with minimal activity

Explanation

Breathing techniques such as pursed-lip breathing and cool airflow from a fan reduce breathlessness in advanced COPD. Oxygen is indicated for hypoxemia but not routinely for normoxemic patients.

Question 22Patient Care and Therapeutic Decision-Making

Which approach best supports shared decision-making about goals of care with a patient who has advanced illness?

  1. Provide a single written directive to sign without discussion
  2. Defer all discussion to family members
  3. Present only the option the clinician believes is best
  4. Explore the patient's values and priorities, then discuss treatment options consistent with them Correct answer.

Explanation

Shared decision-making elicits the patient's values and goals and integrates them with clinical options and evidence. This supports informed choices and respects autonomy.

Question 23Patient Care and Therapeutic Decision-Making

A patient with advanced cancer has severe pain and also reports new confusion and myoclonus after a recent opioid increase. Which explanation is most likely?

  1. Adequate analgesia requiring no change
  2. An allergic reaction to the opioid
  3. Progression of disease unrelated to the opioid
  4. Opioid toxicity with accumulation of active metabolites Correct answer.

Explanation

Confusion and myoclonus after an opioid dose increase suggest accumulation of active metabolites and possible opioid toxicity. Assessment should include dose review, hydration, renal function, and consideration of rotation or dose reduction.

Question 24Patient Care and Therapeutic Decision-Making

Which factor most increases the risk of opioid-related respiratory depression in a palliative patient?

  1. Adequate hydration
  2. Regular use of a stimulant laxative
  3. Concurrent use of benzodiazepines or sedatives Correct answer.
  4. Use of acetaminophen for fever

Explanation

Combining opioids with benzodiazepines or other sedatives potentiates central nervous system and respiratory depression. Risk is heightened in older adults, renal impairment, and with rapid dose escalation.

Question 25Patient Care and Therapeutic Decision-Making

A patient with a prognosis of days to weeks has intractable pain despite escalating opioid doses and reports severe distress. Which step best reflects appropriate specialist-level management?

  1. Reassess the pain mechanism and consider specialist input, adjuvants, or proportionate sedation for refractory suffering Correct answer.
  2. Continue escalating the opioid indefinitely without reassessment
  3. Stop all analgesia to prevent dependence
  4. Transfer the patient to an intensive care unit for monitoring

Explanation

Refractory pain requires reassessment of mechanism and specialist involvement, with adjuvants for neuropathic components and, when suffering remains refractory, proportionate palliative sedation under established safeguards. Uncontrolled escalation alone risks toxicity.

Question 26Patient Care and Therapeutic Decision-Making

A patient with advanced cancer is started on a long-acting opioid for chronic pain. Which medication should be prescribed for breakthrough pain?

  1. A transdermal opioid patch applied as needed
  2. A long-acting opioid at the same dose as the scheduled dose
  3. An NSAID alone, since the baseline is already controlled
  4. A short-acting opioid at a dose proportional to the total daily dose Correct answer.

Explanation

Breakthrough pain is managed with a short-acting opioid, typically at 10–20% of the total daily opioid dose, given as needed. Long-acting formulations are not appropriate for as-needed use because of their delayed onset and prolonged effect. NSAIDs alone are insufficient for severe breakthrough pain, and transdermal patches are not titratable for acute flares.

Question 27Patient Care and Therapeutic Decision-Making

Which bowel regimen should be started prophylactically when a patient begins regular opioid therapy?

  1. A bulk-forming fiber supplement alone
  2. No prophylaxis until constipation occurs
  3. An osmotic laxative such as polyethylene glycol alone
  4. A stimulant laxative such as senna, with or without a stool softener Correct answer.

Explanation

Opioids cause constipation through decreased peristalsis and increased sphincter tone, so a stimulant laxative is recommended prophylactically. Bulk-forming agents are less effective in opioid-induced constipation and may worsen obstruction risk. Osmotic agents alone do not address the reduced motility component.

Question 28Patient Care and Therapeutic Decision-Making

A patient with advanced illness reports dryness of the mouth. Which intervention is most appropriate for xerostomia in this setting?

  1. Encouraging caffeine-containing beverages to stimulate saliva
  2. Prescribing an anticholinergic medication
  3. Restricting oral fluids to reduce secretions
  4. Frequent sips of water and sugar-free chewing gum or saliva substitutes Correct answer.

Explanation

Xerostomia is managed with moisture replacement such as sips of water, ice chips, sugar-free gum, and saliva substitutes. Caffeine and anticholinergics worsen dryness. Fluid restriction is inappropriate and can cause discomfort.

Question 29Patient Care and Therapeutic Decision-Making

A patient with advanced cancer develops a pressure injury over the sacrum. Which measure is most important for local wound care?

  1. Keeping the wound dry and uncovered
  2. Repositioning and pressure-relieving support surfaces Correct answer.
  3. Applying a heat pack to increase circulation
  4. Massaging the area around the injury

Explanation

Pressure relief through repositioning and support surfaces is the cornerstone of pressure injury management. Heat, massage, and leaving the wound uncovered can cause further damage or infection. Moist wound healing is generally preferred for appropriate wound types.

Question 30Patient Care and Therapeutic Decision-Making

A patient near the end of life has a dry mouth and is no longer able to drink. Which intervention best addresses mouth care?

  1. Starting intravenous fluids for hydration
  2. Encouraging large volumes of oral fluids
  3. Using lemon-glycerin swabs to stimulate saliva
  4. Frequent oral care with moistened swabs and lip balm Correct answer.

Explanation

In the last days of life, mouth care with moistened swabs and lip balm provides comfort without forcing fluids. Large oral fluids may be unsafe, and intravenous fluids do not reliably relieve thirst and may worsen edema or secretions. Lemon-glycerin swabs can be irritating and are not recommended.

Question 31Patient Care and Therapeutic Decision-Making

Which route is generally preferred for opioid administration in a patient with advanced illness who has an intact gastrointestinal tract and stable pain?

  1. Subcutaneous
  2. Rectal
  3. Intramuscular
  4. Oral Correct answer.

Explanation

The oral route is preferred when the gastrointestinal tract is functional because it is noninvasive, flexible, and cost-effective. Intramuscular injections are painful and unreliable. Subcutaneous and rectal routes are reserved for when oral intake is not feasible.

Question 32Patient Care and Therapeutic Decision-Making

Which statement best describes the role of a goals-of-care conversation in palliative care?

  1. It is a single discussion that does not need to be revisited
  2. It is primarily used to document a do-not-resuscitate order
  3. It explores the patient's values and priorities to guide treatment decisions Correct answer.
  4. It should be initiated only when death is imminent

Explanation

Goals-of-care conversations elicit the patient's values, goals, and priorities to align treatment with what matters most to them. They are not limited to code status or the imminently dying and should be revisited as circumstances change. A single discussion is insufficient because preferences evolve.

Question 33Patient Care and Therapeutic Decision-Making

Which assessment finding is most consistent with mild delirium in a palliative patient?

  1. Focal weakness on one side of the body
  2. Gradual memory loss over months without attention deficits
  3. Fluctuating attention and disorientation that worsens in the evening Correct answer.
  4. Stable, unchanging confusion over several weeks

Explanation

Delirium is characterized by acute onset, fluctuating course, and inattention, often worse in the evening (sundowning). Stable confusion over weeks, focal weakness, and gradual memory loss suggest other diagnoses such as dementia or stroke.

Question 34Patient Care and Therapeutic Decision-Making

A patient with advanced cancer has pain that is well controlled on a stable opioid dose but reports drowsiness. Which initial approach is most appropriate?

  1. Discontinue the opioid entirely
  2. Immediately switch to a different opioid
  3. Add a stimulant medication without further assessment
  4. Assess for other causes of sedation and consider reducing the dose if pain remains controlled Correct answer.

Explanation

Sedation may be due to the opioid, other medications, or the underlying illness. If pain is controlled and sedation persists, a cautious dose reduction or evaluation for other causes is appropriate before switching or stopping. Abrupt discontinuation risks withdrawal and pain crisis.

Question 35Patient Care and Therapeutic Decision-Making

A patient with advanced illness has nausea and vomiting with a suspected metabolic cause. Which medication class is most appropriate for nausea from metabolic causes?

  1. Dopamine antagonists such as haloperidol or metoclopramide Correct answer.
  2. Serotonin antagonists such as ondansetron
  3. Antihistamines such as diphenhydramine
  4. Anticholinergics such as scopolamine

Explanation

Metabolic nausea is often mediated by dopamine and is treated with dopamine antagonists such as haloperidol or metoclopramide. Antihistamines are more useful for vestibular causes, anticholinergics for motion-related or secretion-related nausea, and serotonin antagonists for chemotherapy-induced nausea.

Question 36Patient Care and Therapeutic Decision-Making

A patient with advanced illness reports constipation despite a stimulant laxative. Which additional measure is most appropriate?

  1. Increasing the stimulant laxative to a very high dose
  2. Adding a bulk-forming fiber supplement
  3. Adding an osmotic laxative such as polyethylene glycol Correct answer.
  4. Discontinuing the stimulant laxative

Explanation

If constipation persists on a stimulant laxative, adding an osmotic agent such as polyethylene glycol is a common next step. Bulk-forming fiber can worsen symptoms in patients with poor intake or obstruction risk. Escalating the stimulant alone may cause cramping without addressing stool consistency.

Question 37Patient Care and Therapeutic Decision-Making

A patient with advanced illness has a malignant wound with heavy exudate. Which dressing is most appropriate?

  1. A transparent film dressing
  2. A hydrocolloid dressing
  3. A dry gauze dressing changed infrequently
  4. An absorptive foam or alginate dressing Correct answer.

Explanation

Heavy exudate requires an absorptive dressing such as foam or alginate to manage moisture and protect surrounding skin. Transparent films and hydrocolloids are poorly suited to heavy exudate and may cause maceration. Dry gauze is less effective for exudate management and can adhere to the wound.

Question 38Patient Care and Therapeutic Decision-Making

A patient with advanced cancer has severe pain and is opioid-naive. Which approach is most appropriate for initiating opioid therapy?

  1. Start a high dose of a long-acting opioid
  2. Start a transdermal fentanyl patch
  3. Start methadone at a high dose
  4. Start a low dose of a short-acting opioid and titrate to effect Correct answer.

Explanation

For opioid-naive patients, therapy should begin with a low dose of a short-acting opioid and be titrated to effect to avoid toxicity. Long-acting opioids and transdermal fentanyl are not appropriate for initial titration in opioid-naive patients. Methadone requires special expertise and is not first-line for initial dosing.

Question 39Patient Care and Therapeutic Decision-Making

Which symptom is most characteristic of hypercalcemia of malignancy in a palliative patient?

  1. Polyuria and polydipsia only
  2. Fever and chills
  3. Confusion and constipation Correct answer.
  4. Bradycardia and hypertension

Explanation

Hypercalcemia commonly presents with confusion, constipation, nausea, and lethargy. Fever, chills, and isolated polyuria are less specific. Bradycardia and hypertension are not typical; hypercalcemia can cause shortened QT and arrhythmias.

Question 40Patient Care and Therapeutic Decision-Making

A patient with advanced illness and a prognosis of months has fatigue. Which intervention is most appropriate for cancer-related fatigue?

  1. Recommend strict bed rest
  2. Prescribe a stimulant as first-line therapy
  3. Start high-dose corticosteroids
  4. Encourage appropriate physical activity and energy conservation Correct answer.

Explanation

Appropriate physical activity and energy conservation are first-line for cancer-related fatigue. Strict bed rest can worsen fatigue and deconditioning. Stimulants and corticosteroids are not first-line and carry significant adverse effects.

Question 41Patient Care and Therapeutic Decision-Making

Which statement about the use of corticosteroids for symptom management in advanced cancer is most accurate?

  1. They are safe for long-term use without tapering
  2. They are first-line for neuropathic pain
  3. They should be used routinely for all patients with fatigue
  4. They can improve appetite and energy but require monitoring for hyperglycemia and infection Correct answer.

Explanation

Corticosteroids may improve appetite, energy, and pain from bone metastases or edema, but they carry risks such as hyperglycemia, infection, and adrenal suppression, so monitoring and tapering are needed. They are not first-line for neuropathic pain and should not be used routinely for all fatigue.

Question 42Patient Care and Therapeutic Decision-Making

A patient with advanced illness has dyspnea and anxiety. Which nonpharmacologic intervention is most appropriate to include in the care plan?

  1. Avoiding any discussion of breathlessness
  2. Teaching pursed-lip breathing and using a fan for airflow Correct answer.
  3. Restricting all activity
  4. Encouraging complete bed rest

Explanation

Nonpharmacologic measures for dyspnea include breathing techniques, a cool fan to the face, and activity pacing. Bed rest and activity restriction can worsen deconditioning. Avoiding discussion increases anxiety and does not address the symptom.

Question 43Patient Care and Therapeutic Decision-Making

A patient with advanced illness is receiving opioids and develops myoclonus and agitation. Which cause should be considered?

  1. Opioid withdrawal
  2. Serotonin syndrome
  3. Opioid-induced neurotoxicity Correct answer.
  4. Malignant hyperthermia

Explanation

Myoclonus, agitation, and confusion in a patient on opioids suggest opioid-induced neurotoxicity, often due to accumulation of metabolites. Withdrawal typically causes anxiety, sweating, and diarrhea but not myoclonus. Serotonin syndrome and malignant hyperthermia have different clinical features.

Question 44Patient Care and Therapeutic Decision-Making

Which factor most increases the risk of opioid-related respiratory depression in a patient with advanced illness?

  1. Use of acetaminophen
  2. Use of a stimulant laxative
  3. Concurrent use of benzodiazepines Correct answer.
  4. Use of a proton pump inhibitor

Explanation

Benzodiazepines and other sedatives potentiate opioid-induced respiratory depression. Laxatives, proton pump inhibitors, and acetaminophen do not increase this risk.

Question 45Patient Care and Therapeutic Decision-Making

A patient with advanced cancer has a malignant bowel obstruction and is not a surgical candidate. Which medication combination is most appropriate for symptom control?

  1. A prokinetic agent to relieve the obstruction
  2. High-dose corticosteroids as the sole treatment
  3. An opioid for pain, an antiemetic, and octreotide to reduce secretions Correct answer.
  4. A bulk-forming laxative to promote bowel movements

Explanation

In inoperable malignant bowel obstruction, symptom control includes opioids for pain, antiemetics for nausea, and octreotide to reduce gastrointestinal secretions. Prokinetics are contraindicated in complete obstruction. Bulk-forming laxatives can worsen obstruction. Corticosteroids may be used but are not the sole treatment.

Question 46Patient Care and Therapeutic Decision-Making

A patient with advanced illness has a prognosis of days and is receiving subcutaneous medications. Which site is most appropriate for subcutaneous administration?

  1. The abdomen or thigh Correct answer.
  2. The antecubital vein
  3. The gluteal muscle
  4. The deltoid muscle

Explanation

Subcutaneous injections are typically given into the abdomen or thigh, where there is adequate subcutaneous tissue. Deltoid and gluteal sites are for intramuscular injections. The antecubital vein is for intravenous access.

Question 47Patient Care and Therapeutic Decision-Making

A patient with advanced illness is started on methadone for pain. Which statement about methadone is most accurate?

  1. It is not effective for neuropathic pain
  2. It has no risk of QT prolongation
  3. It is the safest first-line opioid for opioid-naive patients
  4. It requires careful titration because of its long and variable half-life Correct answer.

Explanation

Methadone has a long and variable half-life, so careful titration and monitoring are essential. It is not first-line for opioid-naive patients because of the risk of accumulation. It can prolong the QT interval and is often used for neuropathic pain.

Question 48Patient Care and Therapeutic Decision-Making

A patient with advanced cancer has severe pain and is receiving a high dose of morphine. The patient develops confusion and myoclonus. Which action is most appropriate?

  1. Add a benzodiazepine
  2. Increase the morphine dose
  3. Continue the same dose and observe
  4. Rotate to a different opioid with a lower risk of neurotoxicity Correct answer.

Explanation

Opioid-induced neurotoxicity from morphine metabolites can cause confusion and myoclonus. Rotating to an opioid with a lower risk of neurotoxicity, such as fentanyl or methadone, is appropriate. Increasing the dose would worsen toxicity, and adding a benzodiazepine does not address the cause.

Question 49Patient Care and Therapeutic Decision-Making

A patient with advanced illness has a prognosis of weeks and reports severe, continuous pain. Which opioid formulation is most appropriate?

  1. A long-acting opioid given around the clock with a short-acting opioid for breakthrough pain Correct answer.
  2. A short-acting opioid given only as needed
  3. A transdermal opioid patch changed daily
  4. A long-acting opioid given only as needed

Explanation

For continuous severe pain, around-the-clock long-acting opioid with a short-acting breakthrough medication is appropriate. Short-acting only as needed does not provide continuous relief. Long-acting as needed is unsafe, and transdermal patches are not changed daily.

Question 50Patient Care and Therapeutic Decision-Making

A patient with advanced illness has severe dyspnea despite optimal treatment of the underlying disease. Which opioid approach is most appropriate?

  1. Opioids are contraindicated in dyspnea
  2. High-dose opioids to sedate the patient
  3. Low-dose opioids titrated to relieve breathlessness Correct answer.
  4. Only nebulized opioids are effective

Explanation

Low-dose opioids, usually starting with small doses and titrating to effect, can relieve refractory breathlessness. High-dose opioids to sedate are not appropriate. Opioids are not contraindicated in dyspnea. Nebulized opioids are not routinely recommended due to limited evidence.