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CHPN practice questions

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Question 1Assessment and Care Planning

Which pain assessment tool is designed for a patient with advanced dementia who cannot self-report pain?

  1. Wong-Baker FACES scale
  2. Brief Pain Inventory
  3. PAINAD scale Correct answer.
  4. Numeric Rating Scale

Explanation

PAINAD is an observational tool that scores breathing, negative vocalization, facial expression, body language, and consolability, so it can be used when a patient cannot report pain. Scales that require a verbal or numeric self-rating depend on intact cognition and communication.

Question 2Assessment and Care Planning

The Palliative Performance Scale (PPS) expresses a patient's functional status in which form?

  1. A score from 0 to 10, with 10 the highest function
  2. A percentage from 0% to 100% in 10% increments Correct answer.
  3. A stage from I to IV based on tumor burden
  4. A count of dependent activities of daily living

Explanation

The PPS rates ambulation, activity, self-care, intake, and level of consciousness to yield a score from 0% (death) to 100% (fully ambulatory, normal activity, no evidence of disease) in 10% decrements. Serial PPS scores describe functional decline and support prognosis discussions.

Question 3Assessment and Care Planning

Which finding is the most reliable indicator of the severity of a hospice patient's dyspnea?

  1. The patient's own description of breathlessness Correct answer.
  2. Oxygen saturation by pulse oximetry
  3. Depth and symmetry of chest excursion
  4. Respiratory rate measured while the patient is at rest

Explanation

Dyspnea is a subjective experience, so the patient's self-report is the standard for assessing severity and response to treatment. Physiologic measures correlate poorly with the sensation of breathlessness.

Question 4Assessment and Care Planning

Which instrument is a validated two-item screen for depression in seriously ill patients?

  1. CAGE
  2. PHQ-2 Correct answer.
  3. Braden Scale
  4. Mini-Cog

Explanation

The PHQ-2 asks about depressed mood and anhedonia over the past two weeks and is validated as an efficient first-step screen in palliative populations. A positive screen is followed by the PHQ-9 or a clinical interview.

Question 5Assessment and Care Planning

Which tool does a hospice nurse use at the bedside to identify delirium?

  1. Edmonton Symptom Assessment System
  2. Palliative Performance Scale
  3. Confusion Assessment Method Correct answer.
  4. Zarit Burden Interview

Explanation

The Confusion Assessment Method identifies delirium through acute onset with a fluctuating course, inattention, disorganized thinking, and altered level of consciousness. It can be completed quickly and repeated to track change.

Question 6Assessment and Care Planning

On the Edmonton Symptom Assessment System, how does a patient rate each symptom?

  1. As one of three categories: mild, moderate, or severe
  2. On a numeric scale from 0 to 10 Correct answer.
  3. As present or absent
  4. On a five-point Likert scale from 1 to 5

Explanation

The ESAS asks patients to rate the severity of each symptom from 0 (absent) to 10 (worst possible) using a numeric scale, producing a symptom profile that can be trended over time.

Question 7Assessment and Care Planning

Hospice eligibility requires the certifying provider to document a prognosis of approximately how long if the disease follows its expected course?

  1. Six months or less Correct answer.
  2. Twenty-four months or less
  3. Twelve months or less
  4. Three months or less

Explanation

Hospice eligibility under the Medicare hospice benefit requires documentation that the terminal illness has a prognosis of six months or less if it runs its usual course, with recertification at each benefit period. Functional, nutritional, and disease-specific criteria support that prognosis.

Question 8Assessment and Care Planning

A patient with metastatic cancer reports pain that has not changed despite two opioid dose increases. The patient mentions fear of dying and an unresolved rift with a son. Which framework best explains this presentation?

  1. Total pain, which includes physical, emotional, social, and spiritual factors Correct answer.
  2. Incident pain, which occurs predictably with movement or weight bearing
  3. Pseudoaddiction, which is drug-seeking behavior driven by unrelieved pain
  4. Opioid tolerance, which develops when escalating doses are needed for the same effect

Explanation

Total pain holds that suffering has physical, emotional, social, and spiritual dimensions, so pain persisting despite adequate opioid titration signals unaddressed nonphysical factors. Addressing the fear and the fractured relationship becomes part of the plan of care.

Question 9Assessment and Care Planning

A hospice patient taking scheduled morphine has had no bowel movement in four days and now reports cramping abdominal pain with small amounts of liquid stool. Which problem should the nurse suspect first?

  1. Radiation-induced enteritis
  2. Opioid-induced hyperalgesia
  3. A new bowel obstruction from tumor progression
  4. Fecal impaction with overflow incontinence Correct answer.

Explanation

Hard stool in the rectum with liquid stool passing around it produces cramping and small-volume overflow diarrhea, a common pattern when an opioid is given without an adequate bowel regimen. A focused abdominal and rectal assessment confirms impaction before laxative escalation.

Question 10Assessment and Care Planning

A patient with advanced lung cancer reports new shortness of breath today. Which action should the nurse take first?

  1. Assess for reversible causes such as effusion or anxiety Correct answer.
  2. Administer the prescribed as-needed dose of morphine immediately
  3. Increase the nasal oxygen flow rate to the maximum
  4. Ask the family whether the patient seems more breathless today

Explanation

New or worsening dyspnea warrants a focused search for reversible contributors such as pleural effusion, anemia, pulmonary embolism, infection, anxiety, or worsening heart failure before symptom treatment is escalated. Those findings determine whether opioids, oxygen, drainage, or anxiolytics are appropriate.

Question 11Assessment and Care Planning

A patient near the end of life becomes restless and agitated, and the provider orders haloperidol. Which assessment should the nurse complete before administering the drug?

  1. Hearing acuity and visual fields
  2. Recent weight change and albumin level
  3. Urinary retention, constipation, and pain Correct answer.
  4. Blood glucose and hemoglobin A1c

Explanation

Agitation at the end of life is frequently multifactorial, and reversible contributors such as unrelieved pain, urinary retention, constipation or impaction, dehydration, and drug effects should be identified before antipsychotic treatment. Treating the cause often reduces the need for sedation.

Question 12Assessment and Care Planning

A daughter caring for her dying father at home tells the nurse, "I can't keep doing this. I haven't slept in a week." What is the nurse's best initial action?

  1. Reassure her that caregiving usually becomes easier with time
  2. Suggest that she stop giving the scheduled opioid doses
  3. Assess caregiver burden and explore respite and support services Correct answer.
  4. Refer her to a bereavement support group for anticipatory grief

Explanation

Statements such as this signal caregiver strain and possible exhaustion, so the nurse should formally assess burden and resources and offer respite, home health aide hours, or inpatient options. Bereavement support may follow, but the immediate need is practical and emotional support for the caregiver.

Question 13Assessment and Care Planning

A patient newly diagnosed with ALS wants to document preferences about future use of mechanical ventilation. What is the nurse's most appropriate action?

  1. Discuss advance directives and the patient's goals for future care Correct answer.
  2. Ask the patient's spouse to decide about ventilation later
  3. Defer the discussion until the patient loses the ability to speak
  4. Refer the patient to an attorney to prepare a will and estate plan

Explanation

Patients with a new neurodegenerative diagnosis should be offered information and a structured goals-of-care discussion while they can still participate, with the chosen surrogate included. Documented preferences about ventilation, feeding, and setting of care guide later decisions.

Question 14Assessment and Care Planning

A patient says, "I must have done something terrible to deserve this." Which domain of assessment does this statement most directly reflect?

  1. Spiritual or existential distress Correct answer.
  2. Financial strain and insurance coverage
  3. Cognitive status and decision-making capacity
  4. Physical functioning and symptom burden

Explanation

Statements of deserved punishment reflect spiritual or existential distress, including guilt, meaninglessness, or a sense of abandonment, which is assessed separately from physical, cognitive, and financial concerns. Chaplaincy and the interdisciplinary team address this dimension.

Question 15Assessment and Care Planning

A bedbound hospice patient has a Braden Scale score of 12. Which nursing intervention is most appropriate?

  1. Apply a heating pad to the heels overnight to improve local circulation
  2. Massage reddened areas over the sacrum and heels each shift
  3. Turn and reposition on a schedule using a pressure-relief surface Correct answer.
  4. Limit oral fluids to reduce moisture and skin breakdown risk

Explanation

A Braden score of 12 indicates high risk for pressure injury, so prevention centers on scheduled repositioning, a pressure-redistributing support surface, moisture and shear management, and adequate nutrition and hydration. Reddened areas over bony prominences are never massaged.

Question 16Assessment and Care Planning

A family asks that a feeding tube be placed for their mother, who has advanced dementia and now takes little by mouth. Which nursing action best guides this discussion?

  1. Calculate the patient's body mass index and daily caloric needs
  2. Explore the patient's wishes and comfort-focused goals Correct answer.
  3. Explain that the patient will recover with adequate nutrition
  4. Report the patient's 24-hour intake and output to the family

Explanation

In advanced dementia, anorexia and decreased intake are expected consequences of the disease, and artificial nutrition does not improve comfort, function, or survival. The nurse elicits the patient's documented wishes, manages hunger and thirst symptomatically, and supports the family through the decision.

Question 17Assessment and Care Planning

Two siblings disagree about hospice enrollment for their mother, who lacks decision-making capacity and has no documented advance directive. What should the nurse do first?

  1. Identify the legal decision maker and the patient's known wishes Correct answer.
  2. Postpone the decision until the patient is lucid again
  3. Hold a family vote and follow the preference of the majority
  4. Ask the attending physician to make the decision on the family's behalf

Explanation

When a patient lacks capacity and has no advance directive, the nurse identifies the person legally authorized to make health care decisions and elicits the patient's known values and prior statements. That surrogate then applies substituted judgment in discussion with the team.

Question 18Assessment and Care Planning

Which description best matches the typical illness trajectory of organ failure, such as advanced heart failure?

  1. Steady functional decline over months with a predictable terminal week
  2. Episodic exacerbations with periods of stability and sudden death risk Correct answer.
  3. Prolonged dwindling over years with gradual loss of self-care ability
  4. Sudden death without any preceding functional decline or warning

Explanation

Organ failure such as advanced heart failure typically follows a sawtooth pattern of relative stability punctuated by acute exacerbations, partial recovery, and a risk of sudden death, which makes prognosis harder than in cancer. Cancer more often shows steady decline, while dementia and frailty show prolonged dwindling.

Question 19Assessment and Care Planning

Which action is most important when completing medication reconciliation at hospice admission?

  1. Review all prescription, over-the-counter, and herbal products Correct answer.
  2. Reconcile using the discharge summary from the last hospitalization
  3. Ask only about scheduled medications taken for chronic illness
  4. Continue all home medications until the physician reviews them in a week

Explanation

Medication reconciliation must capture every source, including prescription drugs, over-the-counter products, and herbal or dietary supplements, and weigh each against the patient's goals and remaining life expectancy. This prevents duplication, interactions, and burdensome polypharmacy.

Question 20Assessment and Care Planning

A patient with mild baseline dementia becomes acutely confused and sees insects on the wall two days after starting an opioid, with a new urinary tract infection. Which assessment best explains this change?

  1. Progression of the underlying dementia
  2. Terminal restlessness of the dying phase
  3. Delirium from multiple contributing factors Correct answer.
  4. An acute grief reaction

Explanation

Delirium is characterized by acute onset, a fluctuating course, inattention, and perceptual disturbances, and it is usually multifactorial, as with a new medication plus infection here. Dementia has an insidious, stable course, and terminal restlessness occurs only in the final days.

Question 21Assessment and Care Planning

A patient with metastatic prostate cancer reports new mid-thoracic back pain, leg heaviness, and difficulty initiating urination that began yesterday. What is the nurse's priority action?

  1. Notify the provider now for urgent imaging and evaluation Correct answer.
  2. Schedule a routine outpatient imaging study for the following week
  3. Give the scheduled long-acting opioid and reassess in four hours
  4. Reassure the patient that these symptoms are expected with bed rest

Explanation

New back pain with progressive weakness and urinary hesitancy in a patient with metastatic cancer suggests spinal cord compression, a neurologic emergency. Immediate provider notification, urgent MRI, and corticosteroids preserve neurologic function and reduce pain.

Question 22Assessment and Care Planning

A patient with a brain tumor refuses a recommended treatment and asks to leave the hospital. Which element determines whether the patient has decision-making capacity?

  1. Whether the patient's choice agrees with the family's and team's preference
  2. Documentation that the patient is not clinically depressed
  3. A Mini-Mental State Examination score of at least 24
  4. Ability to understand, appreciate, reason, and express a choice Correct answer.

Explanation

Decision-making capacity rests on four abilities: understanding the relevant information, appreciating how it applies to oneself, reasoning about options, and communicating a choice. Cognitive test scores, depression, and family opinion inform but do not determine capacity.

Question 23Assessment and Care Planning

A patient with metastatic breast cancer has become drowsy and confused over several days. Which accompanying findings would most suggest hypercalcemia rather than imminent death?

  1. Anuria, bradycardia, and cool extremities
  2. Mottling of the knees and Cheyne-Stokes respirations
  3. Fever, purulent sputum, and coarse breath sounds
  4. Constipation, polyuria, and thirst Correct answer.

Explanation

Hypercalcemia of malignancy classically causes confusion, constipation, polyuria, thirst, weakness, and nausea, and it is a reversible contributor to decline. Mottling and Cheyne-Stokes respirations indicate the dying phase, while fever and purulent sputum indicate infection.

Question 24Assessment and Care Planning

Which feature most suggests major depression rather than uncomplicated grief in a bereaved caregiver?

  1. Yearning for the deceased that gradually lessens
  2. Pervasive anhedonia and worthlessness nearly every day Correct answer.
  3. Temporary disbelief and numbness in the first weeks
  4. Waves of sadness triggered by reminders of the deceased

Explanation

Uncomplicated grief comes in waves, is triggered by reminders, and usually preserves self-esteem, whereas major depression is pervasive, with persistent anhedonia, worthlessness, and functional impairment most of the day. The distinction determines whether treatment or supportive grief work is indicated.

Question 25Pain Management

According to the World Health Organization three-step analgesic ladder, which medication class is recommended for the first step in mild pain?

  1. A tricyclic antidepressant used alone
  2. A strong opioid such as morphine
  3. A corticosteroid such as dexamethasone
  4. Acetaminophen or an NSAID Correct answer.

Explanation

The WHO ladder begins with non-opioid analgesics such as acetaminophen or an NSAID, often with an adjuvant, for mild pain; it moves to weak or low-dose opioids for moderate pain and strong opioids for severe pain. Adjuvants may be added at any step but do not replace the analgesic step itself.

Question 26Pain Management

Which adverse effect of long-term opioid therapy persists because patients do not develop tolerance to it?

  1. Pruritus
  2. Sedation
  3. Nausea
  4. Constipation Correct answer.

Explanation

Tolerance develops to most opioid effects, including nausea, sedation, and pruritus, usually within days to weeks of continued dosing. Tolerance to opioid-induced constipation is minimal, so a prophylactic bowel regimen with a stimulant laxative is started at the same time as the opioid.

Question 27Pain Management

The hospice concept of total pain refers to pain that:

  1. resolves once the underlying disease is treated
  2. is limited to the physical sensation described by the patient
  3. has physical, emotional, social, and spiritual elements Correct answer.
  4. is measured primarily with a 0-to-10 numeric rating scale

Explanation

Total pain describes pain as a multidimensional experience with physical, psychological, social, and spiritual components. Effective relief therefore requires assessment and intervention across all four domains rather than analgesic titration alone.

Question 28Pain Management

A patient near the end of life can no longer swallow and has been receiving oral morphine. Which route is generally preferred for continuing opioid therapy in the home hospice setting?

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

Explanation

The subcutaneous route is the mainstay of parenteral opioid delivery in hospice because it is reliable, comfortable, and manageable at home with a butterfly needle or infusion device. Intramuscular injections are painful with erratic absorption in cachectic patients, and intravenous access is often unavailable or burdensome at home.

Question 29Pain Management

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

  1. PAINAD Correct answer.
  2. CAGE questionnaire
  3. Wong-Baker FACES scale
  4. 0-to-10 numeric rating scale

Explanation

The PAINAD is an observational tool scored on breathing, negative vocalization, facial expression, body language, and consolability, and it is validated for older adults with advanced dementia. The CAGE screens for alcohol problems, and the other two scales require the patient to report or indicate a pain level.

Question 30Pain Management

What is considered the most reliable indicator of pain in a cognitively intact adult?

  1. Changes in vital signs
  2. The nurse's behavioral observations
  3. The family's description of the patient
  4. The patient's own report Correct answer.

Explanation

Pain is a subjective experience, and the patient's self-report is the gold standard whenever the patient can communicate. Behaviors and vital signs are adjuncts that are relied on only when self-report is not possible, because physiologic signs of pain are nonspecific.

Question 31Pain Management

Which medication is classified as an adjuvant analgesic and is commonly used for neuropathic pain?

  1. Gabapentin Correct answer.
  2. Lorazepam
  3. Docusate
  4. Ondansetron

Explanation

Adjuvant analgesics are drugs whose primary indication is not pain but that relieve certain pain types; gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are first-line for neuropathic pain. The other agents listed have no analgesic effect.

Question 32Pain Management

A patient takes oxycodone extended-release 20 mg by mouth every 12 hours for baseline pain, a total of 40 mg per day. Which dose of immediate-release oxycodone is most appropriate for breakthrough pain?

  1. 40 mg
  2. 5 mg Correct answer.
  3. 2.5 mg
  4. 15 mg

Explanation

A breakthrough dose is typically 10% to 20% of the total daily opioid dose, given as an immediate-release formulation and then titrated to effect. Ten percent of 40 mg is 4 mg and twenty percent is 8 mg, so 5 mg falls within the recommended range.

Question 33Pain Management

Morphine 10 mg given intravenously is approximately equivalent to which dose of oral morphine?

  1. 60 mg
  2. 30 mg Correct answer.
  3. 10 mg
  4. 20 mg

Explanation

The standard equianalgesic ratio for morphine is 1:3 when converting from the intravenous to the oral route, so 10 mg intravenously equals about 30 mg by mouth. Oral morphine has a bioavailability of roughly one-third that of the parenteral form.

Question 34Pain Management

When a patient is rotated from one opioid to another because of inadequate analgesia or intolerable side effects, the newly calculated equianalgesic dose should generally be:

  1. increased by 25% to 50%
  2. doubled for the first 24 hours
  3. reduced by 25% to 50% Correct answer.
  4. given unchanged, then titrated

Explanation

Cross-tolerance between opioids is incomplete, so a patient switched to a new opioid may experience a greater effect than the equianalgesic table predicts. Standard practice is to reduce the calculated dose by about 25% to 50% and then titrate to effect, with the largest reductions when switching to methadone.

Question 35Pain Management

Transdermal fentanyl is most appropriate for which patient?

  1. an opioid-naive older adult with new back pain
  2. an opioid-tolerant patient with stable chronic pain Correct answer.
  3. a patient whose pain is not yet controlled on short-acting opioids
  4. a patient with acute sickle cell vaso-occlusive crisis

Explanation

Transdermal fentanyl is indicated only for opioid-tolerant patients whose chronic pain is stable and who require continuous around-the-clock opioid. It is unsuitable for acute or rapidly changing pain because absorption continues for hours after the patch is removed.

Question 36Pain Management

A hospice patient receiving scheduled morphine has a respiratory rate of 6 breaths per minute and is difficult to rouse. After stopping the opioid, which action is most appropriate?

  1. Permanently withhold all opioids and continue to monitor closely
  2. Give diluted naloxone titrated to improved breathing Correct answer.
  3. Administer naloxone 0.4 mg IV push undiluted
  4. Give flumazenil to reverse the opioid effect

Explanation

In opioid-induced respiratory depression the goal is to restore breathing, not to fully reverse analgesia, so a small diluted dose of naloxone is titrated to a safe respiratory rate. Full-dose boluses can precipitate severe pain, agitation, and acute withdrawal.

Question 37Pain Management

Which adjuvant medication is particularly useful for pain caused by bone metastases?

  1. Lidocaine 5% patch
  2. Amitriptyline
  3. Dexamethasone Correct answer.
  4. Gabapentin

Explanation

Corticosteroids reduce peritumoral edema and are used for bone pain, capsular liver pain, and nerve compression. They can be combined with other therapies such as radiation or bisphosphonates for metastatic bone disease.

Question 38Pain Management

Which pharmacologic property of methadone contributes to its usefulness in neuropathic pain?

  1. Antagonism at NMDA receptors Correct answer.
  2. Inhibition of serotonin reuptake
  3. Selective COX-2 inhibition
  4. Blockade of peripheral sodium channels

Explanation

Methadone is a mu-opioid agonist that also antagonizes NMDA receptors, which is thought to help with neuropathic pain and opioid tolerance. It has a long and variable half-life and can prolong the QT interval, so titration requires care.

Question 39Pain Management

A patient with bone metastases has well-controlled pain at rest but severe pain every time she is repositioned. What is the best approach?

  1. Substitute a fentanyl transdermal patch for the current opioid
  2. Give a short-acting opioid 20 to 30 minutes beforehand Correct answer.
  3. Restrict repositioning to once every 12 hours
  4. Substantially increase the around-the-clock long-acting opioid dose

Explanation

This is incident pain, which is predictable and provoked by movement; it is managed by premedicating with a short-acting opioid before the activity rather than by escalating the baseline dose. Increasing the around-the-clock opioid would raise the risk of toxicity without preventing the movement-related pain spike.

Question 40Pain Management

A patient with sickle cell disease repeatedly asks for pain medication earlier than ordered and seems preoccupied with getting it. After the regimen is adjusted and the pain is controlled, the behavior stops. This behavior is best described as:

  1. Drug diversion
  2. Physical dependence
  3. Pseudoaddiction Correct answer.
  4. Addiction

Explanation

Pseudoaddiction describes drug-seeking behavior that results from undertreated pain and resolves once analgesia is adequate. It is distinguished from addiction, which involves compulsive use and continued use despite harm, independent of pain relief.

Question 41Pain Management

A patient taking long-term opioids has had no bowel movement in five days despite scheduled senna and docusate. Examination shows no obstruction or ileus. Which medication is most appropriate to add?

  1. Bismuth subsalicylate
  2. Loperamide
  3. Methylnaltrexone Correct answer.
  4. Ondansetron

Explanation

Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist that relieves opioid-induced constipation without reversing analgesia. It is used when traditional laxatives fail and there is no evidence of obstruction.

Question 42Pain Management

Which statement about the lidocaine 5% patch is accurate?

  1. It provides systemic analgesia equivalent to a low-dose opioid
  2. It is applied continuously for 24 hours without a rest period
  3. It is applied to intact skin for up to 12 hours Correct answer.
  4. It should be applied to broken skin to speed absorption

Explanation

The lidocaine 5% patch is applied to intact skin over the most painful area for up to 12 hours in any 24-hour period. It works locally with minimal systemic absorption and is used for localized neuropathic pain such as postherpetic neuralgia.

Question 43Pain Management

Which opioid is the safest choice for severe chronic pain in a patient with stage 4 chronic kidney disease?

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

Explanation

Fentanyl is preferred in advanced kidney disease because its metabolites are inactive and do not accumulate. Morphine, codeine, and meperidine all have metabolites that accumulate in renal failure and can cause neurotoxicity or seizures.

Question 44Pain Management

A patient reports no pain relief and no adverse effects from codeine. What is the most likely explanation?

  1. The patient is a CYP2D6 poor metabolizer Correct answer.
  2. The patient has developed tolerance over the past few days
  3. The dose is too high for the patient's weight
  4. Codeine must be given intravenously to work

Explanation

Codeine is a prodrug that depends on CYP2D6 to be converted to morphine; poor metabolizers obtain little analgesia, while ultrarapid metabolizers risk toxicity. The absence of both benefit and side effects points to a lack of conversion.

Question 45Pain Management

A patient with cancer pain has had escalating opioid doses. He now reports that his pain has become diffuse and more severe, and light touch is painful. What is the most likely explanation?

  1. Opioid-induced hyperalgesia Correct answer.
  2. Serotonin syndrome
  3. Opioid withdrawal syndrome
  4. Progressive disease requiring further dose escalation

Explanation

Opioid-induced hyperalgesia presents as worsening, diffuse pain and allodynia with dose escalation, reflecting sensitization rather than new nociception. Management is opioid dose reduction or rotation, not further escalation.

Question 46Pain Management

A patient with metastatic prostate cancer reports new severe mid-back pain, and you note new leg weakness and urinary retention. What is the priority action?

  1. Notify the provider urgently; give dexamethasone Correct answer.
  2. Apply heat to the back and encourage ambulation
  3. Increase the long-acting opioid dose and reassess in 24 hours
  4. Schedule an outpatient MRI in one week

Explanation

New back pain with leg weakness and bladder dysfunction suggests spinal cord compression, an oncologic emergency in which treatment within hours preserves neurologic function. Dexamethasone is given promptly while urgent imaging and oncology consultation are arranged.

Question 47Symptom Management

A hospice patient with advanced dementia and limited verbal ability appears uncomfortable during repositioning. Which approach is best for assessing this patient's pain?

  1. Use a validated behavioral observation tool such as PAINAD Correct answer.
  2. Ask the patient to rate pain on a 0-to-10 numeric rating scale
  3. Defer analgesia until the patient spontaneously reports pain
  4. Rely on vital signs alone to determine whether pain is present

Explanation

When self-report is unreliable, validated behavioral tools (for example PAINAD, Abbey, or DOLOPLUS) that score facial expression, body language, and vocalization are recommended. Vital signs do not reliably indicate pain, and waiting for a spontaneous verbal report leaves suffering untreated. Caregiver input is useful but does not replace a structured tool.

Question 48Symptom Management

Which prophylactic measure should be started when an older adult begins scheduled opioid therapy for cancer pain?

  1. No prophylaxis until the patient reports constipation
  2. A high-fiber diet with bulk-forming laxatives alone
  3. A scheduled stimulant laxative such as senna Correct answer.
  4. Docusate sodium given as a single agent

Explanation

Opioid-induced constipation is mediated by gut mu receptors, and tolerance to it does not develop, so prophylaxis is started with the opioid. A stimulant laxative such as senna, often combined with an osmotic agent, is standard; docusate alone has little supporting evidence. Bulk-forming agents can worsen symptoms when fluid intake is poor.

Question 49Symptom Management

Which medication is first-line for relieving dyspnea in a patient with advanced cancer who is not hypoxemic?

  1. Scheduled albuterol nebulizers around the clock
  2. Low-dose oral or subcutaneous morphine Correct answer.
  3. High-flow oxygen by mask regardless of saturation
  4. Nebulized furosemide given every 6 hours

Explanation

Opioids are first-line for refractory dyspnea at the end of life; they reduce air hunger and the distress of breathlessness. Oxygen provides benefit mainly to hypoxemic patients and often does not help others. Bronchodilators help only when bronchospasm is present.

Question 50Symptom Management

Which oral care measure is appropriate for a patient with chemotherapy-induced mucositis?

  1. Scrub the oral lesions vigorously with a firm toothbrush twice daily
  2. Rinse with an alcohol-based mouthwash after every meal
  3. Use saline or bicarbonate rinses with a soft toothbrush Correct answer.
  4. Apply hydrogen peroxide rinses every four hours

Explanation

Gentle mechanical cleaning with a soft brush plus bland saline or sodium bicarbonate rinses removes debris and keeps the mucosa moist without further irritation. Alcohol-containing rinses dry and damage healing tissue, and vigorous scrubbing traumatizes ulcers. Hydrogen peroxide is cytotoxic to new tissue.