ACHPN - Advanced Certified Hospice and Palliative Nurse Examination Managing Imminent Death Symptoms Questions and Answers

Question 1

A 72-year-old hospice patient with metastatic colon cancer has been comfortable on a regimen of long-acting oral morphine 60 mg every 12 hours.
He is now unable to swallow and is transitioning to the actively dying phase.
The ACHPN needs to convert his basal opioid to a continuous subcutaneous infusion.
Using a standard oral to parenteral morphine conversion ratio of 3:1, what is the correct initial rate for the continuous subcutaneous morphine infusion?

Accepted Answer

1.7 mg/hour

Answer

5 mg/hour

Answer

10 mg/hour

Answer

3.3 mg/hour

Question 2

A patient in the last hours of life is exhibiting significant restlessness, moaning, and attempting to climb out of bed, despite not appearing to be in pain. Repositioning and a quiet environment have not been effective. The patient's family is very distressed by these behaviors. Which of the following interventions is most appropriate to manage this patient's terminal agitation?

Accepted Answer

Administering a benzodiazepine such as lorazepam or midazolam.

Answer

Applying soft restraints to ensure patient safety and prevent falls.

Answer

Requesting a psychiatric consult to assess for an underlying mood disorder.

Answer

Administering a bolus dose of an opioid, as this is likely a sign of undertreated pain.

Question 3

An 80-year-old patient with end-stage renal disease, receiving hospice care, develops prominent myoclonic jerks while on a continuous subcutaneous infusion of hydromorphone for pain. Which of the following is the most appropriate initial management strategy?

Accepted Answer

Rotate to a different opioid, such as methadone or fentanyl, and consider adding a benzodiazepine.

Answer

Increase the rate of the hydromorphone infusion to treat the jerks as a pain equivalent.

Answer

Add a non-steroidal anti-inflammatory drug (NSAID) to the patient's regimen.

Answer

Administer an anticholinergic agent like glycopyrrolate to counteract the side effect.

Question 4

An unresponsive patient in the final days of life develops a fever of 38.9°C (102°F). The patient does not appear distressed. The family asks if something should be done. Which of the following statements represents the most appropriate approach to managing fever in this context?

Accepted Answer

The primary goal is to treat the fever only if it is causing distress to the patient, often with acetaminophen administered rectally.

Answer

Aggressive treatment with antibiotics and IV fluids should be initiated immediately to treat the underlying infection.

Answer

Fever is a normal part of the dying process and should never be treated with medication.

Answer

An ice-water bath is the most effective non-pharmacologic method to rapidly reduce the temperature.

Question 5

The daughter of a hospice patient who is actively dying calls the ACHPN in distress, stating, "My mother's feet and hands are cold and have a purple, blotchy look to them. What is happening?"

Accepted Answer

"This is a normal change called mottling. It happens as circulation slows and is a sign she is nearing the end. We can place a light blanket on her for comfort."

Answer

"Apply several heating pads to her legs and arms to warm them up and restore circulation."

Answer

"This is a sign of a blood clot. I will call for an ambulance to take her to the emergency room immediately."

Answer

"This indicates severe dehydration. We need to increase her fluid intake immediately, possibly with a subcutaneous infusion."

Question 6

When a patient in the last days of life loses the ability to swallow safely (terminal dysphagia), what is the primary guiding principle for managing oral intake?

Accepted Answer

Transition all essential medications to parenteral or rectal routes and focus on gentle oral care for comfort.

Answer

Initiate artificial nutrition and hydration via a feeding tube to prevent starvation.

Answer

Encourage the family to frequently offer small sips of water to prevent the sensation of thirst.

Answer

Use thickened liquids exclusively to ensure the patient receives some form of oral hydration safely.