AOCNP Palliative Care and Symptom Management 5 — Questions and Answers
Question 1: A patient with advanced cancer develops hypercalcemia of malignancy (serum calcium 13.5 mg/dL). Which is the first-line pharmacologic treatment?
- Oral calcium supplements to recalibrate serum levels
- Intravenous bisphosphonate such as zoledronic acid after IV hydration (Correct answer)
- Subcutaneous calcitonin as the sole long-term agent
- Oral corticosteroids as the primary treatment
Correct answer: Intravenous bisphosphonate such as zoledronic acid after IV hydration
IV hydration followed by an IV bisphosphonate (zoledronic acid or pamidronate) is the first-line treatment for malignancy-associated hypercalcemia.
Question 2: When converting a patient from IV hydromorphone 1.5 mg/hour continuous infusion to oral extended-release opioids, the nurse practitioner should:
- Use a 1:1 ratio because IV and oral doses are equivalent
- Calculate total 24-hour IV dose, apply equianalgesic conversion, and reduce by 25–30% for incomplete cross-tolerance (Correct answer)
- Simply stop IV and start the oral agent at the same numeric dose
- Double the IV dose to account for oral bioavailability
Correct answer: Calculate total 24-hour IV dose, apply equianalgesic conversion, and reduce by 25–30% for incomplete cross-tolerance
Equianalgesic conversion tables are used to calculate the equivalent oral dose, then a 25–30% reduction is applied to account for incomplete cross-tolerance during opioid rotation.
Question 3: A patient with advanced pancreatic cancer reports severe neuropathic pain described as burning and shooting despite adequate opioid dosing. Which adjuvant analgesic has the best evidence as a first-line addition?
- Oral antihistamine (diphenhydramine)
- Tricyclic antidepressant (nortriptyline) or gabapentinoid (gabapentin/pregabalin) (Correct answer)
- Topical capsaicin 0.025% cream alone
- Vitamin B12 supplementation
Correct answer: Tricyclic antidepressant (nortriptyline) or gabapentinoid (gabapentin/pregabalin)
Tricyclic antidepressants and gabapentinoids are first-line adjuvant analgesics for neuropathic pain in cancer patients, per NCCN and WHO guidelines.
Question 4: Which ethical principle is most directly invoked when a palliative care NP provides high-dose opioids for refractory symptoms, accepting that respiratory depression is a possible but unintended side effect?
- Autonomy
- Justice
- Doctrine of double effect (Correct answer)
- Veracity
Correct answer: Doctrine of double effect
The doctrine of double effect justifies an action with both good (symptom relief) and potentially bad (respiratory depression) effects when the intent is the good effect and the good outweighs the harm.
Question 5: A patient receiving palliative radiation for painful bone metastases asks when to expect pain relief. The nurse practitioner should counsel that onset of analgesic effect typically occurs:
- Within 2–4 hours of the first fraction
- Within 1–4 weeks after the start of treatment (Correct answer)
- Only after completing the full fractionated course (6–10 weeks)
- Pain relief from radiation is unpredictable and rarely occurs
Correct answer: Within 1–4 weeks after the start of treatment
Palliative radiotherapy for bone pain typically produces a response within 1–4 weeks; partial or complete pain relief is achieved in approximately 60–70% of patients.
Question 6: An oncology NP is managing a patient with cancer anorexia-cachexia syndrome. Which pharmacologic agent has demonstrated short-term improvement in appetite and quality of life in this population?
- Megestrol acetate (Megace) (Correct answer)
- Metformin
- High-dose multivitamin supplementation
- Erythropoiesis-stimulating agents
Correct answer: Megestrol acetate (Megace)
Megestrol acetate (a progestational agent) improves appetite and caloric intake in cancer-related anorexia-cachexia, though it does not improve survival.
Question 7: A patient in the last hours of life becomes agitated and confused despite opioid therapy. Which intervention is most appropriate for managing terminal restlessness/agitation?
- Increase opioid dose as the sole intervention
- Add a benzodiazepine (e.g., midazolam or lorazepam) or neuroleptic (e.g., haloperidol) alongside opioids (Correct answer)
- Initiate empiric antibiotics for presumed delirium from infection
- Apply physical restraints to protect the patient
Correct answer: Add a benzodiazepine (e.g., midazolam or lorazepam) or neuroleptic (e.g., haloperidol) alongside opioids
Terminal agitation is best managed by combining opioids with a benzodiazepine (midazolam, lorazepam) or haloperidol to address the neuropsychiatric component of distress.
AOCNP Palliative Care and Symptom Management 5
A patient with advanced cancer develops hypercalcemia of malignancy (serum calcium 13.5 mg/dL).
Which is the first-line pharmacologic treatment?