CHPN - Certified Hospice and Palliative Nurse Non-Pain Symptom Management Questions and Answers — Questions and Answers
Question 1: A hospice patient with advanced lung cancer is experiencing severe dyspnea and anxiety. The patient is already on a stable dose of long-acting morphine for pain. Which of the following interventions is the MOST appropriate initial approach to manage this acute episode of dyspnea?
- Administering a dose of nebulized saline.
- Increasing the patient's supplemental oxygen to 10 L/min via non-rebreather mask.
- Administering a breakthrough dose of a low-dose, short-acting opioid like morphine. (Correct answer)
- Administering a stat dose of a benzodiazepine such as lorazepam.
Correct answer: Administering a breakthrough dose of a low-dose, short-acting opioid like morphine.
Opioids are the first-line pharmacological treatment for dyspnea at the end of life. They work by altering the central perception of breathlessness. A low-dose, short-acting opioid is the recommended initial approach. While benzodiazepines can be used to manage the anxiety component associated with dyspnea, they are not the primary treatment for the sensation of breathlessness itself. Increasing oxygen is often not effective for dyspnea in normoxic patients, and nebulized saline has no proven benefit.
Question 2: A nurse is caring for an imminently dying patient who has developed a loud, gurgling sound with breathing, commonly known as a 'death rattle.' The family is very distressed by the sound. Which non-pharmacological intervention should the nurse implement FIRST?
- Perform deep tracheal suctioning to clear the secretions.
- Administer a stat dose of atropine drops sublingually.
- Reposition the patient on their side or elevate their head. (Correct answer)
- Withhold all oral fluids immediately.
Correct answer: Reposition the patient on their side or elevate their head.
The first-line intervention for managing a death rattle is non-pharmacological. Repositioning the patient, such as turning them onto their side, can facilitate the drainage of secretions from the upper airway and may reduce the gurgling sound. Deep suctioning is invasive, often ineffective for this type of secretion, and can cause agitation. Pharmacological interventions like anticholinergics are considered secondary, and while fluid intake may be reduced, repositioning is the initial action to address the noisy breathing.
Question 3: A patient with end-stage pancreatic cancer is experiencing anorexia and significant weight loss (cachexia). The physician is considering pharmacological interventions to stimulate appetite. Which of the following medications has been shown to be effective for this purpose but also carries a significant risk of venous thromboembolism?
- Olanzapine
- Dexamethasone
- Dronabinol
- Megestrol acetate (Correct answer)
Correct answer: Megestrol acetate
Megestrol acetate, a progestational agent, is commonly used to stimulate appetite in patients with cancer-related anorexia-cachexia syndrome. However, a well-documented and significant side effect is an increased risk of venous thromboembolic events, such as deep vein thrombosis and pulmonary embolism. Dexamethasone and olanzapine can also stimulate appetite but are not associated with the same high risk of VTE. Dronabinol has weaker evidence for appetite stimulation.
Question 4: Which of the following is the MOST appropriate first-line pharmacological agent for managing delirium and agitation in a terminal patient who is unable to swallow oral medications?
- Lorazepam
- Haloperidol (Correct answer)
- Phenobarbital
- Propofol
Correct answer: Haloperidol
Haloperidol is a first-generation antipsychotic that is frequently recommended as the first-line agent for managing hyperactive delirium and agitation at the end of life. It can be administered via multiple routes, including subcutaneously or intramuscularly, making it suitable for patients who cannot swallow. Benzodiazepines like lorazepam may worsen delirium unless it is caused by alcohol or benzodiazepine withdrawal. Phenobarbital and propofol are typically reserved for refractory agitation requiring palliative sedation.
Question 5: A hospice nurse is developing a plan of care for a patient experiencing significant anxiety related to their prognosis. Which non-pharmacological intervention is a key component of managing anxiety in hospice patients?
- Encouraging the patient to avoid discussing their fears.
- Providing structured and rigid daily schedules.
- Recommending strenuous physical exercise.
- Utilizing active listening and providing a supportive presence. (Correct answer)
Correct answer: Utilizing active listening and providing a supportive presence.
A cornerstone of non-pharmacological anxiety management in hospice is therapeutic communication and presence. Active, empathetic listening and providing a supportive, calm presence allows patients to express their fears and concerns, which can significantly alleviate anxiety. Other non-pharmacological approaches include mindfulness, music therapy, and spiritual support.
Question 6: A patient with advanced heart failure reports persistent, bothersome nausea without vomiting. The patient describes a constant feeling of fullness and bloating. Which prokinetic agent would be a logical choice to manage these specific symptoms?
- Ondansetron
- Scopolamine
- Metoclopramide (Correct answer)
- Lorazepam
Correct answer: Metoclopramide
Metoclopramide is a prokinetic agent that enhances gastrointestinal motility and gastric emptying. It is effective for nausea associated with symptoms of gastric stasis, such as bloating and early satiety, which are common in patients with advanced illness. Ondansetron is a serotonin 5-HT3 antagonist, more effective for chemotherapy- or radiation-induced nausea. Scopolamine is an anticholinergic used for motion sickness or bowel obstruction. Lorazepam is an anxiolytic that can help with anticipatory nausea.
CHPN - Certified Hospice and Palliative Nurse Non-Pain Symptom Management Questions and Answers
A hospice patient with advanced lung cancer is experiencing severe dyspnea and anxiety.
The patient is already on a stable dose of long-acting morphine for pain.
Which of the following interventions is the MOST appropriate initial approach to manage this acute episode of dyspnea?