CHPN - Certified Hospice and Palliative Nurse Hospice and Palliative Nurse Knowledge 1 — Questions and Answers
Question 1: A hospice patient with end-stage renal failure on scheduled oral morphine develops myoclonus and increasing agitation. Which action is most appropriate?
- Increase the morphine dose to achieve better pain control
- Add a scheduled benzodiazepine and continue the current morphine dose
- Rotate to an alternative opioid such as hydromorphone or fentanyl (Correct answer)
- Discontinue all opioids and transition to non-opioid analgesics only
Correct answer: Rotate to an alternative opioid such as hydromorphone or fentanyl
In renal failure, morphine's active metabolite morphine-6-glucuronide (M6G) accumulates and causes neuroexcitatory toxicity, including myoclonus, agitation, and seizures. Opioid rotation to hydromorphone or fentanyl, which do not produce neuroexcitatory metabolites to the same degree, is the appropriate intervention.
Question 2: When is palliative sedation considered ethically appropriate in hospice care?
- When any patient requests it due to fear of future suffering
- When refractory symptoms cannot be controlled by other means and the patient is near the end of life (Correct answer)
- As a first-line treatment for existential or spiritual distress
- Only when the patient has a DNR and no active advance directive disputes exist
Correct answer: When refractory symptoms cannot be controlled by other means and the patient is near the end of life
Palliative sedation is ethically indicated for refractory, intractable symptoms (such as intractable pain, dyspnea, or delirium) in imminently dying patients when all other symptom management strategies have failed. It requires informed consent and is distinct from euthanasia in both intent and mechanism.
Question 3: A family member of a dying hospice patient tells the nurse, 'I know my mother is still alive, but I already feel like I've lost her.' Which nursing response is most therapeutic?
- 'What you're describing is called anticipatory grief — it's a normal part of caring for someone who is dying.' (Correct answer)
- 'It may be too early to grieve; try to focus on the meaningful time you still have together.'
- 'These feelings suggest you may be experiencing clinical depression and should see a psychiatrist.'
- 'To protect your emotional health, consider limiting the time you spend at the bedside.'
Correct answer: 'What you're describing is called anticipatory grief — it's a normal part of caring for someone who is dying.'
Anticipatory grief is a well-recognized, normal psychological response that begins before the actual death of a loved one. Validating and normalizing this experience is a cornerstone of family-centered hospice care and helps prevent complicated bereavement after the death occurs.
Question 4: Which non-pharmacological intervention has the strongest evidence for reducing the perception of dyspnea in palliative care patients?
- Teaching pursed-lip breathing and diaphragmatic breathing exercises
- Applying supplemental oxygen to all dyspneic patients regardless of oxygen saturation
- Repositioning the patient to a prone position to optimize ventilation
- Directing airflow across the patient's face using a handheld fan (Correct answer)
Correct answer: Directing airflow across the patient's face using a handheld fan
Directed airflow across the face (via a handheld or bedside fan) stimulates trigeminal nerve receptors, which modulates the central perception of breathlessness. Evidence supports its effectiveness even in non-hypoxic patients. Supplemental oxygen is only beneficial when documented hypoxia is present.
Question 5: A patient with advanced cancer tells the hospice nurse, 'I don't want to talk about dying — I just want you to fix me.' Which communication approach is most appropriate?
- Remind the patient firmly that curative treatment is no longer a realistic option
- Explore what 'getting better' means to the patient and what they are most hoping for (Correct answer)
- Contact the physician to evaluate whether resuming disease-directed therapy is possible
- Document the patient's statement and avoid revisiting the topic in future visits
Correct answer: Explore what 'getting better' means to the patient and what they are most hoping for
Using open-ended, exploratory questions (e.g., 'What does getting better look like for you?') allows the nurse to understand the patient's underlying values, hopes, and fears without forcing a confrontational conversation about dying. This patient-centered approach, grounded in motivational interviewing, builds trust and opens the door for future goals-of-care discussions.
Question 6: A hospice patient with known brain metastases presents with persistent nausea, positional worsening, and a new-onset headache. Which antiemetic is most appropriate?
- Metoclopramide, to enhance gastric motility and reduce nausea at the dopamine receptor
- Ondansetron, to block serotonin receptors in the chemoreceptor trigger zone
- Dexamethasone, to reduce cerebral edema and lower intracranial pressure (Correct answer)
- Prochlorperazine, to block central dopamine receptors in the vomiting center
Correct answer: Dexamethasone, to reduce cerebral edema and lower intracranial pressure
Nausea in the setting of brain metastases is primarily driven by increased intracranial pressure causing direct stimulation of the vomiting center. Corticosteroids such as dexamethasone reduce peritumoral cerebral edema and thereby address the underlying mechanism. Prokinetics and dopamine antagonists are more appropriate for GI-mediated or opioid-induced nausea.
CHPN - Certified Hospice and Palliative Nurse Hospice and Palliative Nurse Knowledge 1
A hospice patient with end-stage renal failure on scheduled oral morphine develops myoclonus and increasing agitation.
Which action is most appropriate?