CHPN Pain Management Strategies 2 — Questions and Answers
Question 1: A hospice patient on long-acting morphine reports breakthrough pain occurring 5-6 times per day. What is the most appropriate intervention?
- Discontinue the long-acting opioid
- Increase the long-acting opioid dose (Correct answer)
- Add an adjuvant analgesic only
- Switch to a different opioid class
Correct answer: Increase the long-acting opioid dose
Frequent breakthrough pain (more than 3-4 episodes/day) indicates the baseline long-acting opioid dose is inadequate and should be increased.
Question 2: Which equianalgesic conversion is correct when rotating from oral morphine 60 mg/day to oral oxycodone?
- 30 mg oxycodone/day
- 40 mg oxycodone/day (Correct answer)
- 60 mg oxycodone/day
- 90 mg oxycodone/day
Correct answer: 40 mg oxycodone/day
The standard equianalgesic ratio of oral morphine to oral oxycodone is approximately 1.5:1, so 60 mg morphine converts to roughly 40 mg oxycodone per day.
Question 3: A palliative care nurse is assessing a patient with neuropathic pain unresponsive to opioids alone. Which adjuvant is first-line for this pain type?
- Haloperidol
- Gabapentin (Correct answer)
- Metoclopramide
- Dexamethasone
Correct answer: Gabapentin
Gabapentin (and pregabalin) are first-line adjuvant analgesics for neuropathic pain in palliative care.
Question 4: When calculating an appropriate breakthrough opioid dose, what percentage of the total daily opioid dose should typically be used?
- 1-5%
- 10-15% (Correct answer)
- 25-30%
- 50%
Correct answer: 10-15%
Breakthrough doses are standardly calculated as 10-15% of the total daily opioid dose, administered every 1-4 hours as needed.
Question 5: A patient with bone metastases has pain well-controlled at rest but reports severe movement-related (incident) pain. What intervention most specifically targets incident pain?
- Doubling the long-acting opioid
- Administering a rapid-onset opioid 20-30 minutes before activity (Correct answer)
- Switching to methadone
- Starting a ketamine infusion
Correct answer: Administering a rapid-onset opioid 20-30 minutes before activity
Rapid-onset opioids given prophylactically before anticipated painful activities are the standard approach to incident (movement-related) pain.
Question 6: Which non-pharmacological intervention has the strongest evidence for reducing pain perception in hospice patients?
- Therapeutic touch
- Guided imagery and relaxation techniques (Correct answer)
- Acupuncture performed by the nurse
- Homeopathic remedies
Correct answer: Guided imagery and relaxation techniques
Guided imagery and relaxation techniques have the strongest evidence base among non-pharmacological approaches for pain modulation in palliative populations.
Question 7: A hospice patient develops myoclonus and increased sedation after a recent opioid dose increase. What is the most likely cause?
- Opioid addiction
- Opioid-induced neurotoxicity from accumulation of metabolites (Correct answer)
- Uncontrolled anxiety
- Drug-seeking behavior
Correct answer: Opioid-induced neurotoxicity from accumulation of metabolites
Opioid-induced neurotoxicity — often due to accumulation of active metabolites such as morphine-6-glucuronide — can cause myoclonus, sedation, and cognitive changes.
CHPN Pain Management Strategies 2
A hospice patient on long-acting morphine reports breakthrough pain occurring 5-6 times per day.
What is the most appropriate intervention?