CHPN Pain & Symptom Management 2 — Questions and Answers
Question 1: A hospice patient on scheduled morphine reports breakthrough pain occurring 4-5 times daily. What is the most appropriate intervention?
- Discontinue scheduled morphine and switch to PRN only
- Increase the scheduled around-the-clock morphine dose (Correct answer)
- Add a non-opioid adjuvant and leave the opioid unchanged
- Refer the patient back to oncology for re-evaluation
Correct answer: Increase the scheduled around-the-clock morphine dose
Frequent breakthrough pain (>3-4 episodes/day) indicates the scheduled baseline dose is inadequate and should be titrated upward.
Question 2: Which adjuvant analgesic is first-line for neuropathic pain in hospice patients who can tolerate oral medications?
- Ibuprofen
- Methadone
- Gabapentin (Correct answer)
- Ketorolac
Correct answer: Gabapentin
Gabapentin (and pregabalin) are first-line adjuvants for neuropathic pain due to their efficacy and relative tolerability.
Question 3: A patient with hepatic metastases has ascites causing severe dyspnea and abdominal discomfort. Which intervention most directly addresses both symptoms?
- Initiate high-dose corticosteroids
- Perform therapeutic paracentesis (Correct answer)
- Start a bowel regimen
- Increase opioid dosing only
Correct answer: Perform therapeutic paracentesis
Therapeutic paracentesis removes ascitic fluid, directly reducing intra-abdominal pressure and relieving both dyspnea and abdominal pain.
Question 4: When converting a patient from oral morphine 60 mg/day to IV morphine, what is the correct equianalgesic IV daily dose?
- 60 mg IV
- 30 mg IV
- 20 mg IV (Correct answer)
- 10 mg IV
Correct answer: 20 mg IV
The oral-to-IV morphine ratio is approximately 3:1, so 60 mg oral ÷ 3 = 20 mg IV per day.
Question 5: A hospice patient develops opioid-induced constipation. Which laxative regimen is most appropriate as first-line prophylaxis?
- Bulk-forming agents such as psyllium alone
- Stimulant laxative such as senna with or without a softener (Correct answer)
- Enemas administered daily
- Magnesium supplements
Correct answer: Stimulant laxative such as senna with or without a softener
Stimulant laxatives (senna) with or without docusate are recommended first-line prophylaxis for opioid-induced constipation in palliative patients.
Question 6: A patient with end-stage COPD experiences refractory dyspnea despite optimized bronchodilators. Which pharmacologic intervention has the strongest evidence for relieving dyspnea in this setting?
- Benzodiazepines alone
- Systemic opioids (Correct answer)
- Nebulized furosemide
- High-flow oxygen in all patients
Correct answer: Systemic opioids
Low-dose systemic opioids have the strongest evidence base for relieving refractory dyspnea in end-stage lung disease.
Question 7: Which of the following best describes the concept of 'total pain' as introduced by Dame Cicely Saunders?
- The numeric rating scale score that integrates resting and movement pain
- The combined physical, psychological, social, and spiritual dimensions of suffering (Correct answer)
- The cumulative opioid dose required to achieve complete analgesia
- The sum of all pain scores recorded over a 24-hour period
Correct answer: The combined physical, psychological, social, and spiritual dimensions of suffering
Dame Cicely Saunders coined 'total pain' to describe suffering as an integration of physical, emotional, social, and spiritual components, foundational to hospice philosophy.
CHPN Pain & Symptom Management 2
A hospice patient on scheduled morphine reports breakthrough pain occurring 4-5 times daily.
What is the most appropriate intervention?