CHPN Pain & Symptom Management 3 — Questions and Answers
Question 1: A terminally ill patient can no longer swallow oral medications. Which route is generally preferred for continuous opioid delivery in hospice?
- Intramuscular injection every 4 hours
- Subcutaneous continuous infusion via CSCI (Correct answer)
- Transdermal fentanyl patch changed every 24 hours
- Rectal suppository every 8 hours
Correct answer: Subcutaneous continuous infusion via CSCI
Subcutaneous continuous infusion (CSCI) via a syringe driver is preferred when the oral route is lost because it is minimally invasive, comfortable, and maintains steady drug levels.
Question 2: A patient's family asks why the nurse is giving morphine when the patient appears comfortable and is breathing slowly. What is the most accurate response?
- Morphine is being given to hasten death and reduce suffering at the end
- Morphine controls pain and dyspnea; the dose is titrated to comfort, not to respiratory rate (Correct answer)
- The slow breathing means morphine is working perfectly to sedate the patient
- Morphine is only given to prevent pain and has no effect on breathing
Correct answer: Morphine controls pain and dyspnea; the dose is titrated to comfort, not to respiratory rate
Opioids are titrated to symptom control; slow respirations near death are a sign of the dying process, not opioid toxicity, when doses are appropriately titrated.
Question 3: Which symptom cluster is most characteristic of opioid toxicity in a hospice patient?
- Hypertension, tachycardia, and diaphoresis
- Myoclonus, confusion, and pinpoint pupils (Correct answer)
- Diarrhea, bronchospasm, and bradycardia
- Hyperthermia, rigidity, and agitation
Correct answer: Myoclonus, confusion, and pinpoint pupils
Opioid toxicity classically presents with myoclonus, delirium/confusion, and miosis (pinpoint pupils), often prompting opioid rotation.
Question 4: When is opioid rotation (switching to a different opioid) most indicated in palliative care?
- Whenever a patient requests a change in medication
- When pain is uncontrolled despite dose escalation or intolerable side effects develop (Correct answer)
- Routinely every 30 days to prevent tolerance
- Only when the oral route is lost
Correct answer: When pain is uncontrolled despite dose escalation or intolerable side effects develop
Opioid rotation is indicated for inadequate analgesia despite escalation or for intolerable side effects, using equianalgesic dosing with a 25-30% reduction for incomplete cross-tolerance.
Question 5: A hospice patient reports that her pain is a 3/10 at rest but spikes to 8/10 with repositioning. This is best classified as:
- Chronic background pain
- Incident (movement-related) breakthrough pain (Correct answer)
- Idiopathic breakthrough pain
- Neuropathic central sensitization
Correct answer: Incident (movement-related) breakthrough pain
Pain that is predictably triggered by a specific activity like repositioning is classified as incident breakthrough pain, a subtype of breakthrough pain.
Question 6: Which non-pharmacologic intervention has the strongest evidence for reducing pain and anxiety in hospice patients?
- Therapeutic touch alone as primary pain management
- Music therapy as a complement to analgesic medication (Correct answer)
- Aromatherapy as a replacement for opioids
- Chiropractic manipulation at end of life
Correct answer: Music therapy as a complement to analgesic medication
Music therapy has a strong evidence base as a complementary intervention for reducing pain perception and anxiety in palliative and hospice populations.
Question 7: A patient with bone metastases has pain that is described as constant, aching, and worse with weight bearing. Which adjuvant is most appropriate alongside opioids?
- Tricyclic antidepressants
- NSAIDs or corticosteroids (Correct answer)
- Anticonvulsants such as gabapentin
- Antipsychotics
Correct answer: NSAIDs or corticosteroids
NSAIDs and corticosteroids address the inflammatory component of bone pain and are effective adjuvants for skeletal metastases alongside opioids.
CHPN Pain & Symptom Management 3
A terminally ill patient can no longer swallow oral medications.
Which route is generally preferred for continuous opioid delivery in hospice?