CHPN Pain & Symptom Management 4 — Questions and Answers
Question 1: A hospice patient with advanced dementia cannot self-report pain. Which validated tool is most appropriate for assessing pain in this population?
- Numeric Rating Scale (NRS)
- Visual Analog Scale (VAS)
- PAINAD (Pain Assessment in Advanced Dementia) (Correct answer)
- McGill Pain Questionnaire
Correct answer: PAINAD (Pain Assessment in Advanced Dementia)
The PAINAD scale assesses pain through observable behaviors (breathing, vocalization, facial expression, body language, consolability) in patients who cannot self-report.
Question 2: Terminal secretions ('death rattle') in a dying patient are best managed initially with:
- Vigorous oral suctioning to clear secretions
- Repositioning and anticholinergic medications such as glycopyrrolate (Correct answer)
- Chest physiotherapy and humidified oxygen
- IV antibiotics for presumed aspiration pneumonia
Correct answer: Repositioning and anticholinergic medications such as glycopyrrolate
Repositioning and anticholinergic agents (glycopyrrolate, hyoscine) reduce secretion production and are the standard initial management for terminal secretions.
Question 3: A patient on a fentanyl transdermal patch develops fever. What clinical concern does this raise regarding pain management?
- Fever indicates opioid-induced infection and the patch must be removed immediately
- Fever increases transdermal fentanyl absorption, potentially causing toxicity (Correct answer)
- Fever decreases patch adhesion, requiring more frequent patch changes
- Fever has no significant effect on transdermal drug delivery
Correct answer: Fever increases transdermal fentanyl absorption, potentially causing toxicity
Fever increases skin blood flow and temperature, accelerating transdermal fentanyl absorption and raising the risk of opioid toxicity.
Question 4: Which statement about methadone use in hospice is most accurate?
- Methadone has a short, predictable half-life making it easy to titrate
- Methadone's long and variable half-life requires careful titration and monitoring (Correct answer)
- Methadone is the preferred first-line opioid for all hospice patients
- Methadone cannot be used for neuropathic pain
Correct answer: Methadone's long and variable half-life requires careful titration and monitoring
Methadone's unpredictable and prolonged half-life (8-80+ hours) risks accumulation and delayed toxicity, requiring careful titration by experienced clinicians.
Question 5: A hospice patient is experiencing refractory nausea despite ondansetron. She has nausea triggered by movement and position changes. Which antiemetic class is most appropriate to add?
- Corticosteroids
- Anticholinergics such as scopolamine (Correct answer)
- Proton pump inhibitors
- Prokinetics such as metoclopramide
Correct answer: Anticholinergics such as scopolamine
Movement-triggered nausea (vestibular origin) is best treated with anticholinergic agents like scopolamine, which act on the vestibular system.
Question 6: In palliative sedation for refractory symptoms, which ethical principle most directly justifies its use?
- Autonomy — the clinician decides what is best
- Beneficence — relieving suffering outweighs the risk of hastening death (Correct answer)
- Justice — all patients deserve equal access to sedation
- Non-maleficence alone, without balancing other principles
Correct answer: Beneficence — relieving suffering outweighs the risk of hastening death
Palliative sedation is ethically justified primarily by beneficence and the doctrine of double effect — the intent is symptom relief, not hastening death.
Question 7: A hospice nurse notes a patient's pain is well-controlled at rest but poorly controlled at dressing changes. The BEST pre-procedural approach is:
- Skip the dressing change until pain is fully resolved
- Administer a short-acting opioid 30-45 minutes before the procedure (Correct answer)
- Double the scheduled opioid dose for the entire day
- Use topical anesthetic cream only and avoid systemic opioids
Correct answer: Administer a short-acting opioid 30-45 minutes before the procedure
Pre-procedural administration of a short-acting opioid 30-45 minutes before a painful procedure (incident pain) optimizes analgesic plasma levels during the intervention.
CHPN Pain & Symptom Management 4
A hospice patient with advanced dementia cannot self-report pain.
Which validated tool is most appropriate for assessing pain in this population?