CHPN Pain & Symptom Management 5 — Questions and Answers
Question 1: A patient with end-stage heart failure has refractory edema and dyspnea. Which comfort-focused intervention is most appropriate in hospice?
- Aggressive IV diuresis with daily electrolyte monitoring
- Low-dose opioids for dyspnea relief and diuretics titrated for comfort, not fluid balance targets (Correct answer)
- Strict fluid restriction of 500 mL/day regardless of symptoms
- Immediate transfer to hospital for hemodynamic monitoring
Correct answer: Low-dose opioids for dyspnea relief and diuretics titrated for comfort, not fluid balance targets
In hospice, diuretics are titrated to symptom relief (reducing dyspnea and discomfort) rather than strict fluid balance targets, combined with opioids for breathlessness.
Question 2: Which of the following best describes pseudoaddiction in the context of hospice pain management?
- A genetic predisposition to opioid dependence in terminal patients
- Drug-seeking behavior resulting from undertreated pain, which resolves with adequate analgesia (Correct answer)
- The psychological dependence that develops after one week of opioid use
- An iatrogenic syndrome caused by abrupt opioid discontinuation
Correct answer: Drug-seeking behavior resulting from undertreated pain, which resolves with adequate analgesia
Pseudoaddiction describes behavior mimicking addiction (requests for more medication, clock-watching) that stems from undertreated pain and disappears when pain is adequately controlled.
Question 3: A hospice patient reports burning, shooting pain radiating down the leg. This pain quality most suggests:
- Visceral pain from hepatic capsule distension
- Somatic pain from a pathologic fracture
- Neuropathic pain from nerve compression (Correct answer)
- Inflammatory pain from infection
Correct answer: Neuropathic pain from nerve compression
Burning, shooting, or electric-shock pain radiating along a dermatomal or peripheral nerve distribution is characteristic of neuropathic pain.
Question 4: A patient's family reports the patient stopped eating and sleeping more. The nurse recognizes these as signs of the natural dying process. What is the priority nursing action?
- Insert a nasogastric tube to maintain nutrition
- Educate the family that these are expected changes and continue comfort measures (Correct answer)
- Order laboratory tests to rule out a reversible metabolic cause
- Increase IV fluids to maintain hydration
Correct answer: Educate the family that these are expected changes and continue comfort measures
Decreased oral intake and increased sleep are normal signs of the active dying process; the nurse's priority is family education and maintenance of comfort-focused care.
Question 5: When using the World Health Organization (WHO) analgesic ladder, a patient with moderate pain (4-6/10) not controlled by step 1 agents should be stepped up to:
- High-dose NSAIDs alone
- Weak opioids such as tramadol or low-dose oxycodone (Correct answer)
- Strong opioids such as IV morphine
- Invasive procedures such as nerve blocks
Correct answer: Weak opioids such as tramadol or low-dose oxycodone
Step 2 of the WHO ladder recommends adding weak opioids (tramadol, codeine, low-dose strong opioids) for moderate pain uncontrolled by non-opioids.
Question 6: A hospice patient with a history of substance use disorder requires opioid analgesia. What is the most appropriate approach?
- Withhold all opioids due to the risk of relapse
- Provide opioid analgesia with clear goals, close monitoring, and team communication (Correct answer)
- Use only non-opioid analgesics regardless of pain severity
- Require urine drug screens before every medication refill
Correct answer: Provide opioid analgesia with clear goals, close monitoring, and team communication
Patients with substance use disorder have the same right to pain management; a structured approach with clear goals, monitoring, and interdisciplinary team involvement balances access with safety.
Question 7: Which symptom is LEAST likely to be managed with a corticosteroid (e.g., dexamethasone) in hospice care?
- Malignant bowel obstruction pain and nausea
- Cerebral edema from brain metastases
- Opioid-induced constipation (Correct answer)
- Cancer-related fatigue and appetite loss
Correct answer: Opioid-induced constipation
Opioid-induced constipation is managed with laxatives, not corticosteroids; dexamethasone is used for cerebral edema, bowel obstruction, anorexia, and fatigue.
CHPN Pain & Symptom Management 5
A patient with end-stage heart failure has refractory edema and dyspnea.
Which comfort-focused intervention is most appropriate in hospice?