CHPN Study Guide 3 — Questions and Answers
Question 1: A CHPN notes that a patient on 60 mg oral morphine every 4 hours is requesting breakthrough doses every 2 hours. What is the MOST appropriate next step?
- Administer the breakthrough dose on request without changing the scheduled dose
- Notify the physician to reassess and consider increasing the scheduled opioid dose (Correct answer)
- Withhold the breakthrough dose because the patient is requesting too frequently
- Switch the patient to a non-opioid analgesic
Correct answer: Notify the physician to reassess and consider increasing the scheduled opioid dose
Frequent breakthrough dose use (more than 3 times in 24 hours) indicates inadequate baseline analgesia and the scheduled dose should be titrated up.
Question 2: Which of the following is a key component of a Goals of Care conversation in palliative nursing?
- Presenting only the treatment options the team recommends
- Eliciting the patient's values, fears, and understanding of their illness (Correct answer)
- Focusing exclusively on DNR/DNI status
- Deferring all conversations to the attending physician
Correct answer: Eliciting the patient's values, fears, and understanding of their illness
Goals of Care conversations are patient-centered and require eliciting values, prognosis understanding, and personal fears to guide care planning.
Question 3: A hospice patient with COPD develops increased dyspnea. After ruling out reversible causes, the MOST evidence-based pharmacologic intervention is:
- Benzodiazepines as first-line therapy
- Low-dose opioids (e.g., oral morphine 5 mg q4h) (Correct answer)
- High-flow oxygen for all patients
- Systemic corticosteroids as monotherapy
Correct answer: Low-dose opioids (e.g., oral morphine 5 mg q4h)
Low-dose opioids are the gold standard for managing refractory dyspnea in palliative care patients.
Question 4: The Kübler-Ross model of grief includes five stages. Which stage is characterized by the patient attempting to negotiate with a higher power or medical team?
- Denial
- Anger
- Bargaining (Correct answer)
- Depression
Correct answer: Bargaining
Bargaining is the stage where patients attempt to negotiate (e.g., 'If I can just live to see my grandchild born...') as a way of coping with loss.
Question 5: Which medication is the FIRST-LINE treatment for death rattle (noisy secretions) in the actively dying patient?
- Lorazepam IV
- Glycopyrrolate or hyoscine (scopolamine) (Correct answer)
- Furosemide IV
- Nebulized normal saline
Correct answer: Glycopyrrolate or hyoscine (scopolamine)
Anticholinergic agents like glycopyrrolate or scopolamine reduce secretion production and are first-line for death rattle.
Question 6: When assessing a patient for depression versus normal grief in the context of terminal illness, which feature is MOST indicative of clinical depression requiring treatment?
- Sadness about impending death
- Pervasive hopelessness, worthlessness, and suicidal ideation beyond a wish to die sooner (Correct answer)
- Tearfulness when discussing loved ones
- Decreased appetite in the final weeks of life
Correct answer: Pervasive hopelessness, worthlessness, and suicidal ideation beyond a wish to die sooner
Pervasive hopelessness, worthlessness, and suicidal ideation (distinct from passive wishes for death to come) distinguish clinical depression from expected grief.
Question 7: A palliative patient's family demands that 'everything be done' but the patient previously completed an advance directive requesting comfort-focused care. The nurse's PRIORITY action is:
- Follow the family's wishes because they know the patient best
- Honor the patient's advance directive as it reflects the patient's autonomous wishes when competent (Correct answer)
- Wait for a hospital ethics committee before making any decision
- Request a psychiatric consult for the patient
Correct answer: Honor the patient's advance directive as it reflects the patient's autonomous wishes when competent
A valid advance directive reflects the patient's wishes made while competent and takes precedence over family demands when the patient lacks decision-making capacity.
CHPN Study Guide 3
A CHPN notes that a patient on 60 mg oral morphine every 4 hours is requesting breakthrough doses every 2 hours.
What is the MOST appropriate next step?