CPNRE - Canadian Practical Nurse Registration Examination Gerontological and Palliative Care Questions and Answers Flashcards

An 82-year-old resident with moderate dementia and a history of falls is prescribed a new antihypertensive. Two days after initiation, the practical nurse notices the resident is more confused than usual and has had two near-falls during morning care. Blood pressure readings have been 102/58 and 98/60 mmHg. Which nursing action is the MOST appropriate first response?

Answer: Hold the next dose and notify the physician of orthostatic hypotension symptoms and increased fall risk

The resident is showing signs of medication-induced orthostatic hypotension (BP readings below 100/60, increased confusion, near-falls). In older adults with dementia, antihypertensives must be titrated cautiously because age-related physiological changes impair baroreceptor sensitivity and compensatory mechanisms. Holding the dose and promptly notifying the physician is the priority action — this is a medication safety concern requiring reassessment of the dose, not a nursing-only intervention. The other options are supportive but do not address the root cause.

A palliative care client with end-stage COPD is experiencing dyspnea rated 8/10. The client is not hypoxic (SpO₂ 91%). The care plan includes PRN low-dose morphine for refractory dyspnea. A family member insists the nurse should NOT give morphine because 'it will stop his breathing.' Which response by the practical nurse is MOST accurate?

Answer: Low-dose opioids titrated for dyspnea relief in palliative care have been shown to reduce the sensation of breathlessness without causing clinically significant respiratory depression at therapeutic doses

Evidence-based palliative care supports the use of low-dose opioids to relieve refractory dyspnea. The principle of double effect is well-established: the intent is to relieve suffering, and at therapeutic doses, properly titrated opioids do not cause respiratory depression in opioid-naive patients with dyspnea. Family education is a key nursing role. Option B is incorrect because increasing oxygen does not relieve dyspnea when the client is not significantly hypoxic and dyspnea is a subjective sensation. Option C is dismissive. Option D is inappropriate and delays necessary symptom relief.

A practical nurse is assessing pain in an 88-year-old resident with severe Alzheimer's disease who is unable to verbalize. The nurse notices the resident grimacing, clenching fists, and resisting repositioning. The family states 'she never complains so she must be fine.' Which assessment approach is MOST appropriate?

Answer: Use a validated behavioral pain assessment tool such as the PACSLAC or PAINAD scale to objectively quantify pain indicators

Cognitively impaired older adults are at high risk for undertreated pain because they cannot self-report. Behavioral pain scales like PAINAD (Pain Assessment in Advanced Dementia) and PACSLAC are validated tools for this population and assess indicators such as facial expressions, body language, vocalizations, and resistance to care. Family report alone is insufficient and often unreliable for pain intensity in advanced dementia. While empirical analgesic trials can be part of a stepwise approach, beginning with a validated tool ensures objective documentation and clinical defensibility.

During a palliative care family meeting, the substitute decision-maker (SDM) for a dying 79-year-old client requests that 'everything possible' be done, including CPR and mechanical ventilation, despite the client's previously documented advance directive refusing these interventions. The practical nurse's MOST appropriate immediate action is to:

Answer: Inform the SDM that advance directives reflect the client's own autonomous wishes and are legally binding, then involve the palliative care team and social worker to facilitate further discussion

A validly executed advance directive represents the client's autonomous decision-making while they had capacity and is legally binding in Canadian provinces. The SDM's role is to make substituted judgment — decisions the client would make — not personal preferences. The practical nurse must respectfully clarify the legal and ethical weight of the directive while involving the full interdisciplinary team (social work, palliative care physician, possibly ethics consultation) to support the family through grief and conflict. Option B violates the client's documented wishes. Option C avoids the issue. Option D is correct in principle but abrupt and non-therapeutic.

A 76-year-old client with chronic kidney disease (CKD Stage 4) and osteoarthritis is admitted to long-term care. The admitting physician orders celecoxib 200 mg daily for joint pain. The practical nurse reviewing the medication reconciliation should be MOST concerned because:

Answer: NSAIDs including COX-2 inhibitors are contraindicated in significant renal impairment as they reduce renal prostaglandin synthesis, worsening GFR and risking acute kidney injury

NSAIDs, including selective COX-2 inhibitors like celecoxib, reduce synthesis of prostaglandins that maintain renal afferent arteriolar dilation. In patients with CKD, this compensatory mechanism is critical for maintaining GFR. Prescribing an NSAID in Stage 4 CKD risks acute-on-chronic kidney injury, fluid retention, hyperkalemia, and accelerated progression to kidney failure. The practical nurse should flag this as a high-risk medication error and consult the prescriber before administration. The Beers Criteria explicitly lists NSAIDs as potentially inappropriate in older adults with reduced renal function.

A palliative care client is in the active dying phase with Cheyne-Stokes respirations and mottled extremities. The family is present and extremely distressed by the irregular breathing pattern, saying, 'Please do something — she's suffocating!' The client is unconscious and has no orders for repositioning restrictions. Which nursing intervention is the MOST therapeutic response to the family's concern?

Answer: Educate the family that Cheyne-Stokes respirations are a normal physiological sign of the dying process and do not cause the client distress, then offer comfort measures such as mouth care and positioning

Cheyne-Stokes respirations (periodic breathing with crescendo-decrescendo cycles and apneic pauses) are a normal and expected finding in the final hours to days of life, caused by changes in CO₂ sensitivity in the brainstem. The unconscious client is not experiencing air hunger or suffering. The nursing priority is family education, emotional support, and continuation of comfort measures. Applying oxygen does not alter the dying trajectory and may prolong the dying process without benefit. Requesting sedation solely for family distress is ethically inappropriate. Excluding the family removes their opportunity for meaningful presence at end of life.