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

An 82-year-old client with advanced dementia and dysphagia is receiving palliative care. The family insists on nasogastric tube feeding, believing it will prevent aspiration pneumonia and prolong life comfortably. What is the most appropriate nursing response?

Answer: Explain that evidence does not support tube feeding in advanced dementia for preventing aspiration or improving comfort, and facilitate a goals-of-care discussion

Current evidence demonstrates that tube feeding in advanced dementia does not reduce aspiration pneumonia, prevent pressure injuries, improve nutrition, or prolong comfortable life. It can actually increase discomfort and agitation. The nurse's role is to provide accurate, evidence-based information to support informed decision-making and facilitate a goals-of-care conversation aligned with the client's palliative plan — not simply comply with family requests or defer responsibility.

A 78-year-old client on a palliative care unit is receiving a continuous subcutaneous infusion of hydromorphone for pain. The nurse notes the client has a respiratory rate of 8 breaths/min, is difficult to arouse, but has a pain score of 9/10 when briefly wakened. What is the priority nursing action?

Answer: Assess the full clinical picture, including oxygen saturation and level of consciousness, before intervening, and notify the palliative care team

In palliative care, a respiratory rate of 8 in a dying client is not automatically a crisis requiring naloxone. Naloxone would precipitate acute withdrawal and severe pain — a harmful outcome in end-of-life care. The nurse must first complete a full assessment (SpO2, consciousness, colour, secretions) and consult the palliative team for dose titration guidance. The goal is comfort, not reversal of opioid effect. Stopping the infusion would abandon pain control. Increasing the dose without assessment is unsafe.

During a home visit, a practical nurse is caring for an 89-year-old client with terminal heart failure. The client states: 'I want to stop my furosemide — the trips to the bathroom are exhausting and I feel no better.' The client has capacity. What is the nurse's most appropriate action?

Answer: Respect the client's autonomous decision, document it, inform the care team, and discuss what symptom changes to expect if the medication is stopped

A capable adult in palliative care has the right to refuse or discontinue any treatment, including medications that extend life. The nurse's role is not to override this decision or pathologize it. The appropriate actions are to acknowledge the decision respectfully, thoroughly document it, notify the interdisciplinary team, and provide anticipatory guidance about likely symptom changes (e.g., increased edema, dyspnea) so the client can make a fully informed choice and prepare. Reducing the dose without a physician order is outside nursing scope.

A practical nurse working in a long-term care facility observes that an 84-year-old resident with moderate Alzheimer's disease consistently resists personal care (bathing, dressing) by screaming and striking out at staff. The care team has documented this as 'combative behaviour' and proposed physical restraints during care. What is the nurse's best approach?

Answer: Implement person-centred dementia care strategies — identify triggers, modify care routine timing and approach, use distraction and music — and advocate against restraint use

Resistance to care in dementia is communication — the client is expressing distress, pain, or fear they cannot verbalize. Physical restraints cause physical and psychological harm, increase agitation, and are not appropriate as a first-line response to care resistance. Evidence-based dementia care involves identifying and addressing triggers (timing, environment, approach, pain), using familiar routines, music, and gentle communication. The nurse has a professional and ethical obligation to advocate against restraints and lead implementation of person-centred alternatives. PRN anxiolytics are a pharmacological restraint and require a full assessment justification, not routine use.

A 76-year-old client with end-stage COPD is admitted to a palliative unit. Despite being on scheduled opioids for dyspnea, the client reports persistent air hunger rated 8/10. The nurse notices the client also has significant anxiety and is mouth breathing rapidly. Which intervention is most likely to provide additional symptomatic relief beyond opioid dose review?

Answer: Encourage pursed-lip breathing and position the client with a handheld fan directed at the face, and address anxiety with a benzodiazepine as ordered

In palliative COPD, dyspnea management goes beyond opioids and oxygen. A handheld fan directed at the perioral/nasal area stimulates trigeminal mechanoreceptors and is evidence-based for reducing the sensation of breathlessness even without changing actual oxygenation. Anxiolytic therapy (e.g., lorazepam) addresses the significant anxiety-dyspnea cycle. High-flow oxygen via non-rebreather is inappropriate in COPD (hypercapnic drive risk) and is not a palliative comfort goal. BiPAP is an escalation of life-prolonging technology inconsistent with palliative intent unless specifically part of the care plan. Fluid restriction does not address dyspnea in COPD.

A practical nurse is conducting a pain assessment on a 91-year-old client with severe vascular dementia who is non-verbal. The client grimaces, tenses their legs, and has increased restlessness during repositioning. A previous nurse charted 'no pain — client unable to report.' What is the most appropriate nursing action?

Answer: Use a validated observational pain tool such as the PACSLAC or PAINAD to systematically assess behavioural pain indicators and document findings

Non-verbal clients with advanced dementia cannot self-report pain, but this does not mean pain is absent. Behavioural pain indicators (grimacing, guarding, restlessness, vocalizations) are valid signals. Validated observational tools such as PACSLAC (Pain Assessment Checklist for Seniors with Limited Ability to Communicate) or PAINAD are specifically designed for this population and must be used. The previous charting reflects an assessment gap, not an accurate finding. Simply giving a PRN without documentation fails professional standards. BPSD and pain are not mutually exclusive — pain is often the underlying trigger for BPSD and must be ruled out first, not last.