CHPN Practice Exam

Routine home care is the appropriate setting for this patient. This patient no longer qualifies for general inpatient hospice care based on the lack of symptoms. A reduced level of consciousness is expected and can be managed in the home. Respite is not appropriate, as the patient is presently inpatient. Continuous home care would require a higher symptom burden.

"I want to be home with my family," indicates that the patient's priority is quality of life over length of life. Having nothing to look forward to is a signifier of depression, not acceptance. A psychological or spiritual referral would be more appropriate. If the patient wants to live one more year, realistic or not, hospice is inappropriate. If the patient is focused on the cause of the cancer, it indicates his priority is not on quality of life.

The patient's desire to attend the rodeo should take priority in the plan of care. Educating the patient about the risks associated with this outing would be recommended. There is nothing in the question to indicate that the patient will need a chaperone.

Upper body swelling is an indicator of superior vena cava syndrome (SVCS). Concentrated urine, not dilute, is a sign of syndrome of inappropriate diuretic hormone (SIADH), another oncologic emergency. Though constipation may indicate hypercalcemia or bowel obstruction, which is common in many cancer patients. Dependent edema is also a non-emergent finding.

Noisy, congested respirations (known as "terminal secretions") are very common during the dying process, and are also sometimes referred to as a “death rattle”. Typically, they do not cause discomfort for the patient, but can be very distressing to family members. Repositioning the patient by turning him on his side can be helpful to decrease the noise associated with this situation. Anticholinergics can also be administered, but typically, once the secretions start, anticholinergic effectiveness is limited.

Patients with emphysema may find some relief from dyspnea by leaning forward while sitting, and placing arms over a table (“tripod position”), due to the lengthened tension-state of the diaphragm in this position. Lowering the head of the bed would likely worsen dyspnea; pursed mouth-breathing, rather than deep nose-breathing, would be of greater benefit to lessening dyspnea; although guided imagery may improve mood, evidence does not demonstrate that it affects dyspnea directly.

John's symptoms are due to right sided (diastolic) heart failure, when the ventricle does not fill adequately, leading to a generalized edema of the extremities and the hepatic system. Symptoms of right sided failure include nausea, anorexia, peripheral edema, ascites, weakness, and weight gain. Poor cardiac output, decreased ejection fraction, organ perfusion failure are indicative of left-sided heart failure.

When changing analgesics, a dose reduction is recommended for cross-tolerance. Recommendations vary, but reduction can be up to 50% of the original dose. Increases in doses are possible in the future, but not at the time of conversion and not without more assessment data. Though tolerance is a concern with conversion of opioids, dependence is not. Assessing cognition is not indicated.

The patient has pain and it needs to be treated. Since morphine has worked in the past, the most likely scenario is that the patient has developed a tolerance and the dose needs to be increased. The next step would be to try another opioid. Stopping the opioid would cause withdrawal and increase discomfort. Titrating off of morphine would only be indicated if there was no more pain. Addiction is not a concern for this patient.

This patient is most likely experiencing myoclonus related to high opioid doses. The nurse should work with the providers to rotate to a new opioid. Supplementary hydration would be a solution if this myoclonus is related to hypercalcemia. Massage and education may help but will not address the root cause of the myoclonus.

Breakthrough pain is intermittent episodes of pain that occur in patients with chronic pain. This type of pain can be related to some type of activity, of unknown origin, or can occur as analgesic failure at the end of a pain medication's period of effectiveness. Opioid regimens for pain management in the hospice and palliative care setting should include a long-acting agent, once dosing need is established, and a short-acting agent to cover episodes of breakthrough pain.

Since the oral route is always preferred if possible, Madge should be converted to liquid dosing of her current long-acting pain medication q 4hrs ATC (convert from Oxycontin® to liquid oxycodone), while maintaining the same dosing as currently ordered for breakthrough pain. Since most liquid forms are quite concentrated, even patients who are minimally responsive can tolerate such small volumes in the buccal space and typically maintain excellent pain control.

Transdermal fentanyl, also known as a fentanyl patch, is a good choice for individuals with pain who cannot swallow or do not remember to take their medication, and would need to be titrated to effect for this patient. It is a particularly good choice for Margaret because she may be forgetful due to her brain metastasis, which would not improve by providing liquid morphine instead of tablets. As she does not live with a caregiver, depending on the neighbor to assure adequate pain management is not an effective plan. As Margaret is not in pain crisis, symptom control efforts should be initiated and the effect evaluated before referral to an inpatient hospice setting.

Jordan is experiencing end-of-dose failure, which indicates that in the last hours of the dosing cycle, the blood levels of the drug are decreasing before uptake of the next scheduled dose. This is different than breakthrough pain, characterized by episode of pain despite control of continuous baseline pain. By shortening the round-the-close drug interval, Jordan will experience more stable drug blood levels. Increasing the prn dosing would only result in a short-acting bolus just prior to the next dosing cycle and could cause sedation and other side effects. A switch to another opioid is not necessary as this is typically done due to an undesirable side effect. A corticosteroid would not provide the desired pain management result in the last hours of the dosing cycle.

The nurse may consider all these actions, but the priority will be to irrigate the wound. The presence of purulent drainage does indicate infection, but further assessment cannot be done until the wound is clean. After it is clean and the wound bed assessed, the nurse would choose the appropriate dressing. Any calls to the provider and patient education could occur after the wound is cared for.

Fiber supplementation is considered a bulk-forming laxative. This is not generally recommended in hospice due to the water required to be effective. Inadequate water availability would worsen constipation and potentially lead to obstruction. The other options are appropriate.

Unexplained syncope, as well as previous cardiac arrest with resuscitation, and an embolic stroke originating from the cardiac system are all indicators of poor prognosis in this patient population.

To avoid vasovagal symptoms (tachycardia, hypotension, fainting), it is important to draw the fluid off slowly with no more than 1-1.5 liters removed at any one time. Fully draining the pleural space (if more than 1.5 liters is present) could result in pain, vasovagal responses, and cough. In the palliative setting, it is ideal to have a caregiver instructed on how to properly access the catheter. Drainage should never occur over an 8-hour period, as prolonged catheter access can result in infection or embolus.

Insertion of a nasogastric tube for decompression venting and emptying of stomach contents is the most appropriate intervention at this stage of obstruction. Bowel rest is necessary, but bowel rest alone will not empty the stomach contents and hopefully reduce vomiting. A Foley catheter will not improve the obstruction; introduction of food while the obstruction is present will only complicate the situation.

The Hospice Medicare and Medicaid Benefit pays for outpatient services such as emergency room visits when arranged by the hospice team. The benefit does not cover room and board for hospice services in a private home or room and board in a nursing home; it does not cover prescription drugs or treatment intended to cure the terminal illness. The benefit also requires that all care for the terminal illness  is given by the hospice provider chosen, with the exception of the patient's regular doctor or nurse practitioner, chosen to be the attending physician for the hospice care.

Medicare hospice regulations require that the hospice must provide bereavement services to the family and any other individuals that are identified on the bereavement care plan for up to 1 year following the patient's death. There is no distinction between direct family members and other individuals associated with the patient.

Using terms such as "I wish" and "I had hoped" acknowledge the changes that are obvious while respecting the family's spiritual wishes to not discuss death directly. Confronting the wife by accusing her of not being helpful or not being ready to talk about death devalues their beliefs about death; diverting the discussion to the medical director may be helpful, but is not the most appropriate choice.

The decision to elect code status is the patient's decision. It is legally and ethically reversible. It would be unethical for the family to go against the patient's clearly stated wishes. In this case, the family should engage in further discussion with the patient. A visit from the chaplain may be beneficial for this family, but the decision to reverse the DNR is the patient's only.

Asking her to show you how she performs the skill is the most effective means of demonstrating competency. After instructing patients/caregivers regarding any given skill or task, the following should occur, as a minimum: (1) Request a statement of understanding; (2) Watch a return demonstration if appropriate; and (3) Document the response. These are essential aspects of ensuring adult learning and patient safety.