Assessment and Intervention

Question 1

General Order of Operation for hospice/PC SW
(SAPPARAH)

Answer 1

1. Screen in order to–
2. Assess in order to–
3. Plan with the interdisciplinary team in order to–
4. Plan social work interventions in order to–
5. Apply intervention–
   (Hand off or discharge if intervention is by another discipline)
6. Re-assess (intervals may be determined by the nature of the intervention)–
7. Adjust intervention as needed–
8. Hand-off or discharge

Question 2

Spiritual history tool - FICA

Answer 2

Faith and belief;
Importance of spirituality;
Community membership; and
Addressing these issues in health care.

Question 3

Roger is a 73-year-old with a diagnosis of end-stage prostate cancer with metastasis to the spine.
He is scheduled to undergo surgical stabilization of a vertebral fracture which is causing him a
great deal of pain. Of the following, which best describes this treatment modality?
a. Cyberknife Radiosurgery
b. Prophylactic surgery
c. Palliative surgery
d. Curative surgery

Answer 3

C

Question 4

Brian is a 65-year-old with a history of end-stage small cell lung cancer. His wife called to report
that she had to call the police because he had become increasingly confused and combative,
then grabbed his gun and ran out into the driveway. What do you suspect may be happening in
Brian’s situation?
a. He has an unreported history of domestic violence.
b. He is having a reaction to his benzodiazepines.
c. He has brain metastasis.
d. He has mixed alcohol with his opioid dosage

Answer 4

. c - Since small cell lung cancer often metastasizes to the brain, Brian should be evaluated for this suspected diagnosis. Patients who have changes in behavior, and have a cancer diagnosis with this known metastatic pattern should be evaluated for this complication. Palliative treatment options may include radiation, surgery and chemotherapy. Medical management focuses on control of headache, cerebral edema and seizures. The steroid of choice is dexamethasone for treatment of cerebral edema

Question 5

Victor is a 65-year-old with end-stage head and neck cancer with a large pulsating neck tumor
near his carotid artery. He has signed a DNR and wishes to die at home. Of the following, which
interventions may be most helpful for Victor and his family?
a. Preparing them for carotid artery rupture
b. Instructing regarding access to emergency services after carotid artery rupture
c. Providing the number for biohazard companies
d. Encouraging Victor to spend his last days in a hospice facility to decrease trauma to his
family

Answer 5

20. a - There is high possibility of carotid artery rupture in Victor’s situation, and both and he and his family should receive as much preparation as possible for this traumatic event. Victor’s wishes to die at home should be honored, within the framework of his family’s dynamics. If rupture occurs, events will occur rapidly, so advanced preparation is critical. Dark towels should be provided to absorb blood and manage bleeding, and prefilled syringes of pain medication and/or sedatives should be available. Areas of oozing may be treated with topical epinephrine. Both patient and family should also be educated that carotid artery rupture may not occur externally.

Question 6

When assessing a patient with pulmonary disease for hospice eligibility, which of the following
would be indicators of advanced disease?
a. Uncontrolled hypertension
b. Cor pulmonale
c. Mild dyspnea after climbing stairs
d. Cardiac arrhythmias

Answer 6

b - Cor pulmonale is one of the indicators of advanced pulmonary disease. Both obstructive and restrictive pulmonary diseases can cause increased pulmonary pressure, which leads first to right ventricular failure (cor pulmonale), and then to left ventricular failure. Other indications of advanced pulmonary disease include respiratory failure, weight loss >10% over six months and tachycardia defined as pulse rate >100 bpm. Early respiratory failure involves hypoxia and hypercapnia, which cause breathlessness, poor activity tolerance, and poor quality of life.

Question 7

Anemia is a common finding in patients with chronic renal failure due to decreased production
of erythropoietin. What symptom may be associated with this condition in the hospice patient
with end-stage renal failure?
a. Increased risk of bleeding
b. Dyspnea
c. Increased risk of deep vein thrombosis (DVT)
d. Increased risk of pulmonary embolism (PE

Answer 7

b - Dyspnea is a common finding in the hospice patient who has end-stage renal failure and is anemic. Since the red blood cells carry oxygen, and are reduced in patients with anemia, these patients have lower tissue oxygenation as a result. Additional associated symptoms are chest pain and weakness, due to the same pathophysiology.

Question 8

Frank is a 74-year-old hospice patient who was diagnosed with non-Hodgkin’s lymphoma 8 years ago
and underwent treatment with subsequent remission. The lymphoma recurred 1 year ago and has
been unresponsive to chemotherapy and surgical intervention. He has been hospitalized, in a
rehabilitation facility or nursing home for the past 8 months, with decreasing mental and physical
capacity along with significant weight loss and dependence for all activities of daily living. He has now
been at home with hospice care for the past 4 days and has been primarily unresponsive the majority
of that time but appears comfortable.
As the hospice nurse, you receive a call from Frank’s family that after being unresponsive for 4
days; he awoke this morning, smiled at his family and tried to speak. He remains alert and
comfortable per the family. The family believes he is getting better and request you visit. What
is the best response for the nurse to address the family’s belief that he is improving?
a. “He is still dying. You should not be hopeful for any type of interaction or time with him”.
b. “He may actually be closer to death now as many patients have a brief, temporary period
of alertness prior to death”.
c. “He may be improving slightly. We will have to watch and see what happens next”.
d. “You should enjoy this time with him and not worry about what could happen”.

Answer 8

b - The best response for the nurse in this scenario is to honestly, carefully and compassionately explain the improvement in awareness/alertness as a common temporary event in some patients prior to imminent death and encourage them to make the most of the this uncertain, yet meaningful time with their loved one.

Question 9

Which of the following conditions are associated with endocrine disorders such as
hyperparathyroidism, diabetes mellitus, and Addison’s disease?
a. Depression.
b. Substance abuse.
c. Anxiety.
d. None of the above.

Answer 9

. a - Depression is commonly associated with these disorders. Anxiety is related to Cushing’s disease, hypo/hyperglycemia, carcinoid syndrome, pheochromocytoma and hypo/hyperthyroidism.

Question 10

Of the following, which patient/family belief system would NOT be a barrier to the appropriate
assessment and treatment of a patient’s pain?
a. Physical dependence on pain medicine is common.
b. Pain is inevitable with aging.
c. Good patients do not complain.
d. Morphine should only be used as a last resort

Answer 10

b - Providing a thorough explanation regarding the definition and intent of palliative sedation would be most important. There are 1-2% of patients at end of life who experience refractory and intolerable symptoms who can benefit by the use of sedation with the goal of relieving distress in all realms of the pain experience

Question 11

Mabel is a 72-year-old with a diagnosis of end stage breast cancer with metastasis to the bone.
She has been having increased pain, but states she is afraid to use too much pain medication for
fear she might become “addicted”. Of the following, which is the most appropriate response?
a. Addiction is age-related, and she is not at risk.
b. Addiction is different than physical dependence.
c. Addiction occurs when the drug’s effect is reduced over time.
d. Her fears are correct and dosing should be limited

Answer 11

. b - Mabel should be provided with an explanation of addiction, and how it differs from physical dependence. Addiction is a “primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.”52 Characteristics of addiction include inability to control drug use, compulsive use and continued use even when harm or craving occurs. In contrast, physical dependence is “a state of adaptation that is manifested by a drug class specific to withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist”. Tolerance involves decreased effectiveness of a drug over time

Question 12

Of the following, which are important parameters to include in a comprehensive pain
assessment?
a. Site
b. Character
c. Intensity
d. All of the above

Answer 12

d - All of the above should be included in a comprehensive pain assessment, in addition to the following: onset, duration and frequency, intensity, exacerbating factors, associated symptoms, alleviating factors, medication history, impact on quality of life and physical examination. An updated method of incorporating vital information of the comprehensive pain assessment is “PQRST” and reads as follows: The “P” in PQRST stands for “Provocation” or “Palliation.” The “Q” in the pain assessment PQRST method represents “Quality” of the pain. The “R” in this useful mnemonic tool stands for “Region” or “Radiation”. The “S” measures the “Severity” of the pain and is usually gauged on a scale of 0 to 10, 10 being the worst possible pain. The final set of questions in “T” assesses time.

Question 13

What is the RULE of motivational interviewing?

Answer 13

1. Resist: resist giving suggestions to our patients for their problems
2. Understand: understand the patient’s motivation by being a curious listener and attempting to elicit the patient’s own underlying motivation for change.
3. Lesson: listen with a patient centered, empathic approach.
4. Empower: empowering the patient helps them understand that they are in control of their actions, and any change they desire requires them to take steps towards that change.

Question 14

Margaret is a 93-year-old patient with a hospice diagnosis of Alzheimer’s disease and associated
debility. What functional assessment scoring system should be used to help determine her
hospice eligibility?
a. Karnofsky score
b. Glasgow score
c. MODS score
d. AIS score

Answer 14

a - The Karnofsky scoring system can be used to evaluate functional status in any patient, and is particularly helpful as part of the criteria for determining hospice eligibility for the patient with a diagnosis of debility unspecified. The Karnofsky scoring ranges from 100% (normal, no complaints, no evidence of disease) to 0% (death) in increments of 10.

Question 15

Joe is a retired railroader who has been diagnosed with end-stage pulmonary fibrosis. He has
had increased dyspnea, increased sleeping and decreased appetite. He has been unable to get
out of bed for the past week, and has had several bouts of urinary incontinence, which is a
change for him. His wife says that he used to love company, but recently he has been refusing
visitors, and states that he “just wants to be left alone.” In the context of his other symptoms,
what is the most likely cause for Joe’s withdrawal?
a. He is embarrassed about his incontinence.
b. He is upset with his wife.
c. He is in the dying process.
d. His medication needs adjusted.

Answer 15

. c - Viewed in the context of his other symptoms, Joe appears to be in the dying process, which may last for days in some cases. Physical and emotional withdrawal is a very common indicator of imminent death, and the patient’s wishes should be honored accordingly. This is often difficult for caregivers and family members to deal with, since they often would like to be able to spend as much time as possible with the patient in the limited time they have left, and may not understand the reasons behind the patient’s withdrawal

Question 16

Which of the following would be an example of a cognitive-based complementary therapy?
a. Acupuncture
b. Massage
c. Music therapy

Answer 16

139. c - Music therapy, art therapy, biofeedback, creative visualization, focused breathing, guided imagery, hypnosis, meditation, music therapy, and progressive muscle relaxation are all examples of cognitive-based complementary therapies. The others listed here along with acupressure, aromatherapy, chiropractic medicine, exercise, nutrition, polarity, Reiki, Shiatsu, therapeutic touch and yoga are examples of physical-based therapies.

Question 17

Which of the following is not one of the five domains of complementary/alternative medicine
recognized by the National Center for Complementary and Alternative Medicine?
a. Alternative mental systems.
b. Mind-body interventions.
c. Energy therapies.
d. Biologically-based therapies.

Answer 17

. a - The 5 domains are Alternative medical systems, mind=body interventions, energy therapies, biologically-based therapies, manipulative and body-based methods, and energy therapies.

Question 18

Of the following, which is the most significant benefit of the use of complementary/alternative
therapies as opposed to traditional medical methods in the hospice/palliative care population?
a. Limited cost
b. Limited side effects
c. Limited travel
d. None of the above

Answer 18

. b - The most significant benefit to hospice and palliative care patients is the limited side effects of these therapies as opposed to traditional medical methods of symptom management (typically pharmacological, with many side effects and interactions).

Question 19

Recognized benefits of massage therapy and aromatherapy in hospice/palliative care include
which of the following?
a. Sense of well-being
b. Decreased mood swings
c. Immediate pain relief
d. All of the above
e. Both a and c only

Answer 19

. e - Immediate pain relief and a sense of well-being are recognized benefits of massage therapy and aromatherapy in cancer patients according to research studies. Decreased mood swings are not specifically stated as being recognized.

Question 20

Of the following, which may indicate a poor prognosis for the hospice patient with a diagnosis of
end-stage cardiac disease?
a. Infection
b. Edema
c. Bleeding
d. Unexplained syncope

Answer 20

. d - 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.

Question 21

When a hospice patient has a diagnosis which may involve anticipated hemorrhage in the home,
what should be the focus of care?
a. Access to biohazardous cleanup
b. Support of the patient and family
c. Replacing blood loss
d. Preventing hemorrhage

Answer 21

b - When hemorrhage is anticipated as part of disease progression for a hospice patient, treatment should focus on support of the patient and family. Providing education and preparation are vital components to helping them cope with such a traumatic event. Dark towels should be made available, as well as pre-filled syringes of pain medication and/or sedative, which can be administered if time allows.

Question 22

Of the following, which is true regarding the use of morphine for the hospice patient with
terminal dyspnea?
a. May cause respiratory depression
b. Sometimes mistaken with euthanasia
c. May cause addiction
d. Easy to overdose

Answer 22

b - There sometimes exists the belief that the use of morphine within the hospice population for the treatment of terminal dyspnea is somehow related to euthanasia, which is not the case. This can become an ethical concern, since healthcare providers and family members may withhold treatment, mistakenly believing that use of morphine at this time may cause respiratory depression, which also is not the case. Use of morphine for the relief of dyspnea provides comfort and palliation of this very distressing symptom, and extensive education must be provided.

Question 23

. Pneumothorax is a condition which may be associated with certain diagnoses seen in hospice
care. Of the following, who may be most vulnerable to sustaining a pneumothorax?
a. Patient with ovarian cancer
b. Patient with AIDS
c. Patient with colon cancer
d. Patient with prostate cance

Answer 23

. b - Patients with AIDS who also have pneumocystis carinii pneumonia sometimes form bronchopulmonary fistulas, which can create a persistent pneumothorax which may be difficult to resolve. These patients may have thoracic systems in place in the home for management by the hospice team. Patients with pulmonary diseases, such as emphysema (pneumothorax created by a ruptured pulmonary bleb), may also have higher risk for development of pneumothoraces.

Question 24

If the current bowel regimen is not effective, when should an osmotic laxative be ordered?
a. After 5 days with no bowel movement
b. After 3 days with no bowel movement
c. After 4 days with no bowel movement

Answer 24

. b - If the current regimen is not effective, and there is no bowel movement after 3 days, then an osmotic laxative should be ordered. If there is liver involvement as part of the patient’s disease process, then lactulose is a good option, since it will also help to lower elevated ammonia levels. If there is no liver involvement, sorbitol is a just as effective, and less expensive

Question 25

. Madge is a 69-year-old with colon cancer who has had progressive weakness and decreased immobility. She lives alone, has been ambulatory with a walker, and is very proud of her independence. As her condition deteriorates, she has been spending more time in bed, and is unable to get around as she used to. When you visit, you find her tearful and struggling to clean the floor because she was incontinent for stool on the way to the bathroom. What may be helpful for Madge in her situation? a. Asking her daughter to move in with her b. Asking a neighbor to help her to the bathroom c. Providing a bedside commode d. Increasing her frequency of home health aide visits

Answer 25

. c - Providing a bedside commode would help Madge to maintain her independence and allow more convenient access to toileting facilities, which has become more difficult for her as her mobility has decreased. She will need continued monitoring for further support as her needs continue to change with disease progression

Question 26

Of the following, which should be suspected if a patient has cramping and colicky pain in the mid to upper abdomen that is relieved with vomiting? a. Small bowel obstruction b. Large bowel obstruction c. Bowel strangulation d. Fecal impaction

Answer 26

a - Symptoms of small bowel obstruction typically include cramping and colicky pain in the mid to upper abdomen that is relieved with vomiting. The pain associated with a large bowel obstruction is usually cramping in nature, located in the lower abdomen and increases over time. Bowel strangulation should be suspected if the patient has severe steady pain. Fecal impaction is often found when the patient has loose stool which oozes around the site of the impaction

Question 27

Which of the following diagnoses would carry the greatest risk for gastrointestinal bleeding? a. End-stage COPD b. End-stage renal failure c. End-stage cardiac disease d. End-stage liver disease

Answer 27

175. d - Of the options noted, the patient with a diagnosis of end-stage liver disease is at greatest risk for gastrointestinal bleeding, due to alterations in the production of clotting factors and initiation of the coagulation cascade.

Question 28

Of the following, what is a primary concern when caring for a patient who has an indwelling catheter and has blood in the urine from any etiology? a. Renal hemorrhage b. Anemia c. Catheter migration d. Catheter patency

Answer 28

d - Catheter patency is a concern when there is blood present in the urine from any source. Clots may form in the urine, which can obstruct the catheter, and therefore impede urinary outflow. It may be necessary to intermittently irrigate the catheter, or in instances of large amounts of blood, to maintain a continuous irrigation with a 3-way indwelling catheter

Question 29

Fully understanding a patient’s disease trajectory and wishes for care are critical when supporting the needs of the patient with decreasing mobility. Of the following, why are these such important considerations? a. The patient may be too tired to exercise b. The patient’s family may not want extra equipment c. Care planning may outline different goals d. Physical therapy may be too expensive

Answer 29

c - When supporting the needs of the patient who is experiencing decreasing mobility, it is very important to understand the patient’s disease trajectory and the patient’s wishes for care. Care planning for a hospice patient who is in the final stages of disease progression will be vastly different than for the palliative care patient whose goals include continued mobility and optimizing of independence. T

Question 30

Which of the following would NOT be an appropriate intervention for a patient who is reporting an excessively dry mouth, which is impairing his level of comfort? a. Artificial saliva b. Antifungal swish and swallow c. Increased hydration d. Lip balm

Answer 30

b - Swish and swallow with an antifungal agent would not be an appropriate intervention for the patient with an excessively dry mouth, as this is the treatment for thrush. Often, medications or treatments create a dry mouth, and interventions such as artificial saliva, increased hydration and lip balm are adequate measures to increase the patient’s comfort level

Question 31

. Frank is a 69-year-old with end-stage lung cancer who has a history of alcoholism and domestic violence. His condition has deteriorated and he is now very weak, bedbound and unable to care for himself. His wife of 50 years has taken over his care. When you visit, you find him to be apparently well cared-for, but with increased pain. Upon assessment, he reports that his wife told him “he deserved to be in pain after all he’d done to her” and would not give him his pain medication. Of the following, which is the most appropriate response? a. Report the patient’s wife to community social services b. Meet privately with the patient’s wife to assess the situation c. Refer the patient’s wife to a support group d. Arrange for the patient to be removed from the home

Answer 31

b - Initially, meeting privately with the patient’s wife would be the best option, in collaboration with IDT members who can provide additional expertise in helping to assess and support appropriate interventions for the situation. The patient’s wife should be provided a nonjudgmental environment in which to express her feelings, with a resolution agreed upon by all parties to ensure that the patient’s needs for care and comfort are optimally met.

Question 32

Jan is a 49-year-old with end-stage breast cancer with widespread metastasis to the lungs. She has been experiencing intermittent episodes of extreme dyspnea, and states she is having increasing anxiety, since she is afraid that she will not be able to control her symptoms. Of the following, which intervention may immediately increase her sense of control over her situation? a. Recommend a hand-held fan b. Consult with the hospice social worker c. Consult with the hospice chaplain d. Request Reiki therapy

Answer 32

. a - Patients often find that use of a hand-held fan, with the air blown directly onto their cheeks, is very helpful to decrease dyspnea. Pre-drawn liquid medications, such as low-dose morphine and lorazepam that the patient can self-administer, are also often helpful. The key is to provide the patient with interventions that she can initiate independently, to increase her sense of control over her symptoms, which may help to reduce her anxiety. Anxiety is a multi-faceted symptom, and collaboration with all members of the IDT would be most helpful

Question 33

Jan’s husband has refused to attend any of her healthcare appointment with her. He states he does not believe that she actually has cancer, and is convinced that she will get well very soon. At your most recent visit, he stated, “I’ve never trusted doctors. She just has the flu, and I know she’ll get better soon.” Jan is tearful at times, and states she feels all alone in dealing with her illness. Of the following, which would be the most appropriate response to this situation? a. Read copies of Jan’s medical reports to her husband. b. Accompany Jan’s husband in a meeting with her physician. c. Collaborate with IDT members to arrange a family meeting with Jan and

Answer 33

. c - Arranging a family meeting with Jan and her husband, in collaboration with other IDT members, will provide a safe and supportive environment for them both. Denial is often used as a survival mechanism to deal with facts and emotions that the individual may believe are too painful to endure. Providing the opportunity for them both to express their feelings in an environment of expert support may lead to increased openness, and the opportunity for both to experience acceptance and closure prior to Jan’s death

Question 34

Don is a 72-year-old with end-stage colon cancer who is homeless. He has stated that he is afraid that he will not get the care he needs because everyone else has abandoned him, and “hospice probably will, too, since I live under a bridge.” Of the following, what approach may be most helpful to allay Don’s fears? a. Reinforce non-abandonment in his care b. Recommend that he sign a DNR c. Recommend admission to an inpatient hospice facility for care d. Recommend that he move into a shelter

Answer 34

a - Don needs to know that he will not be abandoned in his care, and that he will be able to maintain control over his own choices. In addition, reassurance that he will have adequate pain and symptom management, as well as continuity in his care, regardless of his circumstances, are key elements in helping to decrease his fears

Question 35

Which of the following definitions is most closely associated with cachexia? a. Inability to take in nutrients b. Inadequate intake of nutrients c. Impaired gastric emptying d. Oral mucosa pain

Answer 35

b - Cachexia is defined as weight loss or wasting due to inadequate intake of nutrients, which can be caused by many etiologies, including those which create increased nutritional losses. Anorexia is defined as a loss of appetite or inability to take in nutrients.

Question 36

A diagnosis of dementia is based on several factors. This includes memory loss (both short and long-term), plus one or more of which of the following? a. Apraxia b. Ataxia c. Amnesia d. Agitation

Answer 36

. a - In addition to memory loss, a diagnosis of dementia is made when one or more of the following is also present: aphasia (language problems); apraxia (organizational problems); agnosia (unable to recognize objects or their purpose); disturbed executive function (personality and inhibition).

Question 37

In assessing for level of consciousness (LOC), which of the following factors are recognized? a. Alertness b. Response to voice c. Response to activity d. Both a and c e. Both a and b

Answer 37

. e - Alertness, response to voice and painful stimuli are the factors utilized in assessing for LOC. Response to activity is not one of the factors. The common mnemonic is “AVPU” Alert, Voice, Pain, Unresponsive. The levels most commonly utilized in hospice and palliative care are LOC Ialert, interactive; LOC II- lethargic, but able to respond briefly; LOC III- stuporous, minimally responsive; LOC IV- unresponsive.

Question 38

Fred is a 46-year-old patient with a history of an aggressive glioblastoma who has recently been admitted to your hospice program. He lives at home with his wife and three young children. Which of the following potential symptoms should be immediately addressed in his plan of care and with his family/caregivers? a. Potential for dysphagia b. Potential for increased weakness c. Potential for sudden death d. Potential for seizures

Answer 38

d - The most urgent potential symptom to address in this patient’s plan of care would be the potential for seizures as brain tumors typically result in an increased risk for seizure activity. Ferrell & Coyle note that seizures occur in 25% of those with brain metastases. Preventive or emergency seizure medication should be made available and the family instructed on signs of seizure activity and medication administration. The symptoms of dysphagia and increased weakness are less urgent and sudden death is not a symptom, but may need to be addressed as well given the presence of young children in the home.

Question 39

What is necessary in order to fully assess a patient’s report of constipation? a. Complete history and physical examination b. Report of decreased stool volume/frequency c. Report of abdominal discomfort d. None of the above

Answer 39

a - A complete history and physical examination are necessary in order to fully assess a patient’s report of constipation. Diagnosis and interventions cannot be based on reports of decreased stools or abdominal discomfort.

Question 40

Causes of constipation within the oncology population include all of the following except: a. Tumor- related b. Medication- related c. Hypocalcemia d. Concurrent disease

Answer 40

c - The causes of constipation within the oncology population include tumor-related, medicationrelated, concurrent diseases such as diabetes, hypothyroidism, colitis, diverticulitis; and secondary effects of disease such as decreased appetite, fluid intake, weakness, inactivity; and hypercalcemia. Hypocalcemia can lead to diarrhea

Question 41

The goal of diarrhea management is to do which of the following? a. Eliminating or minimizing the factors causing diarrhea. b. Providing interventions to temporarily modify diet. c. Replacing lost fluid volume immediately. d. Both a and c.

Answer 41

a - The goals of diarrhea management are to eliminate or minimize the factors causing diarrhea, providing dietary interventions, and maintaining fluid and electrolyte balance as appropriate. Dietary interventions may or may not be temporary and fluid volume is not immediately replaced

Question 42

James is a 47-year-old palliative care patient beginning radiation therapy for prostate cancer. He has been told to anticipate radiation-induced diarrhea. What should be your education to him regarding this potential treatment side effect? a. Radiation-induced diarrhea is not common and he need not worry. b. Radiation-induced diarrhea occurs within the first week and resolves quickly with proper care. c. Radiation-induced diarrhea can occur within the 3rd week of treatment and continue after radiation has been completed. d. Radiation-induced diarrhea occurs within the first week and can continue after radiation is complete.

Answer 42

c - Radiation-induced diarrhea typically occurs at the end of the 3rd week of treatment and can continue after radiation has been discontinued.

Question 43

Which of the following are the most likely factors associated with diarrhea in a significant percentage of bone marrow transplant patients? a. Infection b. Graft vs. host disease c. Radiation d. Both b and c

Answer 43

d - Radiation and graft vs. host disease are the most likely factors related to diarrhea in 35-50% of bone marrow transplant patients.

Question 44

Ascites in the presence of which of the following diagnoses does not correlate with a poor prognosis? a. Pancreatic cancer b. Colon cancer c. Ovarian cancer d. Stomach cancer

Answer 44

c - Ovarian cancer is one of the few exceptions where the presence of ascites is not correlated with a poor prognosis and these patients can have an improved survival rate with surgical intervention and treatment for their ascites.

Question 45

Greg is a 47-year-old hospice patient who is admitted for end-stage lung cancer. He has a previous history of anxiety and depression which is now exacerbated by his diagnosis and symptoms of shortness of breath. He lives alone and despite being admitted to hospice, is adamant that he is not dying. 280. What is the most important factor the nurse should recognize and incorporate into her assessment of Greg’s emotional status? a. What the issues were previously that led to his anxiety and depression. b. What coping strategies were helpful to Greg previously. c. Was he ever hospitalized for his previous symptoms. d. All of the above.

Answer 45

. b - The most important predictor of psychological adjustment to illness is the emotional stability and coping strategies used by the person prior to their diagnosis. While the other issues could be of limited benefit, it is not the nurses job to pry into patient’s history, but to gather the information that will be most helpful moving forward. Therefore, the knowledge of previous coping strategies would be the most important factor for the nurse in this case

Question 46

Greg asks you if you think he is “crazy” because of his reports of high levels of anxiety and depression related to his illness. Your best response is which of the following? a. “No, of course not. Knowing you are going to die is very stressful and hard to cope with”. b. “No, I don’t think you are crazy, but are you taking all your medications as prescribed”. c. “No, I don’t, but have you thought more about your final arrangements and written your will?” d. “No. Anxiety and depression are normal responses to events in all our lives, especially illness”

Answer 46

. d - The best response to Greg’s question is to reinforce that anxiety and depression are normal responses to life events, especially illness and that it is the intensity, duration, and associated symptoms that impact the ability to function that distinguishes these as ‘disorders’ from general symptoms in response to life events

Question 47

Which of the following statements most accurately reflects the importance of the nursing assessment of depression for Greg? a. Depression is a normal response to illness. b. Unrecognized depression impairs quality of life, immune response and survival. c. Depression is not impacted by culture. d. None of the above

Answer 47

b - Depression that is under-recognized, and under-treated has the potential to decrease immune response, decrease survival time, impair the ability to adhere to treatment and impair quality of life.

Question 48

What would not be the best method to approach a discussion regarding Greg’s prognosis and impending death? a. Inquire about his knowledge related to his illness and prognosis. b. Inquire about his wishes for continued treatment options if available. c. Involve the social worker to confirm his wishes for final arrangements. d. Discuss the course of his illness and its impact on his life

Answer 48

. c - The least effective method in approaching a discussion regarding Greg’s prognosis and impending death would be to have the social worker attempt to confirm his wishes regarding final arrangements. This would likely result in increased anger/hostility related to his already existing denial. Denial is a coping mechanism to protect from what one fears is to come. Inquiring about his knowledge of his illness, discussing the course of the illness and wishes for continued treatment if it were available are all options that allow Greg to have control of the conversation, in a situation where he has lost significant control. Giving the patient as much control, autonomy and independence as possible is essential given this is often their greatest fear

Question 49

. Why is the assessment of sleep patterns in hospice and palliative care patients so important? a. Insomnia is a prevalent, distressing and undermanaged symptom. b. Insomnia is easily overcome. c. Insomnia is effectively treated with medications only. d. Insomnia requires a mental health assessment by the social worker.

Answer 49

a - Assessment of sleep patterns in hospice and palliative care patients is important because it is a prevalent, distressing and undermanaged symptom that can be exacerbated by illness.

Question 50

Richard is a 69-year-old with end-stage esophageal cancer who is a previous alcoholic, and has been estranged from his only daughter for all of her adult life. He has been remorseful about this, stating that he wants things to be different in their relationship before he dies. 303. What would be an appropriate patient-centered goal for Richard’s plan of care? a. Richard will resolve the relationship before he dies. b. Richard will have the opportunity to attempt to resolve the relationship before he dies. c. Richard’s daughter will accept his apology. d. Richard will contact his daughter

Answer 50

b - Setting a goal that Richard will have the opportunity to attempt to resolve the relationship before he dies allows a framework that is within the patient’s control. He cannot control his daughter’s response to his efforts. Contacting his daughter would be an intervention that could take place toward achieving this goal

Question 51

Which of the following would be an appropriate expected outcome of Richard’s goal of having the opportunity to attempt to resolve the relationship before he dies? a. Richard will experience resolution. b. Richard’s daughter will forgive him. c. Richard will see his daughter. d. Richard will write his daughter a letter

Answer 51

. a - The expected outcome is that Richard’s efforts will allow him to experience resolution. Regardless of whether his relationship is actually resolved with his daughter, there is still the possibility that Richard’s efforts toward that end may allow him to experience emotional and spiritual peace

Question 52

Of the following, what would be an appropriate intervention that could be added to Richard’s plan of care that would include him in this process? a. Call Richard’s daughter and tell her he is sorry. b. Write a letter for Richard to his daughter. c. Assist Richard in contacting his daughter. d. Call Richard’s daughter and tell her he is terminally ill.

Answer 52

305. c - Assisting Richard in contacting his daughter will allow him to be part of the process, and empower him in his healing. If resolution of the relationship does take place, it will most likely be more meaningful for Richard’s daughter to receive outreach directly from her father, instead of a healthcare provider

Question 53

There are many interventions that may be included in Richard’s nursing plan of care. Which of the following is most important? a. Preparing Richard for his daughter’s response. b. Preparing an alternate plan if she will not have contact with him. c. Collaborating with the IDT. d. Arranging for Richard to get a haircut before his meeting

Answer 53

. c - Collaboration with the hospice chaplain and social worker, as well as other members of the IDT, will provide expert support for Richard as he undertakes what may be a difficult task. Care planning for the hospice patient and family always involves an interdisciplinary approach

Question 54

Of the following, which would be an appropriate outcome to measure as a means of evaluating Richard’s plan of care for this issue? a. Pain level b. Richard’s stated experience c. Appetite d. All of the above

Answer 54

. d - All of the above options, as well as others, could be used for evaluating Richard’s plan of care. Many additional outcomes may also be measured, depending on his baseline status and how the situation has been impacting specific aspects of his physical and psychosocial/spiritual status

Question 55

If measured outcomes do not indicate achieving the stated goal that Richard will have the opportunity to attempt to resolve the relationship before he dies, how may that goal be updated? a. Richard will let go of his need for resolution with his daughter. b. Richard will define an alternate means for inner resolution for this relationship. c. Richard will focus on his other goals. d. Richard will find a means to distract himself.

Answer 55

b - An appropriate update for the goal would be that Richard will define an alternate means for inner resolution for this relationship. This is an important issue for Richard, and will most likely continue to have an impact on his overall quality of life and dying process, if he is unable to find some means of resolving it

Question 56

HO and PC Assessment is guided by a. Fast Fact psychosocial Assessment b. Evidence Based literature c. standards from Clinical Practice Guidelines for Quality Palliative Care and NASW e.Social Work values f. all the above g. b through E

Answer 56

G. ( No standard psychosocial assessments exist)

Question 57

§ Ms. A. is a 55yr old female with a hx of HIV, heart failure and CKD. Her nephrologist ask for a palliative care consult because she is “refusing” to start dialysis. As the palliative care social worker you are asked to complete a psychosocial assessment. What questions would you ask?

Answer 57

What is your understanding of your illness? § What are you hoping for? § What worries you? § What helps you cope with all of this? § What has helped you cope with stress in the past?

Question 58

which of the follow is not a tool for MSW Ho/Pc assessment? a. SWAT (social work asssement tool) b. MHA (mental health assessment) c. Psychological Pain assessment form

Answer 58

B

Question 59

MSW PC consult assessment does not include A. Clinical Hx: (age, diagnosis, reason for consult) B. Symptoms C. Genogram D. Illness Understanding E. Hopes F. Worries/Fears

Answer 59

C.

Question 60

Client-centered counseling intervention for ”eliciting behavior change by helping clients to explore and resolve ambivalence" developed by William Miller and Stephen Rollnick ?

Answer 60

Motivational Interviewing

Question 61

What is the clinical tool developed with the aim of reinforcing the sense of personhood and dignity, enabling health care providers (HCPs) to see patients as people and not solely based on their illness. a. MI (Motivational Interviewing) b. PDQ (Patient Dignity Question) c. IFS (Internal Family Systems)

Answer 61

B. PDG= What do I need to know about you as a person to give you the best care possible?

Question 62

NCHPC Domain 2"Physical Aspects of Care" guideline for screening and assessment includes: a. conduct in language preferred using professional medical interpreter b. use validated symptom and functional assessment tools, policies, standards c. conducts and documents ongoing pain, symptoms, function status, symptoms distress and QOL. d. Assess Pt and caregiver cognitive and physical ability to manage meds and meet caregiving needs. e. Assess risk of diversion of controlled substances and SUD. f. All of the above

Answer 62

F. and in addition: Attention to symptom assessment in Pt's with communication challenges due to delirium, cognitive =, developmental, mechanical interference of voice Attention given to onset, quality, severity, provoking and relieving factors, level of burden, impact on function and QOL, meaning of distressing symptoms, Pt's GOC.

Question 63

NCHPC Guidelines for PC, domain 3: Psychological and Psychiatric Aspects criteria for screening and assessments: a. in cases where Pt does not have decisional capacity, ID the surrogate decision maker/assess their capacity to decision make on behalf of Pt. b. Regularly assess and documents tx efficacy, response to tx, Pt and family preferences c. Ongoing assessment for anticipatory grief; risk of prolonged grief disorder d. All of these

Answer 63

D; in addition: assess full spectrum of how Pt/fam are coping with illness;if present ID behavior health condition and incorporate specialist to assist with complex dx assessment and med management perform culturally and developmentally sensitive screening and assessment

Question 64

NCHPC Guidelines for PC, domain 3: Psychological and Psychiatric Aspects criteria for screening and assessments at a minimum includes culturally and developmentally screening for which of the following: a. Emotional distress, anxiety, depression b. Pt/Fam coping strategies and dynamics to concerns and distress c. Diet preferences e. Presence of delirium/dementia f. Spiritual assessment related to psych distress and concerns g. Risk, history of SUDS H. Risk, history of attempted suicide i. Current or previous trauma/PTSD j. Dual dx--pre existing psych dx vs those stemming from serious illness Dx

Answer 64

all but C

Question 65

NCHPC Guidelines for PC, Domain 4, social aspect of care: goal of assessment?

Answer 65

screen and assess for Pt and family supports, social relationships, resources and care environment based on the best available evidence to maximize coping and QOL

Question 66

NCHPC Guidelines for PC, Domain 4, social aspect of care: Criteria includes which of the following A. before involving family or caregivers, the Pt or decision maker IDs who can participate in the assessment and care planning process, as well as their level of involvement. b. A separate assessment of family's needs, resources, resiliency, and capacity to provide care c. A physical examination of the Pt d. Assess and address indicators of caregiver burnout/isolation

Answer 66

All but C

Question 67

NCHPC Guidelines for PC: Domain 5 Spiritual Care. What are the 3 distinct components of spiritual assessment?

Answer 67

1. Spiritual screening (every Pt and fam to ID distress/needs) 2. Spiritual history (ID prefer/beliefs, values/rituals) 3. full spiritual assessment ( Symptoms such as spiritual distress/strengths/resources are ID and documented)

Question 68

NCHPC Guidelines for PC: Domain 5 Spiritual Care criteria for assessment includes which of the following? A. screening assessment conducted using standardized tools. B. screening in completed as part of every clinical assessment--and designed to evaluate the presence of absence of spiritual needs or distress. C. Spiritual history included that may ID preference and values that may affect medical decision making. D. Screening for depression and anxiety E. Complete spiritual assessment triggered on results of screening and history.

Answer 68

all but D

Question 69

NCHPC Guidelines for PC: Domain 6: Cultural aspects of care. Screening and assessment uses evidence based practices to assess Pt/Fam cultural preferences regarding which of the following? a. health care practices b. oral hygiene c. customs e. beliefs and values f. level of health literacy g. preferred language

Answer 69

all but B

Question 70

NCHPC Guidelines for PC: Domain 6: Cultural aspects of care. before screening and assessment, IDT recognizes the need to be which of the following? a. non judgmental and Pt with Pt/Fam b. Mindful of potential biases c. aware of power dynamics inherent in Pt/family care d. be up to date on CPR certification e. Conscious of historical trauma and how it impacts Pt/Fam care

Answer 70

all but D

Question 71

NCHPC Guidelines for PC: Domain 6: Cultural aspects of care. essential PC skills needed by all clinicians: a. Incorporate PC specialists and cultural representative into care pan to navigate cultural nuances as needed. b. Ability/willingness to acquire culturally relevant knowledge/skills to recognize how culture influences Pt/fam c.. membership in a nondominant group

Answer 71

All but c

Question 72

NCHPC Guidelines for PC: Domain 7:Care nearing EOL: Criteria for assessment and screening include: a. Assess for signs and symptoms Pt is near EOL b. Educate Pt/CG how to recognize and manage common symtpoms c. reviews AD and honors Pt's wishes d. reviews and confirms tx decisions; potential transition in care settings, doc Pt's wishes and preferences e. discusses autopsy, organ/tissue donation/anatomical gifts in culturally sensitive/age appropriate manner f. provides info and support to Cg/Fam providing care to Pt

Answer 72

All the above

Question 73

NCHPC Guidelines for PC: Domain 8:ethical/legal aspects of care: screening and assessment goal:

Answer 73

the patient's preferences and goals for medical care are elicited using core ethical principles and documented.

Question 74

NCHPC Guidelines for PC: Domain 8:ethical/legal aspects of care: screening and assessment criteria include which of the following? a. discuss achievable GOC in context of Pt values and preferences b. Pt's with disabilities are assumed to have decision making capacity unless determined otherwise c. consider the aspects of Pt care that may burden or have ill effects on family. IDT has responsibility to ID and within scope of practice ID resources to meet needs. d. Sign POLST form when the patient is unable e. AD education provided to promote communication and understanding of Pt's preferences across care continuum.

Answer 74

all but D also: Pediatric patients --child's views/preferences are assessed and documented and gven appropriate weight in decision making. Pts not decisionally capable and have not previously expressed their values, follow state laws to ID default decision maker

Question 75

The type of conflict characterized by mistrust, hostility and fear is which of the following? a. Perceived conflict b. Felt conflict c. Structural conflict d. Role conflict

Answer 75

b - Felt conflict is represented by the negative feelings of mistrust, hostility and fear between two or more parties. Perceived conflict reflects the perception of each party regarding the other party’s position. Structural conflict refers to conflict related to structural (reporting) relationships. Role conflict reflects the lack of clarity regarding roles/responsibilities that leads to conflict.

Question 76

Which form of communication would be most effective in resolving a conflict between a patient and caregiver? a. Email communication b. Face to face communication c. Telephone communication d. Non-verbal communication

Answer 76

b - Face to face communication is the most effective means of resolving conflict as it tends to save time and achieves better understanding.

Question 77

The most effective method of resolving conflict is which of the following? a. Negotiation b. Collaboration c. Confrontation d. Accommodating

Answer 77

c - Confrontation is considered to be the most effective method of resolving conflict through a problem-oriented approach that brings the conflict into the open and attempts to resolve it through knowledge and reason. Negotiation attempts to achieve agreement even though consensus will never be attained. Collaboration is utilized in an attempt to satisfy both parties concerns and resolve the problem without defeating the opponent. Accommodation involves an unassertive, cooperative approach in which one party neglects their own concerns in favor of another.

Question 78

All of the following are examples of the areas of intervention within the care planning process except: a. Palliative/Therapeutic b. Evaluation c. Educational d. Assessment

Answer 78

b - The four intervention areas include Palliative/Therapeutic, Educational, Collaboration, and Assessment.

Question 79

CMS/ Medicare Conditions of Participation (CoPs) require which of the following regarding the care planning process at the time of admission? a. Informed consent for hospice admission b. Initial and comprehensive assessments as the foundation c. Physician driven d. Facility driven

Answer 79

b - The CoPs require that the initial and comprehensive assessment form the basis for the development of the care plan for all areas of the interdisciplinary team based upon the patient’s need for medical, nursing, psychosocial, emotional and spiritual care.

Question 80

Betty is a 79-year-old patient with end-stage ovarian cancer. She has numerous boxes of loose pictures, and states that she would love to organize them into photo albums to give to her family, but does not have the energy for such a project. Of the following, which may be a helpful option? a. Give Betty the name of a service to hire. b. Give Betty the name of a vendor who scans photos to digital format. c. Offer to request a hospice volunteer to help her. d. Recommend that she ask her family to help her.

Answer 80

c - Offering to request a hospice volunteer to help her would be the most helpful option. This would provide a wonderful opportunity for life review for Betty, and empower her to do something for her family that won’t be costly.

Question 81

How often should the individualized plan of care for the patient/family be updated? a. No less frequently than every 7 calendar days and with any status changes b. When patient/family status changes occur c. When the hospice medical director requests an update d. No less frequently than every 15 calendar days and with any status changes

Answer 81

d - The individualized plan of care for the patient/family must be updated no less frequently than every 15 calendar days and when the patient/family status changes, according to the Hospice Medicare Conditions of Participation. The plan of care must be reviewed at each visit by each discipline as well and updated as needed.

Question 82

When developing an individualized plan of care for the patient and family, who should be included in providing input? a. The patient and family, hospice aide, hospice chaplain b. The hospice counselor, volunteer and medical director c. Both a and b d. The hospice primary nurse only

Answer 82

c - All IDT members involved in the patient’s care, including the patient and family, should be involved in developing an individualized plan of care for the patient and family

Question 83

Of the following, which would be the best option for involving the patient and family in the IDT discussion in a hospice residential setting, if they would like to participate? a. Ask them to attend the meeting in the conference room. b. Hold the meeting in the hall outside the patient’s room. c. Hold the meeting at the patient’s bedside. d. Ask them to attend the meeting in the manager’s office.

Answer 83

c - The best option for involving the patient and family in the IDT discussion in the hospice house setting would be to hold the meeting at the patient’s bedside. This would allow all parties to participate within the privacy of the patient’s room.

Question 84

If the patient would like to participate in the discussion of his care at an IDT meeting, which of the following would be an appropriate response? a. Agency policy doesn’t permit patients to participate. b. A summary of the meeting outcomes can be provided. c. The patient may attend the meeting in person or by conference call. d. The hospice medical director can provide an update to the patient.

Answer 84

c - Arranging for the patient to attend the meeting in person or by conference call is the appropriate response. The patient and family are at the center of the interdisciplinary team, and should be encouraged to participate whenever possible.

Question 85

It is quite common for family members to disagree with each other about various aspects of a patient’s care. Sometimes, this occurs due to poor communication among various parties. Of the following, which may be the most helpful approach to engaging all family members in optimal communication? a. Ask the patient to speak individually to each of them. b. Remind family members that all decisions belong to the patient. c. Collaborate with the hospice counselor for further support. d. Ask the patient to write a letter to each family member involved.

Answer 85

c - Since each situation is unique, collaborating with the hospice counselor for further support and expertise would enhance optimal outcomes. Family dynamics can be very complex, and negative emotions may be heightened during times of crisis.

Question 86

Steve is a 79-year-old from Greece who only speaks Greek, and is having difficulty understanding what is happening to him. His wife is his primary caregiver, and also does not speak English. His daughter speaks fluent English, and but works full-time, so is not able to be present during your routine visits. Of the following, what may be the best option for this situation? a. Call the daughter at work and ask her translate. b. Ask the daughter to create a translation board. c. Obtain a translator through the hospice’s contracted agency. d. Try to use gestures that he will understand.

Answer 86

c - Obtaining a translator through the hospice’s contracted agency is the best option. It is certainly helpful to have family members act as translators when absolutely necessary. However, if possible, it is best to have an objective party provide translation, to ensure that the views and wishes of family members which may differ from that of the patient do not skew the message being delivered.

Question 87

Of the following, which patient situation would qualify for a change in level of care to continuous home care? a. Uncontrolled pain b. Need for companionship c. Incontinence d. Established tube feedings

Answer 87

a - Uncontrolled pain is an appropriate patient situation for a change in level of care to continuous home care. This level of care is provided during brief periods of crisis in order to allow the patient to remain at home. Care must be provided at least 8 hours per day, and more than 50% of that care must be skilled nursing care (RN or LPN/LVN) in order to qualify for the Medicare reimbursement rate for continuous care.

Question 88

When teaching patients and families the proper disposal of dressings soiled with blood or exudate, which of the following statements is accurate? a. Dispose in regular trash. b. After wrapping in a plastic bag, dispose in regular trash. c. After placing in a plastic container, dispose in regular trash. d. Must be disposed in a container for biohazardous waste

Answer 88

d - Universal precautions must be maintained in all settings, therefore dressings or other supplies which are soiled with blood or body fluids must be disposed of in appropriate

Question 89

When a patient is starting on a new medication which is ordered with an increasing titration schedule, which of the following is an appropriate statement as part of teaching medication management to the patient’s caregiver? a. If the medication is stopped, decreasing titration won’t be necessary. b. Titration is recommended for all medications. c. Titration allows the patient’s body to adjust to the medication. d. Titration is not necessary, just start on the highest dose.

Answer 89

c - When teaching the principle of titration for medication management, it is important for the patient/family to understand the purpose. Many medications have side effects that will be worsened if the medication is started at a dosage that is intolerable for the patient. If this occurs, the patient and/or family may decide the medication side effects outweigh the benefits, and discard what could be very helpful therapy. Appropriate titration teaching optimizes patient safety and outcomes.

Question 90

Janet is a 68-year-old previously healthy woman who suffered a traumatic subdural hematoma two weeks ago with significant brain damage that has remained unchanged since the incident. She has since remained unresponsive except for opening her eyes occasionally at random. She does not follow commands. She has been receiving nasogastric tube feedings despite having a living will that notes she does not wish to be fed artificially if her condition is irreversible. She requires total care for all activities of daily living. The patient is physically stable however, and needs to be transferred within the next 10-14 days as her insurance will no longer pay for her hospital stay. You are asked by the care manager as the palliative care/hospice nurse to meet with the family and review the plan of care and options for discharge. 345. When meeting with the family what should be the nurse’s first priority to address? a. Identify which nursing home they want patient to be transferred to and make necessary arrangements. b. Discuss the patient’s wishes outlined in the living will and adapt the plan of care accordingly. c. Inform the family that all support will be removed and patient sent home with hospice as her care in the hospital is no longer paid for. d. Review with the family that you do not believe the patient’s care should be changed as there is still hope for her to recover.

Answer 90

d - The best action would be for the nurse to involve the IDT and arrange a family meeting to allow for a discussion in an open, respectful method of communication and to remind everyone of the patient’s wishes which are to be honored and upheld.

Question 91

Examples of successful patient goal attainment related to hospice and palliative care include all of the following except: a. Identifying and completing important relationships. b. Reaching personal goals before death only. c. Finding meaning in life closure. d. Reaching personal goals both before and after death.

Answer 91

b - Reaching personal goals are not limited to only prior to death. Goals are also put in place for after death and this gives meaning to patients and families that their life/loved one’s life provides ongoing meaningfulness after death.

Question 92

After a patient’s death, which member of the IDT typically coordinates bereavement support transitioning for the patient’s family? a. The patient’s nurse b. The hospice volunteer c. The hospice counselor d. The hospice director

Answer 92

c - The hospice counselor is typically the member of the IDT who coordinates bereavement support transitioning for the patient’s family. Other members of the IDT may also participate in this support as appropriate.

Question 93

Emily’s father has just died. When you arrive at the home to attend his death, she states that she has several siblings coming from out of town, who will not be arriving for several hours. Since her father will be cremated, she would like to keep his body in the home until they arrive, so they can say good-bye. Of the following, which is the most appropriate response? a. “There is a specific time in which his body must be removed.” b. “They should be able to see him at the funeral home.” c. “We can make a video for them.” d. “We’ll get him ready and wait for them.”

Answer 93

d - Often, the setting of the patient’s death is the last opportunity for family members to see the patient’s body prior to cremation, and sometimes burial. Therefore, care must be taken to bathe the body, dress it in a manner that the family chooses, and prepare the immediate environment as a peaceful setting in which the family can have privacy and time to say good-bye. In most cases, there is not a specific timeframe in which the patient’s body must be removed from the home, within reason. Collaboration with the IDT is critical to provide optimal support.

Question 94

Of the following, which is the optimal length of time for a visit for death attendance? a. One hour b. Two hours c. Three hours d. According to need

Answer 94

d - The length of a visit for death attendance is defined by the need present in the individual situation. It is critical to provide needed attention and resources to support the family at this difficult time. Care must be taken to gather appropriate IDT members, provide support for the family, and proper care and dignity for the patient’s body. Some families may be well-prepared for a patient’s death, while others may not be prepared at all. Sensitivity to the needs of the individual situation is critical. There’s only one chance to get this right.

Question 95

At time of death, which of the following is the highest priority? a. Efficiency in visitation time. b. Notifying the funeral home as soon as possible. c. Adhering to patient/family beliefs and customs. d. Prompt removal of the patient’s body.

Answer 95

c - Of the options noted, adhering to patient/family beliefs and customs is the highest priority. Different cultures and religions may have specific practices regarding death and handling of the deceased person’s body. The role of the hospice staff is to provide optimal care and support, while respecting cultural and religious preferences.

Question 96

Jackie is a 69-year-old, whose daughter, Rachel, has been her primary caregiver for the past 6 months. During Jackie’s death attendance, Rachel begins to cry, and states that she loved being able to take care of her mom. Of the following, what may be most helpful to Rachel during this time? a. Ask her to participate in bathing/dressing Jackie’s body. b. Provide her with literature about bereavement groups. c. Ask her to take a break while you prepare Jackie’s body. d. Call the hospice counselor for her.

Answer 96

a - Asking an appropriate family member to participate in preparing the patient’s body can be a very sacred and healing event. Primary caregivers who have occupied this role for any period of time may be especially appreciative of this final opportunity to provide tender care for their loved one’s body. While offering appropriate privacy for the family is important, hospice staff should be present during times of turning the patient’s body, etc, when unexpected sounds and drainage events may occur which can be distressing if anticipatory preparation is not provided.

Question 97

Ed is an 89-year-old with end-stage lung cancer who is in the dying process. His two daughters, Bobbie and Vicki, do not get along, and frequently have arguments over Ed’s bed about who should get to spend time with him. Although Ed has not been verbally responsive for several days, he becomes more restless and agitated when this is occurring. Of the following, which may be most helpful in this situation? a. Ask that they both remain out of the room. b. Increase Ed’s medication. c. Limit time that they spend with Ed. d. Recommend that they agree upon a schedule for visiting

Answer 97

d - Though many options may be possible, recommending that they agree upon a schedule for visitation would be the best option of those listed. It’s understandable that they both want to be with their father, but their disagreements are disrupting his comfort, and must be addressed. A third party, such as the hospice counselor, would be an excellent resource in helping them to work through difficult

Question 98

Martha states that she is committed to ensuring that Joe not be alone when he dies, and has been maintaining a constant vigil. However, she is becoming exhausted, and states that she does not have anyone else who can sit with him. Of the following, what would be the most appropriate response? a. “Joe may want to be alone when he dies.” b. “Let me see if we can get some volunteers to help.” c. “You have to take care of your health first.” d. “Joe probably isn’t aware that anyone is there.”

Answer 98

b - Hospice volunteers can be a wonderful system of support for the dying patient and his family. They can provide a time of respite for exhausted family members, and enhance peace-of-mind, knowing that their loved one is not alone.

Question 99

Martha’s husband, Joe, is in the dying process in his home. She would like to know what procedures will take place regarding the funeral home after he dies. Of the following, what is the most accurate description? a. She will need to call an ambulance when he dies. b. She will need to call the funeral home herself. c. Hospice staff will contact the funeral home. d. He will need to go to the hospital to be pronounced.

Answer 99

c - Hospice staff typically contact the funeral home that the patient/family has chosen for removal of the patient’s body from the home or nursing facility. This occurs once appropriate procedures regarding death attendance by hospice staff and required pronouncement of the deceased have been completed.

Question 100

Which MSW interventions have shown modest efficacy for reducing pain severity? A. Distraction B. Education C. CBT D. Relaxation E. Guided Imagery F. hypnosis based CBT G. Diaries and Journals H. Acceptance Based Therapy

Answer 100

All but H. Oxford Pb 278

Question 101

Are social and pyschological interventions a substitute for medication and medical palliation interventions?

Answer 101

NO The are best used as adjuncts, complementary and integrative strategies that may help minimize the experience of pain/and or the associated distress or improve coping

Question 102

What is the benefit of educating Pt and family about the multiple aspects of pain and symptom management? A. Decrease anxiety B. promote acceptance of the tx plan C. engage families who are ambivalent about medication and potential side effects such as confusion or sedation D. Less law suits

Answer 102

Everything but D. Oxford 277

Question 103

The purpose of CBT in Palliative care/Hospice context? A. seek and ID thought patterns and behaviors that contribute to pain experience. B. Use self talk coaching to foster coping and self effficacy C. ID negative thoughts, beliefs, or unrealistic expectations that increase distress and may interfere with coping with pain or other symptoms

Answer 103

All the above \Oxford 277

Question 104

8 specific barriers to pain management MSW can help to ID and address: A. Addiction B. Tolerance C. Stoicism D. Fatalism E. Side effects F. Stigma G. Burden H. Fear of OD

Answer 104

all above Oxford 280

Question 105

Is Physical Dependence on medications the same as addiction?

Answer 105

No: state of adaptation that manifests as withdrawal syndrome and can be brought on by a variety of factors, including stopping medication abruptly. (seen with opioids, steroids, betablockers)

Question 106

Is Tolerance to medication the same as addictions?

Answer 106

No: decline in drug effectiveness at a give doseage over a period of time

Question 107

Recent research in hospice settings suggests that family caregivers frequently have concerns about pain and pain management and that these concerns may be overlooked by team providers. How can MSW help? A. evaluate for barriers to pain and symptoms management B. when ID barriers, provide interventions to dispel myths, correct misconceptions C. Explore caregiver expectations to see if they are congruent with scope and limitation of services D. Advocate at IDT , make sure team is alerted/informed

Answer 107

All the above Oxford 281

Question 108

MSW treatment approaches for agitation include A. Calm soothing voice B. Warn brefore touching C. Apologize for causing distress D. Keep person warm, covered E. Companion if response is positive F. Experiment with light music G. touch gently, observe response H. provide continuity of staff

Answer 108

All the above Oxford 280

Question 109

MSW treatment approaches for Dyspnea A. CBT B. relaxation therapy C. Art therapy D. message therapy E. Guided Imagery

Answer 109

All the above Oxford 280

Question 110

MSW treatment approaches for Fatigue include A. CBT B. Expressive group therapy C. Supportive therapy D educational interventions E Group psychotherapy F Exercise

Answer 110

All the above Oxford 280

Question 111

MSW treatment approaches for nausea include A. symptom monitoring B. progressive muscle relaxation C. systematic desensitization D. hypnosis E. Cognitive distraction

Answer 111

All the above Oxford 280

Question 112

MSW treatment approaches for pain include A. CBT B. Relaxation C. Guided imagery D. hypnosis E. coping skills training F. problem solving G Systematic reminders

Answer 112

All the above Oxford 280

Question 113

the most frequent and distressing symptom according to cancer patients?

Answer 113

Fatigue Oxford 283

Question 114

PC consult with married couple dealing with wife's new dx of lung cancer. She reports suffering increased levels of pain and dyspnea. The husband reports thaat according to their spiritual belief system this illness is punishment for wife's past transgressions. They are open to palliative interventions and aske that their spiritual beliefs be respected. How are this couple viewing symptoms and suffering?

Answer 114

as redemptive constructs

Question 115

49 yo male Caucasian, married, no children, athiest dx with end stage pancreatic cancer given prognosis of 3 months. Reports increased level of pain "7". However, he adamantly refuses medications. He reports "the pain reminds me I am alive". His wife does not like seeing him suffer and cries openly, expressing that she hopes hospice can do something to alleviate the suffering. How does Pt view his suffering? Are husband and wife goals congruent?

Answer 115

Symbolic suffering no, they are conflicting

Question 116

What are two broad therapies models used in the setting of palliative care, both sugegsting ways to view and work with the process of adjustment? A. Somatic based B. Meaning based C. schema therapy D. CBT

Answer 116

B and C Oxford pg 191

Question 117

Principles to guide meaning based pyschotherapy include A. human beings have a propensity toward meaning B. We are driven to find fulfilment and significance in life C. In stress situation how the person understands their current circumstance assists in the process of coping. D. way person makes sense of their world is prejudiced by the need for stability in life and an optimistic bias E. We are social beings who need to feel significance and a sense of belonging. F. Those who lose meaning or are unable to find meaning in suffering can experience profound despair

Answer 117

All the above Oxford 193

Question 118

Meaning based therapy in the palliative care setting is A> putting a positive spin on the life limiting illness B. provides an alternative focus to balance suffering and meaning. C. Illuminates those aspects of a person's life deemed to be central to the person's sense of significance and purposel

Answer 118

B,C Oxford 194

Question 119

After the volunteer has been scheduled, Margaret’s daughter calls to thank you, and states that she would like to take her mom for a weekend away to take a break. However, she is not sure how to arrange care for her father. Of the following, which may be the best option? a. Continuous care nursing b. Asking a neighbor to stay c. Hiring an agency that provides caregiving d. Respite care

Answer 119

- Respite care would be the best option. Under the hospice Medicare benefit, patients/families are entitled to a certain number of respite days on a regular basis to provide the opportunity for the caregiver to take a break. This is usually arranged as a short-term stay at a nursing facility and paid through the hospice Medicare benefit. Patients must meet certain skilled criteria to be eligible for continuous care nursing (Level 2 care), and hiring an agency for 24-hour care can be cost-prohibitive for most families.

Question 120

Steve is a 79-year-old from Greece who only speaks Greek, and is having difficulty understanding what is happening to him. His wife is his primary caregiver, and also does not speak English. His daughter speaks fluent English, and but works full-time, so is not able to be present during your routine visits. Of the following, what may be the best option for this situation? a. Call the daughter at work and ask her translate. b. Ask the daughter to create a translation board. c. Obtain a translator through the hospice’s contracted agency. d. Try to use gestures that he will understand.

Answer 120

c - Obtaining a translator through the hospice’s contracted agency is the best option. It is certainly helpful to have family members act as translators when absolutely necessary. However, if possible, it is best to have an objective party provide translation, to ensure that the views and wishes of family members which may differ from that of the patient do not skew the message being delivered.

Question 121

Myra is an 89-year-old with end-stage liver disease, and secondary diagnoses of dementia and atrial fibrillation. She is a resident of a nursing home, and has recently been admitted to hospice. When performing her skin assessment, you note bruising around her breasts and genital area. What potential issue should be of major concern in Myra’s situation? a. Coagulation cascade abnormalities b. Sexual abuse c. Coumadin overdose d. Esophageal varices

Answer 121

b - Bruising around the breasts and genitals should create suspicion for sexual abuse. Elder abuse is a growing problem in America, and nurses are uniquely positioned to recognize and intervene on the behalf of vulnerable populations, such as the elderly. According to the National Center of Elder Abuse (NCEA), major types of elder abuse include physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, financial or material exploitation and self-neglect.

Question 122

Jorge is a 59-year-old, undocumented citizen from Mexico who is referred to your agency for hospice care. He has stage IV liver cancer, speaks no English and lives with other undocumented workers on a rural farm in your area. These workers share a single cell phone number and there is no other contact information other than the address of the farm. You are asked to contact Jorge and introduce hospice and schedule his admission visit. 387. What is the best action to take in contacting Jorge to schedule your visit? a. Call the phone number and leave a message that you are with hospice with someone so that Jorge can return your call. b. Drive to the farm and talk to the farm owner since you could not speak with anyone who spoke English on the phone. c. Contact a translation service and make a joint call to the number using translator to ask to speak with Jorge. d. Call the referral source and inform them that you do not have any Spanish speaking staff and cannot take the referral.

Answer 122

c - Hospice regulations require that agencies must be able to provide services and materials in the patient’s language. Therefore, the best action to take is to utilize a translation service to provide the translation for the initial call as well as future visits/phone calls etc. It is always best to use a third party as opposed to a family member, friend etc. to ensure that the message is being translated properly and completely. Options A and B are HIPAA violations as you do not have permission to release information about Jorge to his fellow workers or to the owner. It is not allowable under CMS regulations to refuse the referral based upon language as that is discriminatory.

Question 123

After a few weeks of caring for Jorge on the farm, and with effective control of his symptoms; he decides that he wishes to travel home to Mexico where his family lives and remain there until his death. Which of the following would not be the best action to take to facilitate this transition for Jorge? a. Coordinate with his attending physician, the IDT and patient’s family to ensure that he will be able to obtain medications, care etc. upon his arrival. b. Have the patient sign revocation papers immediately since he will no longer be receiving care from your agency. c. Discharge the patient upon his departure and provide necessary documentation for his travel and ongoing care as needed/requested. d. Provide assistance with arranging travel as needed, utilizing translation services when necessary.

Answer 123

b - The action that you would not want to take in this scenario would be to have the patient sign revocation papers immediately. Part of hospice care is ensuring and advocating for patient’s wishes along with their self-determination for life closure. Jorge’s wish is to return home, and it is the responsibility of the interdisciplinary team to assist in whatever way possible to make that wish a reality.

Question 124

You have recently begun to visit Charles, an elderly, frail palliative care patient who lives in an assisted living facility. He is very hard of hearing and therefore has his television volume at the highest level during your visits. You have asked him to turn it down just for your visit, but he continues to refuse. His vision is excellent though and he enjoys reading and writing. What is your best action to take so that you can ensure that you complete an effective visit? a. Turn the volume down for your visit, and then allow him to turn it back up when your visit is complete. b. Ask the patient why he doesn’t have hearing aids when he is clearly very hard of hearing. c. Tell the assisted living staff that he is being uncooperative and have them take charge to make him comply. d. Communicate with him through a note pad with questions and allow him to write his responses.

Answer 124

d - The best action in this situation is not to force the patient to turn the volume down, or to insist upon him obtaining hearing aids or involve the facility staff. Since the patient has excellent vision and enjoys reading and writing, the best action is to perform the majority of your visit communication through this method. This allows you to engage the patient in a manner that he enjoys and respects his autonomy as well.

Question 125

Jimmy is now actively dying and his friends along with volunteers have been arranged to be with him 24/7 so that he does not die alone. At your afternoon visit today, you notice that Jimmy is in the same clothes and in the same position as when you left yesterday morning along with a heavily soiled brief. What is your best initial response to this situation? a. Advise the caregiver that you will be reporting them to Adult Protective Services immediately. b. Inquire of the caregiver the time of their arrival, the care provided, and the status of Jimmy during their stay. c. Report this to your supervisor immediately for necessary action. d. Advise the caregiver to leave immediately as they are clearly neglectful.

Answer 125

b - The best initial response to this situation is to inquire about the caregiver’s time with the patient, the care provided and the patient status. Although this situation appears to be neglectful, there may be additional information or rationale for what you are seeing. It is important not to rush to judgement and make reports or accusations before a complete assessment of the patient and situation is accomplished.

Question 126

When a patient becomes weak enough to require that a hospital bed be placed in the home, which of the following is the most important consideration when scheduling delivery of the bed? a. Whether additional staff may be needed b. Where the bed will be placed c. Whether the bed will fit through the doors in the home d. If the family has appropriate bedding

Answer 126

a - When scheduling delivery of a hospital bed, it may be necessary to coordinate the assistance of additional staff members to help with patient transfer if the patient is too weak to stand and transfer to the new bed. When the need arises for a hospital bed in the home, this is often due to a decline in the patient’s condition. Hospital beds typically are transported in collapsible units, therefore, door width should not be an issue.

Question 127

If a patient is being transferred into continuous home care under the hospice Medicare benefit, which of the following statements is true? a. Reimbursement is based on the number of days as defined in the benefit. b. Reimbursement is based on specific criteria as defined in the benefit. c. Patients can receive this level of care at any time for any need. d. Care may be provided for less than 8 hours per day.

Answer 127

b - Reimbursement for continuous home care under the hospice Medicare benefit is based on specific criteria as defined in the benefit. This level of care is designated for brief periods of crisis as a supportive means to help the terminally ill patient stay at home. Care must be provided for at least 8 hours per day, and more than 50% of care must be provided by skilled nursing staff (RN or LPN/LVN).

Question 128

The three C’s of outpatient palliative care include which of the following? a. Cooperation, Communication and Closure b. Collaboration, Cooperation, and Coordination c. Coordination, Collaboration and Closure d. Cooperation, Collaboration and Communication

Answer 128

a - The correct answer is Cooperation, Communication and Closure. All of the others are certainly important as well, but these are the key features identified as necessary and at the heart of outpatient palliative care.

Question 129

What should I know about pediatric Hospice?

Answer 129

1. Data on pediatric hospice is sparse. 2. Differs from adult hospice in that concurrent curative care maybe allowable. 3. diagnosis Differ considerably from adult hospice, e.g.Congenital disease and accidents. 4. Typically preceded by extensive, costly medical efforts e.g. PICU stays. 5. Programs may not be tied to Medicare funding. 

Question 130

"what have you learned about life you would want to pass to others?" "What are your most important accomplishments and what to you feel most proud of? Are example of questions from A. Acceptance Based Therapy B. Somatic Therapy C. Dignity Therapy D. Cognitive Behavior THerapys

Answer 130

C. Dignitty therapy debveloped byp Chochinov

Question 131

Core Skills of Motivational intervieweing?

Answer 131

OARS Open ended questions Affirmations of positive traits Reflective listening Summarize Pt's experience

Question 132

Goal is to elicit change talk in the ambivalent client A. CBT B. Motivational Interviewing C. Exposure THerapys

Answer 132

B

Question 133

Goal is to go over things that are most meanigful to Pt and document their legacy A. CBT B. Psychodynamic THerapy C. Dignity therapy

Answer 133

C Dignity therapy Chochinov

Question 134

Do you ever wish al of this was over?What do you hope for? Besides the physical symptoms of your illness, what causes you the most distress? On a scale of 0 to 10, rate your suffering? Compared to your physical pain and symptoms whih would you conisder to be worse for you at this moment? Questions that assess Pt's A. Mood B. resiliences C. suffering

Answer 134

C.

Question 135

8 issues of chronic illness in medical crises counseling; (all that apply) a. Control B. Self image C. Anger D. dependency E. financial F. All above

Answer 135

A through D plus stigma, abandonment, isolation and death

Question 136

WHAT IS THE PATIENT DIGNITY QUESTION?

Answer 136

What do I need to know about you as a person to give you the best care possible?

Question 137

PCT (Person centered therapy) non directive empathetic approach to empower and motivate Patient in process Goal to develop insights into the Pt's illness and it's impact on their relationships 5 questions used in PCT

Answer 137

What brings you joy? What makes you proud? What does a day in your life look like? If you could leave the hospital right now, what might you do or wantyet to do? Where do we go from here?

Question 138

Techniques for this therapy include: cognitive restructuring,relaxation techniques, promoting self soothing and pleasurable activities, problem solving around symptoms, mindfulness meditation a. PCT B. CBT C. Dignity therapy

Answer 138

B. CBT Goals to acknolwedge Pt's fears, worries education about cyclical and bidirectional nature of physical symptoms and anxiety create awareness of automatic thoughts and triggers utilize techniques to address intrusive thoughts, calm acute stress response, manage depression or anxiety

Question 139

Goal is to help Pt's construct a new life story by understanding the beliefs, assumptions, and values underlying their life stories A. PCT B. Dignity Therapy C. Narrative THerapy

Answer 139

c. Narrative Stages normalizing strenghtening reflecting/deconstructing re authoring/reconstructing celebrating and conecting. to: forgive onself and others, acknowledge grieve and accept life choices, move beyond regret