Symptoms and Management

Question 1

: A patient you see regularly shares a lot of information with you. The
nurse asks you about the patient’s subjective response to receiving a new
medication in order to help the patient adjust to it.
You are most likely to tell the nurse:
A. The patient says her pain score has increased from a 2 to 5 after the dose
B. The patient seems to need to go to the bathroom more after the dose
C. The patient worries that the new medication means she is sicker
D. The patient worries that her cat needs to have her home to brush her

Answer 1

C

Question 2

A patient you see regularly shares a lot of information with you. Which of the
following information would you share first with the nurse?
A. The patient says her pain score has increased from a 2 to 5 after the dose of a
new medication.
B. The patient seems to need to go to the bathroom more after the dose of a new
medication.
C. The patient worries that the dose of a new medication means she is sicker than
she had been.
19
D. The patient worries that she needs to get home because her cat needs to be
brushed or will get ill.

Answer 2

A

Question 3

: A patient has a fear of needles. She has to have injections weekly for
her chemo treatment. The MOST effective treatment option is:
A. Exposure therapy
B. Cognitive behavioral therapy
C. Anti-anxiety medication
D. Psychodynamic psychotherapy

Answer 3

A. Exposure therapy, which is a subset of CBT treatment, in which the client is
gradually exposed to more intense fear-inducing stimuli over a period of time, is
the most effective of the treatments listed.

Question 4

x

Answer 4

x

Question 5

What are the signs of distress?

Answer 5

Talking about suicide or wanting it to be all over now
seeking methods to hasten death
talk about hopeless or helplessness
talk about being burden to loved ones
talk about unbearable pain/suffering
past suicide attempts
triggering events in addition to terminal illness
history ineffective coping strategies (as reported by Pt)

Question 6

x

Answer 6

x

Question 7

x

Answer 7

x

Question 8

x

Answer 8

x

Question 9

x

Answer 9

x

Question 10

What advice for families around terminal lucidity (rally)?

Answer 10

Prepare them for possibility of rally
follow the lead of the dying person for odd meals or visit by someone in particular
listen carefully and respond to their needs for conversation/silence, life review, goodbyes
after lively interaction/persons energy may be gone
regardless of how alert encourage support by sitting at bedside and holding hand/stroking arm

Question 11

How to prepare families for what to expect at TOD?

Answer 11

breathing may stop before the heart
pupils completely dilate
muscles completely relax (bowel/bladder)
face relaxes, looks peaceful, rush of air may be released
should be no rush to declare death

Question 12

at EOL what are some reasons the medical setting can be trauma or re-traumatizing?

Answer 12

power differential
invasiveness of some treatments

Question 13

Characteristics of psychosocial distress?

Answer 13

recent notification of terminal illness
current/future financial worries or crises
social and/or family isolation/withdrawal
no or potential for no adequate shelter
cultural discord
needs of minor children and/or compromised adults
SI
history of depression/ DSM dx
substance abuse/misuse

Question 14

non pharma/medical intervention strategies to help alleviate pain (complementary)

Answer 14

CBT and hypnosis based CBT
Distraction
Education about symptoms
relaxation
guided imagery
Diaries/journals
massage
Reiki
Music
use of virtual reality technology

Question 15

You are employed as a licensed social worker for hospice and also have a license as a massage therapist. May you provide massage to your hospice patients?

Answer 15

If you are paid to provide social work services you may not provide massage services (NASW)

Question 16

Non pharma medical interventions for pain treatment (all that apply)
A.. TENS
B. Equine therapy
C. Radiation and Surgical interventions
D. OT and PT
E. Intraspinal analgesia
F. Acupuncture

Answer 16

All but B

Question 17

Clinical depression can be mistaken for
a. hyperactive delirium
b. dementia
c. hypoactive delirium

Answer 17

C

Question 18

Roberta is a 54-year-old with end-stage lung cancer whose condition has declined significantly
over the past week, with increased difficulty swallowing. She has recently stopped eating and
drinking, and her husband is worried she is “starving to death” and wonders if tube feedings
should be started. Roberta previously completed an Advanced Directive that stated she did not
want to be kept alive by artificial means and that stated she wanted to stay in her home to die.
What information may be helpful for Roberta’s husband in this stage of her disease progression?
a. She may be receiving too much morphine.
b. Dehydration increases comfort during the dying process.
c. Intravenous fluids would be more appropriate.
d. She should be admitted to the hospital.

Answer 18

. b - It would most likely be helpful for Roberta’s husband to know that dehydration actually increases comfort during the dying process. As the patient progresses through this stage, various body systems typically begin to decrease normal functioning, including the renal and cardiac systems. Diminished eating and drinking is part of the body’s normal adaptation to these changes, which prevents fluid overload. Artificial addition of fluids is typically not recommended in this situation, since fluid overload may occur, leading to increased respiratory distress and patient discomfort

Question 19

Katherine is a 64-year-old with end-stage ovarian cancer who has been experiencing increasing
weakness and been bedbound for the past two weeks. Recently, she has not been eating or
drinking much, and has been sleeping more. On today’s visit, you notice that the scant amount
of urine in her drainage bag is very dark. Her husband is concerned about her condition. What
would be the most appropriate action?
a. Change the catheter
b. Encourage fluids
c. Educate the husband about the dying process
d. Flush the catheter

Answer 19

3. c - Educating the husband about the dying process would be the most appropriate action. Families should be educated about the signs and symptoms of imminent death so they will know what to expect and how to prepare. Decreased urine output with concentrated urine is very common findings during the dying process as the renal system begins to fail.

Question 20

What is a primary concern when a patient who is in the dying process begins to have difficulty
swallowing?
a. Aspiration
b. Symptom management
c. Family education
d. All of the above

Answer 20

. d - All of the options noted are primary concerns when the dying patient begins to have difficulty swallowing, which is a common occurrence. Aspiration prevention is certainly a concern, as well as transitioning the patient from oral medications that have been in use for symptom management to an appropriate route. Liquid medications may still be acceptable alternatives, since they are typically concentrated and administered in very low volumes, and many can be absorbed through the buccal mucosa. Anything in pill form should not be administered at this point. Other options include topical administration as well as subcutaneous, intravenous and intraosseous infusions. Families should be educated regarding swallowing limitations to prevent harm to the patient from well-meaning actions.

Question 21

x

Answer 21

x

Question 22

which of the following is NOT a common breathing pattern when a patient is actively dying?
a. Kussmaul respirations
b. Cheyne-Stokes breathing
c. Apnea
d. Agonal breathing

Answer 22

a - Kussmaul respirations, a form of hyperventilation which is typically associated with
metabolic acidosis, is not a common breathing pattern when a patient is actively dying.
Cheyne-Stokes breathing, which is an irregular pattern of breathing which may progress to
periods of apnea is very common. Apnea, with progressively longer periods without
breathing, is common as death approaches

Question 23

Which of the following statements is true regarding pain management for the patient who is in
the dying process?
a. Pain usually increases.
b. Pain medication must be increased.
c. Pain medication may need to be decreased.
d. There is usually no pain

Answer 23

. c - As organ systems fail during the dying process, pain medication may need to be decreased, depending on the patient’s status. The inability to efficiently clear medications through the hepatic and renal systems may create an accumulation of medication, which can be monitored by assessing for side effects such as increased somnolence or myoclonus. Generally, if the patient is showing no indications of toxicity, the pain medications should typically be left at the same dosage that the patient has been receiving prior to entering the dying process. Route of administration needs to be adjusted as appropriate.

Question 24

Margaret is a 90-year-old patient with end-stage breast cancer with bone metastasis who has
entered the dying process and is no longer responsive. Margaret had been experiencing
increased pain over the past few weeks, prior to entering the dying process, which required
adjustments to her pain management regimen. Now that Margaret is unresponsive, what will be
the most accurate indicator of her pain?
a. A pain assessment scale using numbers
b. A pain assessment scale using faces
c. Behavioral changes
d. The caregiver’s assessment

Answer 24

. c - Behavioral changes are the most reliable indicators of pain in the patient who is no longer able to respond. It must be noted that the dying patient may have many reasons for restlessness, including urinary retention, constipation and the early stages of delirium. Once other underlying causes have been ruled out and/or addressed, behavioral changes should be attributed to pain and treated appropriately.

Question 25

Richard is an 80-year-old with a diagnosis of Parkinson’s disease who has shown signs and symptoms of imminent death over the past 12 hours. Two of his daughters, who are nurses, want to provide nursing care for him in his final hours, and have declined the offer of continuous care nursing. When you enter the home for your visit, you find that they have moved the patient’s mattress to the floor, since he has been confused and restless, and tries constantly get out of bed, though he is too weak to stand. They have been administering medications as ordered, and the patient has a urinary catheter to straight drain. What may be most helpful in this patient’s care? a. Bedrails b. Soft restraints c. A holistic approach d. Continuous care nursing

Answer 25

. c - Patients who are in the dying process typically do not maintain mental clarity until time of death due to a number of factors. Mentation changes can occur on a wide scale, from mild anxiety to severe delirium, and identifying a single underlying cause is often difficult. Ruling out possible causes and treating them accordingly is the first priority, but overall, a holistic approach must be taken, and may include trial and error to determine what interventions are most helpful. Such interventions may include medication therapy, reduction of environmental stimuli, and the use of alternative approaches such as Reiki therapy, aroma therapy and music therapy

Question 26

x

Answer 26

x

Question 27

Steve is a 49-year-old husband and father of 2 young boys with a diagnosis of end-stage colon cancer with metastasis to the liver. His wife called, upset, requesting a visit because he has new onset back pain, and is having trouble walking. What do you suspect may be happening with Steve? a. Start of the dying process b. Spinal cord compression c. Poor medication compliance d. Early delirium

Answer 27

. b - Steve is most likely experiencing spinal cord compression, which is an oncologic emergency. Pressure on the cord caused by tumor invasion or cord ischemia creates neurological symptoms which may quickly progress to complete paralysis. Localized back pain may be the only symptom prior to paralysis occurring, or may be accompanied by motor deficits such as hypotonicity and hyperreflexia as well as sensory deficits such as paresthesia, bowel and bladder incontinence and urinary retention. This condition requires emergency treatment in accordance with patient/family goals and the patient’s condition. Diagnosis and treatment options include high dose corticosteroids, MRI or CT scan, radiation and surgical consult for decompression and stabilization

Question 28

Which of the following most accurately describes the disease course for the patient in the terminal phase status-post cerebral vascular accident (CVA)? a. Multiple exacerbations over months to years b. Slow deterioration c. Acute, non-reversible episode d. All of the above

Answer 28

d - All of the above choices describe the disease course of the terminal phase for the patient who has suffered a cerebral vascular accident (CVA) and meets hospice criteria for care. Neurological conditions, along with cardiovascular, renal and respiratory conditions, are non-cancer diagnoses commonly seen in the hospice population. The progression of disease for these conditions is unpredictable and may involve many exacerbations over months to years. Most patients with these conditions die due to failure of one or multiple organs as a result of progressive debility

Question 29

Of the following, what is the most predictable indicator of end of life in the patient with amyotrophic lateral sclerosis (ALS)? a. Weakness of sphincters and extraocular muscles b. Choking spells c. Involvement of respiratory muscles d. Fasciculations and impaired speech

Answer 29

d - All of the above choices describe the disease course of the terminal phase for the patient who has suffered a cerebral vascular accident (CVA) and meets hospice criteria for care. Neurological conditions, along with cardiovascular, renal and respiratory conditions, are non-cancer diagnoses commonly seen in the hospice population. The progression of disease for these conditions is unpredictable and may involve many exacerbations over months to years. Most patients with these conditions die due to failure of one or multiple organs as a result of progressive debility

Question 30

Dialysis-dependent patients with chronic renal failure who have decided to discontinue dialysis typically manifest signs and symptoms of uremia. Of the following, which are signs and symptoms associated with uremia in this patient population? a. Hypotension b. Hypokalemia c. Muscle cramps d. Hyponatremia

Answer 30

c - Muscles cramps are included in a variety of symptoms that occur in a uremic state. Additional symptoms include skeletal deformity, twitching, severe pruritus, CHF and coronary insufficiency and hypertension. Encephalopathy may occur as the patient’s condition worsens and death approaches.

Question 31

End-stage liver disease creates hepatic failure from a number of etiologies. One of the indications of advanced liver disease is ascites. Of the following, which is a major risk of ascites? a. Hepatic encephalopathy b. Esophageal varices c. Respiratory compromise d. Liver capsule pain

Answer 31

c - Respiratory compromise, spontaneous bacterial peritonitis and hepatorenal syndrome (HRS) are major risks of ascites. In its most virulent form (type I) there is an inexorable worsening of TOP

Question 32

Certain comorbid illnesses are predictors of poor outcomes in the patient with advanced HIV disease. Of the following, which is NOT one of them? a. Liver decompensation b. Metastatic neoplasms c. Treatable infections d. Progressive encephalopathy

Answer 32

c - Opportunistic infections are common in this patient population, but if they respond to treatment, they are not a predictor of poor outcomes. Other options noted are included as predictors of poor outcomes, in addition to lymphomas unresponsive to treatment, substance abuse and opportunistic infections which are not responsive to treatment

Question 33

Many hospice patients have the comorbidity of diabetes mellitus, either type I or type II. Often, this is a major contributor to the development of the patient’s terminal diagnosis. Therefore, it is important for hospice nurses to be aware of the variety of complications that may arise from diabetes. Of the following, which is a symptom of the diabetic complication of autonomic neuropathy? a. Recurrent infections b. Postural hypotension c. Multi-organ failure d. Peripheral vascular disease

Answer 33

. b - Postural hypotension is included in the various symptoms associated with autonomic neuropathy associated with diabetes. Other symptoms include persistent tachycardia, neurogenic bladder, incontinence of urine or feces and diabetic nephropathy. Other complications of diabetes mellitus include diabetic retinopathy, peripheral vascular and coronary artery disease, impaired gastrointestinal motility, diabetic neuropathy, recurrent infections, impaired wound healing and multi-organ failure

Question 34

Although much progress has been made in the treatment of HIV, what remains a major concern regarding this disease? a. Viral mutations b. Limited prognosis c. Lack of screening d. None of the above

Answer 34

. a - The most concerning, complex factor regarding HIV is its continued ability to mutate in addition to the crossing of socioeconomic, cultural, political and geographic borders. 48. d - All of the above along with micronutrients, surveillance of symptoms and prophylactic treatment are all important factors for health promotion in the HIV population.

Question 35

Which of the following are important factors in the health promotion of palliative care patients with HIV? a. Diet b. Exercise c. Stress management d. All of the above.

Answer 35

. a - The most concerning, complex factor regarding HIV is its continued ability to mutate in addition to the crossing of socioeconomic, cultural, political and geographic borders. 48. d - All of the above along with micronutrients, surveillance of symptoms and prophylactic treatment are all important factors for health promotion in the HIV population.

Question 36

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. 50. Which of the following symptoms would be indicative of imminent death in Frank? a. Increased urinary output b. Increased intake c. Increased activity d. Increased heart rate

Answer 36

d - As death becomes more imminent, the heart rate can double, but with decreased contraction due to decreased blood pressure and overall fluid volume as a result of dehydration. Urine output, intake and activity would remain decreased as signs of imminent death, not increased

Question 37

Of the following, which statement is most accurate in terms of the pain experience? a. 40-50% of patients have severe pain. b. 70-90% of patients with advanced disease experience pain. c. Pain scores (on a 0-10 scale) ≥ “8” greatly impact quality of life. d. It is estimated that 45-50% of all patients could be pain free

Answer 37

b - Pain is experienced by 70-90% of patients with advanced disease. Of these patients, 40-50% experience moderate pain, and 25-30% have severe pain. Pain scores (on a 0-10 scale) ≥ “4” greatly impact quality of life. It is estimated that 85-90% of patients could be pain free, and 98-99% could have their pain controlled, using the knowledge and methodologies available today

Question 38

Which of the following most accurately describes “breakthrough” pain? a. Associated with pathological fractures b. Refers to a new psychological or spiritual insight c. Can occur as end-of-dose failure d. An aspect of opioid pseudo-addiction

Answer 38

C

Question 39

If Roberta becomes unable to communicate verbally, what will be the most important aspect of her pain assessment? a. Family/caregiver input b. Her pain level prior to losing ability to verbalize c. Change in behavior d. Her vital signs

Answer 39

c - Change in behavior is the gold standard in assessing pain in the individual who is cognitively impaired or unable to communicate verbally. A furrowed brow is an excellent indication that the patient is uncomfortable and can be used as an indication of the effectiveness of the pain management regimen. Family and caregiver input is also a critical component

Question 40

What are the three etiologies of cancer pain syndromes? a. Direct tumor involvement, cancer therapy and non-cancer pain b. Neuropathic pain, visceral pain and bone pain c. Hollow organ pain, peripheral neuropathy and somatic pain d. Phantom limb pain, ischemic pain and sensory neuron pain

Answer 40

a - The three etiologies of cancer pain syndromes are pain associated with direct tumor involvement, pain associated with cancer therapy and pain unrelated to cancer or cancer therapy. Many patients have pre-existing pain which occurs in other sites and may not be related the patient’s cancer diagnosis.

Question 41

Statistics indicate that 30-97% of patients with AIDS experience pain. Of this, what percentage is estimated to be directly related to HIV infection? a. 40% b. 20% c. 70% d. 50%

Answer 41

d - It is estimated that 50% of the pain that patients with AIDS experience is directly related to HIV infection, and 30% is related to therapy. HIV pain is usually classified similarly to cancer pain syndromes in that there is pain directly related to the virus, pain related to the treatment, and non-related pain. Nearly one half of pain in HIV/AIDS is neuropathic pain, which spares no part of the nervous system. Pain may result from direct viral infections, infection with secondary pathogens, or be a side effect of drug therapy (neurotoxic). Central or peripheral manifestations and, particularly, painful peripheral neuropathies, generally follow the stage of HIV. Knowledge about the stage of the disease is imperative in the diagnosis of painful conditions as they vary by stage

Question 42

Of the following, which type of pain is common in patients with multiple sclerosis (MS)? a. Ischemic pain b. Bone pain c. Neurological pain d. Visceral pain

Answer 42

c - Neurological pain is common in patients with multiple sclerosis (MS). Examples include paroxysmal trigeminal neuralgia, optic neuritis, periorbital pain and extremity pain. Musculoskeletal pain is also common, and presents as extremity pain and low back pain. Pain is experienced in 55-82% of individuals with MS.

Question 43

When is pain most often experienced after a stroke? a. Several weeks b. Several days c. Several months d. Several years

Answer 43

. c - The medical literature estimate of the prevalence of chronic post-stroke pain ranges from 32- 42% at four to six months and 11-21% at twelve to sixteen months after a stroke. Shoulder pain alone has been found to affect up to 72% of post-stroke survivors. If one were to include other causes of post-stroke pain, this number could be significantly higher. It is usually accompanied by decreased temperature sensation, may be deep or superficial, and can be severe. Allodynia (painful response to a normally innocuous stimulus) and hyperalgesia (increased response to a painful stimulus) are often present. Mechanical shoulder pain is another common post-stroke pain syndrome, though it is unrelated to the cerebral injury.

Question 44

Hilda is an 89-year-old patient with a diagnosis of Alzheimer’s disease. Recently, she fell, and fractured her left hip. She underwent surgery for a hip replacement. When you visit her in the hospital, she is noted to be having a great deal of post-operative pain, for which she is receiving prn dosing of pain medication. Of the following, what type of pain most accurately describes Hilda’s situation? a. Chronic pain b. Acute pain c. Visceral pain d. Refractory pain

Answer 44

. b - Hilda is having acute pain, which usually has a clear cause, is reversible and has observable signs. In contrast, the cause for chronic pain is often not clear. Chronic pain can create decreased social interaction, depression and insomnia. There may not be any observable or behavioral signs of chronic pain.

Question 45

Ron is a 66-year-old patient with a diagnosis of colon cancer with liver metastasis. When reporting his pain, he describes it as a “cramping” pain in his abdomen, which often “aches”. What type of pain is Ron experiencing? a. Somatic pain b. Referred pain c. Neuropathic pain d. Visceral pain

Answer 45

d - Ron is experiencing visceral pain, which is often difficult to localize, and may be described as “cramping”, with a sensation of aching and pressure. This type of pain can be controlled with conventional analgesics, antispasmodics, and possibly antineoplastic agents, depending upon the situation.

Question 46

What type of physical pain responds well to anti-depressant medications as a primary or adjuvant analgesic? a. Visceral pain b. Nociceptive pain c. Neuropathic pain d. Bone pain

Answer 46

. c - Neuropathic pain responds well to anti-depressants, anticonvulsants and corticosteroids as either primary or adjuvant analgesics. This type of pain is described as sharp, burning and shooting. Examples include spinal nerve compression, invasion of nerves by tumors, post-herpetic neuralgia and post-stroke pain syndromes

Question 47

What is a common site of referred pain for the patient who has gallbladder or liver disease? a. Left shoulder b. Right arm c. Right shoulder d. Sacrum

Answer 47

. c - A patient with gallbladder or liver disease may have referred pain to the right shoulder or back. Referred pain is a phenomenon in which pain is experienced distant from the site of origin. Pain from tumors in the pancreas, lower esophagus, stomach or retroperitoneal area may be referred to the back

Question 48

Rebecca is a 49-year-old with end stage lung cancer who has been on morphine sulfate for pain for one week. She has quickly developed a tolerance for the side effects of opioids, except one. Of the following, which one would that be? a. Respiratory depression b. Sedation c. Constipation d. Nausea

Answer 48

. c - Tolerance develops quickly for the side effects of opioids, with the exception of constipation. The patient’s body will never adjust to this side effect, and therefore the patient must remain on an appropriate bowel regimen that typically consists of a stool softener and cathartic for the duration of opioid therapy. Additional orders are usually in place to adjust the bowel regimen to effect according to specific guidelines

Question 49

Of the following, which medication does not have a dosage ceiling and can be titrated to effect? a. Codeine b. Morphine c. Hydrocodone d. Nalbuphine

Answer 49

. b - Morphine is a pure opioid agonist and does not have a dosage ceiling, therefore, it can be titrated to effect. Though there is no dosage ceiling, side effects, such as constipation, will become more severe at higher doses, so adjustments to the bowel regimen must be made as the opioid dosage is increased. In addition, morphine also has the active metabolites morphine 6-glucuronide (M6G) and morphine 3-glucuronide (M3G) which may be retained more by the elderly and those with decreased renal function. Increased M3G levels can produce myoclonus, and increased M6G levels can cause sedation.

Question 50

When using transdermal delivery systems for patients who are cachectic, which of the following is an appropriate consideration? a. They may need lower doses than a person of normal weight. b. They may need higher doses than a person of normal weight. c. This is not an appropriate delivery system for cachectic patients. d. None of the above

Answer 50

b - Studies have indicated that cachectic patients have lower blood levels of the medication being delivered through a transdermal system due to decreased subcutaneous tissue available for absorption. Therefore, such patients may need higher doses than the person of normal weight. In addition, these patients may also experience more erratic absorption of the drug.

Question 51

Of the following, which tricyclic antidepressant is NOT the preferred choice for use in treating neuropathic pain? a. Amitriptyline b. Nortriptyline c. Desipramine d. All of the above

Answer 51

. a - Of the tricyclic antidepressants, amitriptyline is not the preferred choice for use for treating neuropathic pain, due to increased side effects from anticholinergic actions. These include dry mouth, constipation, mentation changes and cardiac changes.

Question 52

Of the following, what are the most common side effects that the patient should be monitored for when using tricyclic antidepressants? a. Sedation, orthostatic hypotension, urinary retention b. Sedation, tremors, urinary frequency c. Sedation, cardiac impairment, increased bleeding d. Sedation, respiratory depression, gastropathy

Answer 52

. a - The most common side effects of tricyclic antidepressants are sedation, orthostatic hypotension, urinary retention and cardiovascular impairment. Dosage should be adjusted according to the patient’s wishes if side effects become burdensome

Question 53

Of the following, what other class of medications can be used as an adjuvant to treat neuropathic pain? a. Serotonin selective reuptake inhibitors (SSRIs) b. Serotonin-norepinephrine reuptake inhibitors c. Anticonvulsants d. Both b and c

Answer 53

d - Both anticonvulsants and serotonin-norepinephrine reuptake inhibitors are additional classes of medications that can be used as adjuvant medications to treat neuropathic pain.

Question 54

Margaret is a newly admitted 65-year-old with a diagnosis of stage IV breast cancer with metastasis to the lungs and brain. She has been confused, agitated, is very sensitive to touch and her pain is not well-controlled with her current pain management regimen which includes transdermal fentanyl. The hospice medical director would like to convert her to oral morphine and states he may reduce her dose of the new medication by 25% Of the following, what non-pharmacologic interventions would be most appropriate to add to Margaret’s pain regimen at this time? a. Music therapy b. Physical therapy c. Massage therapy d. Counseling

Answer 54

a - Since, at this time, Margaret is confused, agitated and sensitive to touch, the best nonpharmacologic option to add to her regimen would be music therapy. All other options either include physical touching or the ability to function cognitively at a higher level. Once Margaret’s basic need for adequate pain management is met, these options may be appropriate

Question 55

When you explain the new dosing schedule to Margaret’s husband, he states that he never gives her a rescue dose when she is due for her long-acting dose at the same time, even if she is in a lot of pain. He states that he’s afraid he’ll “kill” her with an overdose. Of the following, what would be the most appropriate response? a. His fears are warranted and he’s wise to be careful b. He can hold the long-acting dose when he gives the rescue dose c. The long-acting dose is released over an extended period d. Consult with the social worker to help him with his fears

Answer 55

. c - The most appropriate response would be to provide Margaret’s husband with education about how the long-acting agent and short-acting agent work differently to provide optimal pain relief for Margaret. Since the opioid in the long-acting agent is released over an extended period of time, giving Margaret her rescue dose at the same time will not “overdose” her, and will provide optimal pain relief quickly. The long-acting agent provides a consistent blood level of opioid for pain relief, and the short-acting agent provides needed intermittent treatment that is quickly available for Margaret’s pain if it worsens.

Question 56

Since hospice care involves the patient and family, what additional interventions may be helpful for Margaret’s husband as he deals with the challenges of changes in her condition? a. Ask the hospice medical director to prescribe an anti-anxiety agent for him b. Collaboration with the hospice chaplain and social worker c. Offer to have the hospice massage therapist give him a massage d. Ask the hospice physical therapist to provide treatment for his back pain

Answer 56

b - Collaboration with the interdisciplinary team is a critical aspect of hospice care. Involving the hospice chaplain and social worker is an excellent means of providing support for the entire patient/family unit. Unfortunately, nurses may sometimes focus too much on pharmacologic/physical interventions, and/or tend to function too independently. Hospice care is a wonderful collaborative effort, in which all team members play an equally vital role in meeting the physical, psychosocial and spiritual needs of the patient and family unit

Question 57

After meeting with the hospice counselor, Rachel states that she is ready to try a few alternatives to pain medicine to try to decrease her pain. She says the counselor mentioned reiki, aromatherapy, music therapy and massage therapy. She states she is still not used to interacting with so many people and does not want to feel invaded. In light of her feelings, which of the following would be the most appropriate non-pharmacologic options for Rachel? a. Massage and music therapy b. Reiki therapy and massage c. Aromatherapy and massage d. Reiki and aroma therapy

Answer 57

d - Since Rachel does not like much stimulation, non-touch therapies would likely be most appropriate for Rachel at this point. Reiki (a non-touch energy therapy) and aromatherapy would be excellent options according to Rachel’s wishes.

Question 58

Nausea is also a common side-effect of opioid use. If Rachel experiences this, what education can you provide that may be helpful for her? a. Opioid-induced nausea never goes away b. Opioid-induced nausea is very difficult to treat c. Opioid-induced nausea usually resolves after about a month d. Opioid-induced nausea usually resolves after about a week

Answer 58

. d - It would be helpful to educate Rachel regarding the fact that opioid-induced nausea usually resolves after about a week of starting the medication. With a diagnosis of pancreatic cancer, Rachel may have more than one etiology for her nausea, therefore, it will be important to try to determine causative factors in order to provide appropriate treatment

Question 59

If Rachel continues to have nausea, of the following, what interventions would be appropriate? a. Bland foods, identify etiology b. Serve foods warm, administer metoclopramide c. Warm environment, administer scopolamine patch d. Decrease meal frequency, administer dexamethasone

Answer 59

a - Nausea can be due to a variety of factors in this patient population, therefore, if it’s possible to determine etiology, this will guide pharmacologic intervention to the appropriate agent. Diet modifications, such as eating bland foods, small frequent meals and avoiding greasy or fatty foods may be helpful. Additionally, serving foods at room temperature or cold may help decrease the odor of food preparation, which can add to nausea. If opioid-induced nausea doesn’t resolve, treatment with butyrophenones (ie, haloperidol or droperidol) may be helpful

Question 60

David is a 45-year-old patient with liver cancer who belongs to a religious order that does not believe in using any type of medications for any reason. Therefore, he states he will not accept medication for his pain, no matter how bad it gets. 123. Of the following, what is the most appropriate response? a. Ask the hospice chaplain to help change his mind b. Support his decision and provide alternative therapies c. Provide educational materials about pharmacologic interventions for pain d. Ask his family to intervene

Answer 60

b - Providing alternative therapies and supporting David’s decision is the appropriate response. This honors his value system, and provides him with non-judgmental support of his decision. The role of the hospice professional is to provide options and optimize care and comfort in the context of the patient’s right to self-determination.

Question 61

Emily is a 79-year-old with ovarian cancer who was started on morphine two days ago for the first time. When you call to check on her, she reports excessive generalized itching. Upon visiting, you find her restless with a flat red rash over her upper chest and abdomen. 125. What do you suspect is happening with Emily? a. Side effect of morphine b. Allergic reaction to morphine c. Dermatitis from environmental factors d. Food allergy

Answer 61

. b - Emily is most likely having an allergic reaction to morphine, since it was recently started, and she had not had it previously. Although itching is a common side effect of opioids, a new rash should cause suspicion for an allergic reaction and be treated accordingly

Question 62

Bob is a 66-year-old with lung cancer who has been running a fever for the past several days. His pain management regimen has included orders for fentanyl transdermal 75 mcg/hr patch q72 hours, which was changed yesterday. When you arrive for your visit, you find him much more sedated than usual. His wife states that all he’s done for the past 24 hours is sleep. What do you suspect may be happening with Bob? a. Disease progression b. Brain metastases c. Increased fentanyl dose d. Liver failure

Answer 62

c - Since Bob has a fever, the dosage of his transdermal fentanyl is probably being absorbed more rapidly than usual, increasing his hourly dose. In collaboration with his physician, treating his fever may resolve the issue, or he may need to have his dosage decreased with appropriate breakthrough pain medication available to maintain his comfort level, or his opioid converted to another agent until his fever is under control and his pain medication regimen stabilized.

Question 63

Suzanne is a 38-year-old single mother of three children ages 3-8 who was recently diagnosed with Stage IV breast cancer, declined all treatment and was admitted to hospice care one week ago. She lives alone with her three children and wants to remain as independent as possible to care for her children and ensure their wellbeing as she identifies who will be their ongoing caregiver after her death. 129. Suzanne has been refusing pain medications of any kind despite reporting pain of 6/10 routinely since her admission. What would be the best initial response to her refusal of treatment for her pain? a. “You really should take the pain medicine so your kids don’t have to see you in pain”. b. “What have you done to relieve pain in the past that helped you?” c. “We really need to start you on medicine for your pain because we can’t have you reporting pain that is not treated”. d. “I am going to call the pharmacy and order you some Morphine”

Answer 63

b - Refusal of medication is part of the patient’s rights for autonomy and should be honored. In this case, given the special circumstances it would be best to initially inquire about other methods (non-pharmacological and pharmacological) that the patient may have found beneficial previously that could be incorporated into her plan of care effectively without impacting her independence and ability to care for her children while improving her quality of life. This would be part of your comprehensive pain assessment.

Question 64

You arrive to your scheduled visit with Suzanne to find that she is now unable to manage her medications independently and she is reporting pain of 9/10, is tearful and agitated and has not taken any pain medication for over 12 hours. What should be the initial intervention to assist Suzanne? a. Obtain her consent to be transferred to a facility that can manage her care more effectively. b. Complete your assessment and then consult with her mother to inquire if what she has told you is true. c. Locate her pain medication and administer the highest ordered dose immediately. d. Plan a schedule for medications and set up a med box to eliminate missed doses.

Answer 64

. c - In this situation, the initial intervention should be to alleviate the patient’s pain as quickly as possible. Transferring might be a potential future consideration if necessary, but not as an initial response. Completing an assessment is unlikely to be possible with a patient who is so painful and agitated. In addition, you must believe the patients report of pain as true in all situations. Planning a schedule and med box may be an additional intervention but would not be of immediate benefit to the patient

Question 65

The type of pain experienced towards the end of the usual dosing interval of a regularly scheduled narcotic is which of the following? a. Spontaneous pain b. Incident pain c. Crisis pain d. End of dose failure pain

Answer 65

. d - This type of pain is referred to as end-of-dose failure pain that results from declining blood levels of the around the clock analgesic before administration or uptake of the next scheduled dose. Spontaneous pain is unpredictable and not associated with any activity or event. Incident pain is predictably elicited by specific activities. Crisis pain is typically related to neuropathic symptoms and often is poorly responsive to conventional therapies short of inducing palliative sedation in some patients

Question 66

James is a 49-year-old patient with end-stage liver disease who has been taking Hydromorphone 4mg every 6 hours ATC for pain with good relief for the past few weeks. At today’s visit, he is complaining of significantly increased pain, but is refusing to take more medication stating he cannot allow his children to see him addicted to pain medications. 135. Which term most accurately explains the increasing need for higher doses to control his pain? a. Pseudo-addiction b. Tolerance c. Physical dependence d. Pseudo-tolerance

Answer 66

b - Tolerance is the state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. Pseudo-addiction is the mistaken assumption of addiction in a patient who is seeking relief from pain. Physical dependence is a state of adaptation that is manifested by a drug-class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

Question 67

What would be the best explanation of the use of music therapy to decrease pain in hospice and palliative care patients? a. Music provides a soothing, safe environment that helps to decrease pain. b. Music provides a temporary distraction from the pain experience. c. Music should be utilized with every hospice patient to decrease pain. d. Music should not be tailored to the patient/family’s requests.

Answer 67

a - Music increases the patient’s comfort, is soothing and creates a safe environment to ease the dying process. Although, music can provide a temporary distraction it is not the best explanation here. In addition, music may not be appropriate for every patient/family and it should be tailored to the patient/family’s specific requests.

Question 68

Which complementary therapy has been demonstrated to decrease pain perception by an average of 60% in research studies? a. Music therapy b. Aromatherapy c. Massage d. Reiki

Answer 68

. c - Massage was reported to reduce pain perception by an average of 60% in studies by FerrellTorry and Glick. The other therapies listed are also recognized as beneficial but not to the extent of massage in studies. 1

Question 69

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

Answer 69

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 70

Roberta is a 69-year-old who is status-post CVA who has left-sided weakness and aphasia. She is often frustrated and tearful in her communication attempts, and her daughter often loses patience with her. 143. Of the following, what will be a priority in Roberta’s care? a. Providing prn dosing for anxiolytics b. Understanding what type of aphasia she has c. Providing a support group for her daughter d. Using different communication tools with every visit

Answer 70

b - Understanding the type of aphasia Roberta has is critical to providing optimal care and support for both Roberta and her daughter. Aphasia can be of three different types: sensory (receptive) in which the patient is unable to comprehend written, auditory or visual input; motor (expressive) in which the patient comprehends sensory input, but is unable to adequately communicate; global (sensory and motor) in which the patient can neither comprehend sensory input or communicate. Understanding the extent of Roberta’s limitations is critical, as it is extremely frustrating for patients who have expressive aphasia alone to understand everything and not be able to express themselves. If healthcare professionals and caregivers don’t understand the reality of this situation, it is very difficult for the patient. When caregivers receive accurate information and education, they can be more understanding regarding the patient’s limitations. Speech therapy collaboration is an excellent resource for patients who have aphasia and their families to ensure that they have optimal communication tools available.

Question 71

As Roberta’s disease progresses, she begins to have coughing spells when eating. When asked if she is in pain, she indicates she is not by shaking her head. What do you suspect may be happening with Roberta? a. Partial aspiration b. Poor positioning when eating c. Eating too fast d. Not chewing thoroughly

Answer 71

a - If Roberta is consistently coughing when she is eating, she most likely is experiencing dysphagia from her neurological impairment, and may be partially aspirating her food, increasing her risk for aspiration pneumonia. A speech therapy evaluation would be helpful for evaluation and recommendations

Question 72

. Several weeks later, Roberta’s daughter calls and states that she is unable to get her mother to wake up. Upon visiting, Roberta is very difficult to arouse, with even respirations and vital signs within normal ranges. She does not appear to be in any discomfort. What would be the most appropriate response to Roberta’s change in status? a. Call an ambulance and request hospital admission b. Arrange for an occupational therapy assessment c. Discuss her current status and her daughter’s wishes for her care d. Request a portable chest x-ray and EKG

Answer 72

. c - The most appropriate response is to discuss her current status with her daughter and determine her wishes for her care. If Roberta does not have advanced directives in place, this is an appropriate discussion to be revisited at this time, as well as anticipated course of disease progression if Roberta’s status does not change. Collaboration with the IDT, including Roberta’s physician must take place, and her care plan updated according to her daughter’s wishes

Question 73

As Joe’s disease has progressed, he has become more confused, agitated and even combative at times. He was previously started on haloperidol to help calm him, and has required increasing doses over the last several days until he has finally reached the upper limit of therapeutic dosage. At Joe’s visit today, you notice that he is restless, keeps sticking his tongue in and out and has numerous involuntary movements of his head and extremities that were not present before. What do you suspect is happening with Joe? a. Seizure activity b. Myoclonus c. Tardive dyskinesias d. Terminal restlessness

Answer 73

c - Joe is having tardive dyskinesias, most likely caused by the haloperidol. Tardive dyskinesias involve a range of abnormal and involuntary movements as an expression of extrapyramidal symptoms. Typically, these movements occur in the tongue, face, lips and extremities. Extrapyramidal symptoms can have many causes, including medication-related, disease-related, or metabolic. If the causative factor can be determined and corrected or removed, this is the optimum approach to treatment. In Joe’s case, changing him from haloperidol to another anxiolytic will be an option to attempt to limit his symptoms

Question 74

Rachel is a 40-year-old with a diagnosis of pancreatic cancer. She reports that she is having nightmares frequently, and states her pain has increased, but she refuses to take something for it. When asked about her refusal, she states that she has “done many things wrong” in her life, and that she believes that her diagnosis and her pain is “God’s punishment”. She states, “I deserve to be in pain.” 115. In collaboration with the hospice team, what would be a priority intervention in Rachel’s care? a. Psychosocial and spiritual counseling b. Music therapy c. Massage therapy d. Prayer

Answer 74

a - Psychosocial and spiritual counseling would be priority interventions in Rachel’s situation. Since her pain holds value for her, interventions to alleviate her pain will be most effective once she has the opportunity to deal with deeper issues that are creating her psychological and spiritual distress. Additionally, Rachel should be continually provided with the option for pharmacological and other-modality pain management once she is ready to accept them

Question 75

. When Rachel is started on her opioid dosing, what side effect can be anticipated? a. Agitation b. Constipation c. Respiratory depression d. Myoclonus

Answer 75

b - Constipation is a side effect that can always be anticipated with opioid use. A preventative bowel regimen should be started when opioids are started consisting of a stool softener and cathartic. As opioid doses are increased, bowel regimen dosages should be adjusted as well. 121. d - It would be helpful to educate Rachel regarding the fact that opioid-induced nausea usually resolves after about a week of starting the medication. With a diagnosis of pancreatic cancer, Rachel may have more than one etiology for her nausea, therefore, it will be important to try to determine causative factors in order to provide appropriate treatment

Question 76

“Double-effect” is a barrier or myth that a healthcare provider may have regarding pain management. Of the following, which most clearly describes the context for this principle? a. Opioid naïve patients b. Change in care setting c. Ethical principles d. Communication barrier

Answer 76

c - “Double-effect is an ethical principle that permits an action, intended to have a good effect, when there is a risk of also causing a harmful effect, ONLY when the intention was to provide a good effect.”50 Unfortunately, many healthcare providers apply this principle to end-of-life care, especially pain and symptom management, which creates a barrier to optimal symptom relief. Research continues to support that adequate pain and symptom management at end of life does not shorten life. Other healthcare provider barriers include, but are not limited to, not believing patient’s self-report of pain, believing opioids cause respiratory depression, believing only opioids can treat severe pain, confusion regarding addiction/tolerance/physical dependence and general lack of training and education related to pain assessment, treatment and pharmacology

Question 77

Nausea is also a common side-effect of opioid use. If Rachel experiences this, what education can you provide that may be helpful for her? a. Opioid-induced nausea never goes away b. Opioid-induced nausea is very difficult to treat c. Opioid-induced nausea usually resolves after about a month d. Opioid-induced nausea usually resolves after about a week

Answer 77

d - It would be helpful to educate Rachel regarding the fact that opioid-induced nausea usually resolves after about a week of starting the medication. With a diagnosis of pancreatic cancer, Rachel may have more than one etiology for her nausea, therefore, it will be important to try to determine causative factors in order to provide appropriate treatment.

Question 78

. If Rachel continues to have nausea, of the following, what interventions would be appropriate? a. Bland foods, identify etiology b. Serve foods warm, administer metoclopramide c. Warm environment, administer scopolamine patch d. Decrease meal frequency, administer dexamethasone

Answer 78

. a - Nausea can be due to a variety of factors in this patient population, therefore, if it’s possible to determine etiology, this will guide pharmacologic intervention to the appropriate agent. Diet modifications, such as eating bland foods, small frequent meals and avoiding greasy or fatty foods may be helpful. Additionally, serving foods at room temperature or cold may help decrease the odor of food preparation, which can add to nausea. If opioid-induced nausea doesn’t resolve, treatment with butyrophenones (ie, haloperidol or droperidol) may be helpful.

Question 79

David is a 45-year-old patient with liver cancer who belongs to a religious order that does not believe in using any type of medications for any reason. Therefore, he states he will not accept medication for his pain, no matter how bad it gets. 123. Of the following, what is the most appropriate response? a. Ask the hospice chaplain to help change his mind b. Support his decision and provide alternative therapies c. Provide educational materials about pharmacologic interventions for pain d. Ask his family to intervene

Answer 79

. b - Providing alternative therapies and supporting David’s decision is the appropriate response. This honors his value system, and provides him with non-judgmental support of his decision. The role of the hospice professional is to provide options and optimize care and comfort in the context of the patient’s right to self-determination.

Question 80

Of the following, which modalities may be most helpful for David

Answer 80

a - Cutaneous stimulation, such as the application of heat or cold, may be helpful for David. Other options involve medications of some type, which he states that he does not want. Additional nonpharmacologic options include aromatherapy, biofeedback, transcutaneous nerve stimulation, acupuncture, massage and various psychosocial and spiritual interventions

Question 81

Suzanne is a 38-year-old single mother of three children ages 3-8 who was recently diagnosed with Stage IV breast cancer, declined all treatment and was admitted to hospice care one week ago. She lives alone with her three children and wants to remain as independent as possible to care for her children and ensure their wellbeing as she identifies who will be their ongoing caregiver after her death. 129. Suzanne has been refusing pain medications of any kind despite reporting pain of 6/10 routinely since her admission. What would be the best initial response to her refusal of treatment for her pain? a. “You really should take the pain medicine so your kids don’t have to see you in pain”. b. “What have you done to relieve pain in the past that helped you?” c. “We really need to start you on medicine for your pain because we can’t have you reporting pain that is not treated”. d. “I am going to call the pharmacy and order you some Morphine

Answer 81

b - Refusal of medication is part of the patient’s rights for autonomy and should be honored. In this case, given the special circumstances it would be best to initially inquire about other methods (non-pharmacological and pharmacological) that the patient may have found beneficial previously that could be incorporated into her plan of care effectively without impacting her independence and ability to care for her children while improving her quality of life. This would be part of your comprehensive pain assessment

Question 82

m 39 Questions 129 - 131 are based upon the following scenario: Suzanne is a 38-year-old single mother of three children ages 3-8 who was recently diagnosed with Stage IV breast cancer, declined all treatment and was admitted to hospice care one week ago. She lives alone with her three children and wants to remain as independent as possible to care for her children and ensure their wellbeing as she identifies who will be their ongoing caregiver after her death. 129. Suzanne has been refusing pain medications of any kind despite reporting pain of 6/10 routinely since her admission. What would be the best initial response to her refusal of treatment for her pain? a. “You really should take the pain medicine so your kids don’t have to see you in pain”. b. “What have you done to relieve pain in the past that helped you?” c. “We really need to start you on medicine for your pain because we can’t have you reporting pain that is not treated”. d. “I am going to call the pharmacy and order you some Morphine”. 130. After a few weeks of utilizing complementary therapies of acupressure and guided imagery, Suzanne reports that she has made arrangements for her mother to become the children’s caregiver after her death and that her mother will be staying with her now to help care for both her and the children. She reports she is now agreeable to trying some medications for her pain. Given that she has not previously taken narcotics, what would be the initial recommendation for her generalized pain of 5/10? a. Morphine IR 5-10mg po every 2 hours ATC. b. Ibuprofen 600mg po every 6 hours ATC. c. Hydromorphone 4mg po every 3-4 hours PRN. d. Hydrocodone/Acetaminophen 5/325 1-2 po every 4-6 hours PRN.

Answer 82

c - In this situation, the initial intervention should be to alleviate the patient’s pain as quickly as possible. Transferring might be a potential future consideration if necessary, but not as an initial response. Completing an assessment is unlikely to be possible with a patient who is so painful and agitated. In addition, you must believe the patients report of pain as true in all situations. Planning a schedule and med box may be an additional intervention but would not be of immediate benefit to the patient.

Question 83

James is a 49-year-old patient with end-stage liver disease who has been taking Hydromorphone 4mg every 6 hours ATC for pain with good relief for the past few weeks. At today’s visit, he is complaining of significantly increased pain, but is refusing to take more medication stating he cannot allow his children to see him addicted to pain medications. 135. Which term most accurately explains the increasing need for higher doses to control his pain? a. Pseudo-addiction b. Tolerance c. Physical dependence d. Pseudo-tolerance

Answer 83

. b - Tolerance is the state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. Pseudo-addiction is the mistaken assumption of addiction in a patient who is seeking relief from pain. Physical dependence is a state of adaptation that is manifested by a drug-class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving

Question 84

What would be the best explanation of the use of music therapy to decrease pain in hospice and palliative care patients? a. Music provides a soothing, safe environment that helps to decrease pain. b. Music provides a temporary distraction from the pain experience. c. Music should be utilized with every hospice patient to decrease pain. d. Music should not be tailored to the patient/family’s requests.

Answer 84

. a - Music increases the patient’s comfort, is soothing and creates a safe environment to ease the dying process. Although, music can provide a temporary distraction it is not the best explanation here. In addition, music may not be appropriate for every patient/family and it should be tailored to the patient/family’s specific requests.

Question 85

Which complementary therapy has been demonstrated to decrease pain perception by an average of 60% in research studies? a. Music therapy b. Aromatherapy c. Massage d. Reiki

Answer 85

c - Massage was reported to reduce pain perception by an average of 60% in studies by FerrellTorry and Glick. The other therapies listed are also recognized as beneficial but not to the extent of massage in studies

Question 86

Of the following, which can be defined as a major emotional indicator of depression? a. Guilt b. Hopelessness c. Absence of pleasure d. All of the above

Answer 86

d - All of the options listed are major emotional indicators of depression. Other emotional indicators include feelings of helplessness, worthlessness and low self-esteem. Physical indicators of depression may include disturbed sleep, anorexia, constipation, fatigue and reduced libido

Question 87

Ted is a 64-year-old with end-stage stomach cancer who is in the dying process. He used to be a radio host, has traveled extensively, and has always had a gregarious personality. His wife states that he “never met a stranger.” When you visit, Ted is very weak, and has not been able to get out of bed for the last three days. He acknowledges your presence, but is smiling and staring with fascination at the wall opposite his bed. When you ask what he’s looking at, he states, “I can see it. It’s my whole life going by-one big long movie.” Of the following, which is the most appropriate response? a. Call the doctor and request haloperidol. b. Initiate reorientation therapy. c. Call the hospice social worker to visit. d. Ask Ted to describe what he is seeing

Answer 87

d - Visual life review can be common during nearing death awareness, and should be approached as a valuable aspect of helping patients to finish the psychosocial and spiritual work they may need to complete as part of their preparation for death. Providing a validating, supportive presence will enhance the patient’s experience and ability to optimize it as a final gift. Collaboration with appropriate members of the IDT will ensure that Ted has optimal support in every aspect of his care.

Question 88

Of the following, which would NOT be an appropriate class of medications to use in treating fatigue? a. Corticosteroids b. Stimulants c. Benzodiazepines d. Tricyclic antidepressant

Answer 88

c - Benzodiazepines would not be an appropriate class of medications for treating fatigue. All other options are included as appropriate choices, as well as selective serotonin reuptake inhibitors (SSRIs) and erythropoietin.

Question 89

Jim is a 74-year-old with end-stage multiple myeloma who has routinely been receiving blood transfusions for his severe anemia. He has recently signed a DNR, and states that he wants no further blood transfusions or interventions of any kind for his anemia. What symptom should you anticipate as a result of his worsening anemia? a. Petechiae b. Dyspnea c. Constipation d. Seizures

Answer 89

. b - Due to the decreased oxygen-carrying capacity associated with severe anemia, Jim may experience dyspnea as his anemia worsens. Both Jim and his family should be educated regarding this potential, and anticipatory interventions arranged to manage his symptoms and assure him that his comfort will be optimized

Question 90

Lymphedema is difficult to manage, and may not respond to diuretics, elevation or compression stockings. Of the following, what is one of the most common causes of lymphedema? a. Tumor pressure b. Constipation c. Surgical procedures d. All of the above

Answer 90

d - All of the noted options are common causes of lymphedema, and are included as anything which blocks the return of lymphatic fluid in the periphery or in the abdomen. Lymphedema can be very difficult to treat, once it starts. Use of compression is one of the most effective interventions, if the patient can tolerate it. Another helpful option, depending on patient tolerance, is lymphatic massage by a qualified professional.

Question 91

The primary mode of treatment for severe congestion or “death rattle” at the end-of-life is which of the following? a. Benzodiazepines b. Anticholinergics c. Opioids d. There is no treatment.

Answer 91

231. b - Anticholinergics are the primary mode of treatment for congestion/death rattle at the end of life and include medications such as Hyoscine, Atropine, and Glycopyrrolate

Question 92

Which of the following is a validated tool for the assessment of congestion in palliative and hospice patients? a. FLACC b. VRCS c. MKPI d. FAST

Answer 92

. b - The Victoria Respiratory Congestion Scale (VRCS) is a validated tool that has demonstrated reliability in the assessment of congestion. It is a 0-3 scale with 0 being no congestion heard within 12 inches of patient chest, 1 being congestion heard only at 12 inches from chest, 2 being congestion audible at foot of patient’s bed, and 3 being congestion heard at door of patient’s room. The FLACC scale measures pain, MKPI measures function, and FAST is a dementia scale.

Question 93

What would be the most effective non-pharmacologic intervention for a palliative care patient experiencing intractable cough? a. Oxygen b. Codeine c. Humidifier d. Air conditioning

Answer 93

c - The most effective non-pharmacological intervention is a humidifier. Oxygen and codeine are both considered pharmacological and air conditioning (cold air) could actually exacerbate symptoms

Question 94

Effective interventions for productive coughs include all of the following except: a. Inhaled anesthetic b. Chest physiotherapy c. Oxygen d. Suctioning

Answer 94

a - Inhaled anesthetics would not be an intervention for a productive cough but rather is appropriate for a non-productive cough. Chest physiotherapy, oxygen, suctioning and humidity are effective interventions for productive cough.

Question 95

Which of the following factors have been shown to cause disproportionately severe reporting of dyspnea in patients in comparison to the extent of their pulmonary disease? a. Anxiety b. Dependency c. Obsessiveness d. Depression e. All of the above

Answer 95

e - All of the above factors have been shown to cause disproportionately severe reports of dyspnea in comparison to the extent of illness. This clearly shows that the perception of intensity of dyspnea is affected by many psychological factors as well and must be addressed in the physical assessment

Question 96

What is the closest percentage of patients with metastatic disease who will experience a pleural effusion during the course of their illness? a. 65% b. 20% c. 80% d. 50

Answer 96

. d - Nearly 50% of patients with metastatic disease will experience a pleural effusion during their illness.

Question 97

Which of the following factors promote normal bowel function in palliative and hospice patients? a. Medications b. Decreased dietary fiber c. Fluid intake d. Frequent rest periods

Answer 97

. c - Fluid intake, adequate dietary fiber, physical activity and adequate time and privacy for defecation are the factors that promote normal bowel function.

Question 98

The prevalence of hiccups within cancer patients is estimated to be between which of the following percentages? a. 5-10% b. 30-40% c. 25-30% d. 10-20%

Answer 98

. d - Hiccups are estimated to be prevalent in between 10-20% of cancer patients.

Question 99

Intractable hiccups can result in which of the following conditions? a. Increased sleep, depression, anxiety, nausea. b. Fatigue, depression, nausea, heartburn. c. Insomnia, depression, anorexia, anxiety. d. Depression, shortness of breath, nausea, vomiting

Answer 99

c - Insomnia, depression, anorexia, anxiety, fatigue, shortness of breath, weight loss and heartburn are all conditions resulting from intractable hiccups.

Question 100

Treatment/nursing interventions for hiccups are based upon which of the following? a. Evidence-based methods/treatments b. Trial and error methods/treatments c. Scientifically based methods/treatments d. None of the above

Answer 100

b - Treatment of hiccups is based upon the bias of previous successful methods versus an evidence-based methodology.

Question 101

Nausea and vomiting impacts which of the following dimensions related to quality of life? a. Physical b. Spiritual c. Psychological d. All of the above e. Both a and c only

Answer 101

d - The impact of nausea and vomiting affects all of the quality of life dimensions including spiritual, social, psychological and physical

Question 102

What is the approximate percentage of patients with advanced cancer who will experience nausea and/or vomiting during their illness? a. 25% b. 50% c. 75% d. 90%

Answer 102

b - Research has shown that approximately 50% of patients with advanced cancer will experience the symptoms of nausea and vomiting.

Question 103

Associated serious complications of bowel obstruction include which of the following? a. Surgery b. Fever c. Pain d. Sepsis

Answer 103

d - Sepsis, multi-system failure and death are the serious complications of bowel obstruction.

Question 104

Which of the following symptoms would be most closely associated with a lower GI bleed? a. Coffee ground emesis b. Vomiting of fecal matter c. Black, tarry stools d. All of the above

Answer 104

c - Black, tarry stools would be indicative of a lower GI bleed. Coffee ground emesis would be indicative of an upper GI bleed, and vomiting of fecal matter would be most likely associated with a bowel obstruction.

Question 105

Factors influencing the management of urinary incontinence include which of the following? a. The severity and type b. The wishes of the physician c. The patient’s prognosis d. None of the above

Answer 105

a - The factors influencing management of urinary incontinence include the type of incontinence, the desires of the patient and family and the presence of complicating factors. The wishes of the physician and patient’s prognosis have no impact on management of this condition

Question 106

Treatment of acute urinary retention would include which of the following interventions? a. Intermittent urinary catheterization b. Placement of indwelling urinary catheter c. Ongoing monitoring and attempts to achieve urination d. None of the above

Answer 106

. b - Acute urinary retention is managed by prompt placement of an indwelling urinary catheter

Question 107

Alkylating chemotherapy agents such as cyclophosphamide commonly cause which of the following? a. Acute urinary retention b. Radiation cystitis c. Chemotherapy-induced cystitis d. Markedly decreased bladder capacity

Answer 107

c - Chemotherapy-induced cystitis is commonly caused by alkylating chemotherapy agents such as cyclophosphamide and isophosphamide.

Question 108

What are the primary causes for moderate to severe hematuria in palliative care patients? a. Radiation and chemotherapy b. Infection and radiation c. Chemotherapy and infection d. Medication side-effects and chemotherapy

Answer 108

a - Radiation and chemotherapy account for the most cases of moderate to severe hematuria. Infection, anticoagulant therapy, idiopathic response to steroids or other agents are also potential causes

Question 109

Which of the following is the most important risk factor related to the development of pressure ulcers? a. Nutritional status b. Cachexia c. Immobility d. All of the above

Answer 109

. c - Immobility is the most important risk factor for all populations and is a necessary condition for the development of pressure ulcers

Question 110

Complications of xerostomia include which of the following? a. Increased socialization b. Decreased incidence of oral lesions c. Decreased swallowing ability d. None of the above

Answer 110

The complications of xerostomia include decreased swallowing ability. Other complications include increased incidence of dental caries, gum, tongue and oral lesions, infections, bad breath, changes in taste and alterations in speech and voice functions, with decreased socialization

Question 111

Non-pharmacological interventions for xerostomia include which of the following? a. Yohimbine b. Oral swabs c. Peppermint water d. All of the above e. Both b and c only

Answer 111

. e - Oral swabs, peppermint water, vitamin C, chewing gum/mints, diet modifications, humidity and acupuncture are all non-pharmacological. Yohimbine, artificial saliva, Pilocarpine, Bethanechol. Methacholine, and Cevimeline are all pharmacological interventions

Question 112

Helen is a 69-year-old with end-stage ovarian cancer who has a suspected bowel obstruction. She states that if her doctor recommends surgery, she will not consent to it. She wants to know how her disease will progress if she has no further aggressive intervention. Of the following, which is the most appropriate response? a. “You may have a lot of pain.” b. “Everyone is different, so it’s difficult to say.” c. “Surgery is the best option.” d. “We should be able to keep you comfortable at home.”

Answer 112

d - “We should be able to keep you comfortable at home” is the most appropriate response. With optimal use of palliative interventions such as gastric drainage and medications for pain and symptom relief, the patient should be able to remain comfortable, despite the bowel obstruction.

Question 113

Of the following, which statement is most accurate regarding changes in breathing patterns during the dying process? a. The “death rattle” is very uncomfortable for the patient. b. Abdominal breathing is uncommon. c. High-flow oxygen is always helpful. d. Certain medications are effective to decrease respiratory distress.

Answer 113

d - Both patients and family members should be provided information regarding the use of medications that are easy to administer, and are effective in decreasing respiratory distress that may be present during the dying process. Liquid morphine or liquid oxycodone and liquid lorazepam can be administered during the dying process. This can be achieved by administering very small volumes of the concentrated form via dropper into the buccal space, even if the patient is nonresponsive.

Question 114

When teaching caregivers the signs and symptoms of imminent death, which of the following would NOT be included? a. Mottling of extremities b. Increasing periods of apnea c. Kussmaul respirations d. Decreased responsiveness

Answer 114

c - The pattern of breathing that is referred to as Kussmaul respirations is common in diabetic ketoacidosis. All other options are common indicators of imminent death. Most families find it helpful to be given specific signs and symptoms to watch for, so they are more prepared as the patient begins to enter the dying process.

Question 115

Of the following, who would be the most appropriate team member to teach a family member how to administer liquid medication to a patient who is in the dying process? a. The continuous care nurse b. The hospice aide c. The hospice primary nurse d. Both a and c

Answer 115

d - Medication administration techniques should only be taught by nursing staff, which would include the patient’s primary hospice nurse, as well as the continuous care nurse, if the patient is receiving this level of care.

Question 116

Larry is retired and is caring for his wife, Donna. During your last visit, Donna was started on a new medication, which must be titrated slowly upward for optimal effect. You wrote out an administration schedule for him, which was also listed on the medication bottle. However, during your current visit, you note that Donna has too many pills left according to the titration schedule. Of the following, what is a key principle when teaching caregivers? a. Always write it down. b. Optimize stimulation. c. Adequate lighting. d. Assess for barriers.

Answer 116

d - Assessing for barriers to learning is a key principle when teaching caregivers. In Larry’s case, he may not know how to read and is embarrassed to say so. Therefore, writte instructions may not be helpful for him. If this is the case, he would benefit from having medication boxes filled for Donna. Asking for a return explanation or skill demonstration is an essential aspect of ensuring that adequate learning has occurred.

Question 117

When making your first visit to a patient/family who has been newly admitted to hospice, which of the following is one of the most helpful means to assess their understanding of illness and prognosis? a. “Do you have any questions about your diagnosis?” b. “Do you have any questions about your hospice care?” c. “What has your doctor told you?” d. “How often would you like me to visit?”

Answer 117

c - Asking a patient and family what their doctor has told them helps to open the dialogue regarding their understanding of the illness and prognosis. Unfortunately, patients and families often enter hospice without having been given clear information about these issues. It is important to establish a baseline of understanding and not assume that they possess a complete picture of the situation and the referring physician’s perception of it.

Question 118

Common responses of children to serious illness include all of the following except: a. Magical thinking b. Feelings of guilt c. Increased attention and focus d. Anger and acting out behavior

Answer 118

c - Children’s common responses to serious illness include decreased attention and ability to focus, magical thinking, feelings of guilt, anger and acting out behaviors, fears of abandonment and contracting the disease/illness, along with frustrations regarding a change in lifestyle and possible activities.

Question 119

In providing bereavement support and follow up to the wife of a patient you cared for at length, she tells you that she is distraught over the fact that her pre-school aged grandchildren act as if their grandfather never existed. She states that “they come over and play and act as if nothing has changed”. The proper response to help her better understand the actions of her young grandchildren would be: a. “Children often forget about the person who died quickly”. b. “Given their age, they likely do not understand that death is permanent”. c. “You should sit them down and talk about death and what it means”. d. “Tell their parents to explain that their grandfather is never coming back”.

Answer 119

b - Pre-school aged children typically view death as temporary or reversible as in cartoons. They are often told that the person “went to heaven”, so they assume that the person will “be back”. Given the situation, it is most likely that these young children do not understand that their grandfather’s death is permanent and therefore is the best response for the nurse to help the wife understand their actions. The options of C and D would likely cause more harm and option A does not provide a realistic rationale for the actions of the children.

Question 120

Examples of dysfunctional coping responses/styles include which of the following? a. Humor b. Guilt c. Aggression d. Spiritual rituals e. All of the above. f. Both b and c only

Answer 120

f - Guilt and aggression are both examples of dysfunctional coping responses/styles along with fantasy, minimization, addictive behaviors and psychosis. Functional coping responses/styles include humor, normal grief work, problem-solving and spiritual rituals.

Question 121

Bob is an 88-year-old with end-stage lung cancer, whose condition has deteriorated significantly over the past several days. Bob is cared for by his wife Victoria. 366. Victoria wants to know what to expect as his disease progresses. Of the following, which is the most accurate? a. Sleeping may increase significantly. b. Bleeding may occur. c. Nausea and vomiting are common. d. Dyspnea will be unmanageable

Answer 121

A

Question 122

Why should MSW be aware of physical symptoms? A. Core of palliative care philosophy to consider total pain B. Ethical obligation C. Best equipped to consider cultural/spiritual/legal environment D. Helps justify our position on the team E. Total suffering/total pain core principal of palliative care

Answer 122

ABCE A understanding the whole person means having familiarity with physical symptoms as well as means for addressing psychosocial spiritual aspects of disease B Basic human dignity requires relief from unrelenting pain so a person can even think at all and have relationships. NASW Standard #2 states that the physical, psychological and spiritual manifestations of pain is core knowledge. C Pain is typically managed by controlled and abusable substances. Pts may be undertreated for pain as a result. Role as advocate cannot be understated. E. Physical symptoms only part of Pt's experience, physical symptoms and pyschosocial and spiritual stressors interact to increase stress . Emotional, social and spiritual context surrounding the Pt contributes to the patient's ability to experience a good QOL, Free of distress, to heal

Question 123

MSW can actively promote problem solving by strategically intervening in (ALL THAT APPLY) a. ADVOCACY B. EMOTIONAL SUPPORT C. COPING SKILLS D. TEACHING RELAXATION TECHNIQUES

Answer 123

abc A. encourage family and Pt to openly and accurately share information; advocated for health care team when Pt/family are unrealistic in demands (Pt may be undertreated as a result) B. help Pt feel heard and understood and experience a connection to the team C. Pt's likely not experienced anything like their disease. New skills called for, these should be integrated into daily clinical practice

Question 124

What are the primary barriers to effective symptom management? A. Poorly trained medical care team B. psychosocial barriers C. War on opioids

Answer 124

B. MSW may be first on team to notice change in Pt or their behavior pattern. Pt may reveal their concerns or symptoms more freely with MSW. Our responsibility to report any concerns or observations to health care team

Question 125

What concerns should prompt MSW to discuss symptoms with health care team? A. Pt admitted frequently for symptom control B. Pt's symptoms intractable (not responding to tx) C. Pt has communication challenges D. Pt;/Fam feeling overwhelmed with tx and choices E. Pt demonstrating symptoms of dying F. ALL above

Answer 125

F. communciation: Pt uncomfortable about communicating openly about symptoms Language skills seem adequate at first but Pt does not understanding medical or discharge language

Question 126

What does physical symptom management involve for a MSW? A. Recognizing and addressing physical symptoms B. Addressing the psychosocial spiritual context of tx C. Reconciling medication list

Answer 126

AB A. Integrating PC early in the disease course to help pre empt major issues or side effects. Understanding basics of pharmacology and non pharma approaches B. mind body connection, trauma history, understanding social and economic callenge--can afford access medications/psychoeducational needs of Pt and caregivers

Question 127

A patient is successful in using distraction to minimize his pain while he is in the hospital. When he is watching exciting TV and interacting with it or visiting with friends, his pain is manageable. When distraction decreases he states that his pain is disturbing to him. However, now the staff and his family minimize the level of pain and some say he is feigning discomfort. What is the best strategy for MSW? A. Help Pt reach out to friends to increase number of visits B. Help the team assess what is happening here and recommend using clinical knowledge of the role of distraction as an adjuvant to pain medication

Answer 127

B

Question 128

What variables influence physical symptoms? A. Disease progression B. Medication/tx for the disease C. psychological response to disease or medication D. Pt's emotional state E. Access/availability of appropriate PC or hospice care managment F. Symptoms vary by diagnosis G. All of the above

Answer 128

G. Increase in depression and/or anxiety can incrfease breathlessness and pain Different symptoms may cause discomfort as organs fail, breathing difficulty and fatigue cause more distress than pain in the final days of life

Question 129

Early integration of palliative care for symptoms management includes guiding patients (all that apply) A. To ID symptoms and side effects B. To report symptoms and side effects before they get out of control C. TO learn coping strategies D. To normalize pain as part of the disease process

Answer 129

ABC Coping strategies include: Relaxation/breathing exercises before symptoms necessitate them. decreased levels of stress can also contribute to more effective tx outcomes.

Question 130

Non pharma approach to dyspnea/breathlessness

Answer 130

Reduce Pt's needs for exertion Reposition Pt to more upright position Position compromised lung down Improve air circulation in room (fan, open windows) Adjust humidity Utilized skillful counseling

Question 131

Psychoeducation for dyspnea/breathlessness

Answer 131

ID and avoid triggers that precipitate Help Pt/cg formulate response plan Avoid strong odors, fumes, smoke Calm the CG Teach relaxation and breathing techniques Encourage distraction and mindfulness Art/music therapy massage therapy Pacing for ambulatory Pt

Question 132

Example of helpful breathing technique for dyspnea in alert Pt

Answer 132

Pursed lip breathing Inhale/pursed lip/exhale (longer than inhale

Question 133

MSW work with team/family with imminently dying breathless Pt A. Educate the family of the role of medication, including opiates B. Reassure Pt is dying because of underlying disease C. Reassure treating the symptoms, including breathlessness and anxiety will help the Pt suffer less during the dying process D. Reinforce that appropriately dosed and titrated opiates rarely depress respiration or hasten death BCD.

Answer 133

BCD A MSW role is to reinforce knowledge of medications, RN or MD< ARNP explain/educate initially--RN

Question 134

Major Depression includes how many of the following symptoms? Depressed Mood Diminished Pleasure/Interests Significant weight loss/gain Insomnia/hypersomia Psychomotor agitation/retardation Fatigue Feeling Worthless Recurrent thoughts of death Decreased focus

Answer 134

5 and not the result of substance abuse or medical disorder

Question 135

What MSW should know about depression in advanced illness. T/F a. 8.1 % of American adults experience clinically diagnosed depression b. There are low rates of depressive symptoms in last year of life. c. The burden of depression symptoms change as death approaches. d. Depressive symptoms gradually decrease from 12-14 months before death. e. Depression symptoms escalate from 4 to 1 month before death. f. 57% of Pt in last year of life experience moderate or severe pain for at least a month g. Of these Pt's (F) family members reported that over 20% experienced depression

Answer 135

A. True B. False, High rates C. true D. False, rates increase E True F True G Fale, 51% suffered depression

Question 136

Is clinical depression amenable to treatment in the terminally ill?

Answer 136

YES

Question 137

The need to treat depression depends on A. Intensity B. homicidal ideation C. persistence D. disruption of basic life function E. ACD

Answer 137

E.

Question 138

depressive symptoms do not overlap with symptoms of severe illness? A.Depressed mood B. Diminished pleasure/interest C. Weight loss/gain D. Insomnia/hypersomnia E. fatigue/loss of energy F. Feeling worthless G. Decreased ability to focus H. Recurrent thoughts of death I. Pyschomotor agitation/retardation J. hypoactive delirium

Answer 138

A, F, J

Question 139

Focus of care for depressed seriously ill patients is A. promoting compliance with medical regiments B. ID and correct distorted cognitive perceptions C. acquire coping skills to manage stress and pain E. Effectively use energy to maximize engagement in life F. focus on early childhood trauma

Answer 139

All but F

Question 140

When is the best time for MSW to ask Pt/family about Pt's pain status? A. Let Pt or family bring it up first B. Every patient contact C. When Pt showing signs of pain

Answer 140

B

Question 141

physical symptoms such as pain, dsypnea, fatigue, nausea and agitation can diminish Pt's QOL, how? A. disrupt relationships B. Contribute to social withdrawal C. Contribute to mental health risks D. Fear of being a burden on others D. All of the above

Answer 141

D

Question 142

when team is addressing complex issues that arise during serious illness who is the team member that is a key contributor to care planning as well as ultimate authority when determining goals of care?

Answer 142

the Patient and/or DPOA/family

Question 143

A holistic experience that extends beyond physical symptoms and was first introduced by Dame Cicely Saunders in the l960's A. Acquired pain B. Total Pain C. Existential pain

Answer 143

B. Total pain recognizes the the interplay of psychological and social well being, spirituality and culture==symptoms are influenced by the psychological, social and cultural characteristics of the the individual.

Question 144

Uncontrollable pain, high unrelieved physical symptom burden, depression, feelings of helplessness, delirium, and low family support are major factors when assessing for A. a major desire for hastened death B. thoughts of suicide C. desire to complete advance directive

Answer 144

A and B

Question 145

T/F previously diagnosed or undiagnosed mental health disorder symptoms can be challenging for MSW to differentiate from the serious illness symptoms because symptoms may intersect with those of the medical condition.

Answer 145

T Psychiatrist can assist in these situations as well as in the use of pyschotropic meds

Question 146

Pain with it's complex and dynamic social, cultural, economic, and political correlates, is a ______ problem. A. International B. Social C. Ethical

Answer 146

B. Social oxford text page 273

Question 147

MSW can help minimize inequalities in access to health care among minority populations by A. Increasing vigilance, knowledge, and advocacy a bout pain and disparities in tx. B. Advocate on behalf of vulnerable populations including those living with untreated or undertreated pain C. Assessing the multiple factors that are at the nexus of this troubling reality D. All of the above

Answer 147

D. Oxford Pg 273

Question 148

Dimensions of pain (social, cognitive, spiritual, biological)_ + Personal Interpretation (cultural significance,individual cirucmstances, personal meaning)= A. existential pain B. Synergistic Pain C. Total Pain

Answer 148

C. total pain Oxford Pg 274

Question 149

Role Loss, feeling abandonment Spiritual Pain financial worries Fear of pain or death, diminished Biological Pain coping, changes in body image, helplessness, catastrophizing Questioning life's purpose, feeling Cognitive Pain punished or abandoned by God Existential suffering Physical discomfort, co-morbid Spiritual Pain conditions, tx side effects

Answer 149

Social Cognitive Spiritual Biological Oxford Pg 274

Question 150

In symptom crises which is the first MSW should advocate for? A. Comprehensive pain assessment B. Abbreviated pain assessment

Answer 150

B. Oxford Pg 275

Question 151

Common barriers to assessing pain in palliaitve care/hospcie popultion? A. Cognitive impairment--medications effects or disease B. Pt's and/or family reluctance to discuss pain with team C. Family member reporting higher level of pain by assessing pain through his or own emotions and suffering. D. Pre existing psychiatric illnesses E. Pt unknown to caregivers F. All of the above

Answer 151

F. Oxford Pg 276

Question 152

Reasons Pt may be reluctant to discuss pain with family and/or team A. worry increasing pain is sign of advancing illness B, worry increasing pain will create added stress for family C. raised in culture where stoicism is valued and assertiveness is considered rude. C. may not accept medications for fear of being disloyal to heritage or not strong enough to tolerate pain D. Family minimizing and/or maximizing pain reports E. All of the above

Answer 152

E. Oxoford Pg 276

Question 153

General order of alerts within the team for HO and PC SW

Answer 153

Pain Safety on discharge Spiritual distress HIPAA considered

Question 154

Pain Management mnemonic A Asking --consistently and regularly B Believing-- C ? D Delivering--in timely manner E ?

Answer 154

C. Choosing--correct option E Empowering--education, endourage active voice of family/Pt