, Question 1
A patient with advanced cancer and hepatic impairment reports severe pain but
has developed myoclonus and hyperalgesia on high-dose morphine. Which
opioid rotation strategy is most appropriate?
A. Rotate to hydromorphone at a 1:5 equianalgesic ratio and continue the
same dose.
B. Rotate to fentanyl transdermal and reduce the calculated equianalgesic
dose by 25-50%.
C. Rotate to methadone using a 1:1 ratio with no reduction due to
incomplete cross-tolerance.
D. Add naloxone infusion to reverse neurotoxicity while continuing
morphine.
Correct Answer: B - Rotate to fentanyl transdermal and reduce
the calculated equianalgesic dose by 25-50%.
RATIONALE
Fentanyl is preferred in hepatic impairment due to minimal hepatic
metabolism, and a 25-50% dose reduction is standard when rotating
for neurotoxicity due to incomplete cross-tolerance. Hydromorphone
at 1:5 is incorrect (ratio is closer to 1:5 but not with same dose and
hepatic impairment), methadone requires complex conversion and not
1:1, and naloxone would reverse analgesia and precipitate withdrawal.
Question 2
A family requests that a terminally ill patient not be told the diagnosis, citing
cultural norms. The patient is alert and asks the nurse directly about prognosis.
Which action best reflects culturally congruent, ethically sound practice?
A. Defer to family authority and redirect the patient's questions to the
family.
B. Disclose the full prognosis without exploring the patient's information
preferences.
Page 2
, C. Explore the patient's own information preferences and negotiate a
shared approach with the family.
D. Document the family's request and avoid all prognostic discussions.
Correct Answer: C - Explore the patient's own information
preferences and negotiate a shared approach with the family.
RATIONALE
Culturally congruent care requires assessing the patient's individual
informational preferences rather than assuming family authority or
imposing full disclosure. Negotiating with the family respects
relational autonomy while upholding the patient's right to know.
Deferring entirely or avoiding discussion violates patient autonomy
and ethical standards.
Question 3
In a goals-of-care meeting, a surrogate decision-maker insists on full
resuscitation for a patient with metastasized cancer and no meaningful recovery
potential. Which communication strategy is most effective initially?
A. State that CPR is futile and will not be offered.
B. Ask the surrogate to explain what the patient would consider an
acceptable quality of life.
C. Provide statistics on CPR survival rates and recommend DNR status.
D. Refer the case immediately to the ethics committee.
Correct Answer: B - Ask the surrogate to explain what the patient
would consider an acceptable quality of life.
RATIONALE
Eliciting the patient's values and definition of acceptable quality of life
(substituted judgment) is the cornerstone of shared decision-making
and often reframes the discussion. Stating futility or leading with
statistics can damage trust and is less effective than values
exploration. Ethics referral is premature before exploring values.
Page 3
, Question 4
A patient with end-stage COPD has dyspnea refractory to high-dose opioids
and reports severe anxiety. Which adjunctive intervention is most appropriate?
A. Start a benzodiazepine as first-line monotherapy for dyspnea.
B. Add a low-dose benzodiazepine for anxiety while continuing opioids.
C. Initiate nebulized furosemide as a primary treatment.
D. Use oxygen therapy targeting SpO2 > 98%.
Correct Answer: B - Add a low-dose benzodiazepine for anxiety
while continuing opioids.
RATIONALE
Benzodiazepines are not first-line for dyspnea but are appropriate
adjuncts for anxiety that exacerbates dyspnea, while opioids remain
the cornerstone. Benzodiazepine monotherapy is not recommended,
nebulized furosemide has limited evidence, and targeting SpO2 >98%
is not indicated and may cause hyperoxia.
Question 5
Which statement best reflects the principle of double effect in end-of-life care?
A. Administering high-dose opioids to relieve suffering is permissible
even if it may hasten death, provided the intent is symptom relief.
B. Any treatment that could hasten death is prohibited regardless of
intent.
C. Intent is irrelevant if the outcome is death.
D. Double effect applies only to withdrawal of life-sustaining treatment.
Correct Answer: A - Administering high-dose opioids to relieve
suffering is permissible even if it may hasten death, provided the
intent is symptom relief.
Page 4
A patient with advanced cancer and hepatic impairment reports severe pain but
has developed myoclonus and hyperalgesia on high-dose morphine. Which
opioid rotation strategy is most appropriate?
A. Rotate to hydromorphone at a 1:5 equianalgesic ratio and continue the
same dose.
B. Rotate to fentanyl transdermal and reduce the calculated equianalgesic
dose by 25-50%.
C. Rotate to methadone using a 1:1 ratio with no reduction due to
incomplete cross-tolerance.
D. Add naloxone infusion to reverse neurotoxicity while continuing
morphine.
Correct Answer: B - Rotate to fentanyl transdermal and reduce
the calculated equianalgesic dose by 25-50%.
RATIONALE
Fentanyl is preferred in hepatic impairment due to minimal hepatic
metabolism, and a 25-50% dose reduction is standard when rotating
for neurotoxicity due to incomplete cross-tolerance. Hydromorphone
at 1:5 is incorrect (ratio is closer to 1:5 but not with same dose and
hepatic impairment), methadone requires complex conversion and not
1:1, and naloxone would reverse analgesia and precipitate withdrawal.
Question 2
A family requests that a terminally ill patient not be told the diagnosis, citing
cultural norms. The patient is alert and asks the nurse directly about prognosis.
Which action best reflects culturally congruent, ethically sound practice?
A. Defer to family authority and redirect the patient's questions to the
family.
B. Disclose the full prognosis without exploring the patient's information
preferences.
Page 2
, C. Explore the patient's own information preferences and negotiate a
shared approach with the family.
D. Document the family's request and avoid all prognostic discussions.
Correct Answer: C - Explore the patient's own information
preferences and negotiate a shared approach with the family.
RATIONALE
Culturally congruent care requires assessing the patient's individual
informational preferences rather than assuming family authority or
imposing full disclosure. Negotiating with the family respects
relational autonomy while upholding the patient's right to know.
Deferring entirely or avoiding discussion violates patient autonomy
and ethical standards.
Question 3
In a goals-of-care meeting, a surrogate decision-maker insists on full
resuscitation for a patient with metastasized cancer and no meaningful recovery
potential. Which communication strategy is most effective initially?
A. State that CPR is futile and will not be offered.
B. Ask the surrogate to explain what the patient would consider an
acceptable quality of life.
C. Provide statistics on CPR survival rates and recommend DNR status.
D. Refer the case immediately to the ethics committee.
Correct Answer: B - Ask the surrogate to explain what the patient
would consider an acceptable quality of life.
RATIONALE
Eliciting the patient's values and definition of acceptable quality of life
(substituted judgment) is the cornerstone of shared decision-making
and often reframes the discussion. Stating futility or leading with
statistics can damage trust and is less effective than values
exploration. Ethics referral is premature before exploring values.
Page 3
, Question 4
A patient with end-stage COPD has dyspnea refractory to high-dose opioids
and reports severe anxiety. Which adjunctive intervention is most appropriate?
A. Start a benzodiazepine as first-line monotherapy for dyspnea.
B. Add a low-dose benzodiazepine for anxiety while continuing opioids.
C. Initiate nebulized furosemide as a primary treatment.
D. Use oxygen therapy targeting SpO2 > 98%.
Correct Answer: B - Add a low-dose benzodiazepine for anxiety
while continuing opioids.
RATIONALE
Benzodiazepines are not first-line for dyspnea but are appropriate
adjuncts for anxiety that exacerbates dyspnea, while opioids remain
the cornerstone. Benzodiazepine monotherapy is not recommended,
nebulized furosemide has limited evidence, and targeting SpO2 >98%
is not indicated and may cause hyperoxia.
Question 5
Which statement best reflects the principle of double effect in end-of-life care?
A. Administering high-dose opioids to relieve suffering is permissible
even if it may hasten death, provided the intent is symptom relief.
B. Any treatment that could hasten death is prohibited regardless of
intent.
C. Intent is irrelevant if the outcome is death.
D. Double effect applies only to withdrawal of life-sustaining treatment.
Correct Answer: A - Administering high-dose opioids to relieve
suffering is permissible even if it may hasten death, provided the
intent is symptom relief.
Page 4
