LATEST HOSPICE & PALLIATIVE MEDICINE
CERTIFICATION EXAM OFFERED BY
AMERICAN BOARD OF PHYSICAL MEDICINE &
REHABILITATION (ABPMR) | COMPLETE EXAM
Q&A WITH RATIONALES
1. A 68-year-old male with metastatic lung cancer
reports pain (7/10) despite being on long-acting
morphine 30 mg every 12 hours and immediate-
release morphine 10 mg every 2 hours as needed. He
uses 6 breakthrough doses per day. Which is the
most appropriate next step?
A) Increase long-acting morphine to 60 mg every 12
hours
B) Add gabapentin
C) Switch to hydromorphone
D) Perform nerve block
Correct answer: A
Rationale: Breakthrough doses >4 per day indicate
insufficient baseline analgesia. Increase long-acting
opioid by 30-50%. Gabapentin is for neuropathic pain.
2. A 55-year-old female with metastatic breast cancer
and bone metastases reports severe pain (8/10) at
,rest and with movement. She is on transdermal
fentanyl 50 mcg/hour and morphine immediate-
release 15 mg every 4 hours as needed. She is
sedated (RASS -2). Which is the most appropriate
next step?
A) Reduce fentanyl to 25 mcg/hour
B) Add acetaminophen
C) Continue current regimen; sedation will improve
D) Switch to methadone
Correct answer: A
Rationale: Sedation indicates opioid toxicity. Reduce
the long-acting opioid dose. Acetaminophen is
adjunctive but does not address toxicity.
3. A 72-year-old male with end-stage heart failure
(NYHA class IV) reports dyspnea at rest and with
minimal exertion. He is on low-dose morphine 2.5 mg
every 4 hours. Which is the most appropriate next
step?
A) Increase morphine to 5 mg every 4 hours
B) Add oxygen
C) Add lorazepam
D) Start nebulized furosemide
Correct answer: A
,Rationale: Morphine reduces dyspnea through
central and peripheral mechanisms. Dose can be
titrated upward. Oxygen is for hypoxia, not dyspnea
without hypoxia.
4. A 45-year-old female with metastatic colon cancer
and malignant bowel obstruction has nausea,
vomiting, and diffuse abdominal pain. She has a
nasogastric tube. Which is the most appropriate
pharmacologic regimen?
A) Octreotide + dexamethasone + haloperidol
B) Metoclopramide + ondansetron
C) Erythromycin + pantoprazole
D) Promethazine + diphenhydramine
Correct answer: A
Rationale: Octreotide reduces secretions and
improves obstruction. Dexamethasone reduces
edema. Haloperidol for nausea. Metoclopramide is
contraindicated in complete obstruction.
5. A 62-year-old male with end-stage liver disease
(MELD 28) has ascites, hepatic encephalopathy, and
severe pruritus. He is on lactulose and rifaximin.
Which medication is most effective for pruritus?
, A) Naltrexone
B) Diphenhydramine
C) Cholestyramine
D) Gabapentin
Correct answer: A
Rationale: Naltrexone (opioid antagonist) is effective
for cholestatic pruritus. Cholestyramine is first-line
but may not work in advanced disease.
6. A 70-year-old female with terminal dementia
(Functional Assessment Staging Test stage 7) has
dysphagia and recurrent aspiration pneumonia. Her
family requests a feeding tube. Which is the most
appropriate next step?
A) Place percutaneous endoscopic gastrostomy
(PEG) tube
B) Recommend hand feeding and comfort care
C) Place nasogastric tube
D) Total parenteral nutrition
Correct answer: B
Rationale: Feeding tubes in advanced dementia do
not improve survival, prevent aspiration, or improve
quality of life. Hand feeding is recommended.
CERTIFICATION EXAM OFFERED BY
AMERICAN BOARD OF PHYSICAL MEDICINE &
REHABILITATION (ABPMR) | COMPLETE EXAM
Q&A WITH RATIONALES
1. A 68-year-old male with metastatic lung cancer
reports pain (7/10) despite being on long-acting
morphine 30 mg every 12 hours and immediate-
release morphine 10 mg every 2 hours as needed. He
uses 6 breakthrough doses per day. Which is the
most appropriate next step?
A) Increase long-acting morphine to 60 mg every 12
hours
B) Add gabapentin
C) Switch to hydromorphone
D) Perform nerve block
Correct answer: A
Rationale: Breakthrough doses >4 per day indicate
insufficient baseline analgesia. Increase long-acting
opioid by 30-50%. Gabapentin is for neuropathic pain.
2. A 55-year-old female with metastatic breast cancer
and bone metastases reports severe pain (8/10) at
,rest and with movement. She is on transdermal
fentanyl 50 mcg/hour and morphine immediate-
release 15 mg every 4 hours as needed. She is
sedated (RASS -2). Which is the most appropriate
next step?
A) Reduce fentanyl to 25 mcg/hour
B) Add acetaminophen
C) Continue current regimen; sedation will improve
D) Switch to methadone
Correct answer: A
Rationale: Sedation indicates opioid toxicity. Reduce
the long-acting opioid dose. Acetaminophen is
adjunctive but does not address toxicity.
3. A 72-year-old male with end-stage heart failure
(NYHA class IV) reports dyspnea at rest and with
minimal exertion. He is on low-dose morphine 2.5 mg
every 4 hours. Which is the most appropriate next
step?
A) Increase morphine to 5 mg every 4 hours
B) Add oxygen
C) Add lorazepam
D) Start nebulized furosemide
Correct answer: A
,Rationale: Morphine reduces dyspnea through
central and peripheral mechanisms. Dose can be
titrated upward. Oxygen is for hypoxia, not dyspnea
without hypoxia.
4. A 45-year-old female with metastatic colon cancer
and malignant bowel obstruction has nausea,
vomiting, and diffuse abdominal pain. She has a
nasogastric tube. Which is the most appropriate
pharmacologic regimen?
A) Octreotide + dexamethasone + haloperidol
B) Metoclopramide + ondansetron
C) Erythromycin + pantoprazole
D) Promethazine + diphenhydramine
Correct answer: A
Rationale: Octreotide reduces secretions and
improves obstruction. Dexamethasone reduces
edema. Haloperidol for nausea. Metoclopramide is
contraindicated in complete obstruction.
5. A 62-year-old male with end-stage liver disease
(MELD 28) has ascites, hepatic encephalopathy, and
severe pruritus. He is on lactulose and rifaximin.
Which medication is most effective for pruritus?
, A) Naltrexone
B) Diphenhydramine
C) Cholestyramine
D) Gabapentin
Correct answer: A
Rationale: Naltrexone (opioid antagonist) is effective
for cholestatic pruritus. Cholestyramine is first-line
but may not work in advanced disease.
6. A 70-year-old female with terminal dementia
(Functional Assessment Staging Test stage 7) has
dysphagia and recurrent aspiration pneumonia. Her
family requests a feeding tube. Which is the most
appropriate next step?
A) Place percutaneous endoscopic gastrostomy
(PEG) tube
B) Recommend hand feeding and comfort care
C) Place nasogastric tube
D) Total parenteral nutrition
Correct answer: B
Rationale: Feeding tubes in advanced dementia do
not improve survival, prevent aspiration, or improve
quality of life. Hand feeding is recommended.
