CHPN 2026 Crash Course PDF | Fast Hospice &
Palliative Care Review
1. A patient with advanced cancer develops dyspnea at rest. Despite optimal treatment of the
underlying cause, the patient remains distressed. Which combination of pharmacological and
non-pharmacological interventions is most evidence-based for immediate relief?
A. High-flow oxygen at 15 L/min via non-rebreather mask and positioning in supine
B. Oral morphine 5 mg every 4 hours as needed and a calm, reassuring presence
C. Intravenous midazolam 2 mg bolus and chest physiotherapy
D. Inhaled furosemide 40 mg and cognitive behavioral therapy
Answer: B
Rationale: Low-dose oral morphine is first-line for dyspnea in palliative care, reducing the sensation of
breathlessness. Non-pharmacological measures like a calm environment and positioning (e.g., sitting
upright) are essential. High-flow oxygen is not routinely indicated unless hypoxemic. Midazolam is
reserved for refractory cases, and inhaled furosemide lacks strong evidence. Cognitive behavioral
therapy is not immediate.
2. A hospice interdisciplinary team is discussing a patient with terminal illness who has decisional
capacity but refuses life-prolonging treatments. The patient's family disagrees and pressures the
team to override the patient's wishes. Which ethical principle should guide the team's response?
A. Nonmaleficence, because the family's distress may cause harm to the patient
B. Beneficence, because the team must act in the patient's best interest
C. Autonomy, because the patient's right to self-determination is paramount
D. Justice, because resources should be allocated fairly among patients
Answer: C
Rationale: Autonomy respects the patient's right to make informed decisions about their own care, even if
those decisions conflict with family wishes. Nonmaleficence (do no harm) and beneficence (do good) are
important but do not override a competent patient's refusal. Justice concerns fair allocation, not
individual decision-making. The team should support the patient's choice and facilitate family
understanding.
3. Which of the following best describes the mechanism of action of methadone in managing severe
cancer pain, and what is a critical safety consideration when initiating therapy?
A. Mu-opioid agonist with NMDA receptor antagonism; requires electrocardiogram monitoring for QTc
prolongation
B. Pure mu-opioid agonist; requires liver function tests due to hepatotoxicity
C. Weak mu-opioid agonist with serotonin reuptake inhibition; requires monitoring for serotonin syndrome
D. Kappa-opioid agonist; requires renal function monitoring due to accumulation
Answer: A
Page 1
,Rationale: Methadone is a mu-opioid agonist and also an NMDA receptor antagonist, which may help with neuropathic
pain. It can prolong the QTc interval, so an ECG is recommended before and during therapy. It is not hepatotoxic (B), does
not significantly inhibit serotonin reuptake (C), and is not primarily a kappa agonist (D).
4. A palliative care patient with a history of substance use disorder requires high-dose opioids for
severe pain. Which approach is most appropriate to balance pain management and addiction risk?
A. Avoid opioids entirely and rely on non-opioid analgesics and nerve blocks
B. Use a patient-controlled analgesia pump with continuous monitoring and a pain contract
C. Prescribe short-acting opioids only, with strict limits on quantity
D. Refer to an addiction specialist and defer pain management until detoxification
Answer: B
Rationale: PCA with monitoring and a pain contract allows safe opioid administration while addressing
addiction risk. Avoiding opioids (A) may lead to undertreated pain. Short-acting only (C) may increase
cravings. Detoxification (D) is inappropriate in terminal illness; palliative care and addiction
management can coexist.
5. A patient with end-stage liver disease develops asterixis and confusion. Laboratory results show
elevated ammonia. Which dietary intervention is most appropriate in this palliative context?
A. High-protein diet to prevent muscle wasting
B. Low-protein diet with branched-chain amino acid supplementation
C. Carbohydrate-free diet to reduce ammonia production
D. No dietary changes; treat with lactulose and rifaximin
Answer: B
Rationale: In hepatic encephalopathy, protein restriction is no longer recommended; instead,
branched-chain amino acids may help. However, in palliative care, a low-protein diet with BCAA
supplementation can manage symptoms without worsening malnutrition. High-protein (A) may increase
ammonia. Carbohydrate-free (C) is not evidence-based. Lactulose and rifaximin are pharmacologic, but
dietary modification is also important.
6. A hospice nurse is evaluating a patient with advanced dementia who is unable to communicate.
The patient exhibits facial grimacing, moaning, and restlessness during care. Which pain
assessment tool is most valid and reliable for this population?
A. Numeric Rating Scale (NRS)
B. Pain Assessment in Advanced Dementia (PAINAD) scale
C. Wong-Baker FACES Pain Rating Scale
D. Visual Analog Scale (VAS)
Answer: B
Rationale: PAINAD is specifically validated for patients with advanced dementia and uses behavioral
indicators (breathing, vocalization, facial expression, body language, consolability). NRS, FACES, and
VAS require verbal or cognitive ability, making them inappropriate for this population.
7. Which of the following is a key component of the 'total pain' concept in palliative care?
Page 2
,A. Pain that is refractory to all pharmacological interventions
B. Pain that has both nociceptive and neuropathic components
C. Pain that encompasses physical, psychological, social, and spiritual dimensions
D. Pain that is acute in onset and requires immediate intervention
Answer: C
Rationale: Total pain, introduced by Dame Cicely Saunders, recognizes that suffering is
multidimensional: physical, psychological, social, and spiritual. Refractory pain (A) and mixed pain (B)
are subtypes, but total pain is broader. Acute pain (D) is a temporal category.
8. A patient with terminal cancer develops malignant bowel obstruction. The patient is not a
surgical candidate. Which pharmacologic management is most appropriate?
A. High-dose corticosteroids alone
B. Combination of octreotide, dexamethasone, and an antiemetic
C. Prokinetic agents such as metoclopramide
D. Laxatives and enemas to relieve obstruction
Answer: B
Rationale: In malignant bowel obstruction, octreotide reduces gastrointestinal secretions, dexamethasone
reduces edema, and antiemetics control nausea. Corticosteroids alone (A) are insufficient. Prokinetics
(C) are contraindicated if complete obstruction. Laxatives (D) may worsen pain and are not effective for
mechanical obstruction.
9. A palliative care team is implementing a quality improvement project to reduce hospital
readmissions. Which metric is most appropriate as a primary outcome?
A. Number of hospice referrals made
B. 30-day hospital readmission rate
C. Patient satisfaction scores
D. Average length of stay in hospice
Answer: B
Rationale: The 30-day readmission rate directly measures the project's goal. Hospice referrals (A) may
be a process measure but not the primary outcome. Patient satisfaction (C) is important but not specific
to readmissions. Length of stay (D) can be influenced by many factors and does not reflect readmission.
10. A patient with terminal illness requests medical aid in dying (MAID) in a state where it is legal.
The patient's family is opposed. What is the nurse's primary ethical responsibility?
A. Respect the patient's autonomy and provide support without coercion
B. Honor the family's wishes and discourage the patient from proceeding
C. Refuse to participate and transfer care to another provider
D. Report the request to the ethics committee for review
Answer: A
Rationale: The nurse should respect the patient's autonomous decision and provide non-judgmental
support. The family's opposition does not override the patient's right. While a nurse may conscientiously
object (C), the primary duty is to the patient. Reporting to ethics (D) may be appropriate for
clarification but is not the immediate ethical responsibility.
Page 3
, 11. A patient with advanced heart failure and refractory dyspnea is being considered for palliative
sedation. The patient has decision-making capacity and requests sedation to relieve suffering.
Which ethical principle is most directly in conflict with this request?
A. Beneficence
B. Non-maleficence
C. Autonomy
D. Justice
Answer: B
Rationale: Palliative sedation for refractory symptoms is ethically supported under the principle of
double effect, but the primary ethical conflict is with non-maleficence (do no harm), as sedation may
hasten death. Autonomy supports the patient's request, beneficence aims to relieve suffering, and justice
is not directly relevant.
12. Which of the following best describes the mechanism of action of methadone in the context of
pain management in palliative care?
A. Mu-opioid receptor agonist with NMDA receptor antagonism and serotonin reuptake inhibition
B. Mu-opioid receptor agonist with NMDA receptor antagonism and norepinephrine reuptake inhibition
C. Mu-opioid receptor agonist with weak kappa receptor activity and monoamine oxidase inhibition
D. Mu-opioid receptor agonist with delta receptor antagonism and calcium channel blockade
Answer: B
Rationale: Methadone is a mu-opioid receptor agonist and also an NMDA receptor antagonist, which
may help with neuropathic pain. It also inhibits norepinephrine reuptake, contributing to its analgesic
effects. It does not significantly affect serotonin reuptake or monoamine oxidase.
13. A hospice patient with terminal cancer develops new-onset confusion, myoclonus, and agitation.
The patient has been on morphine for pain and lorazepam for anxiety. Which intervention is most
appropriate?
A. Increase the morphine dose and add haloperidol
B. Discontinue morphine and initiate fentanyl patch
C. Rotate to an equianalgesic dose of hydromorphone and discontinue lorazepam
D. Add phenobarbital for sedation and continue current regimen
Answer: C
Rationale: The symptoms suggest opioid-induced neurotoxicity (OIN), including myoclonus and delirium.
Opioid rotation (e.g., to hydromorphone) is recommended, and benzodiazepines like lorazepam can
exacerbate delirium. Increasing morphine or adding sedatives would worsen the condition. A fentanyl
patch is not appropriate for acute titration.
14. Which of the following is the most accurate statement regarding the use of bisphosphonates in
patients with bone metastases?
A. They reduce the risk of skeletal-related events but do not improve pain control
B. They are contraindicated in patients with renal impairment because of nephrotoxicity
C. They are most effective when initiated after the onset of bone pain
Page 4
Palliative Care Review
1. A patient with advanced cancer develops dyspnea at rest. Despite optimal treatment of the
underlying cause, the patient remains distressed. Which combination of pharmacological and
non-pharmacological interventions is most evidence-based for immediate relief?
A. High-flow oxygen at 15 L/min via non-rebreather mask and positioning in supine
B. Oral morphine 5 mg every 4 hours as needed and a calm, reassuring presence
C. Intravenous midazolam 2 mg bolus and chest physiotherapy
D. Inhaled furosemide 40 mg and cognitive behavioral therapy
Answer: B
Rationale: Low-dose oral morphine is first-line for dyspnea in palliative care, reducing the sensation of
breathlessness. Non-pharmacological measures like a calm environment and positioning (e.g., sitting
upright) are essential. High-flow oxygen is not routinely indicated unless hypoxemic. Midazolam is
reserved for refractory cases, and inhaled furosemide lacks strong evidence. Cognitive behavioral
therapy is not immediate.
2. A hospice interdisciplinary team is discussing a patient with terminal illness who has decisional
capacity but refuses life-prolonging treatments. The patient's family disagrees and pressures the
team to override the patient's wishes. Which ethical principle should guide the team's response?
A. Nonmaleficence, because the family's distress may cause harm to the patient
B. Beneficence, because the team must act in the patient's best interest
C. Autonomy, because the patient's right to self-determination is paramount
D. Justice, because resources should be allocated fairly among patients
Answer: C
Rationale: Autonomy respects the patient's right to make informed decisions about their own care, even if
those decisions conflict with family wishes. Nonmaleficence (do no harm) and beneficence (do good) are
important but do not override a competent patient's refusal. Justice concerns fair allocation, not
individual decision-making. The team should support the patient's choice and facilitate family
understanding.
3. Which of the following best describes the mechanism of action of methadone in managing severe
cancer pain, and what is a critical safety consideration when initiating therapy?
A. Mu-opioid agonist with NMDA receptor antagonism; requires electrocardiogram monitoring for QTc
prolongation
B. Pure mu-opioid agonist; requires liver function tests due to hepatotoxicity
C. Weak mu-opioid agonist with serotonin reuptake inhibition; requires monitoring for serotonin syndrome
D. Kappa-opioid agonist; requires renal function monitoring due to accumulation
Answer: A
Page 1
,Rationale: Methadone is a mu-opioid agonist and also an NMDA receptor antagonist, which may help with neuropathic
pain. It can prolong the QTc interval, so an ECG is recommended before and during therapy. It is not hepatotoxic (B), does
not significantly inhibit serotonin reuptake (C), and is not primarily a kappa agonist (D).
4. A palliative care patient with a history of substance use disorder requires high-dose opioids for
severe pain. Which approach is most appropriate to balance pain management and addiction risk?
A. Avoid opioids entirely and rely on non-opioid analgesics and nerve blocks
B. Use a patient-controlled analgesia pump with continuous monitoring and a pain contract
C. Prescribe short-acting opioids only, with strict limits on quantity
D. Refer to an addiction specialist and defer pain management until detoxification
Answer: B
Rationale: PCA with monitoring and a pain contract allows safe opioid administration while addressing
addiction risk. Avoiding opioids (A) may lead to undertreated pain. Short-acting only (C) may increase
cravings. Detoxification (D) is inappropriate in terminal illness; palliative care and addiction
management can coexist.
5. A patient with end-stage liver disease develops asterixis and confusion. Laboratory results show
elevated ammonia. Which dietary intervention is most appropriate in this palliative context?
A. High-protein diet to prevent muscle wasting
B. Low-protein diet with branched-chain amino acid supplementation
C. Carbohydrate-free diet to reduce ammonia production
D. No dietary changes; treat with lactulose and rifaximin
Answer: B
Rationale: In hepatic encephalopathy, protein restriction is no longer recommended; instead,
branched-chain amino acids may help. However, in palliative care, a low-protein diet with BCAA
supplementation can manage symptoms without worsening malnutrition. High-protein (A) may increase
ammonia. Carbohydrate-free (C) is not evidence-based. Lactulose and rifaximin are pharmacologic, but
dietary modification is also important.
6. A hospice nurse is evaluating a patient with advanced dementia who is unable to communicate.
The patient exhibits facial grimacing, moaning, and restlessness during care. Which pain
assessment tool is most valid and reliable for this population?
A. Numeric Rating Scale (NRS)
B. Pain Assessment in Advanced Dementia (PAINAD) scale
C. Wong-Baker FACES Pain Rating Scale
D. Visual Analog Scale (VAS)
Answer: B
Rationale: PAINAD is specifically validated for patients with advanced dementia and uses behavioral
indicators (breathing, vocalization, facial expression, body language, consolability). NRS, FACES, and
VAS require verbal or cognitive ability, making them inappropriate for this population.
7. Which of the following is a key component of the 'total pain' concept in palliative care?
Page 2
,A. Pain that is refractory to all pharmacological interventions
B. Pain that has both nociceptive and neuropathic components
C. Pain that encompasses physical, psychological, social, and spiritual dimensions
D. Pain that is acute in onset and requires immediate intervention
Answer: C
Rationale: Total pain, introduced by Dame Cicely Saunders, recognizes that suffering is
multidimensional: physical, psychological, social, and spiritual. Refractory pain (A) and mixed pain (B)
are subtypes, but total pain is broader. Acute pain (D) is a temporal category.
8. A patient with terminal cancer develops malignant bowel obstruction. The patient is not a
surgical candidate. Which pharmacologic management is most appropriate?
A. High-dose corticosteroids alone
B. Combination of octreotide, dexamethasone, and an antiemetic
C. Prokinetic agents such as metoclopramide
D. Laxatives and enemas to relieve obstruction
Answer: B
Rationale: In malignant bowel obstruction, octreotide reduces gastrointestinal secretions, dexamethasone
reduces edema, and antiemetics control nausea. Corticosteroids alone (A) are insufficient. Prokinetics
(C) are contraindicated if complete obstruction. Laxatives (D) may worsen pain and are not effective for
mechanical obstruction.
9. A palliative care team is implementing a quality improvement project to reduce hospital
readmissions. Which metric is most appropriate as a primary outcome?
A. Number of hospice referrals made
B. 30-day hospital readmission rate
C. Patient satisfaction scores
D. Average length of stay in hospice
Answer: B
Rationale: The 30-day readmission rate directly measures the project's goal. Hospice referrals (A) may
be a process measure but not the primary outcome. Patient satisfaction (C) is important but not specific
to readmissions. Length of stay (D) can be influenced by many factors and does not reflect readmission.
10. A patient with terminal illness requests medical aid in dying (MAID) in a state where it is legal.
The patient's family is opposed. What is the nurse's primary ethical responsibility?
A. Respect the patient's autonomy and provide support without coercion
B. Honor the family's wishes and discourage the patient from proceeding
C. Refuse to participate and transfer care to another provider
D. Report the request to the ethics committee for review
Answer: A
Rationale: The nurse should respect the patient's autonomous decision and provide non-judgmental
support. The family's opposition does not override the patient's right. While a nurse may conscientiously
object (C), the primary duty is to the patient. Reporting to ethics (D) may be appropriate for
clarification but is not the immediate ethical responsibility.
Page 3
, 11. A patient with advanced heart failure and refractory dyspnea is being considered for palliative
sedation. The patient has decision-making capacity and requests sedation to relieve suffering.
Which ethical principle is most directly in conflict with this request?
A. Beneficence
B. Non-maleficence
C. Autonomy
D. Justice
Answer: B
Rationale: Palliative sedation for refractory symptoms is ethically supported under the principle of
double effect, but the primary ethical conflict is with non-maleficence (do no harm), as sedation may
hasten death. Autonomy supports the patient's request, beneficence aims to relieve suffering, and justice
is not directly relevant.
12. Which of the following best describes the mechanism of action of methadone in the context of
pain management in palliative care?
A. Mu-opioid receptor agonist with NMDA receptor antagonism and serotonin reuptake inhibition
B. Mu-opioid receptor agonist with NMDA receptor antagonism and norepinephrine reuptake inhibition
C. Mu-opioid receptor agonist with weak kappa receptor activity and monoamine oxidase inhibition
D. Mu-opioid receptor agonist with delta receptor antagonism and calcium channel blockade
Answer: B
Rationale: Methadone is a mu-opioid receptor agonist and also an NMDA receptor antagonist, which
may help with neuropathic pain. It also inhibits norepinephrine reuptake, contributing to its analgesic
effects. It does not significantly affect serotonin reuptake or monoamine oxidase.
13. A hospice patient with terminal cancer develops new-onset confusion, myoclonus, and agitation.
The patient has been on morphine for pain and lorazepam for anxiety. Which intervention is most
appropriate?
A. Increase the morphine dose and add haloperidol
B. Discontinue morphine and initiate fentanyl patch
C. Rotate to an equianalgesic dose of hydromorphone and discontinue lorazepam
D. Add phenobarbital for sedation and continue current regimen
Answer: C
Rationale: The symptoms suggest opioid-induced neurotoxicity (OIN), including myoclonus and delirium.
Opioid rotation (e.g., to hydromorphone) is recommended, and benzodiazepines like lorazepam can
exacerbate delirium. Increasing morphine or adding sedatives would worsen the condition. A fentanyl
patch is not appropriate for acute titration.
14. Which of the following is the most accurate statement regarding the use of bisphosphonates in
patients with bone metastases?
A. They reduce the risk of skeletal-related events but do not improve pain control
B. They are contraindicated in patients with renal impairment because of nephrotoxicity
C. They are most effective when initiated after the onset of bone pain
Page 4
