Palliative Care and End-of-Life Management, Exams of Health sciences

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xerostomia - Dry mouth syndrome, leads to decreased swallowing ability, increased dental caries, gum, tongue and oral lesions, infections, bad breath, changes in taste and alterations in speech and voice functions. Social decline pyschosocial complication. xerostomia non-pharmacological treatments - oral swabs, peppermint water, vitamin c, chewing gum/mints, acupuncture, diet modification, humidity Percentage of HIV infection related pain - 50% directly related to infection of 30-97% of AIDS patient experiencing pain Post stroke pain - 32 - 42% experienced at 4-6 months post cva 11 - 21% experienced at 12-16 months post cva Types of common post CVA pain - Mechanical shoulder pain-common Allodynia= Painful response to normally innocuous stimuli Hyperalgesia =Decreased temperature sensation deep, superficial, and or severe

• coxib drugs - withdrawn from market due to adverse effects associated with cardiovascular system Conversion method from oral dose long acting to oral dose short acting - 24 h total of long acting divided by q4h administration plus breakthrough dose of 10-15% of 24 hour total given q2h prn Medication dosage alteration based on increased use of PRN dosage - Add total dosage for PRN use by patient and divide by 2 for amount of increase needed to long acting med Primary factors for subcutaneous infusion - 1. Circulatory status

2. Patient monitoring
3. Infusion site- amount of subcutaneous tissue Calculating breakthrough dose of short acting medication - 10 - 20% of daily total q2h prn Treatment for neuropathic pain - Tricyclic antidepressants Anticonvulsants SSRI Serotonin-norepinephrine reuptake inhibitors Anti-convulsants Starting dose nortryptiline and desipramine - 10 - 25 mg at hs titrated up by 10-25 mg every few days to max of 75-150 mg qd. May take 3-7 days to see effects.

To prevent double effect - When changing opioid decrease dose of new drug by 25% to account for incomplete cross tolerance. Duloxetine - SSRI for treating neuropathic pain and depression Side effects of Tricyclic antidepressants - Sedation, orthostatic hypotension, urinary retention, cardiovascular impairment Gabapentin- normal dosing range for effectiveness - 900 - 1800 mg/d in 3 divided doses Side effects of anticonvulsants - Ataxia, dizziness, sedation. Gabapentin specifically has increased incident of dependent edema. Conversion of morphine oral to morphine IV - 30 mg oral = 10 mg parenteral. Conversion for hourly iv rate = 24h oral total divided by 3 then divide by 24. Morphine to hydromorphone conversion - 10 mg of morphine to 1.5 mg hydromorphone 5 domains of alternative medical systems - 1. mind-body interventions 2 energy therapies

3. biologically based therapies
4. manipulative and body based therapies
5. electromagnetic therapies Classifications of Pruritis according to Bernhard - 1. Systemic
6. Dermatological
7. Neuropathic/neurogenic Elements of Sleep Hygeine - Limiting time in bed, removing clocks from room, avoiding alcohol, nicotine, and caffeine, taking a hot bath, limiting liquids before bed, regulating room temperature, regulating bedtime, limiting daytime napping Categories of sleep disorders - 1. Disorders of excessive somnolence
8. Dysfunctions associated with sleep stages or partial arousal
9. Disorders of sleep wake cycle
10. Disorders of initiating or maintaining sleep. Themes of nearing death awareness - Describing a place, needing reconciliation, talking to or being in the presence of someone who is not alive, knowledge or statements of when death will occur, choosing time of death, preparing for travel or change, being held back, and symbolic dreams. ANA Code of Ethics Provision 1. - The nurse, in all professional relationships, practices with compassion and the recognition of human dignity and worth that is present in every individual.

ANA Code of Ethics- Provision 2. - The primary commitment of the nurse is to the patient, whether the patient is defined as an individual, group, or community. ANA Code of Ethics- Provision 3 - The nurse seeks to protect the health, safety, and rights of the patient. ANA Code of Ethics Provision 4 - The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. ANA Code of Ethics Provision 5 - The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. ANA Code of Ethics Provision 6 - The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. ANA Code of Ethics Provision 7 - The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. ANA Code of Ethics Provision 8 - The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. ANA Code of Ethics Provision 9 - The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principle of social justice into nursing and health policy. National Consensus Project 8 Domains of Palliative Care - 1. Structure and processes of care 2.Physical aspects of care

3. Psychological and psychiatric aspects of care. The domain also specifically describes elements of bereavement services.
4. Social aspects of care
5. Spiritual, religious and existential aspects of care.
6. Cultural aspects of care.
7. Care of patients at the end of life
8. Ethical and legal aspects of care HPNA Code of Ethical Conduct: Principles - 1. Respect for persons
9. Justice
10. Beneficence
11. Confidentiality
12. Role fidelity

Causes of constipation in cancer population - Tumor related, med related, diabetes, hypothyroidism, colitis, diverticulitis, and secondary effects of disease such as decreased appetite, fluid intake, weakness, inactivity, and hypercalcemia. Goal of diarrhea management - Maintain fluid and electrolyte balance. Malignancy related ascites - Impaired efflux of fluid with increased influx of fluid. Symptoms include abdominal distention, pain, nausea early satiety, dyspnea, and decreased mobility. Refractory or Intractable symptoms means: a) require more aggressive tx b) multiple approaches have been used and failed c) symptoms that occur as a side effect of aggressive therapy d) symptoms that have subsided due to medical intervention - b. refractory or intractable symptoms cannot be managed even with aggressive tx. Pain and dyspnea are common symptoms seen in hospice pts that can become intractable and often require transferring to IPU The need to increase opiods in ca pt's is due to: a. cancer progression b. opioid tolerance c. opioid addiction d. opioid non-compliance - a. ca progression Typically as ca progresses, the pain increases requiring increases in opioid mgmt. Tumors can compress or stretch various organs, invade bone, or press on nerves. Palliative sedation is: a. used to relieve refractory symptoms such as dyspnea, agitation, and pain in the imminent pt b. is the use of aggressive opioid therapy to induce a state of sedation for the mgmt. of uncontrolled pain c. only used during in patient acute episodes of uncontrolled symptoms d. does not require a dnr - a. Palliative sedation typically does NOT use opioids. It is usually acquired by the mild use of anesthesia meds and a benzo. Only done on imminent pts and have a signed DNR. Which exam would not be performed on a pt with neutropenia a. central line insertion b. pet scan c. rectal exam d. blood draws - c. rectal exam Due to the risk of translocation of bacteria into bloodstrea, rectal exams are contraindicated on these pts

what is important to check prior to prescribing meds? a. vital signs b. pt's name and address c. pt's allergies c. pt's age - c. allergies Clinicians should not rely on alerts after entering a med in a pts chart, you should make a habit of checking pt's med allergies prior to prescribing a med a pt with ALS is decompensating and has an O2 level of 84% on 6l/NC. The family calls extremely upset and wants to know what you can do. You should first: a. given an opioid to help with s/s of dyspnea b. tell the family to immediately call 911, and have pt transferred to hospital c. tell the family it is an expected part of the disease process d. assess the goals of care and advanced directives - a. Always review goals of care first prior to making decisions because the plan of care is individualized according to their wishes. Some pts don't want to die at home, while others may want more aggressive tx such as bipap or high flow O2. All of the following are ex. of non-pharmacological interventions for managing dyspnea except: a. pursed lip breathing and diaphragmatic breathing b. sitting in a chair with arms resting on legs and leaning slightly forward c. elevating the HOB d. lying supine with feet elevated - d. orthopnea is sob when lying supine. When lying supine, there is more fluid absorption resulting in a greater venous return which leads to more pulmonary congestion and edema which statement requires immediate intervention? a. when i was first diagnosed with ca i thought about killing myself, but now i don't think about it as much b. i wish i were dead c. i'm ok with dying. i have made my peace and ready to go. i have my will and finances in order and have saved up enough pills to end my life d. i won't let this disease kill me. i will kill myself before it does. - c. This pt has a plan. On the fast scale, at what stage is a pt classified as "ambulatory ability is lost", (cannot walk unassisted) a. 7e b. 6c c. 7e d. 7c - d. 7c which pt with chf is eligible for hospice? a. pt with dyspnea with most activity and EF of 20% b. pt with frequent angina, is resistant to standard nitrate therapy and has an EF of 30%

c. pt with NYHA class III CHF with a history of syncope and HIV d. pt with dyspnea at rest, NYHA class IV, unable to carry out minimal physical activity without angina - d. Pts with chf must be in NYHA class IV with significant symptoms at rest. They must be unable to carry out even minimal physical activity without symptoms of dyspnea or angina even though they have been optimally treated with meds. Pt's EF must be 20% or less Which ex. best describes physician-assisited suicide? a. the doc administering an IV push of K+ into a pt's IV line b. a doc prescribing excessive amounts of benzos and explaining to the pt how to take them in order for them to end their life c. a doc prescribing conscious sedation for a pt near death d. a doc giving a pt excessive opioids to contraol pain in a dying pt, although hastening their death - B. PA suicide is implemented by the doc providing a pt with a means to end their life. The doc is not directly killing the pt but is giving them the means to do so. This is different than ordering conscious sedation for refractory pain in an imminent pt. On the PPS scale, pt's with ca must have a score of 70% or less to meet hospice eligibility. what score is required for non-ca pt's? a. 40 or less b. 50 or less c. 20 or less d. 30 or less - b. Pt's with a dx of stroke must have a pps score of 40 or below to be eligible for hospice. This score indicates the pt: a. is mainly in bed for most of the day; unable to do any activity, mainly needs assistance with all self care and has normal or reduced intake b. has reduced ambulation, has limitied activity, inability to do some housework, occas needs assistance with self care, and has normal or reduced intake c. pt is totally bedbound, unalbe to do any activity, total care with adl's and can only take minimal sips. d. pt is fully ambulatory, but unable to do normal or baseline activities that they were previously able to perform, they remain independent is self care , and have normal to reduced intake - a. A 76yr old female has breast ca with mets and has a sudden change in her mental status and starts yelling at family memebers, grabbing at air, seeing things. Family is concerned because pt is usually a&o. She has been on opioids for years, labs show decrease in renal function. family wants a CT of brain. You should: a. do a focused h&p relating to her current change realizing that the pt's deliriu is most likely due to opioid induced neurotoxicity (OIN) b. order ct of brain at family's request c. order donepezil since this is probably start of dementia d. order keppra since benzos are 1st line in tx of dementtia - a.

a potential side effect of opiods is opiod induced neurotoxicity caused by the accumulation of metabolites. pts with poor renal funtion are especially at risk such as the elderly. Antipsychotics such as haldol are typically given along with hydration and opioid reduction. Studies have shown that benzos have no effect on hallucinations and increase confusion in pt's with delirium. A pt with dementia is said to have the inability to maintain sufficient fluid and calorie intake in the past 6 months when evidenced by: a. 15% weight loss or albumin less than 1. b. 10% weight loss or albumin less than 1. c. 20% weight loss or albumin less than 2. d. 10% weight loss or albumin less than 2.5 - d. Dementia pts must be 7c and have at least one other indicator for decline such as 10% weight loss or albumin less than 2.5 in the past 6 months. What is double effect? - Term used when an intervention causes both a positive and negative effect with the positive effect outweighing the negative. A example is a pain med given to an imminent pt although it may hasten the pt's death. 32yr old female has been on opioids for over 2 yrs for ovarian ca. Her family has noticed that the pt;s hand twitches periodically and they want to know what this is from. You reply: a. I will start Keppra since she is having a seizure b. this is called myoclonus and is a side effect from her opioids. I will order clonazepam which should help c. I will review her labs, but she will most likely have to have an EEG d. this is a sign of dementia and although it doesn't cause any problems, I will start her on an anti-psychotic - b. myoclonus is a side effect of opioid use and metabolite accumulation causing involuntary twitching of muscle groups. Benzos are first line drugs given for this condition. All statements are true regarding a Left Ventricular Assist Device (LVAD) except: a. It is a type of pacemaker with leads entering the Left ventricle and atrium b. it is used in pts with end stage heart failure and is not the same as a pacemaker becuase it assumes the function of theL Ventricle instead of simply regulating electrial activity of the heart c. many pts have an LVAD implanted as they await heart transplants d. a 2015 study showed 65% of pts died within 3 years of receiving one - A. LVAD is not a pacemaker but is a mechanical device that assumes the function of the heart in pt's with end stage heart failure. It is implanted in the pt with a lead that exits the body that is attached to an external battery. What indication meets hospice criteria for COPD a. dyspnea with mild exertion b. FEV1 after a bronchodilator less than 30% of predicted c. limited response to bronchodilators d. resting PCO2 greater than 55 - B.

As per the GOLD report, stage 4 COPD is reflective of severe lung damage with lung function less than 30% of normal. Other indicators for hospice eligibility are pco2>50, dyspnea at rest, and having no response to bronchodilators 49yr old pt with metastatic ovarian ca is being evaluated for hospice care. What indicator is most indicative of hospice appropriateness? a. a new liver lesion b. kps of 20 c. frequency in falls d. frequent opioid increases - B. 56 yr old with pancreatic ca states she is having severe abd pain and nausea. Upon exam her stomach is distended, high pitched bowels, palpation of abd reveals tightness and moderate amount of gas, no bm in several days. you suspect: a. duodenal obstruction b. gallstones c. stool impaction d. diverticulitis - A. gastric outlet obstruction secondary to duodenal invasion from progression of malignancy is a late manifestation of pancreatic carcinoma. which indication is most indicative of hospice eligibility in pts with dementia? a. decline in labs b. decline in function c. decline in cogntion d. increase in hospitalizations - b. functional decline on the fast scale is the most significant indicator for hospice eligibility ALS pts can sometimes lose their ability to control their emotions such as inappropriate laughter or crying. This condition is called. a. pseudobulbar affect (PBA) b. emotional liability disorder (ELD) c. frontal brain disorder (FBD) d. frontal cognitive disorder (FCD) - A. you are evaluating a 72yr old male with CHF for hospice eligibility. You know he must have NYHA of IV which means: a. marked limitation of physical activity and is only comfortable at rest. b. unable to carry out any physical activity without discomfort and has dyspnea at rest c. comfortable at rest, but ordinary physical activity results in fatigue, rapid or irregular HR, dyspnea d. pt is oxygen dependent - b. The key terminology for hospice eligibility for CHF is "dyspnea at rest" which places them in classification IV of the NYHA category for heart failure A pt with end stage liver disease who continues to drink:

a. is most likely a good candidate for hospice. b. cannot remain on hospice due to medicare guidelines c. should be set up for an intervention and placed as an in-pt for withdrawal precautions. d. should be given a lecture on why they should stop drinking - a. alcoholism is a disease; the damage in esrd is irreversible and liver transplant is the only option while you are evaluating a pt, they turn to you and say " all i want to do is die". you should: a. empathize and say i dont blame you b. refer the pt for a psych eval c. tell the pt that doc-assisted suicide is an option d. further explore the pt's feelings and ask why they feel like dying - d. Pts with PTSD often use what maladaptive a coping mechanism: a. reflection on previous loss b. excessive use of alchohol c. violent outbursts d. prayer - b. You walk into a home with 24hr caregivers and see that pt is aspirating on tube feeding. You: a. stop the feeding and call the family informing them to d/c feedings b. continue to led feeding run and update family c. have the pt transferred to hospital d. slow it down and inform cg to recheck the pt in a few hours after you leave - a. There comes a time when tube feeding does more harm than good. Transferring a pt to hospital is not within typical goals of care. coping mechanisms for loss include all of the following except: a. online blogging and chatting regarding the loss b. distraction therapy such as kitting or playing games c. attending support groups and buying a new pet d. remaining on antidepressants, antianxiety, sleep meds for over 6 months because they still "can't bear to think about it" without praying or becoming unable to function in public

• d. When is it appropriate to NOT honor a pt;s wishes that does have decision making capacity: a. when the idg team's choices are better than pts b. when the pt keeps changing their mind c. when pt's decisions are unsafe and puts them at risk d. when pt makes decisions base on cost - c. which opioids are typically given to pts with ESRD? a. methadone and fentanyl b. morphine and codeine c.ms contin and hydromorphone

d. buprenorphine and oxycontin - a. methadone's metabolites have been found to be inactive and are excreted via the gut. Fentanyl metabolites are inactive and considered safe to use in renal impairment. Morphine and codeine have active metabolites that will accumulate in the presence of renal failure. oxycodone is synthesized instructure to morphine. Ms Contin is long acting morphine. Dilaudid is a derivative of morphine. 87 yr old female who lives in a snf is typically a&ox2, but has recently become confused and incontinent of urine. First test you should order is: a. ct scan of the head to r/o stroke b. u/a c&s to r/o UTI c. bun and creatinine to r/o dehydration d. cbc to r/o anemia - b. a cognitively impaired pt is moaning, rocking and grimacing. you suspect pt experiencing: a. pain b. anxiety c. sadness and depression d. typical behavior in cognitively impaired pts - a. which tool is used for pain assessment in pts with advanced dementia? a. pain assessment in advanced dementia (painad) b. faces scale c. universal pain assessment tool d. chronic illness pain scale - A. Painad It is recommended that pts with an AICD on hospice care have their device: a. removed b. deactivated c. stay activated for quality of life issues d. stay activated and apply a magnet if it discharges a shock - b. This is recommended due to cardiac arrhythmias in dying pts and preventing the pts from sustaining painful shocks at the end of life. Pt's wife calls you stating spouse has been screaming all night in pain and nothing is working. She states she is exhausted and not sure how much more she can take. you suggest: a. transfer pt to IPU b. tranfer pt to a nursing home c. hiring a cg for additional support d. continuous home care - a. IPU is appropriate for this pt because it will provide symptom mgmt in controlling his pain as well as providing a respite for his wife. Which non-pharmacological approach has been shown to be effective for chronic pain?

a. mindfulness-based stress reduction (MBSR) b. meaning-centered psychotherapy (mcpt) c. psychodynamic psychotherapy (pdpt) d. dignity therapy (dt) - a. MBSR uses meditation techniques to help cope with illness, pain and stress. It focuses on the present moment and non-judgement, so the mind can overcome negative thoughts and feelings. An ekg should be obtained prior to starting methadone on pts with risk factors that include: a. renal impairment b. cognitive disorders c. history of substance abuse d. prior to ekg with qtc greater than 450 - d. risk factors for starting methadone include electrolyte abnormalities, structural heart disease, impaired liver function, endocarditis, a history of ventricular arrhythmia, and a prior ekg with qtc >450. a pt recently dx with lung ca calls you stating they have run out of their meds early. the pt is on morphine IR 10mg q4hrs PRN. your next step is to: a. get a urine drg screen and switch to ms contin 30mg q12hrs with morphine ir 5mg every 4PRN b. inform the pt that you cannot refill their med early and they will just have to go without c. tell the pt that you can no longer care for them since they are abusing their meds d. assume the pt is in pain and refill their current script early - a. Since this is a newly dx pt they could be having uncontrolled pain. obtaining a urine test will show if they are actually taking the med. Switching the pt to a longer acting morphine like ms contin with scheduled dosing and allowing for break through pain control with prn IR morphine will allow the provider to further assess pain mgmt and pt compliance. which meds are typically used for palliative sedation? a. opioids b. midazolam and lorazepam c. anticholinergics and benzos d. amphetamines - b. Medazolam and a short acting benzo are most commonly used. Other meds include chlorpromazine, haldol, phenobarbital, thiopental and propofol. Opioids are not typically used for palliative sedation Which pt is most eligible for hospice? a. 33yo with HIV who has a viral load of greater than 80k, cd4 less and 60, pps 60%, recent hospitalization for cryptosporidium infection b. 87 with stage 4 lung ca, pps of 70, serum calcium of 9, newly dx liver lesion c. 76 yr old with dementia, can't walk without assistance, speaks less than 6 intelligible words, recently hospitalized for aspiration pneumonia d. 52 yr old with end stage liver disease, severe abd pain, albumin 3.5, INR 1.3, has a DNR - c.

Normal serum calcium is: a. 8.9-10. b. 1.5-3. 5 c. 14- 25 d. 35- 45 - a. what type of ca has the worst prognosis a. colon ca b. pancreatic ca c. breast ca. d. prostate - c. regardless of what stage pancreatic ca is diagnosed at the 1 year survival rate is 20% and 5 year survival rate is 7%. Pancreatic ca is still largely considered incurable. Colon, breast, and prostate ca have much higher survival rates. which pt is most likely experiencing end of dose failure: a. pt that has scheduled Percocet 3x day and says "i must be due for my next pain pill because my pain is getting really bad b. pt on Vicodin that says "i don't know why my dr gives me these pills because they don't do anything for me" c. pt that was recently started on fentanyl patch and says "i have had this patch on for an entire day and my pain keeps getting worse d. pt on prn Percocet and states, I'm going to take 2 instead of 1 next time" - a. A pt should not have to wake in the middle of the night for pain meds nor watch the clock because they are in pain and their next pill is not due for an hour. End of dose failure refers to pts taking a scheduled dose of a narc and it not lasting until the next pill is due. which med has the most likelihood of causing qtc prolongation? a. methadone b. Percocet c. hydromorphone d. tramadol - a. you are assessing an HIV pt and notice white patches on sides of tongue, how do you treat this? a. this is an opportunistic bacterial infection, azithromycin b. this is a side effect from antiviral therapy and it's a chronic condition c. this is a fungal infection, nystatin d. this is a viral infection and treat with oral swish and swallow antivral med - c. Candidiasis occurs due to compromised immunity pt with lung ca just finished chemo. labs show increased sed rate of 32, hgb 11, creatinine 1.4 and BUN. Probably dx: a. fatigue b. inflammation

c. anuresis d. dehydration - a. fatigue is one of the most common side effects of ca treatment. what is the most significant indicator for decline in a pt with Alzheimer's? a. a decline in memory b. a decline in function c. a decline in appropriate behavior d. an increase in uti's - b. which med will produce the fastest results for improving depression? a. duloxetine b. sertraline c. eszopiclone d. methylphenidate - d. methylphenidate (ritalin) is a stimulant and works very quickly having a half life of 3. hours. brain atrophy is seen on a ct scan. this can be suggestive of: a. stroke b. dementia c. ALS d. brain ca - b. you are examining a pt with lung ca who complains of SOB and a non-productive cough. you notice dullness on percussion in left lower lung as well as diminished breath sounds. You suspect: a. superior vena cava b. plueral effusion c. cirrhosis with hepatic hydrothorax d. CHF - b. plural effusions are common in pts with lung ca and is often the first presenting symptom. pt's usually present with dyspnea and non-productive cough. kyphoplasty surgery is a procedure used to stop pain and stabilize bone caused by spinal fx and is performed by: a. injecting cement like material into vertebrae b. removing damaged vertebrae c. securely wiring the vertebrae d. replacing the vertabrae - a. which condition most likely indicates that ca has spread to bone causing bone breakdown? a. anemia b. hyperkalemia c. hypercalcemia d. leukocytopenia - a.

bone breakdown causes calcium to be released in the blood what class of meds is typically given in the presence of hypercalcemia? a. ACE inhibitor b. selective uric acid reabsorption inhibitor c. bisphosphonates d. SSRI - c. bisphosphates prevent osteoclast mediated bone loss in the occurrence of hypercalcemia in malignancies. what class of meds is considered first line tx for N/V? a. anticholinergics b. antihistamines c.benzodiazepines d. opioids - a. anticholinergics block the neurotransmitter acetycholine and inhibit the transmission of parasympathetic nerve impulses which reduces spasms of smooth muscles. treatment for opioid induced hyperalgesia (OIH) includes: a. reducing opioid dosage and starting ketamine b. stopping all PO opioids and starting a fentanyl patch since this route has been shown to decrease likelihood of OIH c. stopping all opioids and starting tramadol in addition to an NSAID d. calling 911 since this is considered a life threatening condition - a. what is the best definition of OIH? - Nociceptive sensitization caused by the exposure to opioids characterized by a generalized hypersensitivity to pain, even in areas of the body that were not previously painful. the best definition of allodynia is: - Pain produced by a non-noxious stimulus or a pain response initiated by a previously non-painful stimuli 62 yr old has lung ca and his wife calls you crying because pt has SOB and states his face is swelling up. She screams " even his veins are showing". pt may be experiencing a. progression of ca b. superior vena cava syndrome c. compartmental syndrome d. pericardial effusion - b. this commonly occurs in the presence of chest cancer's that have grown causing compression of the superior vena cava. typical signs include facial edema, dyspnea, vein distention. pt with end stage COPD is experiencing refractory dyspnea. which med would most likely be prescribed? a. morphine b. symbicort

c. atropine d. lasix - a. first line management for excessive secretions in an actively dying pt is: a. administration of an anticholinergic med such as glycopyrrolate b. bedside suction c. repositioning of the pt allowing for the drainage of secretions d. raising HOB to allow for improved air exchange - c. first line is to reposition pt's head to allow secretions to drain naturally; Aggressive suctioning is ineffective and has been found to produce even more secretions; anticholinergics such as glycopyrrolate are given when other mgmt methods have failed pt is having issues with insomnia and depression. What med is best to describe? a. mirtazapine b. wellbutrin c. Zoloft d. cymbalta - a. mirtazapine is often given for insomnia and depression. it is best to give one pill that can treat several issues as well as being cost effective which med would be best to have on hand for a pt with a high potential for seizures? a. valium 5mg PO b. diazepam 5mg IV c. diazepam 10mg rectal gel d. valium 2.5mg SL - c. never give anything PO to a pt having an active seizure. It is not practical for families to have IV meds in the home. rectal diazepam is availabel as a rectal gel in prefilled syringes called Diastat which person is most at risk for developing complicated grief? a. an individual that has experienced previous loss, esp if in childhood b. an atheist c. a person that has a very limited support system d. children less than 14 years of age - a. some of the risk factors for complicated grief include history of mental illness, substance abuse, previous loss and sudden unexpected death. 76 yr old male died 18months ago and his widow calls crying stating she still can't believe he is gone. She rarely leaves the home and states she doesn't want to get out of bed in the morning. What is most important for the practitioner to do prior to hanging up: a. make a 4 week follow up b. find a local grief support group c. refer the pt to a bereavement counselor d. find out local pharamacy to order Zoloft for her - b. medicare pays for bereavement counseling for up to 1 year after the pt's death so additional grief counseling will have to be through a local support group.

54 yr old with breast ca calls to c/o that spouse is no longer attentive and loving, he is hardly home and it's like he is just moving on with his life. He is most likely experiencing: a. caregiver burnout b. complicated grief c. anticipatory grief d. inadequate coping strategies - c. emotional numbness and fear are signs of anticipatory grief. what med is often used in pt's with ALS to control spasticity a. baclofen b. valium c. soma d. gabapentin - a. muscle spasms frequently occur in pts with als and are typically controlled with a muscle relaxant such as baclofen normal albumin level is: a. 3.6-5. 1 b. 8.6-10. c. 1.9-3. d. 6- 29 - a. Pts with end stage liver disease and portal hypertension have an increased risk of: a. bleeding from esophageal varices b. developing liver carcinoma c. developing malignant ascites d. increased ammonia levels - a. increased intrahepatic vascular resistance and increased blood flow through the portal venous system leads to the development of portosystemic collateral veins; pt's have a 30% chance of bleeding out within two years the risk for spinal cord compression is highest in all of the following cancers except: a. pancreatic b. breast c. lung d. prostate - a. any type of ca can spread to the spine, but it is more commonly associated with breast, lung, prostate, kidney, lymphoma and multiple myelomas a pt with hepatic ca develops hemoptysis. What is the most likely cause? a. platelet count of 40k b. esophageal varices c. side effects of nsaid overuse d. vascular invasion of malignancy - d. bleeding often occurs when cancers spread and invade vascular tissue.

pt with stage 3 breast ca c/o of back pain, new onset numbness in her toes as well as loss of bladder control. you immediately want to rule out: a. spinal cord compression b. brain mets c. mets to lower extremities d. mets to the liver - a. spinal cord compression most frequently occurs in which area of the spinal cord? a. cervical b. lumbar c. thoracic d. sacral - c. 70% of metastatic invasion to the spine occurs at the thoracic region; studies show that men experience grief differently than women, for this reason a therapitst knows that men in: a support group: a. must be prompted and encouraged to express their feelings of grief b. are prone to make fun of those outwardly expressing their feelings c. tend to take over and dominate the group d. tend to express grief in a more violent nature than women - a. calcium has a direct relationship with: a. creatinine b. sodium c. phosphate d. albumin - c what condition indicates a worsening of CHF? a. hyperkalemia b. hyponatremia c. hypercalcemia d. hypernatremia - b. antidiuretic hormone release and the reduction in serum sodium correlate the severity of heart failure. signs of spiritual distress include a pt stating: a. I really don't belong to any type of religion b. I really don't know if I believe in God or not c. I really don't understand the bible d. I hate God. there is no purpose to life except to suffer - d. What is evidence based practice? a. practice that is based on research b. practice that is based on theory

c. practice that has sustained the test of time d. practice that is policy based - a. what is the recommended tx for spinal cord compression? a. radiation b. surgical intervention c. steroid injection d. chemo - a. this is first line treatment and should be done within 24 hours of diagnosis; radiation quickly relieves pressure off of the spinal cord by shrinking the tumor a 3rd heart sound is indicative of: a. heart failure b. cardiac arrhythmia c. pericardial effusion d. cardiac tamponade - a. it is indicative of increased ventricular filling and is found in congestive heart failure pt had a stroke and has been in the icu for 3 days. an apnea test was performed to determine brain function. The results were absent respiration and a PaCO2 of 80mmHg. This means: a. positive test for brain death b. negative test for brain death c. inconclusive because this is a normal PaCO d. an eeg should be obtained since this is the gold standard - a. what is the difference between a pt in a coma and a pt in a persistent vegetative state? a. no difference, terms used interchangeably b. coma pt is aware of their surroundings and can hear but unable to interact c. pt in VS has sleep-wake cycles d. coma pt is unconscious for a prolonged period of time but can be awakened by stimulation - c. pt with end stage liver disease is having increased confusion. he has been taking his lactulose and hving bms regularly. He has nausea, dark colored urine, decreased urine, weight gain and jaundice. which lab test should be ordered? a. ammonia level b. creatinine c. albumin d. LFT's - b. a ketamine infusion for OIH works by effecting which receptors? a. gamma-amminobutyric acid (gaba) receptors b. dopamine receptors c. n-methy-d-aspartate (NMDA) receptors d. opioid kappa receptors - c.

The NMDA receptors are the primary binding site for ketamine and is a NMDA antagonist. Ketamine acts as an agonist on dopamine, opioid kappa, and GABA receptors pt with end stage liver disease is icteric and has complaints of severe itching. which med should be tried first to alleviate symptoms of pruritus? a. hydrocortisone cream b. an antihistamine such as benadryl c. naloxone d. a bile resin binder such as cholestyramine - d. pt with stage 4 lung ca with mets has complaints of extreme fatigue that is affecting his quality of life. Which intervention is most helpful? a. methylphenidate b. sertraline c. caffeine d. a good exercise program - a. this is a CNS stimulant and has been shown to improve symptoms of fatigue in ca patients. 22yr old korean pt is hospitalized for renal failure. She is alert and tells the nurse she is concerned about dialysis. Her mother approaches you with questions about pt care. In this culture, who is known to make the healthcare decisions? a. family b. husband, father, oldest son c. mother or wife since females are the caregivers d. the pt if age appropriate and is able to make decisions - b. This culture is family focused although the husband, father or eldest son will most likely have the final say If pt is in their room with eyes closed and meditating, what religion are they most likely practicing? a. muslim b. judaism c. hinduism d. buddhism - d. buddhism What are some of the most important components of an advanced directive? a. assigning a healthcare proxy to make decisions b. delegating assets prior to death c. ensuring post mortem religious beliefs have been carried out d. assigning a POA over your will - a. Many PCPs are referring their pts with chronic pain issues to palliative care. all of the following can be put into place to decrease the abuse of opioids except: a. routine urine testing, opioid contracts, risk tools b. making pts aware that they cannot refill their meds early if they run out c. have the pt tell the pcp what opioid works for them

d. have the pt call the provider if the pain med is not working and have them bring in their med so provider can see how much they have taken - c. some pts require very frequent blood transfusions due to certain anemias and ca. It is appropriate to stop receiving at end of life for all of the following except: a. when the pt's goals of care have been reviewed and state the primary goal is comfort b. when the burden of invasive tx outweighs benefits c. when blood trans show no improvement in fatigue or survival d. pt is at high risk for hemorrhage - d. on admission family is upset stating doc told them pt had two years. You can clearly see that pt has less than 6months. The notes state family is right and doc did say that. What do you do? a. apologize to them and pretend you have wrong pt b. schedule a meeting with oncology to discuss c. tell the family the oncologist was wrong d. recognize this as an overestimated prognosis secondary to family wanting agressive tx - b. What does the acronym GOLD mean in relation to COPD? a. Global initiative for Chronic Obstructive Lung Disease b. Glandular obstructive lung disease c. genetic obstructive lung disease d. gold standard for Obstructive lung disease - a reasons why wounds do not heal in hospice pts include all of the following except: a. poor tissue perfusion b. poor nutritional status c. decreased functional status d. limited ability of family to care for wounds - d. Pt wants to stop dialysis. Pt has a will, signed DNR, appointed son as healthcare proxy. After several days pt becomes confused and lethargic. Son states he wants to revers the DNR and restart dialysis. You should a. call a family meeting and allow son to express his feelings b. tell the son that his father trusted him to carry out his wishes c. explain to him what a healthcare proxy is and inform him that he is breaking his father's trust d. call bereavement and have them counsel him - a. The most appropriate thing to say when someone has died is: a. they must be in a better place than this! b. you won't be able to see them anymore but at least you have memories c. I am sorry for your loss d. well at least now they aren't suffering and in all that pain anymore - c

The term medical futility means: a. there is no beneficial reason to start or continue tx b. there is a medical benefit that outweighs the risk of a tx or procedure c. there is an equal benefit to risk ratio, therefore it is up to the pt if they want to continue tx d. their risk outweighs the benefits of tx - a. A dr enters a pt's room to discuss a pt's disease. He asks the pt what they already know and to what detail they would feel comfortable discussing it. This technique is called: a. ask-tell-ask communication b. linear communication c. permissive communication d. authoritarian communication - a What is the difference between capacity and competence? a. pt's decision making capacity can be determined by medical professionals while competency determined by courts b. the opposite of above c. pt would have to be referred to psychiatry and be diagnosed as incompetent, while a pt's decision making capacity could be determined at bedside d. only a dr can deem a pt as incompetent - a Which person is most at risk for opioid abuse or misuse? a. person with chronic pain issues b. family history of substance abuse c. person with cognitive impairment d. pt's between the ages of 50- 80 - b. A dr tells the NP to start performing paracentesis procedures in pt's homes to prevent hospitalizations. What should the NP do? a. do as dr says and add to collaborative protocol b. check with your states scope of practice for NP's c. state you would be happy to if the dr showed you d. tell the dr that a paracentesis cannot be performed in a pt's home - b. a colleague has been working 2 jobs for over a year and states "all i do is take care of pt's from morning to night". which behavior would be most concerning for burnout? a. colleague starts crying when pt dies b. colleague yells at a nurse stating she's incompetent c. He states "I've got to get out of here. I'm taking my family on vacation" d. states he's tired of educating pt's when they just ignore him and do what they want anyway - a You want to make a policy change that will affect your colleagues. The best way to do this is: a. plan a retreat allowing for open discussion outside of the work environment

b. have a meeting with your colleagues informing them of the change and planned implementation date c. implement the change and expect emotional flexibility tell them that the change was mandated by upper mgmt and you had no choice - a The ethical principle that refers to truth telling is called a. veracity b. non-maleficence c. justice d. beneficence - a how long is a pt's health record considered confidential after their death? a. after a person dies, it's no longer confidential b. up to 5 years after they die c. up to 50 yrs after they die d. up to 3yrs after they die - c A colleague is having a difficult time balancing family and work. you suggest: a. take a vacation b. cutting back to part time c. mindfulness training d. cognitive behavioral training - c When would an ethics consult be appropriate? a. when family is disagreeing with the pt's wishes b. when a family conflict is putting undo pressure on a healthcare surrogate c. when a pt decides they no longer want to be on life sustaining tx d. when a family is demanding life sustaining tx for an unconscious pt for their own financial benefit - d. Pt with substance abuse hx has tested + for weed. You tell them you will no longer write scripts for opioids because of this. The provider may now be at risk for all of the following except: a. withholding of medical care or tx b. not adhering to the ana's goal of hospice and palliative nursing care c. breaking the ethical principle of non-maleficence secondary to withholding pt's pain meds d. responsible behavior by the provider since it is their license and their decision - d A pt with ALS has reached an end point in their disease process. Pt has increased dypnea with no help from non-invasive tx. Family and pt are requesting a trach with mechanical ventilation. Your response should include all except: a. explain that this will not stop the disease process and pt will have increased chance of becoming "Locked In" b. have the issue further discussed in a team meeting involving the pt and family and explain that pt can no longer be on hospice

c. support the pt's autonomy but make sure they understand what the procedure entails; including pt not being able to communicate and the effects of quality of life d. deny the request because this would require respiratory therapy that hospice doesn't provide - d You are in the process of being credentialed for a hospital and are asked for documentation of what services you can provide. What should you provide? a. the scope of practice guidelines of advanced practice nurses in the state you will be practicing b. the scope of practice guidelines for hospice and palliative care in conjunction with the practice restrictions governed by the state c. treatments and procedures that have been included in your collaborative agreement with your state d. your state license, your dea, your board certification, your medicare and medicaid provider #'s, NPI number, recent CEU's and specialty certificates you have received, CPR card and transcripts - b all of the following are examples of professional development activities except: a. striving to "stay under the radar" and inch toward retirement b. participating in professional orgs c. presenting at conferences and publishing d. educating colleagues and mentoring students - a The national consensus project for quality palliative care defines primary pall care as being inclusive to all med professionals and should focus on alleviating suffering, promoting quality of life and using an interdisciplinary approach to care as well as: a. basic symptom mgmt, open communication, and advanced directive discussions b. pain mgmt, ethics, and advanced directive discussion c. right to die autonomy, family cohesion,decision making, DNR d. clergy, social work and therapies - a which org develops, disseminates, and updates the Clinical practice guidelines for quality palliative care? a. hospice and palliative credentialing center (HPCC) b. national hospice and palliative care organization c. national coalition for hospice and palliative care d. american nurses association (ANA) - c Choose the best definition for quality improvement: a. it is a method for continual organization restructure for upholding accreditation standards b. it is a division/department within organizations designed to review pitfalls or damages within an org and provide recommendations for punitive action c. it is a philosophy that organizations use to benchmark, reduce waste, increase efficiency, and improve outcomes using research as a means for continuous evaluation and improvement

d. quality improvement is an avenue for punishing employees for misconduct and medical errors as a way of reducing lawsuits - c An 82yr old pt tells you they no longer want aggressive tx. They state they just want to go home with hospice but don't know if they can afford it. The pt has medicare, so you explain: a. medicare part d covers your hospice benefit b. you pay upfront, but medicare reimburses you c. medicare part b covers it d. medicare part a covers it - d For a pt to meet hospice eligibility with COPD, they must meet 3 criteria which are: - 1. dyspnea at rest, unresponsive to bronchodilators, decreased functional capacity

2. progression of disease evidenced by increasing doctor visits or hospitalizations
3. documentation within the last 3 months of hypoxemia at rest on room air of an oxygen sat of <88% with hypercapnia evidenced by pCO2>50mmHg When ordering a workup on a pt for controlling symptoms and addressing quality of life, the workup should: a.be cost effective, minimally invasive, and in line with their goals of care b. should include tests that allow for a more accurate diagnosis such as mri's and abgs so the pt does not have to continually return for testing c. be very thorough since this is part of their hospice benefit and will be paid by medicare d. order as much as possible so that you do not miss anything in case of a law suit - a. Which statement is part of the hospice and palliative nurses association (HPNA) position statement regarding the value of the advanced practice nurse in palliative care? - B. APRNs have the knowledge and clinical judgment to provide primary palliative care in all settings including advanced care planning. They are uniquely qualified and positioned to address the myriad needs of individuals facing life-threatening, progressive illness. If used to the scope of their practice, they can both improve health care quality and access to care. A pt is concerned that medicare will not pay for their stay in a snf when they are d/c'd from the hospital. you tell the pt: a. medicare will pay for 100days in a snf after hospital d/c b. medicare will pay for 120 days " " " c. medicare will pay for 60 days """ d. medicare will pay for 30 days """" - a. The four levels of care included within the medicare hospice benefit are: - Routine Hospice Care General Inpatient Care Continuous Home Care Inpatient Respite Care Which level of care within the medicare hospice benefit provides around the clock rn direct pt care for acute symptom mgmt within a medicare certified hospital or unit?

a. inpatient respite care b. continuous home care c. general inpatient care d. routine hospice care - C General Inpatient Care a pt's wife asks you how long her husband can be on hospice. you reply: a. under medicare guidelines a pt that is eligible for hospice will have one 30 day benefit period and then unlimited after b. ...6 month benefit period and then 30 days periods c. ...2 90 day benefit periods and then an unlimited number of 60 day periods d. 2 30 day periods and then up to 4 60 day periods after - C What would be the most effective way to bring about changing provider prescribing habits and implementing new policy changes? - Assemble a challenge for employees by arranging small work groups and the group that comes up with the most effective solution wins a prize. Which items would not be covered under medicare part b? a. ambulance transport and durable medical equipment b. getting a second opinion and clinical research c. hospice care and hospitalization d. limited drug coverage - C. When should a palliative care referral be made? a. as soon as a dx is made for life limiting illness b. when the pt is ready for hospice services c. when the family starts raising questions regarding the disease trajectory and tx options d. when all other tx options have been exhausted without success - a. What is a known barrier to end of life care: a. pts living in rural areas b. referrals from specialist for hospice care c. lack of insurance or limited finances d. families not wanting a death in their home - A. They are less likely to receive hospice care due to the limited number of hospice orgs located in rural areas as opposed to the more populated urban areas. a COPD pt will be eligible for hospice if they have all of the following except: a. a PO2 less than or equal to 55mmHg at rest on r/a b. O2 less than 88% at rest on r/a c. hypercapnia evidenced by pCO2 greater than 50mmHg d. responds well to bronchodilators - d. a homeless pt is living in a shelter. What type of pain med would be most appropriate for this pt?