Certified Hospice and Palliative Nurse CHPN Exam Review

Question 1

A nurse receives a referral to evaluate a patient who has been receiving hospice services since 8 months ago. The patient will be entering which of the following benefit periods?

Your Answer: Option(s)

Correct Answer: Option(s) C

Rationale

The patient will be entering the third benefit period.

In hospice care, patients typically receive services for periods of 90 days (the first benefit period) and can re-certify for additional periods. After the initial 90 days, if a patient continues to require hospice services, they enter subsequent benefit periods, with the third benefit period beginning after the second period has been utilized.

A) first
The first benefit period is the initial 90-day period of hospice care. Since the patient has already been receiving services for 8 months, they have surpassed this initial period and cannot be entering it now.

B) second
The second benefit period follows the first and also lasts for 90 days. Given that the patient has been on hospice services for 8 months, they are beyond the timeframe of the second benefit period, meaning they cannot be entering it at this stage.

C) third
Entering the third benefit period occurs after successfully completing the first two benefit periods, each lasting 90 days. Since the patient has been receiving hospice services for 8 months, they have completed the first and second periods and are now entering the third benefit period.

D) fourth
The fourth benefit period is the next phase beyond the third and is also a 60-day extension. However, as the patient has only been in hospice care for 8 months, they have not yet reached the point of entering the fourth benefit period.

Conclusion
In hospice care, patients progress through defined benefit periods, each lasting 90 days. Since the patient has been receiving hospice services for 8 months, they have completed both the first and second benefit periods and are now entering the third benefit period. Understanding these timelines is crucial for effective management of hospice services and ensuring patients receive appropriate care throughout their journey.

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Question 2

A patient has prostate cancer with bone metastasis and a history of seizures controlled with phenytoin. The oncologist orders dexamethasone for increased bone pain. Three weeks later, the patient has a seizure. The MOST likely cause of the seizure is

Your Answer: Option(s)

Correct Answer: Option(s) B

Rationale

Inhibition of phenytoin metabolism.

Dexamethasone is known to induce the hepatic enzymes that metabolize phenytoin, leading to decreased levels of phenytoin in the bloodstream. This reduction can result in subtherapeutic levels of phenytoin, subsequently causing a seizure in a patient with a history of seizure disorder.

A) Adverse reaction to dexamethasone
While dexamethasone can cause several side effects, it is not commonly associated with seizures as a direct adverse effect. The patient's seizure is more likely linked to the alteration in phenytoin metabolism rather than a direct reaction to dexamethasone itself.

B) Inhibition of phenytoin metabolism
Dexamethasone can alter the metabolism of phenytoin by inducing liver enzymes that metabolize the drug, which may lead to lower phenytoin levels in the blood. This decrease can cause the medication to become less effective in controlling seizures, thereby resulting in the patient's seizure after three weeks of treatment.

C) Dexamethasone metabolites
Dexamethasone metabolites are typically not implicated in causing seizures. The metabolites do not interfere with the pharmacokinetics of phenytoin or have a known role in seizure activity. Thus, they are unlikely to be the cause of the patient's seizure.

D) Metastasis to the brain
While brain metastasis can cause seizures, there is no indication in this scenario that the patient's cancer has progressed to involve the brain. The timing of the seizure following a change in medication suggests a metabolic interaction rather than new metastatic disease.

Conclusion
The patient's seizure is most likely due to the inhibition of phenytoin metabolism caused by dexamethasone treatment. This interaction leads to decreased levels of phenytoin, resulting in a loss of seizure control. Understanding drug interactions is crucial in managing patients with complex medical histories, particularly when introducing new medications.

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Question 3

The epidural infusion rate of morphine and bupivacaine has recently been increased, and the patient now complains of decreased sensation in the lower extremities. Which of the following is the MOST likely cause of the decreased sensation?

Your Answer: Option(s)

Correct Answer: Option(s) C

Rationale

Too much bupivacaine is the most likely cause of the decreased sensation.

Increased epidural infusion rates of bupivacaine can lead to heightened levels of the drug in the system, resulting in excessive sensory blockade and decreased sensation in the lower extremities. Bupivacaine is a potent local anesthetic that can cause significant motor and sensory loss when administered in high doses.

A) Morphine-bupivacaine interaction
While morphine and bupivacaine can interact pharmacologically, the primary effect of concern in this scenario is the local anesthetic action of bupivacaine. An interaction does not necessarily lead to decreased sensation, as morphine primarily acts as an analgesic rather than a local anesthetic. Thus, it is not the most likely cause of the decreased sensation.

B) Epidural infection
An epidural infection could potentially cause neurological symptoms, but it is less likely to directly result in decreased sensation due to the immediate effects of anesthesia. Infections often present with fever, pain, or neurological deficits but would not typically cause acute changes in sensation following an increase in medication infusion rates.

C) Too much bupivacaine
Excessive bupivacaine administration can lead to profound sensory and motor block, resulting in decreased sensation in the lower extremities. This is a well-documented effect of local anesthetic overdose, making it the most plausible cause of the patient's symptoms following an increase in the infusion rate.

D) Too much morphine
While excessive morphine can lead to side effects such as sedation or respiratory depression, it does not directly cause decreased sensation in the lower extremities. Morphine's primary role is pain management, and its effects are distinct from those of local anesthetics like bupivacaine.

Conclusion
The patient's complaint of decreased sensation in the lower extremities following an increased infusion rate can be attributed to too much bupivacaine. This local anesthetic has a direct impact on sensory neurons, causing significant loss of sensation when administered in higher doses. Other options, such as morphine interactions or infections, do not account for the acute nature of the symptoms as effectively as the direct effects of excessive bupivacaine.

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Question 4

While receiving palliative care, a patient's colostomy was revised secondary to obstruction. Now on hospice, the current colostomy is no longer viable, and an actively draining fistula has developed. The patient is comfortable. The family requests diagnostic tests to determine the tumor's size and location. Which of the following should be the nurse's FIRST response?

Your Answer: Option(s)

Correct Answer: Option(s) A

Rationale

Explore the family's plans related to requested diagnostics.

The nurse's first response should be to understand the family's intentions and concerns regarding the diagnostic tests. This approach fosters communication and ensures that the family's wishes are acknowledged and respected, especially in the context of hospice care.

A) Explore the family's plans related to requested diagnostics
This choice is the most appropriate initial response, as it prioritizes communication with the family. By exploring their plans and motivations for wanting diagnostic tests, the nurse can provide support and address any misconceptions regarding the goals of care in a hospice setting. This understanding is crucial for aligning care with the patient's and family's wishes.

B) Call the attending physician to report the new fistula
While reporting the new fistula may be necessary at some point, it is not the first priority in this scenario. The patient is already comfortable, indicating that immediate medical intervention is not required. The nurse should first engage with the family to understand their needs before escalating clinical concerns.

C) Assure the family the patient will remain comfortable
Although ensuring the patient's comfort is essential, simply reassuring the family does not address their request for diagnostic tests. This response may overlook the family's desire for involvement in the care process and can lead to feelings of frustration or misunderstanding regarding the patient's situation and care goals.

D) Recommend the patient return to palliative care
Recommending a return to palliative care may not be appropriate at this stage, especially if the patient is already receiving hospice care. This response does not engage with the family's request or the current situation, which could cause confusion. The nurse should first clarify the family's intentions before making such recommendations.

Conclusion
In hospice care, effective communication with the patient's family is vital for ensuring that their wishes are respected. By exploring the family's requests regarding diagnostics first, the nurse can better understand their concerns and provide appropriate support, thereby facilitating a patient-centered approach to care. Addressing the family's needs helps in navigating the complexities of end-of-life care while maintaining the patient's comfort and dignity.

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Question 5

The family of a patient with end-stage dementia has become dissatisfied with the care provided by the current hospice. After a care conference, the family decides to change to another hospice in the area. The current hospice should

Your Answer: Option(s)

Correct Answer: Option(s) B

Rationale

Arrange transfer of services.

The current hospice should facilitate the transfer to ensure continuity of care for the patient while respecting the family's decision to change providers. This arrangement minimizes disruption in care and upholds the patient's dignity during the transition.

A) Ask the family to revoke the Medicare Hospice Benefit
This option is inappropriate because it places the burden on the family to revoke a benefit that is crucial for the patient's care. The hospice should not complicate the transition process by requiring the family to navigate bureaucratic procedures when they have already made their decision to change hospices.

C) Discharge the patient for cause
Discharging a patient for cause is not warranted in this scenario, as the family's dissatisfaction with care does not constitute a legitimate reason for discharge. The hospice's role is to support the patient and the family, and discharging the patient would be contrary to the principles of compassionate care and would likely exacerbate the family's distress.

D) Revoke the Medicare Hospice Benefit
Revoking the Medicare Hospice Benefit is not a necessary or appropriate action when a family chooses to switch hospices. This would unnecessarily complicate the patient's care and could lead to a lapse in services, negatively affecting the patient's well-being during a critical time.

Conclusion
In cases where families wish to change hospice providers, the current hospice must prioritize the patient's ongoing care by arranging a smooth transfer of services. This approach not only respects the family's wishes but also ensures that the patient continues to receive the necessary support and care without interruption. All other options would either complicate the situation or fail to meet the patient's needs appropriately.

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The patient will be entering the third benefit period.

Inhibition of phenytoin metabolism.

Too much bupivacaine is the most likely cause of the decreased sensation.

Explore the family's plans related to requested diagnostics.

Arrange transfer of services.

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